Reproducibility of Novel Soft-Tissue Landmarks on Three-Dimensional Human Facial Scan Images in Caucasian and Asian.

BACKGROUND: Three-dimensional surface imaging is established in many disciplines for objective facial acquisition regarding anthropometry. Former studies addressed the validation of landmark-based measurements for single race. In order to distinguish racial difference, the reproducibility of the landmark measurements must first be validated. OBJECTIVES: Our purpose is to validate the reproducibility of 46 facial soft-tissue landmarks on x, y, z axes to prove their reliability as 3D reference points. METHODS: The study included 80 European Caucasian and 80 Chinese volunteers. Standardized 3D surface imaging was performed using Vectra 3D system. Two raters identified and defined 46 landmarks (138 coordinates), then repeatedly 3D-imaged volunteers' facial region in separate sessions. Coordinates' reproducibility of landmarks is divided into three categories (< 0.5 mm, < 1 mm, and >1 mm) for intra- and inter-rater reproducibility assessments. RESULTS: Coordinates' reproducibility of 160 samples was distributed as follows: Intra-rater: < 0.5 mm (45%), < 1 mm (42%), >1 mm (13%); inter-rater: < 0.5 mm (31.2%), < 1 mm (42%), > 1 mm (26.8%). The reproducibility of landmarks in nasal tip region differs slightly between Caucasians and Asians. Compared to females, males typically have higher landmark reproducibility in lip and chin region. However, there were no differences in the reproducibility ranking of landmarks by gender. CONCLUSION: The majority of the 46 landmarks in the 3D plane are reproducible to 1 mm, which is clinically acceptable. All selected landmarks showed strong consistency across race and gender, suggesting their potential use as reference points in prospective clinical practice. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Quality of Life in Lymphedema Patients Treated by Microsurgical Lymphatic Vessel Transplantation-A Long-Term Follow-Up.

INTRODUCTION: Lymphedema is a chronic condition characterized by the accumulation of lymph fluid in the upper or lower extremities, leading to swelling, discomfort, and disability in everyday life. While various treatment modalities exist, microsurgical lymphatic vessel transplantation (LVT) has emerged as a promising option. However, there is little to no long-term follow-up data regarding patients' improvement in quality of life for this surgical technique. The present study conducts an investigation of the long-term health-related quality of life (HRQoL) over more than 20 years in patients with lymphedema treated with LVT and accomplishes this by utilizing an adapted SF-12 survey. PATIENTS AND METHODS: A retrospective analysis was conducted on patients who underwent LVT between 1 January 1983 and 1 October 2010 at LMU Clinic Munich (n = 35). Quality of life scores were assessed preoperatively and today in terms of physiological conditions, psychological conditions, and burden of therapy using a SF-12 survey adapted to the symptoms and impairments that chronic lymphedemas are known to cause. RESULTS: Our findings demonstrate a significant improvement in HRQoL following LVT, with notable enhancements in physiological and psychological conditions such as burden of therapy. Physiological conditions showed a significant positive change of 3.2648 (p < 0.01). Psychological conditions improved significantly by a factor of 2.0882 (p < 0.01). Additionally, the burden of therapy improved significantly by 1.5883 points (p < 0.01). CONCLUSION: Previous studies have already shown a significant improvement of HRQoL within the first postoperative years for patients treated by LVT. This study also demonstrates significant long-term improvement after LVT, thus underlining the effectiveness of using LVT to improve the quality of live for patients with both primary and secondary lymphedema long-term.

How Reliable Is Breast Volume Assessment When the Patient Is Lying Flat?-Volumetric Assessment of Breast Volume Using a Vectra H2 Handheld Device in Different Positions.

(1) Background: Three-dimensional (3D) volumetric assessment is receiving increased recognition in breast surgery. It is commonly used for preoperative planning and postoperative control with the patient standing in an upright position. Recently, intraoperative use was evaluated with patients in the supine position. The aim of this prospective study was to evaluate the volumetric changes in 3D surface imaging depending on the patient's position. (2) Methods: 3D volumetric analysis was performed using a Vectra-H2 device with patients in standing, sitting, and supine positions. A total of 100 complete datasets of female breasts were included in the study. The measured volumes of each evaluated breast (n = 200) were compared between the three positions. (3) Results: The mean difference between the 3D volumetric assessments of the sitting and standing positions per breast was 7.15 cc and, thus, statistically insignificant (p = 0.28). However, the difference between supine and standing positions, at 120.31 cc, was significant (p < 0.01). (4) Conclusions: The 3D volumetric assessment of breasts in the supine position did not statistically correlate with the validated assessment of breast volume in the standing position while breast volume in the sitting position is reliable and correlates with the assessment of a standing patient. We conclude that intraoperative volumetric assessment should be performed with patients in an upright sitting position.

To Shrink or Not to Shrink? An Objective Assessment of Free Gracilis Muscle Volume Change in Lower-Extremity Defect Reconstruction.

Background: The use of free gracilis muscle flaps in reconstructive surgery of the lower leg is common practice to cover defects. However, there is still a lack of understanding of the morphometric changes that occur in the transferred muscle and area of interest over time, particularly the characteristic volume decrease that is observed over the course of the first year. This study aimed to assess volume changes in patients with free gracilis muscle flap reconstruction following infection, trauma, or malignancies of the lower extremity. Methods: Three-dimensional surface imaging was performed intraoperatively after 2 weeks, 6 months, and 12 months with the Vectra H2 system. A total of 31 patients were included in this study and analyzed. Results: There was an average volume increase of 146.67 ± 29.66% 2 weeks after reconstruction. Compared to this volume increase, there was a reduction of 108.44 ± 13.62% after 12 months (p < 0.05). Overall, we found a shrinkage to 85.53 ± 20.14% of the intraoperative baseline volume after 12 months. Conclusions: The use of non-invasive 3D surface imaging is a valuable tool for volume monitoring after free flap reconstruction of the lower extremity. The free gracilis muscle flap undergoes different phases of volume change over the first year, with the greatest influence on overall change being the development and decongestion of edema. Precise initial surgical tailoring is crucial for optimal long-term functional and cosmetic results.

[Relevance of Early Structured Diagnosis to Successful Nerve Reconstruction: A Case Report of an Alpine Professional Skier with an Axillary Nerve Injury]. / Relevanz früher strukturierter Diagnostik zur erfolgreichen Nervenrekonstruktion: Ein Fallbericht bei Nervus axillaris ­ Verletzung einer alpinen Profi-Skisportlerin.

Among high-speed sports, an increased number of high-speed injuries have been observed in alpine downhill racing. We report the case of a young professional ski racer who sustained a shoulder dislocation with an avulsion of the axillary nerve during a World Cup race. After initial treatment was provided for the shoulder dislocation, the patient was left with abduction weakness and a sensory deficit in the region of the deltoid muscle. She underwent electrophysiological and clinical examinations and visited our centre with delay. We immediately performed surgical treatment with a nerve transfer and nerve transplantation. After only 11 months following her fall, she was able to resume her training program. This case report shows the importance of early diagnostic investigation, a visit to a centre of plastic surgery and the good outcome after surgical treatment in patients with peripheral nerve injuries.

How Useful Is the SSN-Nipple Distance? An Analytical Questionnaire Survey on Anthropometric Measurements for the Aesthetically Ideal Positioning of the Nipple-Areolar Complex.

Several studies have attempted to identify the optimal anthropometric measurement for the aesthetically ideal positioning of the nipple-areolar complex. However, no standardised solutions and measurements for planning surgical procedures have been reached. The aim of this study is to identify the optimal anthropometric measurement between the suprasternal notch (SSN)-nipple distance and mid-clavicle (MC)-nipple distance for the aesthetic position of the nipple-areola complex (NAC) on the breast. A detailed online survey was sent to 300 board-certified plastic surgeons and residents of plastic surgery departments of hospitals in German, Austrian, and Swiss. A similar survey was also provided to 100 patients who had planned or had already undergone breast surgery. All participants were asked to rank the attractiveness of a series of women's breasts in images with different NAC position measurements. The images showed breasts from two different measurements and distances: all the breasts had equal dimensions and proportions and the same areola size. Complete datasets were obtained from 203 of the 300 board-certified plastic surgeons and residents of plastic surgery departments in German-speaking countries (recall 68%) and from 100 patients. The majority of doctors and patients find a symmetrical breast with a mirrored position of the nipple-areola complex more attractive than a non-symmetrical breast. In cases with minor measurement differences, such as 0.5 cm (SSN vs. MC), there is no relevant difference in the breast symmetry. However, at larger distances, the MC-to-nipple distance is superior for achieving aesthetically appealing symmetry compared with the SSN-to-nipple distance. Using the MC-to-nipple distance seems to be superior for correct nipple positioning than the SSN-to-nipple distance and is a valuable preoperative measurement option for breast symmetry with correct nipple height. Further studies on this topic involving a more general population should be conducted to confirm the improvements in perception with the preoperative measurements using the anatomical landmarks.

Investigating the Reliability of Novel Nasal Anthropometry Using Advanced Three-Dimensional Digital Stereophotogrammetry.

Three-dimensional surface imaging systems (3DSI) provide an effective and applicable approach for the quantification of facial morphology. Several researchers have implemented 3D techniques for nasal anthropometry; however, they only included limited classic nasal facial landmarks and parameters. In our clinical routines, we have identified a considerable number of novel facial landmarks and nasal anthropometric parameters, which could be of great benefit to personalized rhinoplasty. Our aim is to verify their reliability, thus laying the foundation for the comprehensive application of 3DSI in personalized rhinoplasty. We determined 46 facial landmarks and 57 anthropometric parameters. A total of 110 volunteers were recruited, and the intra-assessor, inter-assessor, and intra-method reliability of nasal anthropometry were assessed through 3DSI. Our results displayed the high intra-assessor reliability of MAD (0.012-0.29, 0.003-0.758 mm), REM (0.008-1.958%), TEM (0-0.06), rTEM (0.001-0.155%), and ICC (0.77-0.995); inter-assessor reliability of 0.216-1.476, 0.003-2.013 mm; 0.01-7.552%, 0-0.161, and 0.001-1.481%, 0.732-0.985, respectively; and intra-method reliability of 0.006-0.598°, 0-0.379 mm; 0 0.984%, 0-0.047, and 0-0.078%, 0.996-0.998, respectively. This study provides conclusive evidence for the high reliability of novel facial landmarks and anthropometric parameters for comprehensive nasal measurements using the 3DSI system. Considering this, the proposed landmarks and parameters could be widely used for digital planning and evaluation in personalized rhinoplasty, otorhinolaryngology, and oral and maxillofacial surgery.

Artificial Intelligence in Dermatology Image Analysis: Current Developments and Future Trends.

BACKGROUND: Thanks to the rapid development of computer-based systems and deep-learning-based algorithms, artificial intelligence (AI) has long been integrated into the healthcare field. AI is also particularly helpful in image recognition, surgical assistance and basic research. Due to the unique nature of dermatology, AI-aided dermatological diagnosis based on image recognition has become a modern focus and future trend. Key scientific concepts of review: The use of 3D imaging systems allows clinicians to screen and label skin pigmented lesions and distributed disorders, which can provide an objective assessment and image documentation of lesion sites. Dermatoscopes combined with intelligent software help the dermatologist to easily correlate each close-up image with the corresponding marked lesion in the 3D body map. In addition, AI in the field of prosthetics can assist in the rehabilitation of patients and help to restore limb function after amputation in patients with skin tumors. THE AIM OF THE STUDY: For the benefit of patients, dermatologists have an obligation to explore the opportunities, risks and limitations of AI applications. This study focuses on the application of emerging AI in dermatology to aid clinical diagnosis and treatment, analyzes the current state of the field and summarizes its future trends and prospects so as to help dermatologists realize the impact of new technological innovations on traditional practices so that they can embrace and use AI-based medical approaches more quickly.

Nonsubjective Assessment of Shape, Volume and Symmetry during Breast Augmentation with Handheld 3D Device.

Three-dimensional Surface Imaging (3DSI) has become a valuable tool for planning and documenting surgical procedures. Although surface scanners have allowed for a better understanding of breast shape, size, and asymmetry during patient consultation, its use has not been included in intraoperative assessment so far. Validation of the reliability of the intraoperative use of a portable handheld 3DSI equipment as a tool to evaluate morphological changes during breast augmentation surgery. The patients who underwent bilateral subpectoral breast augmentation through an inframammary incision were included in this study. Intraoperative 3DSI was performed with the Artec Eva device, allowing for visualization of the surgical area before incision, after use of breast sizers and implant, and after wound closure. Intraoperatively manual measurements of breast distances and volume changes due to known sizer and implant volumes were in comparison with digital measurements calculated from 3DSI of the surgical area. Bilateral breasts of 40 patients were 3D photographed before incision and after suture successfully. A further 108 implant sizer uses were digitally documented. There was no significant difference between manual tape measurement and digital breast distance measurement. Pre- to postoperative 3D volume change showed no significant difference to the known sizer and implant volume.

Accuracy Assessment of Three-Dimensional Surface Imaging-Based Distance Measurements of the Face: Comparison of a Handheld Facial Scanner and a Stationary Whole-Body Surface Imaging Device.

Three-dimensional surface imaging (3DSI) has been shown to be a useful tool for plastic surgeons in the preoperative, intraoperative, and postoperative setting. The objective of this investigation was to compare the accuracy of facial surface distance measurements using both a handheld facial 3DSI device and a stationary whole-body 3DSI device. Users should be aware of deviations when obtaining 3DSI using the presented imaging devices but should not refrain from using them, as the absolute differences might be too small to play a role in both, clinical and research, settings.

Reliability of 3-dimensional surface imaging of the face using a whole-body surface scanner.

OBJECTIVE: To the knowledge of the authors, no data about the reproducibility and accuracy of 3-dimensional surface imaging of the face using a whole-body scanner are available. Thus, the objective of this investigation was to assess the reproducibility of facial scans acquired using a whole-body imaging device. MATERIAL AND METHODS: This investigation investigated 220 3-D scans of a total of 22 healthy volunteers (with a mean age of 29.36 years). Two consecutive 3-D images using a Vectra WB360 of the volunteers were obtained utilizing a whole-body imaging device. Predefined distances in the face were performed in each scan and compared. Furthermore, surface deviation between two consecutively captured scans was assessed. RESULTS: The distance with the smallest statistical significance was found to be at the nose with p = 0.998, while the biggest statistical significance was found in the midface with p = 0.658. The area with the biggest surface deviation between the superimposed scans was the neck with a root mean square (RMS) of 1.62 ± 1.71, and the area with the smallest surface deviation was the forehead with a RMS of 0.17 ± 0.05. CONCLUSION: The whole-body imaging device investigated in this study can be utilized to capture the face and provides enough accuracy to compare scans. Even though not directly investigated, it can be hypothesized that the error caused by repositioning the patient between a baseline and a follow-up scan will not be too big to consider measurements performed with the whole-body imaging device as impractical.

3D Anthropometric Facial Imaging - A comparison of different 3D scanners.

Facial measurements serve as a valuable tool in the treatment planning of facial plastic surgery. The aim of this study was to evaluate the accuracy and reliability of standard 3D anthropometric measurements of the face made with one low-cost handheld 3D scanner and one industrial-type mobile 3D scanner. There are clear potential benefits of using 3D measurements by means of new handheld mobile scanners. However, the Sense scanner from the class of inexpensive scanners showed significant limitations in more complex areas such as the lip and nose, whereas proportions could be measured satisfactorily.

Anatomic Differences Between the Asian and Caucasian Nose and Their Implications for Liquid Rhinoplasties.

The demand for surgical and nonsurgical esthetic procedures in the nasal region has increased sharply in the past. Anatomic differences of the nose between different ethnicities need to be investigated thoroughly. The objective of this article is to analyze and compare morphometric features of the nose in a mixed Asian-Caucasian study population. The nasal length in Asians was statistically significantly greater than in Caucasians, also after having adjusted for facial height. The nasal dorsal bridge and the nasal base showed statistically significant differences. By keeping these anatomic differences in mind while treating patients, greater efficacy and safety can be achieved.

[Case report of frontobasal reconstruction and volume augmentation using a free gracilis muscle flap and autologous fat grafting: utilising the free flap as a scaffold for fat transplantation]. / Fallbericht einer Frontobasisrekonstruktion und Volumenkorrektur durch freie M. gracilis-Lappenplastik und autologe Fett-Transplantation ­ Die Lappenplastik als Scaffold für eine Fettgewebe-Transplantation.

This case report shows the interdisciplinary treatment of a 28-year-old woman suffering from a pronounced frontal volume defect after severe craniocerebral trauma. The combination of cranioplasty using a polymethylmethacrylate (PMMA) implant, free gracilis muscle flap transfer for soft tissue coverage and serial autologous fat grafting into the muscle flap for subsequent contouring enabled both an adequate and aesthetic reconstruction. This example demonstrates the feasibility of treating increasingly complex composite defects in a multidisciplinary setting, when plastic surgeons are involved.

Validation of two handheld devices against a non-portable three-dimensional surface scanner and assessment of potential use for intraoperative facial imaging.

BACKGROUND: The aim of this study was to compare accuracy and timing of two handheld, mobile three-dimensional surface imaging (3DSI) devices against an established non-portable medical imaging system, and to evaluate future intraoperative use for facial surgery. METHODS: Surface-to-Surface root mean square analysis was used to evaluate both a consumer device (Sense 3D) and a professional surface scanner (Artec Eva) against a reference imaging system (Vectra XT). Two assessors repeatedly 3D-imaged the facial region of an imaging phantom and 30 volunteers in two separate sessions. Using both mobile devices, intraoperative 3DSI of 10 rhinoplasty patients was compared with preoperative reference imaging. Intraclass Correlation Coefficient was calculated for repeated measurements. RESULTS: Artec Eva yielded mean deviations below 0.5 mm for the whole face and all subunits excluding the eye region. Sense 3D showed similar deviations for the whole face, but otherwise only in the central and lateral forehead unit and the medial cheek. Variability was low for both the non-portable Vectra XT and Artec Eva, whereas full-face assessment using Sense 3D resulted in high variability. When compared to the preoperative reference images, intraoperative rhinoplasty 3DSI revealed low deviations for Artec Eva and high deviations for Sense 3D. CONCLUSIONS: The 3D surfaces captured by Artec Eva showed a similarly desirable accuracy for facial imaging as Vectra XT reference images. This handheld device presents a suitable option for the objective documentation during rhinoplasty surgery. Sense 3D was unable to accurately capture complex facial surfaces and is therefore limited in its usefulness for intraoperative 3DSI.

Three-dimensional surface imaging in breast cancer: a new tool for clinical studies?

BACKGROUND: Three-dimensional Surface Imaging (3DSI) is a well-established method to objectively monitor morphological changes in the female breast in the field of plastic surgery. In contrast, in radiation oncology we are still missing effective tools, which can objectively and reproducibly assess and document adverse events in breast cancer radiotherapy within the framework of clinical studies. The aim of the present study was to apply structured-light technology as a non-invasive and objective approach for the documentation of cosmetic outcome and early effects of breast radiotherapy as a proof of principle. METHODS: Weekly 3DSI images of patients receiving either conventionally fractionated radiation treatment (CF-RT) or hypofractionated radiation treatment (HF-RT) were acquired during the radiotherapy treatment and clinical follow-up. The portable Artec Eva scanner (Artec 3D Inc., Luxembourg) recorded 3D surface images for the analysis of breast volumes and changes in skin appearance. Statistical analysis compared the impact of the two different fractionation regimens and the differences between the treated and the contralateral healthy breast. RESULTS: Overall, 38 patients and a total of 214 breast imaging sessions were analysed. Patients receiving CF-RT showed a significantly higher frequency of breast erythema compared to HF-RT (93.3% versus 34.8%, p = 0.003) during all observed imaging sessions. Moreover, we found a statistically significant (p < 0.05) volumetric increase of the treated breast of the entire cohort between baseline (379 ± 196 mL) and follow-up imaging at 3 months (437 ± 224 mL), as well as from week 3 of radiotherapy (391 ± 198 mL) to follow-up imaging. In both subgroups of patients undergoing either CF-RT or HF-RT, there was a statistically significant increase (p < 0.05) in breast volumes between baseline and 3 months follow-up. There were no statistically significant skin or volumetric changes of the untreated healthy breasts. CONCLUSIONS: This is the first study utilizing 3D structured-light technology as a non-invasive and objective approach for the documentation of patients receiving breast radiotherapy. 3DSI offers potential as a non-invasive tool to objectively and precisely monitor the female breast in a radiooncological setting, allowing clinicians to objectively distinguish outcomes of different therapy modalities.

[Whole-body surface assessment - implementation and experiences with 360° 3D whole-body scans: opportunities to objectively monitor the extremities and the body trunk]. / Whole Body Surface Assessment ­ Implementierung und Erfahrungen von 360° 3D Ganzkörperscans: Möglichkeiten zur Objektivierung und Verlaufskontrolle an den Extremitäten und am Körperstamm.

BACKGROUND: Three-dimensional surface imaging (3DSI) has proven to be useful in providing objective aid to the planning process and documentation of various plastic-surgical procedures. Although this technology is routinely used in the surface and volume analysis of the face and breast, it has been of limited use in registering and quantifying the resulting changes to the entire body surface. The aim of this study was the clinical implementation of 360° whole-body scans to evaluate the treatment of lipoedema. PATIENTS, MATERIALS AND METHODS: Three 3DSI devices (Eva, Thor and Sense) were tested for precision and reproducibility regarding whole-body scans. Using a standardised setup consisting of an automatic turntable and predetermined body poses, human subjects were analysed by measuring axial circumferences and quantifying defined layers of body volume. The relevant statistical and clinical deviations were subsequently evaluated. RESULTS: A standardised procedure for 360° scans was successfully implemented. All tested scanners yielded sufficient results with respect to intraindividual reproducibility (p > 0.05). The Eva and Thor scanners delivered comparable results for axial circumference and volume analysis (p > 0.05). The Sense scanner allowed for a precise analysis in the area of the body trunk, but had significant deficits regarding the lower extremity (p < 0.05). The data analysis was then successfully applied to selected clinical cases. CONCLUSION: A procedure to reproducibly capture and analyse the human body was successfully established for clinical use in plastic surgery. Two of the tested 3DSI devices allowed for an objective surface and volume analysis of the human body. The third scanner (Sense) offered the ability to perform 360° scans at a low cost, albeit lacking in precision when applied to certain areas of the body. These findings may help to objectively evaluate the effects of different procedures on the entirety of the body surface in the future.

[Quantitative volumetric analysis of the lower extremity: validation against established tape measurement and water displacement]. / Quantitative volumetrische Analyse der unteren Extremität: Validierung gegenüber etablierter Maßbandmessung und Wasserverdrängung.

BACKGROUND: Tape measures continue to be used for the diagnosis and evaluation of lipoedema and lymphoedema in the clinical routine. Extremity volumes are calculated based on standardised circumferential measurements. Other volume measurements such as water displacement are not applied on a regular basis. This study aimed to evaluate a 3D scanner as an alternative and reproducible tool to objectively measure the volumes of the lower extremity. PATIENTS, MATERIALS AND METHOD: We used a commercially available 3D scanner, the Artec Eva®, to perform 3D scans of the lower extremities on 20 subjects and calculated the volume using the appropriate software. In addition, limb volume was determined with standardised methods using the circumferential method (cone method and disc method) and the water displacement technique. The results and the time taken to perform the three measurement methods were documented and statistically evaluated. RESULTS: There were no significant deviations between the results from 3D volumetry and water displacement (p > 0.05). The cone method significantly overestimated the volume measured by water displacement and 3D volumetry. The disc method revealed no statistically significant differences, but clinically relevant differences with a high variance in the 95 % confidence interval. All methods demonstrated high positive correlations with each other. Water displacement was the most timeconsuming method. CONCLUSION: Our findings obtained from the examination of 40 lower extremities show that 3D scans and software-based volumetric calculations can achieve objective and reproducible measurements in a relatively short time. The deviation from the gold-standard method of water displacement is small. Compared with the cone and disc method, however, we observed clinically relevant deviations with a high variance. We therefore recommend the 3D scan procedure for the objective documentation of conservative and surgical treatments for lipoedema or lymphoedema and have incorporated it into our clinical routine.

Multimodal Therapy of Ulcers on the Dorsum of the Hand With Exposed Tendons Caused by Pyoderma Gangrenosum.

The authors present the case of a 54-year-old man with ulcers on the dorsal hand and forearm with exposed extensor tendons after he received misdiagnoses at 2 other hospitals, leading to deep soft tissue defects from multiple debridements. Due to the complicated nature of the wound, the ulcers did not heal under the systemic medication. After careful debridement, the defect was primarily closed with a collagen-glycosaminoglycan biodegradable matrix (Integra Matrix Wound Dressing, Integra LifeSciences, Plainsboro, NJ) on the dorsal hand and covered with a mesh graft 14 days later. Necrosis and superinfection over the index finger was treated again with systemic antibiotics and an unmeshed skin graft under a vacuum bandage with a mesh wound contact layer (Mepitel, Mölnlycke Health Care, Norcross, GA). The patient was satisfied with the functional and aesthetic outcome 1 month later when wounds were completely healed. The authors conclude that in cases where patients are living with pyoderma gangrenosum, even a challenging and complicated wound can be handled successfully with correct systemic immuno- suppression and appropriate soft tissue coverage.