Skin substitutes with noncultured autologous skin cell suspension heal porcine full-thickness wounds in a one-stage procedure.

Clinical application of skin substitute is typically a two-stage procedure with application of skin substitute matrix to the wound followed by engraftment of a split-thickness skin graft (STSG). This two-stage procedure requires multiple interventions, increasing the time until the wound is epithelialised. In this study, the feasibility of a one-stage procedure by combining bioengineered collagen-chondroitin-6-sulfate (DS1) or decellularised fetal bovine skin substitute (DS2) with autologous skin cell suspension (ASCS) in a porcine full-thickness wound healing model was evaluated. Twelve full-thickness excisional wounds on the backs of pigs received one of six different treatments: empty; ASCS; DS1 with or without ASCS; DS2 with or without ASCS. The ASCS was prepared using a point-of-care device and was seeded onto the bottom side of DS1, DS2, and empty wounds at 80 000 cells/cm2 . Wound measurements and photographs were taken on days 0, 9, 14, 21, 28, 35, and 42 post-wounding. Histological analysis was performed on samples obtained on days 9, 14, 28, and 42. Wounds in the empty group or with ASCS alone showed increased wound contraction, fibrosis, and myofibroblast density compared with other treatment groups. The addition of ASCS to DS1 or DS2 resulted in a marked increase in re-epithelialisation of wounds at 14 days, from 15 ± 11% to 71 ± 20% (DS1 vs DS1 + ASCS) or 28 ± 14% to 77 ± 26 (DS2 vs DS2 + ASCS) despite different mechanisms of tissue regeneration employed by the DS used. These results suggest that this approach may be a viable one-stage treatment in clinical practice.

A Method to Reproduce Symmetry in Midfacial Reconstruction: A Report of 19 Cases.

BACKGROUND: Reconstruction of facial skin defects remains a clinical challenge. With aging, ptosis of tissue over fixed structures creates an important facial feature known as the tear trough. This study aimed to evaluate the efficacy and aesthetic outcome of a novel surgical technique that reproduced this facial feature while avoiding ectropion during midfacial skin defect repair. METHODS: Nineteen patients with midfacial skin defects received local flap reconstruction combined with an anchoring suture. The flap was designed in a unilateral pedicled V-Y pattern. When the flap was advanced to cover the defect, one or two sutures that connected the dermis of the flap with the infraorbital periosteum were made to reproduce the tear trough line. RESULTS: Midfacial defects were successfully repaired with the V-Y flap in all 19 patients. No lower eyelid ectropion or conspicuous scars were noted in any of the patients. Further, the tear trough was successfully reconstructed in each patient. Facial symmetry was maintained with static positioning and animation. CONCLUSIONS: The combination of local V-Y flap reconstruction with anchoring sutures to reproduce facial feature lines is an effective technique in midfacial skin defect repair.

Three patients with full facial transplantation.

Unlike conventional reconstruction, facial transplantation seeks to correct severe deformities in a single operation. We report on three patients who received full-face transplants at our institution in 2011 in operations that aimed for functional restoration by coaptation of all main available motor and sensory nerves. We enumerate the technical challenges and postoperative complications and their management, including single episodes of acute rejection in two patients. At 6 months of follow-up, all facial allografts were surviving, facial appearance and function were improved, and glucocorticoids were successfully withdrawn in all patients.

A randomized trial of diagnostic ultrasound to improve outcomes in focal neuropathies.

INTRODUCTION: Neuromuscular ultrasound is valid, reliable, and accurate, but it is not known whether combining it with electrodiagnostic studies leads to better outcomes in individuals with focal neuropathies. METHODS: One hundred twenty individuals with focal neuropathy, based on history, examination, and electrodiagnosis, were enrolled in this study. All patients underwent neuromuscular ultrasound and were randomized to either have their ultrasound results sent to the referring physician or not have them sent. Outcomes were assessed at 6 months by evaluators blinded to group assignment. RESULTS: The Overall Disability Sum Score and 7 of 8 domains of the Medical Outcomes Study 36-item Short-Form Health Survey (SF-36) showed more improvement in the "report sent" group, although only the general health perception domain was significant (P = 0.005). CONCLUSIONS: Most 6-month outcomes did not reach statistical significance between the 2 groups. However, the "report sent" group had trends toward better outcomes, with significance being reached in the general health perception domain of the SF-36.

Maximizing wound coverage in full-thickness skin defects: A randomized-controlled trial of autologous skin cell suspension and widely meshed autograft versus standard autografting.

BACKGROUND: Traumatic insults, infection, and surgical procedures can leave skin defects that are not amenable to primary closure. Split-thickness skin grafting (STSG) is frequently used to achieve closure of these wounds. Although effective, STSG can be associated with donor site morbidity, compounding the burden of illness in patients undergoing soft tissue reconstruction procedures. With an expansion ratio of 1:80, autologous skin cell suspension (ASCS) has been demonstrated to significantly decrease donor skin requirements compared with traditional STSG in burn injuries. We hypothesized that the clinical performance of ASCS would be similar for soft tissue reconstruction of nonburn wounds. METHODS: A multicenter, within-patient, evaluator-blinded, randomized-controlled trial was conducted of 65 patients with acute, nonthermal, full-thickness skin defects requiring autografting. For each patient, two treatment areas were randomly assigned to concurrently receive a predefined standard-of-care meshed STSG (control) or ASCS + more widely meshed STSG (ASCS+STSG). Coprimary endpoints were noninferiority of ASCS+STSG for complete treatment area closure by Week 8, and superiority for relative reduction in donor skin area. RESULTS: At 8 weeks, complete closure was observed for 58% of control areas compared with 65% of ASCS+STSG areas (p = 0.005), establishing noninferiority of ASCS+STSG. On average, 27.4% less donor skin was required with ASCS+ STSG, establishing superiority over control (p < 0.001). Clinical healing (≥95% reepithelialization) was achieved in 87% and 85% of Control and ASCS+STSG areas, respectively, at 8 weeks. The treatment approaches had similar long-term scarring outcomes and safety profiles, with no unanticipated events and no serious ASCS device-related events. CONCLUSION: ASCS+STSG represents a clinically effective and safe solution to reduce the amount of skin required to achieve definitive closure of full-thickness defects without compromising healing, scarring, or safety outcomes. This can lead to reduced donor site morbidity and potentially decreased cost associated with patient care.Clincaltrials.gov identifier: NCT04091672. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level I.

Examining albumin as a bioindicator of healing capability in patients with diabetic foot ulcers: a retrospective review.

INTRODUCTION: Identifying a bioindicator of healing capacity would be beneficial in guiding treatment of and reducing morbidity in patients with DFU. Hypoalbuminemia is a well-established risk factor for amputation and, thus, a promising candidate. OBJECTIVE: This study was conducted to examine whether albumin values over a 12-week treatment course for DFU correlated with ulcer size and outcomes. MATERIALS AND METHODS: A retrospective review was conducted of 793 patients who presented to the Atrium Health Wake Forest Baptist Wound Care and Hyperbaric Center between 2010 and 2022. Sixty-two patients met the inclusion criteria. Albumin values and wound size data were collected monthly over a 12-week treatment course. RESULTS: Initial albumin values were not significantly different between patients healed by 12 weeks compared with nonhealed patients. Healed proportion and average initial ulcer size in patients with at least 1 hypoalbuminemia value (<3.0 g/dL) were not significantly different from those in patients with normal albumin levels. Patients who trended from normoalbuminemia to hypoalbuminemia displayed significantly increased wound sizes compared to patients with albumin changes within the normal range (0.04 cm² and -1.17 cm², respectively; P < .05). Monthly changes in albumin correlated poorly with wound healing (r = 0.144, P = .240), and large negative albumin trends (>0.5 g/dL per month) did not correlate with increased wound sizes compared with stable or positive trends. CONCLUSION: Albumin's utility as a bioindicator of short-term healing capability is limited to below-normal values.

Multicellular bioprinted skin facilitates human-like skin architecture in vivo.

Bioprinting is a promising alternative method to generate skin substitutes because it can replicate the structural organization of the skin into biomimetic layers in vitro. In this study, six primary human skin cell types were used to bioprint a trilayer skin construct consisting of epidermis, dermis, and hypodermis. Transplantation of the bioprinted skin with human cells onto full-thickness wounds of nu/nu mice promoted rapid vascularization and formation of epidermal rete ridges analogous to the native human epidermis, with a normal-looking extracellular matrix. Cell-specific staining confirmed the integration of the implanted cells into the regenerated skin. Using a similar approach, a 5 centimeter-by-5 centimeter bioprinted autologous porcine skin graft was transplanted onto full-thickness wounds in a porcine excisional wound model. The bioprinted skin graft improved epithelialization, reduced skin contraction, and supported normal collagen organization with reduced fibrosis. Differential gene expression demonstrated pro-remodeling protease activity in wounds transplanted with bioprinted autologous skin grafts. These results demonstrate that bioprinted skin can support skin regeneration to allow for nonfibrotic wound healing and suggest that the skin bioprinting technology may be applicable for human clinical use.

Median nerve changes following steroid injection for carpal tunnel syndrome.

INTRODUCTION: Neuromuscular ultrasound is a painless, radiation-free, high-resolution imaging modality for assessment of the peripheral nervous system. The purpose of this study was to use neuromuscular ultrasound to assess the changes that occur in the median nerve after steroid injection for carpal tunnel syndrome (CTS). METHODS: Ultrasound and nerve conduction studies were performed at baseline and 1 week, 1 month, and 6 months after steroid injection in 19 individuals (29 wrists) with CTS. RESULTS: Significant changes were noted in median nerve cross-sectional area (P < 0.001), mobility (P = 0.001), and vascularity (P = 0.042) at the distal wrist crease after steroid injection, and the nerve cross-sectional area correlated with symptom score and electrodiagnostic parameters. Changes in the ultrasonographic parameters were seen within 1 week of injection. CONCLUSIONS: These findings suggest neuromuscular ultrasound is potentially helpful for the assessment of individuals undergoing treatment for CTS, as typical changes can be expected after successful treatment injection.

Subatmospheric pressure therapy: basic science review.

Subatmospheric pressure (SAP) therapy has evolved as a mainstay in the treatment of acute and chronic wounds over the past 20 years. The significant improvement in wound healing upon application of a SAP therapy system such as the Vacuum Assisted Closure (V.A.C.; KCI, San Antonio, TX) device, historically has been related to general principles such as edema reduction, bacterial clearance, and increased perfusion to the wound bed. Recent investigations have also indicated that microdeformation and regulation of biochemical mediator expression play a role in the improved outcomes seen with SAP therapy. Future studies will pursue further the mechanisms by which SAP functions to render such impressive results in wound healing.

Initial Experience With Autologous Skin Cell Suspension for Treatment of Deep Partial-Thickness Facial Burns.

Facial burns present a challenge in burn care, as hypertrophic scarring and dyspigmentation can interfere with patients' personal identities, ocular and oral functional outcomes, and have long-term deleterious effects. The purpose of this study is to evaluate our initial experience with non-cultured, autologous skin cell suspension (ASCS) for the treatment of deep partial-thickness (DPT) facial burns. Patients were enrolled at a single burn center during a multicenter, prospective, single-arm, observational study involving the compassionate use of ASCS for the treatment of large total BSA (TBSA) burns. Treatment decisions concerning facial burns were made by the senior author. Facial burns were initially excised and treated with allograft. The timing of ASCS application was influenced by an individual's clinical status; however, all patients were treated within 30 days of injury. Outcomes included subjective cosmetic parameters and the number of reoperations within 3 months. Five patients (4 males, 1 female) were treated with ASCS for DPT facial burns. Age ranged from 2.1 to 40.7 years (mean 18.2 ± 17.3 years). Average follow-up was 231.2 ± 173.1 days (range 63-424 days). Two patients required reoperation for partial graft loss within 3 months in areas of full-thickness injury. There were no major complications and one superficial hematoma. Healing and cosmetic outcomes were equivalent to, and sometimes substantially better than, outcomes typical of split-thickness autografting. Non-cultured, ASCS was successfully used to treat DPT facial burns containing confluent dermis with remarkable cosmetic outcomes. Treatment of DPT burns with ASCS may be an alternative to current treatments, particularly in patients prone to dyspigmentation, scarring sequelae, and with limited donor sites.

Outpatient reconstruction using integra* and subatmospheric pressure.

Integra (Integra Lifesciences Corporation, Plainsboro, NJ) has been used in a variety of reconstructive surgical procedures. The application of Integra using subatmospheric pressure (V.A.C., Kinetic Concepts, Inc, San Antonio, TX) has been suggested to be easier, faster, and more consistent than previous dressings, allowing grafting as soon as 1 week after Integra placement. Ten patients were chosen for outpatient reconstructive surgery with Integra and subatmospheric pressure with skin grafting 7-10 days (mean = 8 days) post-Integra. Skin graft take was 75% to 100% (mean = 91.5%). No patients required additional grafting or reconstruction. Integra may be successfully used for reconstruction of difficult areas as an outpatient in combination with subatmospheric pressure (V.A.C.). This allows for expedited treatment, decreased morbidity, and lower cost versus standard Integra application.

Vitamin A and Wound Healing.

Vitamin A is a general term for retinoids. Vitamin A deficiency leads to a variety of cutaneous manifestations. It also functions as a hormone through retinoic acid receptors altering the activity of multiple cell lines. Pancreatic vitamin A levels are critical for retinoid signaling and normal pancreatic control of glucose. Vitamin A deficiency is more common during infection, and supplementation reduces severe morbidity and mortality from infectious diseases. Vitamin A modulates activities at the cellular level and, via its interrelationship with hormones such as thyroid, insulin, and corticosteroids, has diffuse metabolic effects on the body. It plays an important role in all stages of wound healing. Vitamin A is known for its ability to stimulate epithelial growth, fibroblasts, granulation tissue, angiogenesis, collagen synthesis, epithelialization, and fibroplasia. Local (topical) and systemic supplementation with vitamin A has been proven to increase dermal collagen deposition. There are numerous animal studies and limited human studies regarding physiologic effect of vitamin A on acute or chronic wounds via systemic or topical administration. The most common use of vitamin A supplementation is to offset steroids' effect. When considering supplementation, the potential benefits must be weighed against the risk of harm. Vitamin A toxicity can be critical and even result in death. The evidence for supplementation with vitamin A is currently limited to expert opinion and is not backed up by rigorous trials. There is an acute need for therapeutic trials with vitamin A supplementations.

Common hydrotherapy practices and the prevalence of burn wound bacterial colonisation at the University Teaching Hospital in Lusaka, Zambia.

BACKGROUND: In many parts of the world, hydrotherapy plays an important role in the management of patients with wounds including burns. Different centers practice hydrotherapy differently. At the University Teaching Hospital in Lusaka, Zambia, burn patients use a common bathtub for cleaning their wounds which theoretically increases the risk of cross-infection, an important source of morbidity and mortality. There is currently no evidence that hydrotherapy as practiced at our institution leads to cross infection among patients with burns. OBJECTIVE: The objective was to determine if our hydrotherapy practice and water plays a role in cross-infection and what organisms cause this infection. METHODS: This was a prospective analytical study. Patients meeting the selection criteria were recruited. Swabs from the burn wounds were collected on admission (day 0), day 4 and day 7. Weekly swabs of the bathtub were also collected, after the tub had been cleaned and declared ready for the next patient. Weekly water samples were also collected. Selected results, for Staphylococcus aureus and Klebsiella pneumoniae, were subjected to further analysis and PCR. Results were analyzed using statistics software, SPSS version 23. RESULTS: In this study, there were 96 participants of which 51 (53.1%) were males and 45 (46.9%) were females. Age distribution ranged from 5months to 91 years. The modal age range was 1 to 2 years. The modal burn percentage was 6%-10%, followed by 11%-15%. Hot water was the cause of burns in 65.6%. S. aureus and K. pneumoniae were the most common organisms isolated. Others were enteric organisms. In terms of readily available antibiotics, there was more sensitivity to Amikacin and Chloramphenicol than Ciprofloxacin (our commonly used antibiotic). The bathtub also had S. aureus and K. pneumoniae, besides enteric organisms. Sixty five point four percent (65.4%) of the Klebsiella were ESBL (Extended Spectrum Beta Lactamase) producers. The tub had samples that were both ESBL producers as well as widely resistant Klebsiella by other means. No growth was obtained from the water samples. Seventy-two point nine percent (72.9%) of the patients were discharged, 19.8% died, while 7.3% left against medical advice. CONCLUSION: Hydrotherapy as currently practiced at the University Teaching Hospital does contribute significantly to cross-infection among burn patients with widely resistant organisms. The main ones are S. aureus and K. pneumoniae. Switching care to a shower mechanism might help eliminate this problem as the study demonstrates that no bacteria were found in the water samples.

Extensive Hand Thermal and Blast Injury From Electronic Cigarette Explosion: A Case Report.

Background: As the use of electronic cigarettes rises, more reports of injuries related to device explosion are surfacing. Methods: Presented here is the case of a 35-year-old man sustaining extensive thermal and blast injuries to his hand when the device exploded while he was holding it. He required multiple surgeries involving groin flap coverage, tendon transfer, and nerve grafting to optimize his postinjury function. Results: While much of his hand function has been restored, he has continued deficits in range of motion and sensation as a result of the incident. Conclusions: With increasing numbers of such injuries, hand surgeons must be aware of the blast mechanism involved so as to avoid missing deep soft tissue injury or disruption of deep structures, as demonstrated in this case.

A Comparative Study of the ReCell® Device and Autologous Spit-Thickness Meshed Skin Graft in the Treatment of Acute Burn Injuries.

Early excision and autografting are standard care for deeper burns. However, donor sites are a source of significant morbidity. To address this, the ReCell® Autologous Cell Harvesting Device (ReCell) was designed for use at the point-of-care to prepare a noncultured, autologous skin cell suspension (ASCS) capable of epidermal regeneration using minimal donor skin. A prospective study was conducted to evaluate the clinical performance of ReCell vs meshed split-thickness skin grafts (STSG, Control) for the treatment of deep partial-thickness burns. Effectiveness measures were assessed to 1 year for both ASCS and Control treatment sites and donor sites, including the incidence of healing, scarring, and pain. At 4 weeks, 98% of the ASCS-treated sites were healed compared with 100% of the Controls. Pain and assessments of scarring at the treatment sites were reported to be similar between groups. Significant differences were observed between ReCell and Control donor sites. The mean ReCell donor area was approximately 40 times smaller than that of the Control (P < .0001), and after 1 week, significantly more ReCell donor sites were healed than Controls (P = .04). Over the first 16 weeks, patients reported significantly less pain at the ReCell donor sites compared with Controls (P ≤ .05 at each time point). Long-term patients reported higher satisfaction with ReCell donor site outcomes compared with the Controls. This study provides evidence that the treatment of deep partial-thickness burns with ASCS results in comparable healing, with significantly reduced donor site size and pain and improved appearance relative to STSG.

Subatmospheric pressure wound therapy and the vacuum-assisted closure device: basic science and current clinical successes.

This article reviews the development, current theories behind the mechanism of action and clinical use of subatmospheric pressure wound therapy with the vacuum-assisted closure device. An evolving list of indications for subatmospheric pressure therapy is discussed including its use in chronic wounds, traumatic wounds and orthopedic salvage, infected sternal wounds, management of the open abdomen, enterocutaneous fistulae, burn wounds, skin grafts and dermal substitutes, as well as systemic disease processes, such as myoglobinuria. The vacuum-assisted closure device Instill system is also reviewed, in which subatmospheric pressure therapy has been combined with the instillation of therapeutic solutions for the treatment of difficult infected wounds.

Nutrition and Chronic Wounds: Improving Clinical Outcomes.

There is increasing awareness that chronic wound healing is very dependent on the patient's nutritional status, but there are no clearly established and accepted assessment protocols or interventions in clinical practice. Much of the data used as guidelines for chronic wound patients are extrapolated from acutely wounded trauma patients, but the 2 groups are very different patient populations. While most trauma patients are young, healthy, and well-nourished before injury, the chronic wound patient is usually old, with comorbidities and frequently malnourished. We suggest the assumption that all geriatric wound patients are malnourished until proved otherwise. Evaluation should include complete history and physical and a formal nutritional evaluation should be obtained. Laboratory studies can be used in conjunction with this clinical information to confirm the assessment. While extensive studies are available in relation to prevention and treatment of pressure ulcers and perioperative nutrition, less is known of the effect of nutritional deficits and supplementation of the diabetic foot ulcer and venous stasis ulcer patient. This does not necessarily mean that nutritional support of these patients is not helpful. In the pursuit of wound healing, we provide systemic support of cardiac and pulmonary function and cessation of smoking, improve vascular inflow, improve venous outflow, decrease edema, and treat with hyperbaric oxygen. If we address all of these other conditions, why would we not wish to support the most basic of organismal needs in the form of nutrition?

Development of a Burn Escharotomy Assessment Tool: A Pilot Study.

Severe burn injuries can require escharotomies which are urgent, infrequent, and relatively high-risk procedures necessary to preserve limb perfusion and sometimes ventilation. The American Burn Association Advanced Burn Life Support© course educates surgeons and emergency providers about escharotomy incisions but lacks a biomimetic trainer to demonstrate, practice, or provide assessment. The goal was to build an affordable biomimetic trainer with discrete points of failure and pilot a validation study. Fellowship-trained burn and plastic surgeons worked with special effect artists and anatomists to develop a biomimetic trainer with three discrete points of failure: median or ulnar nerve injury, fasciotomy, and failure to check distal pulse. Participants were divided between experienced and inexperienced, survey pre- and post-procedure on a biomimetic model while being timed. The trainer total cost per participant was less than $35. Eighteen participants were involved in the study. The inexperienced (0-1 prior escharotomies performed) had significantly more violations at the discrete points of failure relative to more experienced participants (P = .036). Face validity was assessed with 100% of participants agreement that the model appeared similar to real life and was valuable in their training. Given the advancements in biomimetic models and the need to train surgeons in how to perform infrequent, emergent surgical procedures, an escharotomy trainer is needed today. The authors developed an affordable model with a successful pilot study demonstrating discrimination between experienced and inexperienced surgeons. Additional research is needed to increase the reliability and assessment metrics.

Successful management of adult smoke inhalation with extracorporeal membrane oxygenation.

Pulmonary complications remain one of the leading causes of mortality in patients with burns. We report two cases of adult patients with thermal and inhalation injuries who were placed on extracorporeal membrane oxygenation (ECMO) and survived. Patient 1 was a 42-year-old male who suffered 15% TBSA and a severe inhalation injury requiring intubation upon arrival to the emergency department. Patient 2 was a 24-year-old female in a house fire who received 20%TBSA and was noted to be in respiratory distress and intubated on the scene by the paramedic team. Three days after admission, patient 1 developed severe respiratory failure. He decompensated, despite maximum conventional management, and was placed on ECMO. After 300 hours of ECMO, his pulmonary function had improved, and he was decannulated. Patient 2 also developed severe refractory respiratory failure and was placed on ECMO. She was decannulated 288 hours later. Both patients were discharged home shortly afterwards and have managed well. ECMO should be considered when patients are facing a respiratory death from inhalation injury on conventional mechanical ventilation.

Cutaneous ulcerative lichen planus exhibiting pathergy, response to acitretin.

While ulcerative lichen planus is a common diagnosis when involving the mucosa, it is uncommonly found on the cutaneous surface. Cutaneous ulcerative lichen planus is usually found on the palmar or plantar surfaces and has only rarely been described elsewhere. We describe a case of cutaneous ulcerative lichen planus involving the pretibia and exhibiting pathergy, which to our knowledge has not been previously reported. We also describe successful treatment with oral acitretin in conjunction with topical and intralesional corticosteroids.