Hydrogen-rich saline reduces tissue injury and improves skin flap survival on a rat hindlimb degloving injury model.

BACKGROUND: Degloving injuries represent a challenge in plastic surgery. The aim of this study is to acknowledge the protective effects of hydrogen-rich saline (HRS) solution on a rat hindlimb degloved skin flap. METHODS: Twenty-one Sprague-Dawley rats were divided into three groups (control, saline and HRS). Degloving injury model was established, and flaps were sutured back following 5 min of ischemia. The control group did not receive any treatment. The saline group received intraperitoneal physiological saline (10 ml/kg) and the HRS group received intraperitoneal HRS solution (10 ml/kg) postoperatively and daily for 5 days after the operation. Skin samples were obtained for histological, immunohistochemical and biochemical evaluations. RESULTS: Inflammation was lower in the HRS compared with saline (p = 0.02) and control (p = 0.004) groups. Edema was lower in the HRS compared with saline (p = 0.02) and control (p = 0.001) groups. Malondialdehyde (MDA) level was lower in the HRS than the control group (p = 0.01). Total antioxidant level was higher in the HRS compared with saline (p = 0.009) and control (p = 0.03) groups. Total oxidant level was lower in the HRS than the control group (p = 0.02). Oxidative stress index was lower in the HRS compared with saline (p = 0.001) and control (p = 0.0001) groups`. Vascular proliferation was higher in the HRS compared with the control group (p = 0.01). CONCLUSION: Repeated HRS injections after trauma increased the viability of skin flap in rat degloving injury model by decreasing local tissue injury, due to its antioxidant, anti-inflammatory and angiogenic effects.

Traumatic Avulsion of Upper Eyelid Skin Following Surgery in a Patient With Multiple Myeloma and Amyloid Light-chain Amyloidosis.

Multiple myeloma (MM) is a common hematologic malignancy. Primary systemic amyloidosis or amyloid light-chain (AL) amyloidosis is a rare disease. PURPOSE: This article presents the case of a patient with MM and AL amyloidosis who experienced a severe case of medical adhesive-related skin injury. CASE STUDY: A 64-year-old man with MM, AL amyloidosis, and diabetes presented with a necrotic wound on his left heel that required surgical debridement. The patient experienced a traumatic avulsion of the right upper eyelid skin during the removal of the corneal abrasion preventive tape as well as traumatic avulsion of the left upper eyelid skin while the patient's face was being cleansed. The avulsed right upper eyelid skin above the tarsus was repaired with a full-thickness skin graft. The partly avulsed left upper eyelid skin was repositioned, and an excisional biopsy was taken. Both upper eyelids healed uneventfully. The biopsy specimen revealed increased amyloid deposition in the dermis, subcutaneous tissue, and areas surrounding the veins and sweat glands. CONCLUSION: This case illustrates the increased risk of medical adhesive-related skin injury and other skin damage in patients with MM and AL amyloidosis. In these patients, the use of tape should be avoided to prevent intraoperative corneal abrasion.

Treatment of finger degloving injury with acellular dermal matrices: Functional and aesthetic results.

INTRODUCTION: Finger degloving injuries (FDIs) represent a challenge in hand surgery. When replantation is not possible, several techniques including loco-regional flaps, pocket abdominal flaps and free flaps have been described as methods to provide skin cover and avoid finger shortening. The aim of this study is to present our experience with acellular dermal matrices (ADMs) in the treatment of FDI. MATERIALS AND METHODS: We retrospectively reviewed the charts of 18 patients who presented with FDI and were treated with ADM between December 2015 and July 2017. Surgical outcomes including complications were analysed, and patient-centred assessments were performed at 12 months of follow-up. RESULTS: The follow-up period ranged from 10 to 20 months. All patients showed good integration and vascularisation of the ADM. All the fingers covered with ADM were firm and soft, with a slim and satisfactory appearance at a mean follow-up of 12 months. No limitations in tendon sliding were observed at dynamic sonography one year after surgery. CONCLUSION: ADMs could be regarded as a viable option when dealing with FDIs, if replantation is not possible and finger length is to be preserved. On the basis of these results, the surgical treatment of FDI with ADM is a viable option that produces good functional outcomes and cosmetic appearance.

Um infusor autônomo para um expansor de pele subcutâneo / An autonomous infuser for a subcutaneous skin expander

Introdução: A expansão da pele é um processo fisiológico definido como a capacidade de aumentar sua área superficial em resposta a uma tensão ou a uma dada deformação. Para realizar a cirurgia reconstrutiva, os expansores de pele são implantados sob a pele e periodicamente infiltrados com uma solução salina para fornecer um retalho extra de pele. Quando o volume interno prescrito do expansor é alcançado, a cirurgia reconstrutiva é realizada. Métodos: Foi desenvolvido um dispositivo semiautomático e portátil para facilitar um procedimento de expansão da pele. O dispositivo tem como objetivo simplificar o processo de infiltração, proporcionando mobilidade e independência para o paciente, e assegurando ao médico a qualidade e a precisão das infiltrações realizadas. O dispositivo também permite expansão contínua em pacientes hospitalizados. Resultados: Usando um código, o médico tem acesso ao menu do dispositivo e define a pressão máxima e/ou o valor máximo para cada expansor do paciente. O paciente pode realizar a infiltração e ter acesso ao controle da velocidade de infiltração, reverter ou parar a operação. Todos os dados são gravados em um SIM Card e incluem data, hora, volumes inicial e final, e pressão inicial e final de cada procedimento para cada expansor. Conclusões: O dispositivo automatiza e otimiza a expansão, de modo que o que o médico possa prescrever um limite para cada expansão, seja uma pressão máxima ou voluma infiltrado. Todos os dados são gravados, fornecendo um importante banco de dados sobre o comportamento de pele relacionado a gênero, raça, idade e local da expansão.

Introduction: Skin expansion is a physiological process defined as the ability of human skin to increase its superficial area in response to a stress or given deformation. In reconstructive surgery, skin expanders are implanted beneath the skin and periodically infiltrated with a saline solution to provide an extra flap of skin. When the prescribed internal volume of the expander is reached, reconstructive surgery is performed. Methods: A semiautomatic and portable device was developed and built to facilitate a skin expansion procedure. The device aims to simplify the infiltration process, providing mobility and independence to the patient and assuring the physician of the infiltration quality and precision. The device also enables continuous expansion in hospitalized patients. Results: Using a code, the doctor accesses the menu of the device and sets the maximum pressure and/or value for each expander of the patient. The patient can control the infiltration velocity and reverse or stop the operation. All data are recorded on a simcard and include date, time, initial and final volumes, and initial and final pressures of each procedure for each expander. Conclusions: The device motorizes and optimizes the expansion, allowing the doctor to prescribe a maximum infiltration pressure or volume. All data are recorded to provide an important database of skin behavior related to sex, race, age, and expansion site.

Combined multi-lobed flaps: A series of 39 extensive hand and multi-digit injuries one-staged reconstructions using modified designs of ALT, DPA and chimeric linking flaps.

INTRODUCTION: The use of multiple small flaps linked in a "chain-linked" flap microanastomosed chimeric system is recommended in distal hand and digital defects reconstruction. The aim of this study is to demonstrates our experience utilizing microsurgical fabrication, multi-lobed and linking combined flaps for the reconstruction of hand degloving injuries with complex multidigit soft tissue defects. METHODS: Microanastomosed chimeric flap systems using ALT and DPA modified designed flaps were combined in five selections to cover extensive soft tissue defects involving the hands and multiple digits of 39 patients (M:F - 36:3) from October 2009 to February 2013. Five different microsurgical combined chimeric flap systems utilised in extensive hand and multidigit injuries; innervated ALT flaps, multilobed DPA flaps, innervated ALT flap with multilobed DPA flap, innervated ALT flap with sensate ALT flap and bilobed ALT flap with multilobed DPA flap. All DPA donor sites were reconstructed using free ALT flap and anterior tibial artery propeller flap. RESULTS: Thirty-nine combined free flap extremities reconstructions on 39 patients (M:F - 36:3) with average age 28.5 (18-45) years sustained traumatic degloving injuries, 24 from road traffic accidents and 15 from industrial devices. Five different designs of combined multi-lobed flaps have be successfully used without any peri-operative complications. Average follow-up of 12 months, all flaps survived without complications. Operated extremities showed favorable functional recovery with restoration of the diminished protective sensation on the flap through reinnervation. All flaps survived uneventfully with coverage matching the texture and color of the recipients. Donor sites healed without complication. CONCLUSION: The microsurgical fabrication of chimeric ALT flaps and multilobed DPA flaps is a valuable alternative for the reconstruction of hand degloving injury with complex multidigit soft tissue defects. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Primary reattachment of avulsed skin flaps with negative pressure wound therapy in degloving injuries of the lower extremity.

Large avulsed skin flaps of the lower extremity caused by degloving injuries eventually develop skin necrosis in most cases. The current treatment option involves excision of the degloved skin and reapplication as a full- or split-thickness skin graft. We considered that reattachment of avulsed skin flaps without excision would be theoretically beneficial, since some circulation may remain around the connected pedicle and thus facilitate graft take. Furthermore, securing the skin to the original anatomic position is much easier using retained landmarks. We treated a total of 12 patients (13 cases) with degloving injuries of the lower extremity. In all cases, the avulsed skin flap was defatted and sewn back to the original position, then negative-pressure wound therapy was applied over those grafts as a bolster for approximately 7 days. Most of the avulsed skin flap took excellently, particularly close to the connected pedicle. Nine cases did not need any additional surgical procedures. Four cases required secondary skin graft for a small area of open wound due to partial necrosis of the defatted skin, as well as the raw surface left by the primary skin defect in the initial operation. Primary reattachment of the avulsed skin flaps without excision is convenient and efficient to cover the open wound over the exposed fascia and periosteum in degloving injuries. This would potentially offer a better alternative to definitive wound closure.

Successful Treatment of Life-threatening Posttraumatic Wounds With Negative Pressure Wound Therapy: A Case Report.

INTRODUCTION: Debridement and control of wound drainage are critical for managing patients with extensive traumatic wounds because wound infection can result in sepsis and further complications. CASE REPORT: The authors report the case of a 19-year-old woman with an extensive crush/degloving injury to her right lower limb that was treated with negative pressure wound therapy (NPWT) with a reticulated open-cell foam dressing. The patient received 2 treatments of sharp debridement and vacuum drainage using wall suction and polyvinyl alcohol dressings. Her respiratory failure, sepsis, and septic shock continued to worsen, and she could not tolerate anesthesia. On post admission day 9, after simple debridement where only superficial necrosis tissue was debrided without anesthesia, NPWT was applied for 5 days and removed about 8500 mL of exudate the first day and 6000 mL on the second. After 5 days, her wound began to improve, granulation tissue formed, no necrotic tissues were visible, and vital signs were stable. On day 14, she underwent anesthesia, surgical debridement, and application of NPWT for an additional 5 days. Following autologous skin grafting on day 19, she was removed from the ventilator (which was started on day 3). The extensive wound was effectively closed; she recovered satisfactorily. There was no patient follow-up. CONCLUSIONS: In this case, NPWT, in continuous mode at -125 mm Hg, effectively removed exudate after simple debridement in a patient who could not tolerate anesthesia.

Osteoarticular allograft reconstruction of post-traumatic defect of distal femur in a pediatric patient: A case report and literature review.

Successful results of osteoarticular allografts in reconstruction of periarticular bone defect after tumor resection encouraged its utilization in post-traumatic defects. Here we describe a case of post-traumatic skeletal defect in a 4 year-old girl treated with osteoarticular allograft reconstruction. Due to severity of the associated soft tissue injury and contamination at presentation staged treatment with antibiotic spacer followed by the reconstruction was carried out. At the end of one year the patient achieved 'Musculoskeletal tumor society' functional score of 27 points and radiographic score of 93%. Reconstruction immediately after healing of soft tissues prevented development of any varus or valgus deformity of the knee. Our case demonstrates utility of osteoarticular allograft in a pediatric post-traumatic skeletal defect.