Full-thickness grafting of acute eyelid burns should not be considered taboo.

Split-thickness skin grafts are commonly used for the treatment of acute eyelid burns; in fact, this is dogma for the upper lid. Ectropion, corneal exposure, and repeated grafting are common sequelae, almost the rule. It was hypothesized that for acute eyelid burns, the use of full-thickness skin grafts, which contract less than split-thickness skin grafts, would result in a lower incidence of ectropion with less corneal exposure and fewer recurrences. The records of all patients (n = 18) who underwent primary skin grafting of acutely burned eyelids (n = 50) between 1985 and 1995 were analyzed retrospectively. There were 10 patients who received full-thickness skin grafts (12 upper lids, 8 lower lids) and 8 patients who received split-thickness skin grafts (15 upper lids, 15 lower lids). Three of 10 patients (30 percent) who received full-thickness skin grafts and 7 of 8 patients (88 percent) who received split-thickness skin grafts developed ectropion and required reconstruction of the lids (p = 0.02). No articles were found substantiating the concept that only split-thickness grafts be used for acute eyelid burns. The treatment of acute eyelid burns with full-thickness rather than split-thickness skin grafts results in less ectropion and fewer reconstructive procedures. It should no longer be considered taboo and should be carried out whenever possible and appropriate.     

负压封闭引流技术在躯干部皮肤恶性肿瘤切除术中的应用

目的:探讨负压封闭引流技术应用于躯干部皮肤恶性肿瘤切除术的临床效果,并分析其临床应用价值。方法:回顾性分析2012年5月~2015年3月我院收治的11例躯干部皮肤恶性肿瘤患者的临床资料,均予行肿物切除术并同时行自体皮游离移植术,并外用持续负压封闭引流术于植皮术区。结果:所有患者均接受肿物切除+植皮+封闭负压引流技术治疗。9例患者于4~9天后拆除负压材料,皮片全部成活。1例患者治疗后24小时内吸引管堵塞,经术后于24小时内行管路冲洗疏通后再次行负压吸引,于术后5天首次拆除负压材料,见皮片部分成活,部分皮片仍有浮动,血运未明显建立,予以扩大皮片引流孔后再次行负压封闭引流术,术后9天再次拆除负压材料,见皮片成活较好。1例患者治疗4天后出现新鲜渗血经引流管引出,予拆除负压材料,所植皮片下有积血块,有新鲜渗血,予以清创后再次行负压封闭引流术,术后9天再次拆除负压材料,见皮片成活较好。随访半年到3年,所植皮片无破溃,肿瘤无复发。结论:躯干部皮肤恶性肿瘤切除术中,植皮联合封闭式负压引流技术可使所植皮片固定确实,充分引流渗液积血,利于皮片成活,对无法有效包扎固定肢体特殊部位(肩部、臀部、躯干部)等术区植皮提供了有效方法,具有一定的推广应用价值。     

The use of skin grafts in postburn contracture release: a 10-year review

Postburn scarring and contracture affecting function remain the most frustrating late complications of burn injury. Various techniques are used to release contractures; the choice depends on their location and/or the availability of unaffected skin adjacent to the contracture or elsewhere. A retrospective review was carried out of the case notes of patients who had skin grafting for the release of postburn contracture at the Burns Unit, City Hospital, Nottingham between May of 1984 and August of 1994 to evaluate the experience over this period. Information was obtained about the burn injury, contracture site, interval between burn and release of contracture, indication, age at first release, intervals between releases, operative details (donor and graft sites), complications and nonoperative treatment, and follow-up to the end of the study period. A total of 129 patients underwent skin grafting for release of contractures as opposed to any other method of correction. Full-thickness skin grafts were used in 81 patients (63 percent) and split-thickness skin grafts in 26 (20 percent). Twenty-two patients (17 percent) had both types used on different occasions. Flame burns (41 percent) were the most common causes, followed by scalds (38 percent). Two hundred thirty-nine sites of contracture were released, with the axilla (59) and the hand/wrist (59) being the most common sites involved, followed by the head/neck region (42). It was found that for the same site, release with split-thickness skin grafts was associated with more rereleases of the contracture than with full-thickness skin grafts. Also, the interval between the initial release and first rerelease was shorter than with full-thickness skin grafts (p < 0.048). It was also noted that children required more procedures during growth spurts, reflecting the differential effect of the growth of normal skin and contracture tissue. Patients reported more satisfaction with texture and color match with the full-thickness skin grafts. There was comparable donor-site and graft morbidity with both graft types. The use of skin grafts is simple, reliable, and safe. Whenever possible, the authors recommend the use of full-thickness skin grafts in preference to split-thickness skin grafts in postburn contracture release.     

负压创面治疗技术对皮肤移植成活的临床观察及实验研究

目的:采用负压固定移植皮片方法,观察负压创面治疗技术(negative-pressure wound therapy,NPWT)对游离皮片成活的影响,初步探讨微血管形成与皮肤成活之间的关系。方法:采用回顾性研究的方法,对65例皮肤缺损的患者,根据皮肤移植术后皮片固定方法的不同,分为两组,其中I组为NPWT治疗组,有35例患者,刃厚游离皮片移植术后行创面负压吸引治疗;II组为常规治疗组,有30例患者,刃厚游离皮片移植术后用打包或加压包扎的方式固定。Balb/c小鼠20只,按皮片移植后不同固定加压方式,分为实验组:负压创面治疗技术使用组(10只),对照组:打包加压组(10只),于皮片移植术后第5天,大体观察移植皮片颜色、有无水疱、有无皮下积液及质地,计算并比较皮片成活率,以免疫组化染色标记毛细血管内皮,检测皮片中微血管情况。结果:临床观察表明:I组术后皮片成活时间平均较II组缩短,有统计学差异(P<0.01),I组术后住院治疗时间平均较II组缩短5天,有统计学差异(P<0.01),I组术后抗生素费用、换药次数及换药费用较II组减少,有统计学差异(P<0.01)。动物实验结果表明:术后第5天,实验组小鼠移植皮片中微血管增生较对照组明显增多(P<0.05)。结论:与常规打包或加压包扎固定皮片的方式相比,负压创面治疗技术的应用可以缩短皮片成活时间,缩短患者住院治疗时间,减少抗生素的使用及换药次数,促进移植皮片中毛细血管增生,提高皮片成活率。     

Relationship of B blood group locus to skin allograft in chickens

Skin grafts were exchanged among 21 genotypic pairs of B blood group locus in the non-inbred chicks of White Leghorn at 5–7 days of age. The mean percentages of B locus compatible pairs were 94.7, 84.2 and 56.8 at the 11th, 15th and 19th days after grafting, respectively. These percentages of survival grafts were significantly higher than those of incompatible pairs. The effects of three B alleles were investigated but the the differences of effects of them were not found in this experiment. Two of the prolonged survival grafts survived for 35 days after grafting and all of the incompatible grafts were rejected the 20th day after grafting. The results of skin graft provided evidence that the B blood group locus was a histocompatibility locus or closely linked to such a locus.     

Diminished cellular cytotoxicity in mice hyperimmunized prior to skin grafting

Although cellular cytotoxicity generated in response to primary skin grafts has been studied in the past by several investigators, responses to skin grafts after repeated alloantigeneic stimulation have not been thoroughly studied. Using in vivo and in vitro assays of cellular cytotoxicity mice hyperimmunized prior to skin grafting showed lesser responses in local lymph nodes and spleen than did mice receiving primary grafts. Control experiments showed that suppressed responses were largely specific, were not due to circulating alloantibody, and were reversed if intraperitoneal tumor rather than a skin graft was used to challenge hyperimmunized mice. Early destruction of skin grafts in the immune host before vascularization was complete and thereby causing early elimination of cellular antigen was suggested as the mechanism for diminished cellular cytotoxicity in response to skin grafts in hyperimmunized hosts.     

Induction of long-term tolerance in the quokka (Setonix brachyurus) by thymus and skin allografts into early pouch young.

Intact quokkas (Setonix brachyurus) were grafted with thymus and skin as neonates. Fifty seven percent of primary thymus grafts persisted when donors were less than 32 days of age, compared with only 20% when the dornors were juveniles. This suggested that neonatal tissue was more readily accepted than tissue from adult animals. When the recipients had left the pouch, induced tolerance was tested by grafting thymus and skin from the original donors. Second thymus grafts were generally unsuccessful; however, second skin grafts were accepted and remained intact over the three-year period of observation, provided that the hosts were less than about 40 days of age at the time the first graft were placed.     

负压创面治疗技术对皮肤移植成活的临床观察及实验研究

目的：采用负压固定移植皮片方法,观察负压创面治疗技术（negative-pressure wound therapy,NPWT）对游离皮片成活的影响,初步探讨微血管形成与皮肤成活之间的关系。方法：采用回顾性研究的方法,对65例皮肤缺损的患者,根据皮肤移植术后皮片固定方法的不同,分为两组,其中Ⅰ组为NPWT治疗组,有35例患者,刃厚游离皮片移植术后行创面负压吸引治疗;Ⅱ组为常规治疗组。有30例患者,刃厚游离皮片移植术后用打包或加压包扎的方式固定。Balb／c小鼠20只,按皮片移植后不同固定加压方式,分为实验组：负压创面治疗技术使用组（10只）,对照组：打包加压组（10只）,于皮片移植术后第5天,大体观察移植皮片颜色、有无水疱、有无皮下积液及质地,计算并比较皮片成活率,以免疫组化染色标记毛细血管内皮,检测皮片中微血管情况。结果：临床观察表明：Ⅰ组术后皮片成活时间平均较Ⅱ组缩短,有统计学差异（P〈0．01）,Ⅰ组术后住院治疗时间平均较Ⅱ组缩短5天,有统计学差异（P〈0．01）,Ⅰ组术后抗生素费用、换药次数及换药费用较Ⅱ组减少,有统计学差异（P〈0．01）。动物实验结果表明：术后第5天,实验组小鼠移植皮片中微血管增生较对照组明显增多（P〈0．05）。结论：与常规打包或加压包扎固定皮片的方式相比,负压创面治疗技术的应用可以缩短皮片成活时间,缩短患者住院治疗时间,减少抗生素的使用及换药次数,促进移植皮片中毛细血管增生,提高皮片成活率。     

Pinch skin grafting or porcine dermis in venous ulcers: a randomised clinical trial.

Chronic venous ulcers are common, and even with effective compression or elevation large ulcers may take months to heal. Pinch skin grafting may allow healing from epithelial islands throughout the surface area of the ulcer, and a prospective randomised trial was therefore conducted comparing this treatment with porcine dermis dressings. Most patients were treated as outpatients, 25 ulcers being randomised to treatment with pinch skin grafts and 28 to treatment with porcine dermis. Though the groups were well matched, the mean healing rate in the first week was 15 cm2 for pinch skin grafts compared with 3.5 cm2 with porcine dermis (p less than 0.02). By life table analysis 64% of ulcers treated by pinch grafts were healed at six weeks and 74% by 12 weeks compared with 29% and 46% of ulcers, respectively, treated with porcine dermis dressings (chi2 = 4.1; p less than 0.05). All ulcers that failed to heal within 12 weeks included an area posterior to the medial malleolus, where local compression may have been inadequate. Pinch skin grafting improves the rate of healing in large venous ulcers and is a simple technique that may be performed as an outpatient procedure under local anaesthesia.     

Some factors affecting the spread of mycoplasma in plants

Studying the spread of mycoplasma, the causal agent of potato witches' broom disease, in tomato plants after grafting with infectious grafts ofNicotiana glauca Grah., we found that after 9 days of graft symbiosis a hundred per cent infection occurred, whereas with infectious grafts ofSolanum lycopersicum this took place after 16 days. The first symptoms of the disease were manifested on tomato plants 21 days after grafting with infectiousNicotiana glauca grafts and 28 days after grafting with infectious tomato grafts. The results obtained present evidence for the possible preference of tomato plants for mycoplasma.     

Tissue engineering of cultured skin substitutes

Skin replacement has been a challenging task for surgeons ever since the introduction of skin grafts by Reverdin in 1871. Recently, skin grafting has evolved from the initial autograft and allograft preparations to biosynthetic and tissue-engineered living skin replacements. This has been fostered by the dramatically improved survival rates of major burns where the availability of autologous normal skin for grafting has become one of the limiting factors. The ideal properties of a temporary and a permanent skin substitute have been well defined. Tissue-engineered skin replacements: cultured autologous keratinocyte grafts, cultured allogeneic keratinocyte grafts, autologous/allogeneic composites, acellular biological matrices, and cellular matrices including such biological substances as fibrin sealant and various types of collagen, hyaluronic acid etc. have opened new horizons to deal with such massive skin loss. In extensive burns it has been shown that skin substitution with cultured grafts can be a life-saving measure where few alternatives exist. Future research will aim to create skin substitutes with cultured epidermis that under appropriate circumstances may provide a wound cover that could be just as durable and esthetically acceptable as conventional split-thickness skin grafts. Genetic manipulation may in addition enhance the performance of such cultured skin substitutes. If cell science, molecular biology, genetic engineering, material science and clinical expertise join their efforts to develop optimized cell culture techniques and synthetic or biological matrices then further technical advances might well lead to the production of almost skin like new tissue-engineered human skin products resembling natural human skin.     

Upper eyelid skin grafting: an effective treatment for lagophthalmos following blepharoplasty

Patients who have undergone upper blepharoplasty occasionally develop anterior lamellar insufficiency, which can result in lagophthalmos, corneal decompensation, and even blindness. Historically, skin grafts in the upper eyelid have been considered a last-resort procedure because of poor cosmetic outcomes. Poor cosmetic outcomes result from the traditional practice of placing the skin graft above the eyelid crease. This article describes a surgical technique for upper eyelid skin grafting in which the graft is placed in a supraciliary position. Presented are results of a retrospective study of 20 patients (31 eyelids) who underwent supraciliary upper eyelid skin grafting. The postoperative results were evaluated by examining the improvement in lagophthalmos, the improvement of keratopathy and comfort of the patient, and the cosmetic appearance of the graft. Upper eyelid skin grafting using this surgical technique is an effective and cosmetically acceptable method to improve corneal integrity and comfort in patients who have corneal exposure from insufficient anterior lamella after upper eyelid or eyebrow surgery.     

Cultured epithelial autografts for giant congenital nevi

Eight pediatric patients with giant congenital nevi confluent over 21 to 51 percent body surface area were treated by excision and grafting. The nevus was excised to the muscle fascia, and the open wound was grafted with cultured epithelial autografts and split-thickness skin grafts. The patients have been followed from 17 to 56 months. Seventeen operations were performed in the eight patients, excising a mean of 6.9 percent body surface area at each procedure. The mean duration of anesthesia was 3.7 hours, and the mean operative blood loss was 12.3 percent estimated blood volume. The mean "take" for the cultured epithelial autografts was 68 percent, and for the split-thickness skin grafts, 84 percent. Epithelialization of open wound areas adjacent to the grafts was somewhat slower for the cultured epithelial autografts than for the split-thickness skin grafts, but it led to a healed wound in all patients except one. Ten of the 17 areas grafted with cultured epithelial autografts resulted in small open wounds that required regrafting. Wound contraction under the cultured epithelial autografts and under split-thickness skin grafts was similar and depended more on the anatomic site grafted than on the type of graft employed. in 16 of 17 operations, the cultured epithelium remained as a permanent, durable skin coverage. The use of cultured epithelial autografts allowed a larger area of excision than would have been possible with split-thickness skin grafts alone and, therefore, a more rapid removal of nevus. Cultured epithelial autograft are an important new technique in the care of patients with giant congenital nevi.     

Clinical application of autologous cultured epithelia for the treatment of burn wounds and burn scars

This report presents our experience with autologous cultured human epithelia grafting on burn wounds, burn scars, and skin-graft donor sites in seven patients. Dispersed epidermal cells were cultured with 3T3 cells treated with mitomycin C. After 2 to 3 weeks, cultured epithelia (total 350 to 2250 cm2) were grafted to the wound. The results showed that cultured epithelia grafts did not take so completely compared to the meshed skin grafts used for the coverage of burn wounds. However, cultured grafts placed on aseptic wounds adhered well and showed good appearance. In the histologic findings, normal differentiation of epidermal cells was found. Cultured grafts were bordered from subepidermal granulative tissue with basement membrane. A rete ridge and the adnexal structures were absent in the specimens that adhered to the burn wounds. However, in the specimens that took on abraded wounds, a gently sloping rete ridge and elastic fibers were seen. The histologic findings showed structures resembling normal skin.     

Reinnervation of human skin grafts: a histochemical study

The reinnervation of nine human skin grafts was investigated using histochemical thiocholine methods for the demonstration of cholinesterases. The regenerated cutaneous nerves showed both specific acetylcholinesterase and nonspecific cholinesterase reactions. In the youngest specimens, taken 3 weeks after the grafting, such regenerated nerves were seen both at the subdermal level under the graft and at the margins of the graft. These nerves seemed to orient toward the denervated graft area. The growing nerves were generally distributed in a random fashion. The reinnervation of some hair follicles, erector pili muscles, and sweat glands were observed in well-innervated full-thickness and thick partial-thickness skin grafts. It is suggested that this target-organ control of regenerating nerves occurs as a result of the action of chemotactic factors. A well-innervated graft bed seems to be important for optimum reinnervation of skin grafts. Fibrosis and scarring seem to hamper nerve regeneration.     

Detection of new MHC mutations in mice by skin grafting, tumor transplantation and monoclonal antibodies: a comparison

Two mechanisms of major histocompatibility complex (MHC) mutations have been described in mice; gene conversion and homologous but unequal recombination. However, our knowledge of mutations in MHC is incomplete because studies have been limited almost exclusively to two haplotypes, H-2b and H-2d, while hundreds of haplotypes exist in nature; it has been biased by the use of only one procedure of screening for mutation, skin grafting. We used three procedures to screen for MHC mutations: (1) conventional techniques of skin grafting, (2) syngeneic tumor transplantation and (3) typing with monoclonal anti-MHC antibodies (mAbs) and complement. The faster technique of tumor transplantation detected mutants similar to those discovered by skin grafting technique. Screening with mAbs allowed us to detect both mutants that are capable of rejecting standard skin grafts and those that are silent in skin grafting tests, and which therefore resulted in a higher apparent mutation frequency. Two mutants of the H-2a haplotype were found that carry concomitant class I and class II antigenic alterations. Both MHC mutants silent in skin grafting tests and mutants carrying concomitant class I and class II alterations have never been studied before and are expected to reveal new mechanisms of generating MHC mutations. 1-Ethyl-1-nitrosourea (ENU) failed to induce de novo MHC mutations in male mice in our skin grafting series.     

Leave the fat, skip the bolster: thinking outside the box in lower third nasal reconstruction

Defects of the lower third of the nose often present especially challenging reconstructive dilemmas. The surrounding skin to match is often thick, sebaceous, and sun damaged, none of which characterizes the historically ideal periauricular donor skin for grafting. The surrounding nasal skin is quite stiff, precluding very small local flaps. To avoid the "misplaced patch" appearance of most classic full-thickness grafts to this area or the depressed scar of an elliptical excision, many surgeons turn to larger local or regional flaps. These provide not only skin color and texture match but also the necessary several millimeters of subcutaneous fat necessary for proper tip aesthetics. Many defects of the lower third are small, making many surgeons reluctant to employ these larger flaps with their long scars and potential to twist or distort delicate tip or ala anatomy. The author has sought a means to transport skin and subcutaneous fat for lower third nasal defects outside of flaps. On the basis of the superiority of nasolabial fold scars and a vast positive experience in the literature utilizing skin and fat composite grafts with no bolsters, the author applied these techniques to 33 lower third nasal defects in 29 patients. Of 33 grafts varying in size from 4 mm circular to 17 mm x 16 mm and retaining 1 to 5 mm of fat, no grafts were lost. Four grafts developed a 30 percent area or less of central necrosis resulting in localized depression. Three of these four grafts were in active smokers and the fourth graft was in a former smoker. Aside from these four grafts and one with considerable excess fat early in the series, contour was good to excellent. Hypopigmentation is still common but improves with time. Easily performed composite grafts effectively carry the necessary fat for aesthetic reconstruction and do not risk long scars on the nose and twisting of the tip and ala that can result from flaps. Revisions are infrequent and extremely simple when indicated.     

Description of and treatment to inhibit the rejection of human split-thickness skin grafts by congenitally athymic (nude) rats

Gradual rejection of topically engrafted human split-thickness skin grafts (HSTSG) occurred in greater than 90% of congenitally athymic (nude) rats between 21 and 42 days of grafting. Engraftment and rejection of HSTSG is accompanied by a partial restoration of some cell-mediated immune components, the mixed lymphocyte response and lysis of human target cells. Histologic features of the rejection process were those seen in a host-versus-graft reaction. Immunofluorescent analysis of skin undergoing rejection demonstrated IgG at the basement membrane zone in most grafts. Nude rats rejecting HSTSG had circulating IgG which bound to the basement membrane zone and blood vessels of human skin. Nude rats treated with cyclosporine injections for 21 days had an enhanced survival of HSTSG, 120 or more days.     

Take percentage and conditions of cultured epithelium were improved when basement membrane of the graft was maintained and anchoring mesh was added

To achieve a higher take rate for epithelial grafts, this study investigated grafting techniques. Seventy-seven nude mice received flap grafting in which cultured human epithelium was grafted inside the flap, and 55 nude rats received transplantation of epithelium to a full-thickness skin defect. In each group, four models were studied, including model 1, in which epithelium was cultured with the conventional method; model 2, in which epithelium was cultured with fibrin gel to avoid sheet damage, then absorptive mesh was incorporated into the epithelium for anchoring to the graft bed; model 3, in which epithelium was cultured with fibrin gel and combined with absorptive mesh and artificial dermis containing fibroblasts; and model 4, in which the model 2 epithelium was grafted after artificial dermis was transplanted. The take for these models was evaluated grossly and histologically. The results show that the take percentage of models 2 and 3 was significantly higher than that of model 1 (conventional epithelium) and that there was no significant difference between model 3 (simultaneous grafting) and model 4 (two-step grafting). The difference in the take percentages of the grafts to the flap and to the full-thickness skin defect was also insignificant. In immunohistochemistry, human keratin appeared in all epidermis layers and diversification of the layer was observed in models 2, 3, and 4. In these three models, type IV collagen appeared in the basal layer and the formation of basal membrane was confirmed. These findings suggest that epithelia cultured on fibrin gel and combined with absorptive mesh could be used in a new technique for better, more stable take.     

A new device for free skin grafting in rats

We have employed this device in more than 200 grafting operations with complete success. Its advantage is to avoid the variation of fixing pressure on the grafts that greatly interferes with the experimental results. In addition, this method allows us to inspect the graft during the first week without having to remove the protector each time, which helped us greatly. We have presented a new device for skin grafting in rats that allows us to obtain temporary stabilization and protection of a skin graft. In addition, it allows us to inspect the graft without having to remove the protector.