Negative-pressure wound therapy in skin grafts: A systematic review and meta-analysis of randomized controlled trials.

INTRODUCTION: Although skin grafts are widely used in reconstruction of large skin defect and complex wounds, many factors lead to suboptimal graft take. Negative-pressure wound therapy (NPWT) reportedly increases the graft take rates when added to skin grafting, but a summary analysis of the data of randomized controlled trials has yet to be performed. We conducted this systematic review and meta-analysis of randomized controlled trials to compare the effectiveness and safety of NPWT and non-NPWT for patients with skin grafts. METHODS: We searched PubMed, Embase, Cochrane Library, and CNKI for relevant trials based on predetermined eligibility criteria from database establishment to February 2020. Two reviewers screened citations and extracted data independently. The quality of the included studies was evaluated according to the Cochrane Handbook, whereas statistical heterogeneity was assessed using chi-square tests and I2 statistics. Review Manager 5.3 was used for statistical analysis. RESULTS: Ten randomized controlled trials with 488 patients who underwent NPWT or non-NPWT were included. Compared with non-NPWT, NPWT yielded an improved the percentage of graft take, a reduction in days from grafting to discharge, with lower relative risk of re-operation, and no increased relative risk of adverse event. Further, the subgroup analysis showed an improved the percentage of graft take in negative pressure of 80 mmHg, and no improved the percentage of graft take in negative pressure of 125 mmHg. CONCLUSION: NPWT is more effective than non-NPWT for the integration of skin grafts, and the negative pressure of 80 mmHg can be recommended. Data on adverse events and negative pressure are, however, limited. A better understanding of complications after NPWT and the ideal negative pressure for the integration of skin grafts is imperative.

CSF disturbances and other neurosurgical complications after interdisciplinary reconstructions of large combined scalp and skull deficiencies.

Combined scalp and skull deficiency due to malignant scalp tumors or sequelae of intracranial surgery present challenging entities for both neurosurgeons and reconstructive treatment. In complex cases, an interdisciplinary approach is needed between neurosurgeons and cranio-maxillofacial surgeons. We present a considerably large series for which we identify typical complications and pitfalls and provide evidence for the importance of an interdisciplinary algorithm for chronic wound healing complications and malignomas of the scalp and skull. We retrospectively reviewed all patients treated by the department of neurosurgery and cranio-maxillofacial surgery at our hospital for complex scalp deficiencies and malignant scalp tumors affecting the skull between 2006 and 2019, and extracted data on demographics, surgical technique, and perioperative complications. Thirty-seven patients were treated. Most cases were operated simultaneously (n: 32) and 6 cases in a staged procedure. Nineteen patients obtained a free flap for scalp reconstruction, 15 were treated with local axial flaps, and 3 patients underwent full thickness skin graft treatment. Complications occurred in 62% of cases, mostly related to cerebrospinal fluid (CSF) circulation disorders. New cerebrospinal fluid (CSF) disturbances occurred in 8 patients undergoing free flaps and shunt dysfunction occurred in 5 patients undergoing local axial flaps. Four patients died shortly after the surgical procedure (perioperative mortality 10.8%). Combined scalp and skull deficiency present a challenging task. An interdisciplinary treatment helps to prevent severe and specialty-specific complications, such as hydrocephalus. We therefore recommend a close neurological observation after reconstructive treatment with focus on symptoms of CSF disturbances.

Mortality in paediatric burns at the Women's and Children's Hospital (WCH), Adelaide, South Australia: 1960-2017.

BACKGROUND: Burn injuries are the third leading cause of preventable death in children worldwide, resulting in over 100 000 annual hospitalisations. In the paediatric population, scalds are the commonest mechanism and burn injuries of greater than 40% total burn surface area (TBSA) are associated with a high mortality and morbidity rate. AIMS: The aim of this study was to review mortality in paediatric burns in a tertiary burns centre over a 60-year period, providing an understanding of local causes of mortality and directing future clinical research. METHODS: We reviewed data collected prospectively from patients treated for burn injuries at the WCH from 1960 to 2017. Data of age, gender, mechanism of injury and TBSA were collected. TBSA of 40% and greater were included in the study. RESULTS: All patients with total burn surface area (TBSA) less than 40% survived. There were a total of 75 patients who sustained burns of or greater than 40% TBSA. Overall mortality was 34% (26 of 75) of which 24 occurred in the 1960s. Of the 21 patients who died of flame burn injuries, 12 of them were described as clothes catching alight from being in close proximity to the source of flame. Average length of stay for patients who did not survive was 7 days (1-26). CONCLUSION: Mortality has since declined and the prognosis for survival good, even in TBSA of greater than 90%. The investigations in fabric flammability led by Dr Thomas Pressley and Mr Murray Clarke prompted the rewriting of Australian standards for production of children's clothing. This, in combination with advances in paediatric resuscitation, surgical techniques as well as wound care has improved survival rates and outcomes in extensive burn injuries. Future studies focus to see not only better survival rates, but also better aesthetic and functional outcomes in burn survivors.

Twenty-Five Years of Experience with the Submental Flap in Facial Reconstruction: Evolution and Technical Refinements following 311 Cases in Europe and Africa.

BACKGROUND: The submental flap is a pedicled island flap with excellent color match for facial reconstruction. The flap can be raised with muscle, submandibular gland, or bone and can be transposed to reach defects up to two-thirds of the face. The authors report the primary author's (D.M.) experience of 25 years using the submental flap from its original description to most recent technical evolutions in both Europe and Africa. METHODS: This is a retrospective study including all patients with facial defects who underwent reconstruction using a submental flap between 1991 and 2016. This study included the use of all four variations of the submental flap: platysmal, digastric, extended, and superextended. The authors report technical adaptations and complications encountered. RESULTS: The authors performed 311 facial reconstructions using submental flaps: 32 platysmal, 133 digastric, 91 extended, and 45 superextended variations. In conjunction with these reconstructions, the authors performed 10 osteocutaneous submental flaps and two free flaps. The authors report two cases of total flap necrosis (0.6 percent) and 28 minor complications, including 23 cases of distal skin necrosis (7 percent), one reversible mandibular facial nerve palsy (0.3 percent), and three hematomas (1 percent). CONCLUSIONS: The submental flap has proven to be a reliable flap for head and neck reconstruction. The four technical modifications described use varying amounts of soft tissue to replace tissue lost and can include vascularized bone from the mandibular margin. This flap exemplifies Gillies' principle of "replacing like with like" and should be discussed as an alternative to free tissue transfer in facial reconstruction, especially in settings where resources are limited. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Evaluation and Management of the Burn Patient: A Case Study and Review.

Advances in the management of burn patients have contributed to significant improvements in morbidity and mortality over the last century. The physiologic insult from this injury pattern, however, still requires extensive surgical intervention, resuscitation and multidisciplinary care. This paper will review the standard of care of these patients in the context of a recent case study from our institution.

Biochemical characterization of pure dehydrated binate amniotic membrane: role of cytokines in the spotlight.

AIM: Placental allografts used for tissue regeneration differ in membrane compositions and processing techniques. A uniquely folded dehydrated binate amniotic membrane (DBAM) was biochemically characterized to evaluate its potential role in wound healing. METHODS: Histology, Luminex-based immunoassay and standard in vitro cell biology techniques were employed. RESULTS: Histological staining confirmed that the DBAM was chorion free with epithelial cell layer of the respective amnion membranes facing outward. DBAM had quantifiable levels of relevant cytokines that induced proliferation and migration while bolstering secretory activity of the cells. DBAM retained biological efficacy at a broad range of temperatures. CONCLUSION: Cytokines in DBAM stimulate bone marrow stromal and stem cells that may lead to tissue regeneration and wound healing in a clinical setup.

Wartime Soft Tissue Coverage Techniques for the Deployed Surgeon.

BACKGROUND: Since the start of the conflict in the Middle East in 2001, military orthopedic surgeons have faced complex orthopedic injuries including high-energy soft tissue wounds, traumatic amputations, and open fractures. Although orthopedic surgeons are well trained in the management of osseous injuries, the treatment of soft tissue injuries can be technically challenging and unfamiliar. Early washout, debridement of devitalized tissue, external fixation of bony injuries, and antibiotic therapy remain the foundation of early wound management. However, these unique extremity injuries have no standard plan of care, and definitive treatment options continue to evolve. The following report highlights the typical cases seen in the wartime setting and offers possible solutions for the associated soft tissue injuries. METHODS: A single orthopedic surgeon at a Role 3 combat support hospital performed all cases in this series. This study is a report of the cases that the orthopedic surgeon encountered while deployed and the various techniques that can be used to manage the complex wounds seen in a deployed setting. FINDINGS: Twelve patients were included in this report and the data are shown. Of the 12 patients, 6 were injured by an improvised explosive device (IED), 4 were injured by a high-velocity gunshot wound (HVGSW), 1 was injured by a gunshot wound (GSW), and 1 was injured in an auto versus pedestrian motor vehicle crash. The wound sizes ranged from 10 to 300 cm2. All patients required more than one irrigation and debridement before wound closure. There was a successful outcome in 11 of the 12 patients. The only patient without a known successful outcome was lost to follow up. Six patients were treated with split thickness skin graft (STSG) alone. Four patients were treated with STSG plus an additional means of coverage. One patient was treated with a random flap and one patient was treated with a full thickness skin graft. Integra was used in two of the patients. Each of the patients in whom integra was used had exposed bone and had a successful outcome with respect to tissue coverage. DISCUSSION: This study details different soft tissue coverage techniques that must be learned and possibly employed by the deployed surgeon. Limitations of this study include its retrospective nature and the selected sampling of cases. At initial presentation, the management of war wounds secondary to high-velocity gunshot wounds and improvised explosive devices can be quite daunting. Adhering to firm surgical principles of thorough and meticulous debridement is the foundation of later soft tissue reconstructive options. Once the tissue is deemed clear of infection and contamination, there are myriad treatment options utilizing flaps, synthetic materials, and skin grafting. These are relatively straightforward techniques that the general orthopedic surgeon can utilize while deployed in a combat setting. In the end, it is critical for deployed surgeons to learn multiple techniques to provide definitive soft tissue coverage in a wartime theater.

Tissue Engineered Skin and Wound Healing: Current Strategies and Future Directions.

The global volume of skin damage or injuries has major healthcare implications and, accounts for about half of the world's annual expenditure in the healthcare sector. In the last two decades, tissue-engineered skin constructs have shown great promise in the treatment of various skin-related disorders such as deep burns and wounds. The treatment methods for skin replacement and repair have evolved from utilization of autologous epidermal sheets to more complex bilayered cutaneous tissue engineered skin substitutes. However, inadequate vascularization, lack of flexibility in drug/growth factors loading and inability to reconstitute skin appendages such as hair follicles limits their utilization for restoration of normal skin anatomy on a routine basis. Recent advancements in cutting-edge technology from stem cell biology, nanotechnology, and various vascularization strategies have provided a tremendous springboard for researchers in developing and manipulating tissue engineered skin substitutes for improved skin regeneration and wound healing. This review summarizes the overview of skin tissue engineering and wound healing. Herein, developments and challenges of various available biomaterials, cell sources and in vitro skin models (full thickness and wound healing models) in tissue-engineered skin research are discussed. Furthermore, central to the discussion is the inclusion of various innovative strategies starting from stem cells, nanotechnology, vascularization strategies, microfluidics to three dimensional (3D) bioprinting based strategies for generation of complex skin mimics. The review then moves on to highlight the future prospects of advanced construction strategies of these bioengineered skin constructs and their contribution to wound healing and skin regeneration on current practice.

Evolution of skin grafting for treatment of burns: Reverdin pinch grafting to Tanner mesh grafting and beyond.

BACKGROUND: Skin grafting is the current standard care in the treatment of full thickness burns. It was first described around 1500 BC but the vast majority of advancements have been achieved over the past 200 years. METHODS: An extensive literature review was conducted on Pubmed, Medline and Google Scholar researching the evolution of skin grafting techniques. The authors concentrated on the major landmarks of skin grafting and also provide an overview of ongoing research efforts in this field. RESULTS: The major innovations of skin grafting include Reverdin pinch grafting, Ollier grafting, Thiersch grafting, Wolfe grafting, Padgett dermatome and modifications, Meek-wall microdermatome and Tanner mesh grafting. A brief description of the usage, advantages and limitations of each technique is included in the manuscript. CONCLUSIONS: Skin grafting technique have evolved significantly over past 200 years from Reverdin pinch grafting to modern day meshed skin grafts using powered dermatome. Increasing the expansion ratio and improving the cosmetic and functional outcome are the main focus of ongoing skin grafting research and emerging techniques (such as Integra®, Recell®, Xpansion®) are showing promise.

Variations in Burn Excision and Grafting: A Survey of the American Burn Association.

It is unknown whether variations in burn care affect outcomes or affect the success of emerging therapeutics. The purpose of this study was to assess burn surgeons' preferences in excision and grafting to determine if surgical technique affects outcomes. A 71-item survey evaluating skin grafting techniques and preferences was emailed to members of the American Burn Association in July and August 2015. The survey was anonymous and voluntary. Relationships between variables were evaluated using Fisher's exact test. A P-value of ≤.05 was deemed statistically significant. The survey was sent to 607 burn surgeons, and the response rate was 24%. Clinical judgment is the most widely used method to determine depth of injury. Surgeons who practice in the United States and surgeons who are board certified in general surgery are more likely to determine depth of the burn based on clinical judgment alone (P < .001). Fifty-six percent of surgeons will perform excision as early as postburn day 1 and 73% will excise greater than 20% TBSA in one setting. Surgeons at centers with bed number of ≤10 (P = .024) or surgeons with board certification in plastic surgery (P = .008) are more likely to excise deep partial-thickness burns with an attempt to retain viable dermis. Geographic location, board certification, and burn unit size all contribute to variations in practice. Strong individual preferences make standardization of therapies challenging and may affect the success of new technologies. Burn surgery continues to be an art as much as a science, and accurate documentation of techniques and outcomes is essential for optimizing successes and documenting failures of new treatment methods.

Hypertrophic scarring: the greatest unmet challenge after burn injury.

Improvements in acute burn care have enabled patients to survive massive burns that would have once been fatal. Now up to 70% of patients develop hypertrophic scars after burns. The functional and psychosocial sequelae remain a major rehabilitative challenge, decreasing quality of life and delaying reintegration into society. Approaches to optimise healing potential of burn wounds use targeted wound care and surgery to minimise the development of hypertrophic scarring. Such approaches often fail, and modulation of the established scar is continued although the optimal indication, timing, and combination of therapies have yet to be established. The need for novel treatments is paramount, and future efforts to improve outcomes and quality of life should include optimisation of wound healing to attenuate or prevent hypertrophic scarring, well-designed trials to confirm treatment efficacy, and further elucidation of molecular mechanisms to allow development of new preventive and therapeutic strategies.

The Impact of Race on Advanced Chronic Venous Insufficiency.

BACKGROUND: The study aimed to determine the association between race and patient variables, hospital covariates, and outcomes in patients presenting with advanced chronic venous insufficiency. METHODS: The National Inpatient Sample was queried to identify all Caucasian and African-American patients with a primary International Classification of Diseases, Ninth Revision (ICD-9) diagnosis code for venous stasis with ulceration (454.0), inflammation (454.1), or complications (454.2) from 1998 to 2011. CEAP scores were correlated with ICD-9 diagnosis. Demographics, CEAP classification, management, cost of care, length of stay (LOS), and inpatient mortality were compared between races. Statistical analysis was via descriptive statistics, Student's t-test, and the Fisher's exact test. Trend analysis was completed using the Mann-Kendall test. RESULTS: A total of 20,648 patients were identified of which 85% were Caucasian and 15% were African-American. Debridement procedures had the highest costs at $6,096 followed by skin grafting at $4,089. There was an overall decrease in the number of ulcer debridements, vein stripping, and sclerotherapy procedures between 1998 and 2011 (P < 0.05) for both groups. However, African-American patients had significantly more ulcer debridements than their Caucasian counterparts. CONCLUSIONS: African-American patients with a primary diagnosis of venous stasis present with more advanced venous disease at a younger age compared with their Caucasian counterparts. This is associated with increased ulcer debridement, deep vein thrombosis rates and hospital charges in the African-American cohort. There are no differences in sclerotherapy or skin grafting procedures, LOS or inpatient mortality between races.

Innovations in diabetic foot reconstruction using supermicrosurgery.

The treatment of diabetic foot ulceration is complex with multiple factors involved, and it may often lead to limb amputation. Hence, a multidisciplinary approach is warranted to cover the spectrum of treatment for diabetic foot, but in complex wounds, surgical treatment is inevitable. Surgery may involve the decision to preserve the limb by reconstruction or to amputate it. Reconstruction involves preserving the limb with secure coverage. Local flaps usually are able to provide sufficient coverage for small or moderate sized wound, but for larger wounds, soft tissue coverage involves flaps that are distantly located from the wound. Reconstruction of distant flap usually involves microsurgery, and now, further innovative methods such as supermicrosurgery have further given complex wounds a better chance to be reconstructed and limbs salvaged. This article reviews the microsurgery involved in reconstruction and introduces the new method of supermicrosurgery.

Effectiveness of interventions to enhance healing of chronic ulcers of the foot in diabetes: a systematic review.

The outcome of management of diabetic foot ulcers remains a challenge, and there remains continuing uncertainty concerning optimal approaches to management. It is for these reasons that in 2008 and 2012, the International Working Group of the Diabetic Foot (IWGDF) working group on wound healing published systematic reviews of the evidence to inform protocols for routine care and to highlight areas, which should be considered for further study. The same working group has now updated this review by considering papers on the interventions to improve the healing of chronic ulcers published between June 2010 and June 2014. Methodological quality of selected studies was independently assessed by two reviewers using Scottish Intercollegiate Guidelines Network criteria. Selected studies fell into the following ten categories: sharp debridement and wound bed preparation with larvae or hydrotherapy; wound bed preparation using antiseptics, applications and dressing products; resection of the chronic wound; oxygen and other gases, compression or negative pressure therapy; products designed to correct aspects of wound biochemistry and cell biology associated with impaired wound healing; application of cells, including platelets and stem cells; bioengineered skin and skin grafts; electrical, electromagnetic, lasers, shockwaves and ultrasound and other systemic therapies, which did not fit in the aforementioned categories. Heterogeneity of studies prevented pooled analysis of results. Of the 2161 papers identified, 30 were selected for grading following full text review. The present report is an update of the earlier IWGDF systematic reviews, and the conclusion is similar: that with the possible exception of negative pressure wound therapy in post-operative wounds, there is little published evidence to justify the use of newer therapies. Analysis of the evidence continues to present difficulties in this field as controlled studies remain few and the majority continue to be of poor methodological quality.

What's new in wound treatment: a critical appraisal.

With the growing demand for the specialized care of wounds, there is an ever expanding abundance of wound care modalities available. It is difficult to identify which products or devices enhance wound healing, and thus, a critical and continual look at new advances is necessary. The goal of any wound regimen should be to optimize wound healing by combining basic wound care modalities including debridement, off-loading, and infection control with the addition of advanced therapies when necessary. This review takes a closer look at current uses of negative pressure wound therapy, bioengineered alternative tissues, and amniotic membrane products. While robust literature may be lacking, current wound care advances are showing great promise in wound healing.