Extensive and complex defects of the scalp, middle third of the face, and palate: the role of microsurgical reconstruction

Twenty-one patients with gigantic defects of the scalp and middle third of the face and palate following excision of neglected or recurrent tumors, burns, and infections have undergone microsurgical reconstruction. Wide resection of the middle third of the face, orbit, and palate requires "complex" three-dimensional volume reconstruction, whereas extensive defects of the scalp and skull (exceeding 80 cm2) require coverage of the larger surface area soft-tissue defect and the exposed brain and dura. The latissimus dorsi free-muscle flap and split-thickness skin graft have become our methods of choice for extensive scalp and skull defects. The latissimus dorsi musculocutaneous free flap is preferable for reconstruction of complex palatal and external skin and orbital defects of the middle third of the face. Microsurgical free-tissue transfer reliably frees the oncologic surgeon from the constraints imposed by conventional reconstructive techniques and may therefore allow improved curative or at least palliative resection of these extensive tumors.     

Deep-freeze preservation of cranial bones for future cranioplasty: nine years of experience in Soroka University Medical Center

Background Decompressive craniectomy is routinely performed in many neurosurgical centers to treat intracranial hypertension refractory to medical therapy as a result of head trauma, CVA or various brain tumors. When the patient survives his illness, cranioplasty with autologous bone graft or other reconstructive materials is considered to repair the skull defect. Objective This prospective study reviews the cases of decompressive craniectomies followed by later cranioplasty undertaken at our institute through the years 1996 and 2005 and describes the method used for preservation of removed bone flaps for future cranioplasty. Subjects and methods Sixty-eight patients underwent decompressive craniectomies since 1996. A protocol was designed to prepare the removed bone flaps for deep freeze preservation. After removal, the bone flaps were transferred to the skin bank at our institution within 6 h, gently rinsed using 1–3 liters of sterile saline (0.9% NaCl) supplemented with antibiotics (neomycin, 2 mM) with no dimethylsulfoxide (DMSO), then flaps were wrapped in two layers of sterile plastic coverage and preserved at −80°C. Results The patient’s population will be presented. Since 1996 we have performed 12 cranioplasties using deep-freeze preserved autologous bone graft. It took a rather long learning period, beginning with a single patient per year and continued with several others. Up to now, no case of infection, osteomyelitis or bone resorption following cranioplasty have occurred. Conclusion Deep-freeze preservation of autologous bone grafts to reconstruct skull defects after decompressive craniectomy is a useful procedure and has a low revision rate. N. Grossman: deceased 23 December 2006.     

应用3D适形打印制备网状复合体对兔颅骨缺损的修复作用及安全性研究

目的:探讨采用3D适形打印技术制备的羟基磷灰石/聚乳酸网状复合体在兔颅骨缺损中的修复作用及安全性。方法:以24只新西兰兔为研究对象,以羟基磷灰石/聚乳酸为材料,采用3D适形打印技术制备网状复合体,于兔颅骨顶部制成两个颅骨全层缺损,分别为孔A(左)和孔B(右),孔A(阳性对照组)以自体颅骨为修复材料,孔B(实验组)以复合体为修复材料,观察缺损修复区域的形态学、影像学(X线及CT扫描)及组织学检查结果。结果:植入后24周时,形态学显示:阳性对照组可见致密的骨组织修复,与缺损边缘界限不清,实验组中支架孔隙内纤维组织由新生骨质取代,且新生骨成熟度较提高,材料表面有部分吸收。CT扫描观察显示:冠状面上,阳性对照组缺损修复区域与周围正常骨组织融合为一体,实验组修复材料与缺损边缘融合紧密,与周围正常骨组织结合良好,部分边缘结合不连贯。组织学观察显示:实验组材料部分降解,材料间隔可见新生骨小梁。研究中无实验动物死亡,皮肤切口处缝合良好,无皮下积液,无移植物脱出、红肿感染等情况出现。结论:以3D适形打印技术制备的羟基磷灰石/聚乳酸复合体对兔颅骨缺损有较好的修复作用,能促进缺损区域新骨的形成和生长,且安全性较高。     

VSD负压引流技术结合游离植皮治疗大面积皮肤缺损的 临床疗效研究

目的：研究VSD负压引流技术结合游离植皮治疗大面积皮肤缺损临床疗效。方法：选择2012年4月至2013年10月入我院接受治疗的大面积皮肤缺损患者65例,将其随机分为观察组（35例）与对照组（30例）。观察组患者术前先采用VSD治疗,游离植皮术后继续给予VSD治疗;对照组患者采取打压植皮或传统打包加压治疗。观察和比较两组患者的皮片成活时间、皮片成活率、术后住院治疗时间、换药次数、疼痛评分及家属满意度。结果：观察组患者的皮片成活时间短于对照组、皮片成活率高于对照组、住院时间短于对照组,换药次数少于对照组,两组之间的差异具有统计学意义（P〈0．05）。此外,观察组患者的疼痛视觉模拟评分明显低于对照组,患者家属的满意度评分明显高于对照组,差异具有统计学意义（P〈0．05）。结论：相对于传统的打压植皮或传统打包加压的技术而言,VSD负压引流技术结合游离植皮在治疗大面积皮肤缺损的临床疗效更好,值得在临床上推广使用。     

Survival of skin allografts following embryonic limb bud transplants in the turtle,Chelydra serpentina

Allografts of skin were observed in Chelydra serpentina. The response to these grafts was modified by a previous transplantation of a limb bud at an early embryonic stage. When the same donor was used for all transplants, the first skin graft was accepted by the host. A second skin graft, however, was rejected at about the rate of a simple first set allograft of skin. The animals were conditioned by the embryonic limb graft; this embryonic graft can be undergoing rejection at the same time a first set skin graft from the same donor was being accepted. The tolerance induced by the embryonic graft was sepcific for its donor.     

Lymphedema of the eyelids

Lymphedema of the eyelids is a relatively rare condition whose main effect is to obstruct vision, and it is unsightly. We present 3 cases in which the edema was treated by excision and skin grafting of the eyelid, with satisfactory functional and cosmetic results. It is suggested that a split-skin graft be used for the upper eyelid and a full-thickenss graft for the lower eyelid. The lower eyelid skin can be "de-fatted" and used as a graft, but in the more severe cases we suggest a postauricular skin graft be used.     

A simple method of preparing split-thickness skin grafts for meshing

A simple and rapid technique of mounting a split-thickness skin graft on the Tanner dermacarrier is presented. Initially, petroleum jelly is applied onto the grooved surface of the dermacarrier. The skin graft is not removed from the donor site; instead, the skin graft knife is withdrawn backwards, allowing the graft to slip back, smoothly and evenly, onto the donor site through the knife. The dermacarrier, with the petroleum jelly, is laid onto the graft. The graft adheres to the dermacarrier because of the jelly. No further maneuver is necessary prior to meshing. With this technique it is impossible to apply the graft cut-side up on the recipient site.     

A simple bone dust collector

A new instrument for harvesting craniotome bone dust is described. This has been designed with the contours of the skull in mind and the ideal bone fragment size for satisfactory graft take.     

Prolonged life and improved quality for stored skin grafts

This study is presented as both a follow-up and an extension of previous work on storage techniques for the preservation of skin by refrigeration. Rabbit skin grafts were used to compare the merits of various storage media. One of the media, McCoy's 5A plus serum, gave improved skin graft take and storage half-life. The ability to improve skin graft storage techniques is most beneficial to all aspects of plastic and reconstructive surgery where skin grafting is required. Prolonged graft viability and improved graft quality are of major clinical importance.     

游离植皮联合负压封闭引流治疗骨科创面的临床研究

目的：观察游离植皮联合负压封闭引流（vacuumsealingdrainage,后文简称VSD）对骨科创面的疗效,并与植皮后传统加压包扎相比较,为临床实践提供更好的治疗方法。方法：对广州中医药大学第一附属医院创伤骨科2008年3月至2010年2月收治的65例感染创面病例采取手术清创后予VSD引流,合理应用抗生素,创面感染得到控制后,创面干净,肉芽生成良好,外露的肌腱、骨膜表面有新鲜的肉芽组织覆盖,达到植皮的要求后,随机分成两组,其中30例（实验组）采用游离植皮联合VSD法闭合创面,35例（对照组）采用游离植皮加压包扎植皮区,对两组术后的平均换药次数、创面平均愈合时间、植皮成活率情况、平均住院时间（植皮后）、平均抗生素应用次数（植皮后）进行统计学分析,采用t检验和卡方检验,对此两种方法进行评价。结果：植皮联合VSD组与植皮加压包扎组,在平均换药次数、创面平均愈合时间、植皮成活率、平均住院时间（植皮后）、平均抗生素应用次数（植皮后）的对比,有显著性差异（P〈0.05）。结论：创面达到游离植皮条件后,游离植皮联合VSD负压引流可以促使皮片黏附,保持创面洁净,避免皮下渗液积聚,有利于皮片的存活,与植皮加压包扎组相比,减少了平均换药次数,缩短创面平均愈合时间及平均住院时间（植皮后）,减少抗生素平均应用次数,提高了植皮成活率,说明游离植皮联合VSD组优于游离植皮加压包扎组,游离植皮联合VSD法治疗骨科创面有显著疗效。该手术方法操作简单,术后护理方便,是一种较理想的植皮后的固定方法,有利于创面的愈合,值得临床推广应用。     

Effects of monoclonal anti-H-2Ld and anti-H-2Dd alloantibodies in the immunological enhancement of skin grafts and neonatal heart grafts in the mouse

Three anti-H-2Ld and two anti-H-2Dd monoclonal alloantibodies were analyzed for their capacity to enhance skin graft and neonatal heart graft survival. Of two anti-H-2Ld antibodies with the same specificity but with different isotypes, IgG2a antibody 30-5-7S prolonged graft survival in a skin graft combination with an Ld difference, whereas IgM antibodies did not. A second IgG2a antibody, but with a specificity different from 30-5-7S, was ineffective on its own. However, when mixed with 30-5-7S, skin graft survival was augmented as compared with the prolongation by 30-5-7S alone. Enhancement by anti-H-2Ld antibodies was dependent on the extent of the H-2 graft barrier. It was abrogated on extension of the graft barrier to a D-end H-2 difference by using the B10.A----B10.BR combination. Also, anti-Dd antibodies, either alone or in combination with anti-Ld, were ineffective in this skin graft combination. By using the same graft combination but the less immunogenic neonatal heart graft model, anti-Ld antibodies were still ineffective, but both anti-Dd antibodies were able to enhance graft survival from 15 to 22 days. When mixed with anti-Ld antibody 30-5-7S, graft survival was augmented further to 30 days. These results indicate that two kinds of enhancing alloantibodies may be distinguished. One category interacts with immunodominant epitopes on H-2 molecules, but their effectiveness may be limited to a particular H-2 difference, because immunodominance may vary from one graft barrier to another. In the second category, antibodies are ineffective on their own but they are able to potentiate the effects of antibodies of the first kind. These allocations are relative, however, because they are dependent on the type of graft examined.     

超短波促进烧伤肉芽创面植皮片愈合的临床观察

目的:观察超短波对烧伤肉芽创面受皮区皮片成活的影响。方法:32例自身对照邮票皮移植及40例整张刃厚皮移植术后根据是否给予超短波治疗分别分为两组,治疗组术后接受无热量超短波治疗,对照组术后未接受超短波治疗,观察创面完全愈合时间和愈合创面水泡出现情况进行疗效判定。结果:根据两组患者创面愈合时间进行比较,治疗组明显低于对照组(P<0.01);而在创面水泡出现程度比较中,实验组水泡发生率和严重程度均明显低于对照组(P<0.05)。结论:超短波治疗能明显促进烧伤肉芽创面植皮片的成活,加速烧伤创面的愈合。     

Long-term survival of a free split-thickness skin graft on a large seroma

A free skin graft about 12 cm in diameter transplanted after excision of a Bowen's carcinoma on the back totally survived for a long period on seroma and was confirmed to have revascularization from the host skin margin. Repeated evacuations of the fluid and subsequent pressure dressings failed to cause adherence of the graft to the bed, even on the thirty-ninth postoperative day. Histologic examination of the graft and the bed revealed partial epithelialization on the face-to-face surfaces, to which no adherence was attributed. The incomprehensible phenomenon in this unusual clinical case evokes a new interest in the mechanism of free skin graft survival, particularly in the phase of serum imbibition.     

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.     

Possibility of predicting rat wound epithelization by changes in matrix metalloproteinases activities in wound exudate

The engraftment of a free skin graft introduced into an unhealing wound as a source of epithelization in combination with a transplantation of a dermal equivalent was studied in rats. The course of wound healing was estimated by changes in the activity levels of metalloproteinases (MMPs) in wound exudates. It was shown that the results of skin-graft transplantation could be predicted by monitoring changes in wound exudates MMP-2 and MMP-9 activities. It was found that engraftment of the skin graft occurred at intermediate activity values of MMP-2 and MMP-9 in the wound exudates, whereas their low and high activities correspond to lysis of the transplanted skin graft.     

Split-thickness skin grafting of the myelomeningocele defect: a subset at risk for late ulceration

The appropriate method and timing of the management of the myelomeningocele defect have prompted considerable discussion. Use of split-thickness skin grafts acutely has accomplished wound closure with low morbidity and mortality. This study was designed to address the question of long-term suitability of the technique of split-thickness skin grafting of the myelomeningocele patient. The incidence of late and/or severe skin ulceration and the presence of gibbus deformity were correlated with the method of skin closure. Long-term follow-up revealed a higher incidence of chronic skin ulceration in the split-thickness skin graft group as compared with the primary closure group. All skin breakdowns appeared in the presence of a gibbus deformity, and gibbus deformity was more prevalent in the split-thickness skin graft group. The incidence of skin ulceration and gibbus deformity was site-dependent. A thoracic or thoracolumbar myelomeningocele repair with split-thickness skin graft was significantly more likely to be complicated by skin problems than the defect in the lumbar, lumbosacral, or sacral region. This relationship was secondary to the frequency of gibbus deformity in the more cephalad defects than defects caudad. A treatment plan is outlined that is based on the primary variable of the location of the myelomeningocele and secondarily by defect size.     

The influence of systemic growth hormone administration on the healing time of skin graft donor sites in a pig model

A more rapid healing of skin graft donor sites has often been observed during ultimoratio therapies with growth hormone in adults who have suffered extremely severe burns. The purpose of this animal experimental study was to examine the influence of systemic growth hormone administration on the healing time of skin graft donor sites under standardized conditions in pigs. The animals were 14 (7 experimental and 7 control) male, sexually mature, German domestic pigs, in which 30 skin graft donor sites 8 cm x 4 cm and 0.6 mm deep were created. Fifteen each of the skin graft donor sites were bandaged with the same material [hydrocolloid bandage (Varihaesive E) and PVP-iodine gauze (Braunovidon Gaze)]. The test period was 15 days for each pig, whereby recombinant growth hormone (0.5 IU/kg body weight per day) was applied subcutaneously in the experimental group. The bandages were changed under brief narcosis every 2 days, during which one skin-punch biopsy was taken per skin graft donor site, and blood samples were drawn for determination of the serum IGF-1 values. Photographic documentation was also recorded. The biopsies were examined histologically (hematoxylin and eosin stain) and immunohistochemically (collagen IV and VII, and laminin), whereby histologically the start of keratinization was assessed as a healing criterion. The serum IGF-1 values in the growth hormone group were statistically significantly higher than in the control group. Immunohistochemically, a complete basal membrane was observed in both the experimental and the control group after the 7th or 8th day. A clearly elevated serum IGF-1 level correlated in the growth hormone group with the skin graft donor sites healing. It could thus be demonstrated both clinically and histologically that systemic application of growth hormone results in a statistically significantly more rapid healing of the skin graft donor sites by 2 days earlier than in the control group.     

Direct regulatory role of NKT cells in allogeneic graft survival is dependent on the quantitative strength of antigenicity

The role of NKT cells during immune responses is diverse, ranging from antiviral and antitumor activity to the regulation of autoimmune diseases; however, the regulatory function of CD1d-dependent NKT cells in rejection responses against allogeneic graft is uncertain. In this study, we demonstrated the direct regulatory effects of CD1d-dependent NKT cells using an allogeneic skin transplantation model. H-Y-mismatched skin graft survival was shortened in CD1d-/- recipients compared with wild-type recipients. Adoptive transfer of syngeneic NKT cells via splenocytes or hepatic mononuclear cells into CD1d-/- recipients restored graft survival times to those of wild-type recipients. alpha-Galactosylceramide, a specific activator of NKT cells, further prolonged graft survival. Although CD1d-dependent NKT cells did not extend skin graft survival in either major or complete minor histocompatibility-mismatched models, these cells affected graft survival in minor Ag mismatch models according to the magnitude of the antigenic difference. The afferent arm of NKT cell activation during transplantation required CD1d molecules expressed on host APCs and the migration of CD1d-dependent NKT cells into grafts. Moreover, the regulatory effects of CD1d-dependent NKT cells against alloantigen were primarily IL-10 dependent. Taken together, we concluded that CD1d-dependent NKT cells may directly affect the outcome of allogeneic skin graft through an IL-10-dependent regulatory mechanism.     

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.     

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.