The cosmetic split-thickness skin graft donor site

Any split-thickness skin graft donor site is obvious to some degree because of pigment alterations and, at the worst, it can develop hypertrophic scarring. A predictably superior aesthetic result is possible if this site is converted to a full-thickness defect followed by primary closure, because a linear scar is the only residuum. Using a modified tumescent technique, the groin can also be readily used as a split-thickness donor site if a thin graft is preferred; it captures the attributes of an ideal donor site in which pain is diminished, healing rapid, and the scar inconspicuous, just as when it is used as a full-thickness skin graft donor site.     

Single-stage, autologous breast restoration

The skin-sparing mastectomy, when performed with immediate reconstruction, is a major advance in breast reconstruction. Traditionally, reconstruction of the nipple-areola complex is performed as a subsequent procedure. In this study, 17 patients (mean age, 43 years; range, 35 to 53 years) underwent one-stage breast and nipple-areola reconstruction over a 21-month period. In all cases of breast reconstruction, a buried transverse rectus abdominis musculocutaneous (TRAM) flap was used, and all patients had a simultaneous nipple-areola complex reconstruction performed. Nine patients had a Wise keyhole pattern used and contralateral reduction performed. Four patients retained all their breast skin, and a TRAM skin island was used in another four. It has recently been shown that patients with early-stage breast cancer and peripherally sited tumors have a very low risk of nipple-areola involvement. In 10 patients with early disease and peripheral tumors, the areola was retained (as a thin full-thickness graft), but more recently, in three patients with early-stage disease, the entire nipple-areola complex was used as a thin full-thickness graft. The thin full-thickness skin graft is removed from the breast in an apple-coring fashion, so that most of the ducts are retained as part of the mastectomy specimen. (There was histological confirmation of absence of tumor in the nipples of these patients.)One-stage autologous reconstruction should be considered for all patients undergoing immediate breast reconstruction. In patients with early-stage disease and peripheral tumors, the nipple-areola complex may be retained through the use of a thin full-thickness graft that is applied to a deepithelialized CV flap on the TRAM flap. This allows the best method of nipple-areola complex reconstruction: by retaining the original breast envelope, the color match and texture in the reconstruction are ideal. Patient satisfaction in this study was high. Necrosis of the mastectomy flaps impaired the cosmetic results in some patients. A large multicenter study is required to confirm the effectiveness of this procedure.     

Construction of the nipple with a mushroom-shaped pedicle

Construction of the nipple-areolar complex has been the subject of much interest and many papers. We believe that the best way to ensure nipple protrusion is by the entrapment of tissue above the skin surface so that it cannot retract. This, in principle, is similar to creating an irreducible hernia. This technique for nipple construction employs a circular split-thickness island of skin which has its central circulation preserved through its attachment at the new nipple site. This central stalk represents about one-quarter of the total surface area of the constructed areola. The total diameter of the areolar disk is usually determined by the size of the opposite nipple-areolar complex. The new areola is developed from a full-thickness skin graft taken from the area below the inguinal crease. Once removed, it is sutured over the elevated nipple segment with its central island. The full-thickness graft is sutured into place before a small cruciate incision is made in the center. It should be just large enough to permit the delivery of the dermal-epidermal flap on its stalk up through the opening. Nothing more need be done to the raw undersurface of the split-thickness skin. Its raw surface has no place to reattach because its bed is now covered with the full-thickness graft.(ABSTRACT TRUNCATED AT 250 WORDS)     

Sensory restoration of the skin graft on a free muscle flap: experimental rabbit study.

Transplantation of a muscle flap with free skin graft for wound coverage is a common procedure in reconstructive microsurgery. However, the grafted skin has little or no sensation. Restoration of the sensibility of the grafted skin on the transferred muscle is critically important, especially in palmar hand, plantar foot, heel, and oral cavity reconstruction. The purpose of this study was to investigate the possibility of sensory restoration of the grafted skin on a trimmed muscle surface that has been sensory neurotized after sensory nerve-to-motor nerve transfer, using the rabbit gracilis muscle as an animal model. The ipsilateral saphenous nerve (sensory) was transferred to the motor nerve of the gracilis muscle for sensory neurotization. A 4 x 4-cm2 area of skin island over the midportion of the gracilis muscle was harvested as a full-thickness skin graft. The upper half of the gracilis muscle was then excised, becoming a rough surface. The harvested skin was reapplied on the trimmed rough surface of the muscle. After 6 months, retrograde and antegrade horseradish peroxidase labeling studies were performed through skin and muscle injection. The group with a free skin graft was compared with the group with an intact surface of the gracilis muscle. This study clearly shows that sensory nerves can regenerate and penetrate into the trimmed muscle surface and grow into the overlying grafted skin. However, if the muscle surface is intact as with the compared group, sensory reinnervation of the grafted skin is not possible.     

Wound epithelialization in rats depending on the quantity and orientation of microautotransplants]

Patches of autoskin (0.5 x 1.0 mm) were grafted on a full-thickness rat back skin wound (5.4 cm2). As a result of "island" epithelialization from microautotransplants (MATR), the skin defect underwent repair. It is shown that the advance of the wound re-epithelialization did not depend on MATR number and their orientation in relation to the wound surface. The use of MATR allows to restore the skin defect with the plastic coefficient 1:100. This reduces the deficiency of donor skin at extensive burns.     

Surgical correction of burn deformities of the nose.

We present a method for reconstruction of the everted nostrils of the burned nose. Through a "ram's horn" incision, the everted vestibular lining and lower lateral cartilages are mobilized and repositioned, and the resultant defect is covered with a full-thickness skin graft. The linear scar is created as part of a circle, so that the postoperative contracture will improve the alar contour.     

Facial resurfacing in xeroderma pigmentosum with monoblock full-thickness skin graft

A case of xeroderma pigmentosum with multiple skin tumors on the face that was treated with total excision and replacement of face skin except the eyelids with a monoblock full-thickness abdominal skin graft is reported. The quality and tumor-free features of the monoblock full-thickness skin graft in xeroderma pigmentosum are indicated. Despite the increased morbidity of the donor region, the radical surgical approach advocated here has improved the prognosis in the case reported.     

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.     

Reduction mammaplasty in postburn breasts.

Thermal injury to the anterior chest in the adolescent girl can lead to severe disfigurement of the breasts. Just as in certain non-burn female patients, mammary hyperplasia can occur in patients with previous full-thickness burns of their breasts. Most plastic surgeons have been reluctant to perform reduction mammaplasty in these patients for fear of devascularizing the skin graft or the nipple-areola complex. A series of six patients with full-thickness burns of the breasts and subsequent skin graft coverage before reduction mammaplasty is reported. Four patients had bilaterally burned breasts requiring reduction. Two patients had one burned breast reduced, and one required a balancing procedure on the unburned side. Reduction mammaplasty was performed using the inferior-pedicle technique. The mean amount of tissue removed for the left and right breasts was 454 and 395 g, respectively. There was no nipple loss, hematoma, infection, or major loss of skin flaps. Reduction mammaplasty in this group of patients is safe and carries minimal risk if certain key concepts are followed carefully.     

Repair of large defect of frontal bone with free graft of outer table of parietal bones.

We present a case with a full-thickness bony defect in the frontal area. It was corrected successfully by a free bone graft to the outer table from the parieto-occipital area, partly covered by a flap of periosteum from the same area.     

Lower eyelid reconstruction with a cheek flap supported by fascia lata.

The use of a cheek rotation flap is a well-known method for reconstruction of a large defect of the lower eyelid. In this technique, a separate lining tissue supporting the cheek flap is required for full-thickness reconstruction. Previously, a chondromucosal graft or conchal cartilage has been used to support this flap. Recently, we have used a homologous or autologous fascia lata as support for the cheek flap instead of rigid tissues like cartilages. A fascia lata strip is fixed with tolerable tension to the medial canthal tendon and lateral orbital rim. The inner surface of the fascia and the cheek flap is lined with a buccal mucosa graft to decrease irritation of the conjunctiva and cornea. We present here seven patients in whom this procedure was used for lower eyelid reconstruction following resection of a malignant skin tumor. Based on follow-ups of 7 to 22 months, the functional and aesthetic results have been good in all cases. This procedure may be applicable for total or subtotal reconstruction of the lower eyelid.     

An evaluation of hard palate mucosa graft as a lining material in alar reconstruction: a 7-year experience applied to the full-thickness alar defect

The authors present their experience with 25 hard palate mucosa grafts used as lining material in the reconstruction of full-thickness alar defects. Good "take" was obtained in 22 grafts; the other three grafts incurred necrosis of the overriding skin flaps and postoperative infection. Degree of shrinkage was 11 to 15 percent of grafted size in patients with the type of defect that did not include the alar margin; shrinkage was 26 to 35 percent in patients with the type that included more than 50 percent of the alar margin. In all patients who had a good graft take, the nasal cavities were maintained and there was no nasal obstruction or collapsing during strong breathing. The healing time of the palate donor site varied from 7 days to 5 weeks, depending on the size of the defect. No patients experienced any symptoms at the donor site after healing. The authors concluded that hard palate mucosa can be considered a useful material in alar reconstruction because of the ease in graft harvesting and its support features. When the defect is large enough to involve the total unilateral ala nasi, even though the degree of postoperative shrinkage is comparatively high, hard palate mucosa may be the most suitable material to ensure good take of the graft and less possibility of donor-site morbidity.     

Permanent restoration of human skin treated with cultured epithelium grafting--wound healing by stem cell based tissue engineering--

The technique of epidermal cell culture developed by Green and colleagues made a breakthrough in the treatment of massive wounds in vivo with grown cells in vitro. In the past two decades, progress of culture methods and clinical practice have been made and now it is possible to treat extensive skin defect with large amounts of cultured epithelium. Since 1985, we have been successfully used cultured epidermis as autografts for the permanent coverage of full-thickness burn wounds or excised burn scars, giant nevi, tattoos and so on. Furthermore, cultured epidermis has been available as allografts to promote the healing of chronic skin ulcers or deep dermal burn. In this paper we describe our clinical experience of cultured epithelium grafting for the treatment of wounds and predict new trial of wound management and regeneration based on tissue engineering concept.     

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.     

The effect of epinephrine in local anesthesia on the survival of full- and split-thickness skin grafts: an experimental study

The effect of local anesthesia containing epinephrine on the survival of split- and full-thickness skin grafts remains unclear. In this blinded study, Xylocaine with or without epinephrine was injected subdermally prior to harvesting of split-thickness and full-thickness skin grafts on the dorsum of rabbits. After procurement, the grafts were placed back into their original donor sites. Statistical analysis of graft survival 7 days postoperatively revealed a significant decrease in survival for the full-thickness skin grafts treated with Xylocaine with epinephrine as compared with similar grafts without epinephrine (p less than 0.0005). No significant difference was noted for split-thickness skin-graft survival in grafts treated with Xylocaine with and without epinephrine (p greater than 0.1).     

Effect of size, surface charge, and hydrophobicity of poly(amidoamine) dendrimers on their skin penetration

The barrier functions of the stratum corneum and the epidermal layers present a tremendous challenge in achieving effective transdermal delivery of drug molecules. Although a few reports have shown that poly(amidoamine) (PAMAM) dendrimers are effective skin-penetration enhancers, little is known regarding the fundamental mechanisms behind the dendrimer-skin interactions. In this Article, we have performed a systematic study to better elucidate how dendrimers interact with skin layers depending on their size and surface groups. Franz diffusion cells and confocal microscopy were employed to observe dendrimer interactions with full-thickness porcine skin samples. We have found that smaller PAMAM dendrimers (generation 2 (G2)) penetrate the skin layers more efficiently than the larger ones (G4). We have also found that G2 PAMAM dendrimers that are surface-modified by either acetylation or carboxylation exhibit increased skin permeation and likely diffuse through an extracellular pathway. In contrast, amine-terminated dendrimers show enhanced cell internalization and skin retention but reduced skin permeation. In addition, conjugation of oleic acid to G2 dendrimers increases their 1-octanol/PBS partition coefficient, resulting in increased skin absorption and retention. Here we report that size, surface charge, and hydrophobicity directly dictate the permeation route and efficiency of dendrimer translocation across the skin layers, providing a design guideline for engineering PAMAM dendrimers as a potential transdermal delivery vector.     

Repair of large midline abdominal-wall hernias by a running strip of abdominal skin

Our experience with a full-thickness running strip of abdominal skin for the treatment of large midline abdominal hernias has been very positive. The mechanical properties of the skin strip allow one to reestablish a normal anatomy by bringing the rectus muscle in contact. Clinical and histologic studies have shown that the full-thickness skin rapidly loses its epidermal components and appears to transform itself into a dense connective tissue very similar to normal aponeurosis.     

Surgical method for treatment of syndactyly with osseous fusion of the distal phalanges.

For the interdigital space plasty to correct a syndactyly with fusion of the distal phalanges, we adopted a new operative procedure, covering the exposed distal bone with local rectangular flaps designed transversely on both dorsal and volar surfaces. A full-thickness skin graft from the groin region covers the remaining raw surface. The procedure was performed in six patients, and the flaps measured 6 mm (width) x 12 to 16 mm (length) in four patients, 5 x 15 mm in one patient, and 5 x 18 mm in one patient. Partial necrosis was observed in only one patient, in whom a narrow flap of 5 x 18 mm was used. In the other five patients, however, the results were satisfactory on both external appearance and function during the follow-up period of 3 to 6 years.     

An alginate hydrogel matrix for the localised delivery of a fibroblast/keratinocyte co-culture

There is significant interest in the development of tissue-engineered skin analogues, which replace both the dermal and the epidermal layer, without the use of animal or human derived products such as collagen or de-epidermalised dermis. In this study, we proposed that alginate hydrogel could be used to encapsulate fibroblasts and that keratinocytes could be cultured on the surface to form a bilayered structure, which could be used to deliver the co-culture to a wound bed, initially providing wound closure and eventually expediting the healing process. Encapsulation of fibroblasts in 2 and 5% w/v alginate hydrogel effectively inhibited their proliferation, whilst maintaining cell viability allowing keratinocytes to grow uninhibited by fibroblast overgrowth to produce a stratified epidermal layer. It was shown that the alginate degradation process was not influenced by the presence of fibroblasts within the hydrogel and that lowering the alginate concentration from 5 to 2% w/v increased the rate of degradation. Fibroblasts released from the scaffold were able to secrete extracellular matrix (ECM) and thus should replace the degrading scaffold with normal ECM following application to the wound site. These findings demonstrate that alginate hydrogel may be an effective delivery vehicle and scaffold for the healing of full-thickness skin wounds.     

Enhanced survival of full-thickness skin grafts following the application of DC electrical fields

The present study was undertaken to determine if uses of exogenous electrical fields could improve the posttraumatic quality of dermis and epidermis in isolated grafts in the rat. In blinded procedures, a full-thickness area of skin was removed and reattached to the original site. A galvanic device delivering 4.5 microA of direct current was applied using three electrode orientations: (1) anode above graft (AT; N = 8), (2) cathode above graft (CT; N = 7), and (3) no current (NC; N = 7). Current delivery was discontinued 4 days postoperatively. Quantitative assessment at 7 days postoperatively indicated the presence of necrotic skin over 80 to 90 percent of the graft surface area in NC and CT animals. In contrast, only 50 percent of the graft area was necrotic in AT rats. Histologic examinations indicated a significantly thickened dermis in the AT (versus NC and CT) rats, accompanied by patches of multilayered intact epidermis, which was virtually absent from the other experimental groups. Results are consistent with the hypothesis that direct-current stimulation can affect skin graft survival and repair.