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.     

Liposuction abdominoplasty: an evolving concept

Liposuction abdominoplasty-liposuction of abdominal subcutaneous tissue deep and superficial to Scarpa's fascia, with excision of excess abdominal skin and, when indicated, plication of the anterior rectus sheath without undermining-is an effective, low-risk approach to minimizing abdominal flap undermining. The technique allows aggressive thinning and "sculpting" of full-thickness abdominal subcutaneous tissue and achieves a natural (not featureless) abdominal contour. It minimizes the creation of "dead space," which often leads to postoperative complications, as well as preserves sensory nerve and blood supply to the abdominal skin. The operation may be performed with the patient under local anesthesia, which probably diminishes the risk for deep vein thrombosis. Moreover, additional procedures can be conducted safely and the postoperative course is short, uneventful, and without restrictions; patients return to normal activity within a week or so. New evaluation criteria for abdominoplasty are discussed in this article, the most important of which is the assessment of intraabdominal fat content and its impact on surgical outcome and the decision to perform anterior rectus sheath plication. The concept of a sliding, mobile, sensate abdominal flap, created by liposuction and sustained by multiple neurovascular mesenteries, is also offered.     

Immunosuppression following excision of burn eschar and syngeneic grafting in major thermal trauma.

Recent reports have suggested that very early excision (less than 24 hours post-burn) and primary closure of burn wounds might circumvent the immunosuppression which follows severe thermal trauma. The total body surface are (TBSA) involved in burn injuries of human subjects at risk for significant post-burn immunosuppression is large enough to require grafting. In the present study cell-mediated immunity was measured via one-way allogeneic mixed lymphocyte reactions (MLR) in mice subjected to full-thickness scald wounds over 25-30 percent TBSA followed by escharectomy and syngeneic full-thickness skin grafting. A significant decrease in the proliferative capability of T-cells could be demonstrated on days five and seven post-treatment in unburned grafted animals (day five, 30.7 percent; day seven, 24.8 percent) over untreated normals. T-cells from animals burned but not excised also showed significant hyporesponsiveness (day five, 33.2 percent; day seven, 26.1 percent normal MLR). Animals undergoing both burning and excision showed even more profound immunosuppression (day five, 18.3 percent to 23.7 percent; day seven, 7.4 percent to 11.6 percent normal MLR). Surgical incision without excising the skin did not suppress cell-mediated immunity (day five, 90.8 percent; day seven, 90.4 percent normal MLR). When T-cells from treated animals of each group (with the exception of the incision control group) were added to normal MLR cultures, significant (greater than 50 percent) cell-mediated suppression by suppressor T-cells could be demonstrated. This study showed that the trauma of excision and grafting alone results in depression of cell-mediated immunity. These data call into question the ability of very early excision and grafting to alter the immunosuppression which follows severe thermal trauma.     

Effect of protein depletion on skin graft "take" in rats

Protein malnutrition, with reduction of serum albumin from a normal level of 3.3 gm/dl to a 6-week depleted value of 2.1 gm/dl, does not appear to adversely affect the "take" of rat full-thickness skin grafts.     

Skin flap necrosis in guinea pigs: limitation of glucose supply and accumulation of lactate.

The distribution of glucose and lactate within skin flaps was determined in full-thickness guinea pig skin (excluding the panniculus carnosus). The distal end of the flaps had a low glucose content (less than 50 percent of normal) but high lactate level (2 to 3 times normal) during the 3 days after flap elevation. Progressively decreasing gradients of glucose content, and increasing gradients of lactate content, were demonstrated from the mid-region to the distal end of the flaps at 3 hours postoperatively. The decrease in glucose and the accumulation of lactate may play a significant role in skin necrosis.     

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.     

Use of an innervated skin graft to provide sensation to the reconstructed heel.

An innervated skin graft--a full-thickness skin graft with its nerve supply intact--is presented. In the case described, the sural nerve was preserved and an island of skin supplied by it was transposed to provide sensation to a heel pad, which had first been reconstructed by a cross-thigh flap. This transposed sensation has allowed full activity for 3 years in a young boy wearing normal footwear. This suggests that ulceration of all, or most, heel reconstructions is due to lack of sensation and, further, that the necessary sensation can be provided by this technically simple transposition of an innervated skin graft.     

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.     

Reepithelialization of a full-thickness burn from stem cells of hair follicles micrografted into a tissue-engineered dermal template (Integra)

We report a head and neck full-thickness burn injury that was reconstructed with a tissue-engineered dermal template and then early implantation of microdissected hair follicles through the silicone epidermis 12 days after the burn injury. The treatment resulted in complete reepithelialization and a hair-bearing scalp without the need for a split-thickness skin graft. Restoration of the stem cell population, hair growth, and earlier reepithelialization were achieved using this novel micrografting technique, and histologic examination confirmed maturation of a normal skin type over the subsequent 2 years.     

Vacuum-assisted closure for the treatment of degloving injuries

Degloving injuries of the hand and foot pose difficult reconstructive and rehabilitation challenges. After an excellent experience with split-thickness skin grafting with the vacuum-assisted closure device, we began studies with full-thickness skin grafts and traumatized skin. The device has been used with successful reapplication of full-thickness degloved skin in two patients. The first patient suffered degloving of the foot; the second patient, degloving of the hand.     

Thrombospondin-1 suppresses wound healing and granulation tissue formation in the skin of transgenic mice

The function of the endogenous angiogenesis inhibitor thrombospondin-1 (TSP-1) in tissue repair has remained controversial. We established transgenic mice with targeted overexpression of TSP-1 in the skin, using a keratin 14 expression cassette. TSP-1 transgenic mice were healthy and fertile, and did not show any major abnormalities of normal skin vascularity, cutaneous vascular architecture, or microvascular permeability. However, healing of full-thickness skin wounds was greatly delayed in TSP-1 transgenic mice and was associated with reduced granulation tissue formation and highly diminished wound angiogenesis. Moreover, TSP-1 potently inhibited fibroblast migration in vivo and in vitro. These findings demonstrate that TSP-1 preferentially interfered with wound healing-associated angiogenesis, rather than with the angiogenesis associated with normal development and skin homeostasis, and suggest that therapeutic application of angiogenesis inhibitors might potentially be associated with impaired wound vascularization and tissue repair.     

Trauma, especially of the submandibular glands, causes release of epidermal growth factor into bloodstream in mice

Submandibular glands in mice were traumatized by handling and then removed. Immunoreactive epidermal growth factor (EGF) in serum increased after 5 min and continued to increase, reaching at 1 h a peak of 50-fold normal in males and twice normal in females. If after traumatization the glands were repositioned with their blood supply intact, maximal increase of serum EGF at 1 h was 190-fold control values in males and 2-fold in females. In male mice, incision of abdominal wall skin led to a 15-fold increase of EGF in the serum; this rise was absent 3 days after sialoadenoectomy. After traumatization, repositioned submandibular glands lost 80% of their EGF; after the abdominal wall incision, only 30%. Following removal of submandibular glands, decrease of EGF level in serum was very slow: to 60% of the initial value after 3 days and to 40% after 10 days. By the HPLC characteristics, immunoreactive EGF in control serum and at its peak were indistinguishable. Urinary excretion of EGF was significantly elevated only when its serum level was 190-fold normal. We conclude that traumatized submandibular glands discharge into circulation a large part of their stored EGF. A similar but much less pronounced process takes place after abdominal skin incision. The presence of EGF in serum after its slow decline in sialoadenoectomized mice shows that a fraction of circulating EGF may recirculate prolonging its apparent half-life.     

A 10-year experience in nasal reconstruction with the three-stage forehead flap

Because of its ideal color and texture, forehead skin is acknowledged as the best donor site with which to resurface the nose. However, all forehead flaps, regardless of their vascular pedicles, are thicker than normal nasal skin. Stiff and flat, they do not easily mold from a two-dimensional to a three-dimensional shape. Traditionally, the forehead is transferred in two stages. At the first stage, frontalis muscle and subcutaneous tissue are excised distally and the partially thinned flap is inset into the recipient site. At a second stage, 3 weeks later, the pedicle is divided. However, such soft-tissue "thinning" is limited, incomplete, and piecemeal. Flap necrosis and contour irregularities are especially common in smokers and in major nasal reconstructions. To overcome these problems, the technique of forehead flap transfer was modified. An extra operation was added between transfer and division.At the first stage, a full-thickness forehead flap is elevated with all its layers and is transposed without thinning except for the columellar inset. Primary cartilage grafts are placed if vascularized intranasal lining is present or restored. Importantly, at the first stage, skin grafts or a folded forehead flap can be used effectively for lining. A full-thickness skin graft will reliably survive when placed on a highly vascular bed. A full-thickness forehead flap can be folded to replace missing cover skin, with a distal extension, in continuity, to supply lining. At the second stage, 3 weeks later during an intermediate operation, the full-thickness forehead flap, now healed to its recipient bed, is physiologically delayed. Forehead skin with 3 to 4 mm of subcutaneous fat (nasal skin thickness) is elevated in the unscarred subcutaneous plane over the entire nasal inset, except for the columella. Skin grafts or folded flaps integrate into adjacent normal lining and can be completely separated from the overlying cover from which they were initially vascularized. If used, a folded forehead flap is incised free along the rim, completely separating the proximal cover flap from the distal lining extension. The underlying subcutaneous tissue, frontalis muscle, and any previously positioned cartilage grafts are now widely exposed, and excess soft tissue can be excised to carve an ideal subunit, rigid subsurface architecture. Previous primary cartilage grafts can be repositioned, sculpted, or augmented, if required. Delayed primary cartilage grafts can be placed to support lining created from a skin graft or a folded flap. The forehead cover skin (thin, supple, and conforming) is then replaced on the underlying rigid, recontoured, three-dimensional recipient bed. The pedicle is not transected. At a third stage, 3 weeks later (6 weeks after the initial transfer), the pedicle is divided.Over 10 years in 90 nasal reconstructions for partial and full-thickness defects, the three-stage forehead flap technique with an intermediate operation was used with primary and delayed primary grafts, and with intranasal lining flaps (n = 15), skin grafts (n = 11), folded forehead flaps (n = 3), turnover flaps (n = 5), prefabricated flaps (n = 4), and free flaps for lining (n = 2). Necrosis of the forehead flap did not occur. Late revisions were not required or were minor in partial defects. In full-thickness defects, a major revision and more than two minor revisions were performed in less than 5 percent of patients. Overall, the aesthetic results approached normal.The planned three-stage forehead flap technique of nasal repair with an intermediate operation (1) transfers subtle, conforming forehead skin of ideal thinness for cover, with little risk of necrosis; (2) uses primary and delayed primary grafts and permits modification of initial cartilage grafts to correct failures of design, malposition, or scar contraction before flap division; (3) creates an ideal, rigid subsurface framework of hard and soft tissue that is reflected through overlying skin and blends well into adjacent recipient tissues; (4) expands the application of lining techniques to include the use of skin grafts for lining at the first stage, or as a "salvage procedure" during the second stage, and also permits the aesthetic use of folded forehead flaps for lining; (5) ensures maximal blood supply and vascular safety to all nasal layers; (6) provides the surgeon with options to salvage reconstructive catastrophes; (7) improves the aesthetic result while decreasing the number and difficulty of revision operations and overall time for repair; and (8) emphasizes the interdependence of anatomy (cover, lining, and support) and provides insight into the nature of wound injury and repair in nasal reconstruction.     

Molecular organization of the lipid matrix in intact Stratum corneum using ATR-FTIR spectroscopy

ATR-FTIR spectroscopy is useful in investigating the lateral organization of Stratum corneum (SC) lipids in full-thickness skin. Based on studies of the thermotropic phase transitions in n-tricosane and in excised human skin, the temperature dependence of the CH2 scissoring bandwidth emerged as a measure of the extent of orthorhombic and hexagonal phases. This dependence provides a simpler measure of the lateral order in lipid assemblies than the common spectroscopic approaches based on difference spectra, curve fitting of the CH2 scissoring region, and the position of the CH2 stretching vibrations. It has the advantages of ease of determination, relatively low variability, and high discriminative power for the type of lateral intermolecular chain packing. A comparison of the lateral organization of the lipids at the SC surface of mammalian skin using the scissoring bandwidth revealed considerable differences between human abdominal skin (containing mostly orthorhombic phases), porcine ear skin (containing mostly hexagonal phases), and reconstructed human epidermis (containing mostly disordered phases). This parameter also correctly described the different effects of propylene glycol (minimally disturbing) and oleic acid (formation of a highly disordered phase) on the SC lipids in excised human skin. The procedure described here is applicable to in vivo studies in the areas of dermatology, transdermal drug delivery, and skin biophysics.     

TRAM flap breast reconstruction: tumescent technique reduces blood loss and transfusion requirement

The tumescent technique has been shown to be efficacious in reducing both operative and postoperative bleeding without significant deleterious side effects in suction lipectomy. In this study, the effects of the tumescent technique on postoperative complications in transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction are investigated. All women who underwent a TRAM flap breast reconstruction by the senior author (J.B.) at the Emory Clinic during the years 1990 to 1996 were pooled (n = 386). Any woman who had a preincision infiltration of 0.25% epinephrine-containing saline solution (>200 cc) around the donor site was included in the tumescent group (n = 59). Medical records were reviewed, and rates of partial flap loss, fat necrosis (> or =10 percent flap volume), flap full-thickness skin loss, donor-site complication (skin loss, hernia, or infection), and blood transfusion were determined. Group rates were compared. The infiltrated group had a significantly lower transfusion rate as compared with the control group (0.34 units versus 1.32 units, p < 0.001). The rates of partial flap loss and fat necrosis were less in the tumescent group, but not significantly (0 percent versus 4 percent, p = 0.232; and 1.7 percent versus 10.4 percent, p = 0.058). There were no significant differences in the incidence of full-thickness skin loss or donor-site complications. Donor-site infiltration before incision with a 0.25% epinephrine-containing saline solution significantly reduced the transfusion requirement in TRAM flap breast reconstruction patients without adversely affecting either breast mound or abdominal donor-site complication rates.     

Histophotometric Quantification of the Field Effect and the Extended Field Effect of Tumors

Histophotometric investigations have been made on samples of human skin. Fresh frozen serial sections were fixed and stained for either reactive protein thiols (PSH,) or total reactive protein sulphur (TRPS) using modifications of the DDD-Fast blue B-method. In addition, total protein thiols (PSH,) were stained with the Mercurochromcyanide-method, and proteins were stained using a modified amido-black procedure. Significant differences were found between the different tumours investigated and normal tissue, and also between apparently normal tissue adjacent to the tumours and normal tissue from patients without tumour. To reveal such tumour-related changes of apparently normal tissue, termed the field effect of tumours, a double quotient had to be calculated from the PSH,- and TWS-values determined from both epithelium (epidermis) and connective tissue. In addition, abdominal skin was investigated from patients without tumour and patients with tumours of the female genital tract, liver or breast. With the aid of the double quotient procedure, highly significant differences were found between normal abdominal skin of patients without tumours versus similar samples taken from patients with tumours. The tumour-related changes found with abdominal skin distant from the tumours have been termed the extended field effect of tumours. These general tumour-related changes, independent of the size, state or degree of malignancy of the distant tumour, could be shown to be due to changes in abdominal dermis.     

The epidermis as a graft

Laboratory epidermal autotransplantation was performed on the surface of a full-thickness skin defect using mongrel female rats. Epidermal graft represented suction blister roofs, formed as the result of the donor skin site treatment with lowered up to -0.6 kg/cm2 pressure. It contained all epidermal cell layers. Following 1, 7 and 28 days after the transplantation recipient bed sites containing grafted epidermis were excised and histological study war performed. It was demonstrated that epidermal graft received by the method described was able to grow as well as to differentiate on the surface of a full-thickness skin defect.     

Full-thickness skin wound explants in tissue culture: a mechanical evaluation of healing.

This study was designed to evaluate biomechanically defined wound healing in full-thickness skin explants in tissue culture. The requirement for preculture incubation of wounds in situ was characterized. Full-thickness skin incisions were made in 44 rats and closed immediately. Wounds were incubated in situ for 0, 12, 24, 36, 48, 72, or 96 hours before harvesting and placement into tissue culture media for 6 weeks. Healing was evaluated by biomechanical criteria: tensiometric distraction to wound rupture generated true stress and energy absorption data. Burst-strength (maximum true stress) and toughness (energy absorption) were five times higher in the 48-hour group than in any other group; other groups were not different from each other. This study demonstrates long-term survival of full-thickness skin in culture and shows that full-thickness skin explants heal in tissue culture. Possible explanations for the narrow window of opportunity for harvest (48 hours, no more and no less) are discussed.     

Island scalp flap for superior forehead reconstruction

An island scalp fasciocutaneous flap, based on the posterior superficial temporal vessels, is described for single-stage reconstruction of full-thickness forehead and scalp defects. The hairline can be precisely determined and tailored to restore symmetry. By removing the hair-bearing dermis of the forehead portion of the flap and placing a full-thickness skin graft, aesthetic reconstitution of the forehead skin is achieved. This flap is especially useful when exposed calvarium limits other techniques.     

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.