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Necrotizing fasciitis is a rare but potentially lethal infection of the skin and soft tissue, commonly seen in the perianal and gluteal regions. Concomitant diabetes is a predisposing factor. Primary necrotizing fasciitis of the breast is rare in healthy women. In this article, we present a very rare case of breast necrotizing fasciitis in the context of the literature. We report the case of a 35-year-old female patient who had given birth two months prior to admission and developed necrotizing fasciitis of the breast during lactation. The patient presented to the emergency department with sepsis. Examination revealed widespread erythema, dark discoloration, edema, and necrotic areas indicative of wet gangrene and crepitation in the left breast. Necrotizing fasciitis is a rapid and aggressive disease that can be fatal, and delayed diagnosis may unfortunately result in death. Therefore, careful evaluation of all suspected cases, especially for patients with risk factors, is crucial for early diagnosis and timely treatment. This case highlights the importance of recognizing necrotizing fasciitis of the breast in lactating women to ensure prompt and appropriate management, potentially saving lives., Competing Interests: Conflict of Interest: No conflict of interest was declared by the authors., (©Copyright 2024 by the Turkish Federation of Breast Diseases Societies / European Journal of Breast Health published by Galenos Publishing House.)

We review a case of total penile skin replacement with split-thickness micromesh skin graft (micromesh STSG) due to paraffinoma., Competing Interests: No., (© 2024 The Authors.)

Fournier gangrene (FG) is a life-threatening necrotizing soft-tissue infection of the perineum and external genitalia, which primarily occurs in obese, diabetic males. The mainstay of treatment is source control via early aggressive surgical excision. Wide surgical excision can result in significant soft tissue defects that can be disfiguring and difficult to close. The most common method of closure is split-thickness skin grafting (STSG). Recently, autologous skin cell suspension (ASCS) technology has been used in addition to STSG to provide better wound healing and closure. This patient experienced excellent wound progression, following FG, through the application of ASCS with STSG, despite challenges related to the wounds, anatomical location, comorbidities, size, and the patient's medical history., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, English et al.)

Aplasia cutis congenita (ACC) is a rare congenital disease defined by the absence of skin, most commonly on the scalp. While the exact incidence remains uncertain, ACC presents a significant challenge in clinical management due to its variable presentation and associated complications. We present the case of a newborn male with a large scalp defect attributed to ACC, complicated by a life-threatening scalp hemorrhage. Despite challenges in management, including recurrent infections and failed skin grafts, the patient ultimately achieved satisfactory healing following a series of surgical interventions, including local transposition flap procedures. This case underscores the importance of a multidisciplinary approach to managing ACC, tailored to individual patient characteristics and associated risks. While discrete lesions of ACC typically have a favorable prognosis, extensive defects pose significant risks of morbidity and mortality, highlighting the need for careful consideration of treatment options and close clinical monitoring of affected individuals., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Jumei’an et al.)

Penile strangulation secondary to utilization of a constrictive ring is a rare urologic emergency that requires urgent decompression to prevent prolonged vascular obstruction resulting in necrosis and gangrene. Current literature is mainly comprised of case presentations that focus on management in the acute setting via removal of the ring. Herein, we describe surgical management of a patient who presents in delayed fashion after self-removal of the constrictive ring. We discuss our penectomy-sparing technique of debridement and split thickness skin graft., (© 2024 The Authors.)

Healthcare providers evaluating patients presenting with neurological, visceral, or cutaneous symptoms that are disproportionate to the expected severity may need to consider porphyria in the differential. Porphyria is an inherited condition in which toxic metabolites of the heme pathway are increased. Carriers of porphyrias are asymptomatic and will not present with classical symptoms, nor will levels be elevated, until the disease is induced by certain drugs, hormones, or idiopathic causes such as the stress of trauma. Acute intermittent porphyria (AIP), a form of acute porphyria, is a rare autosomal dominant disease that results in a dysfunctional porphobilinogen deaminase. This consequently increases neurotoxic porphobilinogen and subsequent increase in δ-aminolevulinic acid. Both of these metabolites cause neurovisceral symptoms that afflict the patient in acute attacks. We present a rare case of AIP manifested in a burn patient suffering a burn injury. The patient presented with symptoms indicative of AIP, including altered mental status and abdominal pain accompanied with a chronic history of alcoholism and smoking. A negative work-up, including imaging and findings of associated manifestations consistent with AIP led to a discovery of elevated porphyrins. The patient's course and death due to his injuries gives insight into the presentation of AIP in a burn patient., (© The Author(s) 2023. Published by Oxford University Press on behalf of the American Burn Association. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Background : Distal lower extremity reconstruction is challenging. This study aims to propose a protocol for the treatment of traumatic soft tissue defects. The key concept is to combine the surgical armamentarium of the reconstructive surgeon with the advantages provided by hyperbaric oxygen therapy. Methods : This retrospective study analyzed data of 57 patients affected with unilateral or bilateral lower extremity trauma distal to the knee and involving soft tissues with no indication of immediate reconstruction between 2010 and 2021. Before the reconstructive procedure, all the patients underwent a stick swab procedure for the collection of microbiological samples and debridement. Patients were divided into two treatment groups and only one group underwent a combined therapeutic procedure with hyperbaric oxygen therapy. Negative pressure wound therapy (NPWT) was employed only if deemed necessary according to the defect's depth and wound exudate. Surgical techniques, outcomes, and complications were discussed. Results : All patients achieved a complete recovery with no major complications and only minor complications observed. The study group treated with HBOT had a lower complication rate and lower percentages of minimal and partial graft loss compared with the same complications observed in the control group. No patients experienced HBOT-related complications. Significant reductions in the time to complete healing and the time from reconstruction to healing were found ( p = 0.002 and p < 0.00001, respectively). Conclusions : A lower complication rate was observed in the group treated with HBOT. The administration of HBOT prior to soft tissue reconstruction significantly reduced the time to complete healing and the time interval from skin grafting to healing. However, prospective studies and randomized trials with larger cohorts should be designed to investigate the efficacy of HBOT for the treatment of lower extremity injuries with extensive soft tissue defects.

Minimally invasive surgery is becoming the standard of care across surgical subspecialties. Several new "minimally invasive" options for burn debridement and autografting exist. Enzymatic bromelain-based debridement (BBD) and autologous skin cell spray (ASCS) have independently proven to reduce the rate of split-thickness skin grafting (STSG) and decrease donor site size when grafting is performed. There is a paucity in the literature regarding the combination of these two therapies. The purpose of this study is to characterize a cohort of patients treated with both BBD and ASCS and qualitatively compare data to expected outcomes without these therapies. This retrospective study of a single academic burn center's experience using BBD and ASCS together included 13 patients with a total burn surface area (TBSA) from 1-30% and all had >50% deep partial thickness. All patients received BBD and ASCS. Deeper burns additionally received STSG with ASCS overspray. Median burn size was 14% TBSA (IQR:5.45,20), donor site size was 225 sq cm (IQR:28.5,556.5), and ratio of donor site area to total treatment area of 0.082 (IQR: 0.039, 0.241) was observed. Median observed length of stay (LOS) was 19 days (IQR:10,27), expected LOS was 15.4 days, and O/E ratio 1.06. Donor sites in both groups of patients were much smaller than expected versus treatment with conventional meshed STSG alone and length of stay is lower than expected based on burn size. An emphasis on expenses and scar development will guide future studies into the patient subset and wound features that are best for this combination treatment., (© 2023 Euro-Mediterranean Council for Burns and Fire Disasters.)

Our objective was to compare the outcomes of full thickness skin grafts versus split thickness skin grafts in paediatric hand burn patients. A systematic review and meta-analysis were carried out in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) Guidelines, and an electronic search was conducted to identify all Randomised Controlled Trials and non-randomised studies comparing the outcomes of full thickness skin grafts versus split thickness skin grafts in paediatric hand burn patients. Primary outcomes included development of post-graft contracture and the necessity for surgical release. Secondary outcomes consisted of evaluation of function, cosmesis and colour, scar and feeling, hair growth, and other complaints. For the analysis, fixed effects modelling was applied. Results: ten non-randomised trials with a total of 532 grafts were found. Full thickness skin grafts exhibited a statistically significant decrease in the development of post-graft contracture (Odds Ratio [OR] = 0.35, P = 0.0001) and later surgical releases (OR = 0.06, P = 0.00001). For secondary outcomes, full thickness skin grafts outperformed split thickness skin grafts in post-operative functional ability. However, split thickness skin grafts, showed to be superior in scar, aesthetic, and colour assessments, and less hair growth was observed for split thickness skin grafts. No significant difference was seen in sensation and donor or recipient site complaints. Overall, full thickness skin grafts are a better alternative for paediatric hand burns than split thickness skin transplants because they are linked with reduced post-graft contracture and the requirement for surgical release., Competing Interests: Conflict of interests The author(s) declared that they have no competing interests., (Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Introduction: Hidradenitis suppurativa (HS) is a chronic skin disease that significantly reduces the quality of life of patients, especially affecting the intimate areas. Surgical treatment is one of the tools available for treating HS, which can significantly improve patients' quality of life., Aim: To evaluate the surgical treatment of 31 patients treated surgically at the Centre for Burns Treatment in Sie-mianowice Śląskie, with a follow-up of 6 months., Material and Methods: Thirty-one HS patients were operated on with classical reconstructive methods. The patients were followed up for 6 months in the outpatient clinic. We gathered clinical data of 31 post-operative patients and statistical analysis was performed., Results: 83.87% of the patients were completely healed. The study showed that HS recurrence in the surgical site occurred in 1 (3.23%) patient only after 6 months of follow-up. We found a statistically significant ( p < 0.050) positive correlation between patients' age and body mass index (BMI), disease duration and time of diagnosis. BMI value additionally correlated with disease duration and time of diagnosis, while disease duration correlated with time of diagnosis., Conclusions: Surgical treatment is an effective method in HS. The relatively low recurrence rate after 6 months and, in most patients, full healing, support the good therapeutic effect of surgical treatment., Competing Interests: The authors declare no conflict of interest., (Copyright: © 2023 Termedia Sp. z o. o.)

Hidradenitis suppurativa is a chronic disease that significantly reduces patients' quality of life. Patients are chronically treated with systemic therapies, which are often ineffective. Surgical treatment for severe cases of hidradenitis suppurativa is one option for affected patients. Surgical treatment has its limitations, and wound closure may be particularly problematic. This requires the use of reconstructive techniques. The methods of choice for wound closure are split-thickness skin grafts or local flaps reconstructions. However, each method has its limitations. This is a presentation of a new reconstructive surgical method in hidradenitis suppurativa surgery: the use of a co-graft of Acellular dermal matrix and split thickness skin graft as a novel method in wound closure after wide excisions, based on two cases. The results of this method are very promising: we achieved very fast wound closure with good aesthetic results regarding scar formation. In this paper, we used several examinations: laser speckle analysis, cutometer tests, and health-related quality of life (QoL) questionnaire to check the clinical impact of this method. Our initial results are very encouraging. ADM with STSG as a co-graft could be widely used in reconstructive surgery. This is a preliminary study, which should be continued in further, extended research.

Background: Oral submucous fibrosis is a chronic, progressive, scarring, precancerous condition of oral mucosa which on progression causes severe trismus., Aim and Objectives: To compare and evaluate the efficiency of buccal fat pad, platysmal mucocutaneous flap, nasolabial flap, collagen membrane graft, split thickness skin graft and temporoparietal fascia in reconstruction of surgical defect created by excision of fibrous bands in oral submucous fibrosis., Results: After 6 months of follow-up, the interincisal mouth opening was 40.0 mm in case of buccal pad fat, 24.5 mm in temporoparietal fascia flap group, 33.8 in collagen membrane graft group, 34.5 mm in platysma flap group, 34.7 mm in nasolabial flap group, 29.3 mm in split thickness skin graft. ANOVA statistical analysis for postoperative interincisal distance at various time intervals and between pre-, intra- and postoperative interincisal distances were carried out which showed the results were significant at p value < 0.05 in all groups. No postoperative complications were noted in buccal fat pad group, split thickness skin graft group and collagen membrane group. However, platysmal group had flap necrosis and temporoparietal flap group patients had to undergo a second debulking procedure after one month., Conclusion: From our study, we concluded buccal fat pad yields superior results with respect to postoperative mouth opening and related complications., Competing Interests: Conflicts of interestThe authors declare that they have no conflict of interest., (© The Association of Oral and Maxillofacial Surgeons of India 2021.)

Purpose: To report long-term results and patient reported outcomes of staged anterior urethroplasties, and isolate risk factors for recurrence., Methods:  We reviewed urethroplasty database for all patients who underwent staged urethroplasty from 2000 to 2017. Follow-up included a cystoscopy 4 months after their 2nd stage to assess early success, and then annual follow-up thereafter with post-void residual and symptom assessment. Stricture characteristics, etiology and graft type were analyzed with regards to success., Results:  Forty-nine patients were eligible for inclusion. The median stricture length was 7 cm (3-17 cm). The early success rate demonstrated by cystoscopy at 4 months was 100%. Long-term success was 96.4% in buccal graft (BMG) only patients; however, long-term success fell considerably to 53% in patients requiring any use split thickness skin graft (STSG) in the first stage. Median follow up time was 57 months (6-240 months). On analysis, age, increased stricture length and especially the use of STSG all appeared to be associated with late recurrence. The recurrence group had longer stricture length and were more likely to be panurethral. All recurrences occurred after the initial 4-month cystoscopy with a median time to recurrence of 78 months., Conclusion: Staged repairs that are amenable to BMG-only repairs have high long-term success rates. Increasing stricture length and the addition of split-thickness skin graft were associated with lower success rate in staged urethral reconstruction. Patients requiring staged repairs often experience recurrence in a very delayed fashion reinforcing the need for close, long-term follow up., (© 2021. The Author(s).)

Background: Whilst there is a trend away from aggressive nonorgan sparing surgical treatments for malignant penile disease, a variety of penile preservation options exist but functional outcomes and patient reported outcomes (PROs) in this area are poorly reported to date., Aim: The aim of this study is to report functional outcomes and PROs of total glans resurfacing (TGR) in a consecutive series of patients with lichen sclerosis (LS) or localized penile cancer (PC)., Methods: From 2004 to 2018 a consecutive series of patients underwent TGR for the management of LS or localized PC in a tertiary referral network. Patient clinical records and operative notes were retrospectively reviewed. Statistical analysis was conducted with Stata 12., Outcomes: Urinary and sexual outcomes were recorded utilizing both the International Index of Erectile Function (IIEF) and International Prostate Symptom Score (IPSS) validated questionnaires while PROs were extrapolated from a 5-item "ad hoc" telephone questionnaire administered at 1 year post procedure., Results: 37 consecutive patients were enrolled. Histology results demonstrated LS in 16 patients, with the remaining 21 having a diagnosis of PC. The most common reasons for patient presentation were local pain (32.4%), pruritus (37.8%) and bleeding (29.7%). Median follow-up was 22 (IQR 13-77) months. Median age was 62 (IQR 55-68). Neither of the questionnaires assessing urinary and sexual function showed any significant deterioration after surgery. Glans sensitivity was fully maintained in 89.2% of cases. 94.5% of patients reported to be fully satisfied with the aesthetic appearance of the penis and would consider undergoing the same procedure again if necessary. 91.9% of patients would recommend the same procedure to someone else. An overall improvement of the quality of life was reported by 86.4% of patients., Clinical Implications: TGR should be considered a treatment of choice for selected cases of benign or malignant penile lesions STRENGTHS AND LIMITATIONS: Our study has some limitations, the first being its retrospective nature. Furthermore, despite being one of the largest series to date, follow-up duration is somewhat limited and a control group is lacking., Conclusion: TGR represents an excellent surgical option ensuring satisfactory voiding and sexual function, as well as cosmesis for selected cases of penile lesions. M. Preto, M. Falcone, G. Blecher, et al. Functional and Patient Reported Outcomes Following Total Glans Resurfacing. J Sex Med 2021;18:1099-1103., (Copyright © 2021 International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.)

Split-thickness skin grafts are often applied in the management of primary cutaneous melanoma. It is routine surgical practice to use the contralateral limb because of the alleged risk of donor site metastases that may occur when the ipsilateral limb is used. The rationale and clinical evidence for this routine were assessed in light of current understanding of pathways of metastasis of melanoma. We found the preference for the contralateral limb to go back to Paget's ideas on melanoma spread from 1889, and the clinical observation of five cases of split-thickness skin graft donor site metastases in a series of 226 tumours, published in 1962. We traced ten additional reported cases of melanoma metastases occurring in the skin graft donor site. Contralateral donor sites were involved in seven of these cases. In light of current knowledge, the occurrence and the location of any split skin donor site metastasis are to be considered as mere indicators of an aggressive course of systemic disease. Any location of a split skin donor site, whether ipsilateral or contralateral in relation to the primary tumour, may become the location of metastases but chances that such metastases occur are extremely rare. Because of the lack of evidence in favour of the use of the contralateral limb and because of sound considerations in favour of using the ipsilateral limb, we conclude that there is no objective argument to sustain the dogmatic ban of the ipsilateral limb as a donor site for a split-thickness skin graft in melanoma surgery., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background Hidradenitis suppurativa (HS) severely impacts patients' quality of life (QoL). Surgery has shown potential in improving a patient's QoL in severe disease. Previous studies have evaluated QoL after surgery, but lack a disease-specific questionnaire to better evaluate the unique burden of disease that patients with HS experience. Objective To measure postoperative QoL in patients with HS using a modified version of the disease-specific questionnaire, the Hidradenitis Suppurativa Burden of Disease (HSBOD) Tool. Methods A retrospective study was conducted using 19 patients who underwent surgery for HS. A demographic form and a 19-item disease-specific questionnaire were emailed to patients who consented to complete the survey. Patient-reported outcomes were recorded on a 0-100 scale (100 representing the highest burden of disease). Results Of the 24 patients that received the survey, 19 completed it in its entirety. The mean±SD Burden of Disease (BoD) score for each of the five domains assessed by the survey were: symptoms and feelings (62±27), daily activities (65±30), leisure (57±31), work and school (48±32), and personal relationships (56±27). Pearson's correlation between the number of surgeries each patient underwent and their reported BoD scores were not significant. BoD scores were significantly higher in the symptoms and feelings domain for complex closure compared to both secondary intention and split-thickness skin grafting (STSG). Conclusion Despite having surgery, patients with hidradenitis still report impaired QoL. Further study is ongoing to determine how these measures compare to baseline preoperative values. This instrument provides a valuable tool to determine QoL in patients with hidradenitis., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2021, Guart et al.)

Background: Artificial dermal skin substitutes (ADSS) in combination with split-thickness skin grafts (STSG) are a valuable option for reconstruction of skin- and soft tissue-defects. However, successful incorporation of ADSS can be limited by various factors. We investigated the anticipated benefits of negative pressure wound therapy (NPWT) as an adjunct to support integration of ADSS, in a retrospective, comparative cohort study., Patients and Methods: We performed a retrospective, non-blinded, non-randomized comparative study including 86 patients with various soft-tissue defects, managed by application of either ADSS with or without NPWT based on the surgeon's preference. Outcome measurements comprised ADSS and skin graft take rates and analysis of treatment duration and time to wound healing. Additionally, patients were analyzed for the occurrence of hematoma, seroma, wound infection, and lack of substitute or skin graft adhesion., Results: Demographic data and individual risk factors did not differ with statistical significance between both groups. The combination of ADSS with NPWT led to significantly improved rates of ADSS integration (89 vs. 70.1%; p = 0.035) and skin graft take (91 vs. 76%; p = 0.049) compared to standard wound dressings without NPWT. In addition, while differences in the incidence of seroma were neglectable, NPWT application led to significantly reduced rates of infection of ADSS (2.2 vs. 7.3%; p = 0.043). Moreover, STSG could be performed on average 4 days earlier with the application of NPWT (p = 0.031)., Conclusions: The addition of NPWT to ADSS is a helpful adjunct that reduces time of incorporation and vascularization and improves clinical success rates., Competing Interests: Conflict of interest statement CH has consulted for Integra Lifesciences, Saint Priest, France, and KCI – 3 M, Wiesbaden, Germany. SF and DK received funding from Lohmann & Rauscher GmbH & Co. KG, Neuwied, Germany, for an independent research project. For the remaining authors, none were declared., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Split thickness skin graft (STSG) is a versatile procedure performed for the treatment of wounds resulting from varying pathology. This remains very useful because of its ability for quick healing and low complication rate. The surface of the foot and ankle is an area frequently affected by severe skin and soft tissue structure infections (SSTIs) whose treatment results in wounds. These infections and resultant surgical wounds are commonly seen patients with diabetes. The objective of the present study was to retrospectively evaluate initial healing and immediate post-operative outcomes following STSG application in a diabetic population when negative pressure wound therapy (NPWT) was used as a bolster. Ten patients were identified, including 11 surgical wounds, who underwent STSG bolstered with NPWT from January 2016 to October 2018. Mean follow-up was 13 months (range 1-33 months) with an average time to heal of 17 days (range 14-30 days) for 11 surgical wounds averaging 57 cm 2 (range 6.3 - 91 cm 2 ). Consistent improved outcomes have been demonstrated when compared to alternative bolstering techniques available in the literature making a STSG bolstered with NPWT a powerful tool in the reconstruction of diabetic foot wounds resulting from the treatment of infection. Levels of Evidence: Level IV.

Cryopreserved human skin allografts (CHSAs) are used for the coverage of major burns when donor sites for autografts are insufficiently available and have clinically shown beneficial effects on chronic non-healing wounds. However, the biologic mechanisms behind the regenerative properties of CHSA remain elusive. Furthermore, the impact of cryopreservation on the immunogenicity of CHSA has not been thoroughly investigated and raised concerns with regard to their clinical application. To investigate the importance and fate of living cells, we compared cryopreserved CHSA with human acellular dermal matrix (ADM) grafts in which living cells had been removed by chemical processing. Both grafts were subcutaneously implanted into C57BL/6 mice and explanted after 1, 3, 7, and 28 days (n = 5 per group). A sham surgery where no graft was implanted served as a control. Transmission electron microscopy (TEM) and flow cytometry were used to characterise the ultrastructure and cells within CHSA before implantation. Immunofluorescent staining of tissue sections was used to determine the immune reaction against the implanted grafts, the rate of apoptotic cells, and vascularisation as well as collagen content of the overlaying murine dermis. Digital quantification of collagen fibre alignment on tissue sections was used to quantify the degree of fibrosis within the murine dermis. A substantial population of live human cells with intact organelles was identified in CHSA prior to implantation. Subcutaneous pockets with implanted xenografts or ADMs healed without clinically apparent rejection and with a similar cellular immune response. CHSA implantation largely preserved the cellularity of the overlying murine dermis, whereas ADM was associated with a significantly higher rate of cellular apoptosis, identified by cleaved caspase-3 staining, and a stronger dendritic cell infiltration of the murine dermis. CHSA was found to induce a local angiogenic response, leading to significantly more vascularisation of the murine dermis compared with ADM and sham surgery on day 7. By day 28, aggregate collagen-1 content within the murine dermis was greater following CHSA implantation compared with ADM. Collagen fibre alignment of the murine dermis, correlating with the degree of fibrosis, was significantly greater in the ADM group, whereas CHSA maintained the characteristic basket weave pattern of the native murine dermis. Our data indicate that CHSAs promote angiogenesis and collagen-1 production without eliciting a significant fibrotic response in a xenograft model. These findings may provide insight into the beneficial effects clinically observed after treatment of chronic wounds and burns with CHSA., (© 2020 Medicalhelplines.com Inc and John Wiley & Sons Ltd.)

Background: Split thickness skin grafting (SSG) is an important modality for wound coverage; however, it leads to donor site morbidity. Epidermal grafting (EG) is a promising option for autologous skin grafting which offers minimal donor site morbidity, though it is not known if EG is an effective clinical alternative for SSG. This study compared the efficacy of EG as an alternative to SSG in terms of wound healing outcomes, donor site morbidity, patient satisfaction and adverse events., Methods: EPIGRAAFT is a Phase 2, randomized, open-label trial with two parallel groups: EG and SSG. Patients referred for skin grafting with a healthy granulating wound bed were included. The co-primary endpoints were the proportion of wounds healed and donor site healing time. The secondary endpoints include donor site morbidity measured using Vancouver Scar Scale, mean time for complete wound healing, patient satisfaction assessed using a validated skin grafting questionnaire and incidence of adverse events., Results: Of the 61 patients screened, 44 patients were randomized. There was no difference in the proportion of wounds healed at 6 weeks (p=0.366) and 3 months(p=0.24) as well as the mean time for wound healing (p=0.12). EG resulted in lower donor site morbidity (p=0.001), faster donor site healing time (EG: 4.86 days vs. SSG: 21.32 days) (p<0.0001), and higher overall satisfaction (p<0.001). There were no adverse events reported., Conclusion: This study demonstrated that EG has superior donor site outcomes with faster donor site healing and lower morbidity compared to SSG, while having comparable wound healing outcomes. Patients receiving EG also experienced higher donor site satisfaction compared to SSG. ClinicalTrials.gov identifier: NCT02535481., Competing Interests: Declaration of Competing Interest The authors have no competing interests to declare., (Copyright © 2020. Published by Elsevier Ltd.)

Contact burn injuries to the palm are common in toddlers. We report a case series of 82 paediatric patients (age 7-48 months) with contact burn injury of the palm. We share our experience and outcomes of using plantar split-thickness skin grafts for resurfacing of the paediatric palm. We found that despite the excellent colour and texture match, split-thickness skin grafts from glabrous skin during growth are prone to motion-limiting scare contracture. From this series, we conclude that full-thickness skin grafts remain the reference standard of care in paediatric patients' hands. We recommend that children with burn scars should have regular check-up examinations until they are fully grown. Level of evidence: IV.

A 47-year-old male suffered soft tissue injuries 8 years ago that had been covered by meshed split thickness skin graft. During the last 2 years, he developed a chronic eczema (atopic dermatitis) on both recipient and donor sites on the lower extremities. Eczema on skin graft sites has been described rarely. However, this case is unique since both donor and recipient site were involved. We consider our observation as another example of Ruocco's immunocompromised districts of skin., (© 2019 Wiley Periodicals, Inc.)

Background: Donor site complications secondary to radial forearm free flap (RFFF) reconstruction can limit recovery. Optimizing hand and wrist function in the post-operative period may allow more efficient self-care and return to activities of daily living. Negative pressure wound dressings (NPD) may increase blood flow and perfusion as compared to static pressure dressings (SPD) designed to minimize shear forces during the healing period. This study aims to compare subjective and objective hand and wrist functional outcomes following RFFF reconstruction with split thickness skin grafts (STSG) in patients treated with NPD and SPD., Methods: Adult patients undergoing RFFF with STSG were identified preoperatively and randomized to receive NPD or SPD following their RFFF reconstruction. NPD involved a single-use, portable device capable of applying 80 mmHg of negative pressure to the forearm donor site. SPD involved a volar splint. Dressings were left in place for seven days with subjective and objective function assessed at seven days, one month and three months postoperatively. The primary outcome was self-reported hand function as measured with the function subscale of the Michigan Hand Questionnaire (MHQ). Secondary outcomes included hand and wrist strength, range of motion, sensation, scar aesthetics, and skin graft complications., Results: Twenty-four patients undergoing RFFF were randomized to NPD or SPD. Patients treated with NPD had improved MHQ self-reported functional scores as compared to those treated with SPD at seven days postoperatively (P = 0.016). Flexion at seven days was improved in NPD group (P = 0.031); however, all other strength and range of motion outcomes were similar between groups. There were no differences in rates of graft complications, scar aesthetics, or sensation., Conclusions: In the immediate post-operative period, NPD was associated with improved patient-reported hand and wrist function. Wound care to optimize hand and wrist function could allow for improved patient outcomes in the immediate postoperative period.

Background: Autologous platelet rich plasma (PRP) has significant benefits facilitating improved graft take on wound beds due to hemostasis, adhesive and healing properties. This study aimed at effective use of PRP in wound beds on graft take irrespective of etiology as compared to conventional methods of mechanical fixation using sutures and staples., Methods: Forty cases including 20 in control and 20 in PRP groups admitted to the Department of Plastic Surgery at Vydehi Institute of Medical Sciences and Research Centre, Bangalore were enrolled between October 2015 and September 2017. Freshly prepared autologous PRP was applied on wound beds in the treated group, while conventional mechanical fixation methods like staples and sutures were used in the control group for the fixation of the skin grafts., Results: Most significant result was the instant graft take to the wound bed irrespective of the etiology besides hemostasis and healing properties in the PRP treated group which resulted in considerable reduction of surgeon's time required for the removal of sutures and staples at the final stages. Also, only 10% with graft edema were noted in the PRP treated patients as compared to 68% in the control group. The inner dressings and skin graft were dry in the PRP group and the post-operative etching, weeping and pain at the graft site reduced., Conclusion: The cosmetic appearance of this scar was better in the PRP group besides post-operative edema and graft loss. The study recommends use of PRP at the recipient site of split thickness skin graft., Competing Interests: The authors declare no conflict of interest.

Background: The scalp is the only hidden donor site for split thickness skin grafts. Nevertheless, it is underappreciated due to fear of iatrogenic scarring alopecia. Long-term data showing whether androgenetic hair loss can reveal previously hidden scarring alopecia is unavailable. We aimed to evaluate results and patient satisfaction up to 30years after skin harvest from the scalp., Methods: Burn patients, hospitalized between 1977 and 1987 at the University Children's Hospital Zurich with scalp skin harvest and currently over 30years old, were studied. Medical records and patient satisfaction were analyzed, and a clinical scalp examination was performed., Results: Thirty-two patients (18 males, 14 females) with a current age of 34.13±3.42years participated. Mean follow-up time was 27.09±3.04years. Fifty-four scalp harvests were performed with 1.69±0.96 sequential harvests. Hair growth was considered normal in 97% patients. Androgenetic alopecia (AGA) type Norwood II-VI was seen in 11 patients. Scalp examination revealed 11 unknown likely harvest-related alopecias with a mean size of 0.7cm 2 ., Conclusions: Long-term morbidity of scalp skin harvest and the risk of clinically significant alopecia is very low while patient satisfaction is high. AGA is unlikely to reveal harvest damage previously hidden by regrown hair., (Copyright © 2018 Elsevier Ltd and ISBI. All rights reserved.)

This case report describes a 55-year-old male patient with type II necrotizing fasciitis (NF) of the hand and forearm. The rapid progression of the tissue infection could be successfully stopped with radical surgical débridement and antibiotic therapy. For the reconstruction of the extensive loss of soft tissue a combination of split-thickness skin graft (STSG) and the synthetic dermal substitute MatriDerm® was used. In cases of NF, MatriDerm® and STSG provide a rapidly available and simple alternative to other reconstruction techniques.

Objective: Marjolin's Ulcer (MU) is a rare cutaneous neoplasm arising in cikatrical tissue. Due to its typical clinical presentation as a non-healing lesion in scar tissue, the diagnosis can be delayed and even overlooked., Methods and Results: We present the case of an elderly woman who developed an ulcerated, exophytic lesion in a split thickness skin graft (STSG) on the lateral aspect of the left knee. Histology showed a radically excised highly differentiated squamous cell carcinoma (SCC) with keratine pearls and a component of basocellular carcinoma (BCC). The histological picture combined with the location and long time interval since the primary surgery made the diagnosis of MU highly likely., Discussion: Considering the risk of metastasis and mortality it is important to recognize the diagnosis and initiate adequate treatment., Conclusion: The diagnosis of MU is clinical and confirmed by pathology. The typical long delay from the primary lesion to the malignant transformation might occlude the diagnosis. As such, a thorough anamnesis is essential in a non- healing ulcerated lesion in a cikatrical area to adequately diagnose and treat the condition., (Copyright © 2017 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Full thickness skin graft (FTSG) gives better outcomes than split thickness skin graft (STSG), but it has the drawback of limited donor sites. Anterolateral thigh (ALT), a popular donor site of STSG, is also a popular donor site of perforator flaps. This area has the advantage of large flap size available with primary closure. Based on this we harvested FTSG instead of STSG from the ALT., Methods: We retrospectively reviewed 10 cases of FTSG from the ALT, with the recipient site of foot in 3, ankle in 2, lower leg in 2, forearm in 2, and wrist in 1 patient. In all cases elliptical full thickness skin was harvested from the ALT, and the donor site was closed primarily. The skin was defatted and placed onto the defect with vacuum-assisted closure (VAC). The skin size ranged 7-30 cm in length and 3-12 cm in width. Mean follow up period was 7 months (range, 3-13)., Results: FTSG from the ALT provided durable wound coverage, with excellent color and texture matching. Partial (< 20%) graft failure was observed in 1 case, but no additional surgery was necessary. No patient reported donor site pain at postoperative 2 weeks. No donor site complications were encountered. No patient complained a feeling of tension in the thigh at final follow-up., Conclusions: FTSG from the ALT is feasible with the aid of VAC. Considering the skin quality, large skin size available, early pain relief, and little donor site morbidity, the ALT should be revisited as a donor site of FTSG.

The clinical significance of timely re-epithelialization is obvious in burn care, since delayed wound closure is enhancing the risk of wound site infection and extensive scarring. Topical treatments that accelerate wound healing are urgently needed to reduce these sequelae. Evidence from preliminary studies suggests that betulin can accelerate the healing of different types of wounds, including second degree burns and split-thickness skin graft wounds. The goal of this combined study program consisting of two randomized phase III clinical trials in parallel is to evaluate whether a topical betulin gel (TBG) is accelerating re-epithelialization of split-thickness skin graft (STSG) donor site wounds compared to standard of care. Two parallel blindly evaluated, randomised, controlled, multicentre phase III clinical trials were performed in adults undergoing STSG surgery (EudraCT nos. 2012-003390-26 and 2012-000777-23). Donor site wounds were split into two equal halves and randomized 1:1 to standard of care (a non-adhesive moist wound dressing) or standard of care plus TBG consisting of 10% birch bark extract and 90% sunflower oil (Episalvan, Birken AG, Niefern-Oeschelbronn, Germany). The primary efficacy assessment was the intra-individual difference in time to wound closure assessed from digital photographs by three blinded experts. A total of 219 patients were included and treated in the two trials. Wounds closed faster with TBG than without it (15.3 vs. 16.5 days; mean intra-individual difference=-1.1 days [95% CI, -1.5 to -0.7]; p<0.0001). This agreed with unblinded direct clinical assessment (difference=-2.1 days [95% CI, -2.7 to -1.5]; p<0.0001). Adverse events possibly related to treatment were mild or moderate and mostly at the application site. TBG accelerates re-epithelialization of partial thickness wounds compared to the current standard of care, providing a well-tolerated contribution to burn care in practice., (Copyright © 2017 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Adult stem cells represent a potentially renewable and autologous source of cells to regenerate skin and improve wound healing. Firefighters are at risk of sustaining a burn and potentially benefiting from a split thickness skin graft (STSG). This mixed methods study examined firefighter willingness to participate in a future stem cell clinical trial, outcome priorities and factors associated with this decision., Methods: A sequential explanatory mixed methods design was used. The quantitative phase (online questionnaire) was followed by the qualitative phase (semi-structured interviews). A sample of 149 firefighters completed the online survey, and a purposeful sample of 15 firefighters was interviewed., Results: A majority (74%) reported they would participate in a future stem cell clinical trial if they experienced burn benefiting from STSG. Hypothetical concerns related to receiving a STSG were pain, itch, scarring/redness and skin durability. Participants indicated willingness to undergo stem cell therapy if the risk of no improvement was 43% or less. Risk tolerance was predicted by perceived social support and having children. Interviews revealed four main themes: a desire to help others, improving clinical outcomes, trusting relationships, and a belief in scientific investigation. Many participants admitted lacking sufficient knowledge to make an informed decision regarding stem cell therapies., Conclusions: Firefighters indicated they were largely willing to participate in a stem cell clinical trial but also indicated a lack of knowledge upon which to make a decision. Public education of the role of stem cells in STSG will be increasingly important as clinical trials are developed., (Copyright © 2016 Elsevier Ltd and ISBI. All rights reserved.)

Scalp defect management is complicated secondary to reduced laxity in the scalp and forehead area. For reconstruction of larger defects with exposed bone and loss of the periosteal layer, free flap reconstruction is one option for single-stage surgery, although the procedure is lengthy and includes the possibility of flap loss. We successfully performed a single-stage reconstruction of a large scalp defect using a combination of artificial dermis, split-thickness skin graft, and full-thickness skin graft following wide excision of a cutaneous angiosarcoma, and present our method as one option for the treatment of large oncologic surgical defects in patients who are poor candidates for free flap surgery., Competing Interests: No potential conflict of interest relevant to this article was reported.

The use of negative-pressure wound therapy (NPWT) for management of open wounds and immobilization of split-thickness skin grafts (STSGs) over wounds has been well described. However, there is a concern for potential compromise of flap viability when NPWT is used for skin grafts over pedicled muscle flaps. We have used NPWT to immobilize STSGs in eight patients who underwent a pedicled gastrocnemius muscle flap operation in our department. We applied a negative pressure of -75 mmHg on the muscle flaps for 5 days postoperatively. All wounds healed successfully, with a 97.5 ± 5.5% mean STSG uptake. No flap necrosis was observed. In our series, the use of NPWT for fixation of STSGs over pedicled gastrocnemius muscle flap was effective and had no negative impact on flap viability., (Published by Elsevier Ltd.)

Background: Chronic leg ulcers remain a challenge to the treating physician. Such wounds often need skin grafts to heal. This necessitates a readily available, fast, simple, and standardized procedure for grafting., Objectives: The aim of this work was to test a novel method developed for outpatient transplant procedures., Methods: The procedure employs a handheld disposable dermatome and a roller mincer that cut the skin into standardized micrografts that can be spread out onto a suitable graft bed. Wounds were followed until healed and photographed., Results: The device was successfully used to treat and close a traumatic lower limb wound and a persistent chronic venous leg ulcer. The donor site itself healed by secondary intent with minimal cosmetic impairment., Conclusion: The method was successfully used to graft 2 lower extremity wounds.

Split thickness skin graft (STSG) harvesting from the anterior chest and abdominal wall skin is quite a difficult process. The main reason for the difficulty to perform this process is the unsuitable anatomic characteristics of the anterior trunk, such as irregular wavy-like surface over the ribs and lax abdominal wall skin resulting in collapse due to lack of adequate underneath supporting structures when a downward force is applied by the skin graft dermatome. Lower extremity and especially the thigh are generally chosen as the donor site where the STSGs are easily harvested from. However, extensive lower extremity burns, with or without other region burns, preclude harvesting auto STSGs from this invaluable anatomic site. We harvested K-wire assisted STSGs from the anterior chest and abdominal wall skin of 7 patients with lower extremity burns and also a patient that sustained motor vehicle collision. We encountered no problems in any of our patients both intra and postoperatively by using K-wire assisted STSG harvesting. All of the STSGs donor sites healed uneventfully without complications. In our opinion, K-wire assisted STSG harvesting must always be in the tool-box of any surgeon who deals with extensive burns with or without lower extremity burns and extensive traumas of lower extremities., (Copyright © 2015 Elsevier Ltd and ISBI. All rights reserved.)

Objective: Post-operative pain can significantly affect a patient's ability to recover following surgery. In this study we introduced the concept of post-operative pain evaluation of burn patients as well as a technique for placement and use of subcutaneous catheters for continuous infusion of local anesthetic to provide analgesia following skin harvest from the lateral thigh in a hospital in resource-restricted country--Ukraine., Methods: A total of 109 patients were enrolled in this study. In the control group 64 patients received the standard post-operative pain regimen of metamizole 1 g and/or ketorolac 3%- 30 mg at the discretion of the nursing staff. In the interventional group, 45 patients received the catheter infusion of local anesthetic by elastomeric pump which was placed intraoperatively; it continuously delivers a regulated flow 4-5 ml/h of procaine 0.5% for 48 h to a patient's surgical donor site with the standard pain regimen available for breakthrough pain. All patients were assessed post-operatively and in the peri-dressing change period by the nursing staff. Blood pressure, heart rate, and pain scores were documented based on the Wong-Baker Faces Pain Rating Scale. All data were analyzed using SAS version 9.3. The Student's t test and Fisher's exact test were used to assess differences between groups for continuous variables. The Mann-Whitney U Test was used to examine differences in pain scores between groups. A p value of <0.05 was considered significant., Results: The median pain score immediately following surgery was 5.0 in the control group, which was significantly greater (p=0.03) than median pain score of 4.0 for the patients receiving continuous infusion of procaine. However, there is no statistically significant difference in the median pain score (3.0 and 3.0) after the initial dressing change (p=0.73)., Conclusions: Our Ukrainian colleagues now have a method of objective pain assessment and a new technique in pain management. With assessment linked to intervention, improvement in post-operative pain can be expected., (Copyright © 2015 Elsevier Ltd and ISBI. All rights reserved.)

Objective: To introduce a new technique that combines laparoscopic and vaginal cervicovaginal reconstruction using split thickness skin graft in patients with congenital atresia of the cervix., Design: Video article introducing a new surgical technique., Setting: University hospital., Patient(s): A 16-year-old patient with congenital cervical atresia, vaginal dysgenesis, and ovarian endometrial cyst., Intervention(s): An original technique of combined laparoscopic and vaginal cervicovaginal reconstruction using split thickness skin graft for cervicovaginal reconstruction., Main Outcome Measure(s): A midline incision at the vaginal introitus was made, and a 9-cm canal was made between the bladder and the rectum using sharp and blunt dissection along the anatomic vaginal route, with the aid of laparoscopy to ensure correct orientation. A 14 × 12 cm split thickness skin graft was harvested from the right lateral thigh. By laparoscopy, the level of the lowest pole of the uterine cavity was exposed and the cervix was incised by shape dissection. The proximal segment of the harvested skin to the lower uterine segment was secured, and the distal segment was sutured with the upper margin of vulva vaginally. Surgical technique reports in anonymous patients are exempted from ethical approval by the Institutional Review Board. The patient gave consent to use the video in the article., Result(s): The procedure was successfully completed. Since February 2013, our experiences of combined laparoscopic and vaginal cervicovaginal reconstruction using split thickness skin graft in 10 patients with congenital atresia of cervix were positive, with successful results and without complications or cervical, or vaginal stenosis., Conclusion(s): Our technique is feasible and safe for congenital atresia of cervix, with successful results and without complications or cervical or vaginal stenosis., (Copyright © 2015 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

We describe the case of a 32-year-old woman (gravidity: 4; parity: 2) who underwent cesarean delivery at 37 weeks of gestation and presented with dehiscence and infection of the surgical wound. She had a history of wound infection and dehiscence of the scar from a previous cesarean delivery and dehiscence in the dorsal side of her left hand at the site of intravenous catheterization. The patient was initially diagnosed with a skin infection and later with pyoderma gangrenosum. No evidence of any underlying disease was found. The lesions were treated with systemic corticosteroids and azathioprine, but the lesions were unresponsive to treatment. This complicated case of pyoderma gangrenosum after cesarean delivery, which initially mimicked wound infection, was successfully treated with vacuum-assisted closure and split-thickness skin graft. This synergistic approach with vacuum-assisted closure could be an important treatment option for aggressive and slow-healing lesions., (© 2014 The Authors. Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology.)

The management of patients suffering from burn injury poses unique challenges for the reconstructive surgeon, both in the acute and delayed settings. Once resuscitative measures are optimized and hemodynamic stability is achieved, early burn debridement and coverage is performed. Traditionally, this consists of excision of devitalized tissue and subsequent coverage using split thickness skin grafts. However, in certain instances, and depending on the extent and nature of the burn injury, skin grafting (or even local tissue rearrangement) may not be a reasonable option. in these cases, free tissue transfer may provide a viable reconstructive alternative. While free flap reconstruction is rare in burn surgery, particularly in the acute setting, burn injuries that expose vital structures, such as tendon, nerve, bone, or deep vessels, require robust flap coverage. in the delayed setting, unsightly scar formation and contracture often occurs secondary to skin graft coverage. These significant patient morbidities are often amenable to free tissue transfer as well. This review article discusses the indications, applications, and problems with free flap surgery for burn injuries in both the acute and delayed setting, and summarizes the available literature on microsurgical free tissue transfer for burn management.

Objectives: To assess the effect of an opioid administered topically onto a standardized skin wound in patients without significant comorbidity. Findings to date are contradictory, often obtained from multimorbid patients with wounds lacking uniformity., Methods: Forty-four patients undergoing surgery for skin grafting were randomly assigned to receive morphine (0.25, 0.75 or 1.25 mg/100 cm(2) wound size) in hydroxyethylcellulose gel or placebo applied onto the excised split-thickness donor wound at the end of surgery. Pain, supplementary systemic opioids and adverse effects were assessed during the first 24 h after application. Healing was examined when the dressings were removed., Key Findings: Morphine doses ranged from 0.25 to 5.4 mg (mean 1.93 ± standard deviation 1.34 mg). No differences in pain scores or use of supplementary analgesics were found between the groups. Serious adverse effects did not occur; healing was not impaired. Large intragroup variability was observed for pain scores, wound sizes and supplementary analgesia., Conclusions: Patients treated with topically applied morphine gel onto standardized skin wounds did not report lower pain scores compared with placebo-treated patients. Larger groups would be required to arrive at definitive conclusions. The split-thickness skin graft model can be used for future research., (© 2014 Royal Pharmaceutical Society.)