Use of Banked Tissue in Plastic Surgery

The availability of safe and reliable, banked tissues in India has enabled the use of human bone allografts as a viable alternative to autografts in reconstructive surgery. Lyophilised, irradiated bone grafts were used in 2 cases of rhinoplasty, a case of hemifacial atrophy, and as a chin implant.In the patient with revision rhinoplasty the rib graft was resorbed. The patient with hemifacial atrophy developed seroma and infection in the zygomatic and infraorbital area and the rib graft had to be removed. The graft from the same rib that was placed over the mandible was retained well and incorporated completely. The iliac crest cortico-cancellous grafts did well in the second case of augmentation rhinoplasty and in the augmentation of chin.The primary objective of reconstructive surgery in the treatment of burns, non-healing wounds and pressure sores is to remove the dead tissue and restore the continuity of the skin without delay. Lyophilised, irradiated, human amnion is a temporary biological dressing conveniently available off-the-shelf. It was used in twenty four patients with burns, eight patients with bedsores and six patients with non-healing ulcers mainly on the foot. The total surface areas of burns sustained were from 2% to 40%. The burns ranged from second degree to deep third degree burns. Amnion was not used in patients with infected third degree burns.The amnion provided good biological cover in all the patients. It was easy to handle and apply, and provided pain relief. The duration of healing varied depending on the extent and depth of the wound and the amount of exudate. The superficial bedsores healed with a single application of amnion. Reduced exudate, healthy granulation tissue and enhanced epithelisation were observed following application of amnion.     

Comparison of donor-site healing under Xeroform and Jelonet dressings: unexpected findings

Split-thickness skin grafts remain central to the strategy of burn wound treatment. The dressing used to cover the donor wound site has a significant effect on healing parameters. The purpose of this study was to compare split-thickness skin graft donor site reepithelialization under Xeroform and Jelonet dressings. A dermatome was used to cut two consecutive strips of skin from 25 paired donor sites on the thigh, calf, or back of 19 participants. Standardization of the harvest method was achieved by using the same surgeon to harvest the compared skin graft strips, with attention to consistency of dermatome skin-thickness setting, downward pressure, and angle of dermatome approach. A strip of Xeroform or Jelonet was applied to one of each pair of wounds. Epidermal and dermal thickness was measured from biopsy specimens cut at the midpoint of each split-thickness graft strip. The day of final dressing separation was declared the day of complete donor reepithelialization (healing). The mean healing time for Xeroform and Jelonet was 10.4 +/- 2.6 days (n = 25) and 10.6 +/- 2.8 days (n = 25) (p = 0.76) at sites cut to a mean depth of 0.23 +/- 0.08 mm and 0.23 +/- 0.09 mm (p = 0.89), respectively. There was no correlation between graft thickness and healing time for sites dressed with Xeroform (r = 0.17) or Jelonet (r = 0.02). Donors sites reharvested 10 to 21 days after a prior harvest healed an average of 3.1 days earlier than virgin sites (8.4 +/- 1.6 versus 11.5 +/- 2.6 days, p < 0.001), although reharvested grafts were on average 0.05 mm thicker (p = 0.10). The mean thickness of reepithelialized donor-site epidermis (0.13 +/- 0.04 mm, n = 30) was found to be twice the thickness of virgin epidermis from the same sites (0.06 +/- 0.02 mm, n = 38, p < 0.001). Thirty-six grafts harvested with dermatomes set to cut 8/1000 inch (0.20 mm) deep ranged from 0.12 to 0.42 mm thick, with only eight of these grafts measuring within +/-10 percent of the desired thickness setting. Before donor dressing separation, Xeroform and Jelonet dressings were judged to be more comfortable by nine patients and one patient, respectively, whereas no difference was detected by six patients. The authors now use Xeroform as the preferred donor dressing.     

Decellularized amnion scaffold with activated PRP: a new paradigm dressing material for burn wound healing

Direct application of amnion has greater risk of immunological rejection and infection. Decellularization is an effective method to lower the risk of immune complications and infections. The bioreactor assembly with multiple cassettes was designed for decellurization of multiple amnions with different cell types simultaneously in single run. A detergent-based protocol was modified to remove all cellular components from amnion and diminish the DNA content to render it non-immunogenic. Amnion (n = 10) were treated with 2% sodium dodecyl sulphate (SDS), 5% dimethyl sulfoxide (DMSO) and 2% sodium deoxycholeate (SD). Decellularized amnion samples were analyzed by haematoxylin–eosin staining (HE), Alcian blue pH 1 (AB-pH-1), 4,6-diamnionidino-2-phenylindol (DAPI), Massion’s trichrome stain, DNA quantification, mechanical testing and scanning electron microscopy (SEM). Histological analysis showed complete removal of cellular components and the histoarchitecture of scaffold remained intact. Amnion scaffold activated with platelet rich plasma (PRP) and calcium chloride composition supported better adherence to the wound than amnion alone. Only single application showed good healing. In vivo assessment of activated amnion revealed stable dressing. It has good promising outcome. At day 7, histologically the wounds treated with activated amnion were almost closed without scarring and showed well differentiated epidermis, proliferation of keratinocytes, hair follicles and basement membrane as compared to controls and silver nitrate gel dressings in a mouse (Mus musculus). Cryopreservation had no adverse effect on the mechanical properties of the amnion scaffold. Cryopreservation of decellularized amnion by Dulbecco’s modified eagle medium (DMEM) was expected to prepare off-the-shelf skin substitutes and preserve them to be immediately available upon request of patients’ needs.     

EVALUATION OF EXPOSURE TREATMENT OF BURNS

For purposes of comparison with the occlusive dressing method of treating burns, the exposure method was used in 30 cases—16 of first and second degree and 14 of third degree. Attempt was made to simulate the conditions which might be expected to prevail in mass treatment of burned patients—inadequate personnel and materials. Elaborate measures to immobilize burned areas were not employed.Healing of first and second degree burns was natural and the results satisfactory without further treatment. In third degree burns, skin grafting was necessary after the eschar was removed. Cracking of the eschar several days before time to remove it in some cases of third degree burns necessitated use of occlusive dressings in the last few days before skin grafting was done.The exposure method is considered valuable in circumstances in which saving of time, material and personnel is indicated. Generally it is not suitable for treatment of encircling burns of the trunk or extremities, since maintaining the integrity of the eschar is extremely difficult in such situations.     

A prospective, blinded, randomized, controlled clinical trial of topical negative pressure use in skin grafting

Topical negative pressure has been demonstrated to improve graft take in a number of noncomparative studies. This study aimed to assess whether split-thickness skin graft take is improved qualitatively or quantitatively with topical negative pressure therapy compared with standard bolster dressings. A blinded, prospective, randomized trial was conducted of 22 adult inpatients of Liverpool Hospital between July of 2001 and July of 2002 who had wounds requiring skin grafting. After grafting, each wound half was randomized to receive either a standard bolster dressing or a topical negative pressure dressing. Skin graft assessment was performed at 2 weeks by a single observer blinded to the randomization. Two patients were lost to follow-up and were excluded from the study. There were 20 patients (12 men and eightwomen) in the study group. The median patient age was 64 years (range, 27 to 88 years), and the mean wound size was 128 cm2 (range, 35 to 450 cm2). The wound exposed subcutaneous fat in eight patients, muscle in six patients, paratenon in four patients, and deep fascia in two patients. At 2 weeks, wounds that received a topical negative pressure dressing had a greater degree of epithelialization in six cases (30 percent), the same degree of epithelialization in nine cases (45 percent), and less epithelialization in five cases (25 percent) compared with their respective control wounds. Graft quality following topical negative pressure therapy was subjectively determined to be better in 10 cases (50 percent), equivalent in seven cases (35 percent), and worse in three cases (15 percent). Although the quantitative graft take was not significant, the qualitative graft take was found to be significantly better with the use of topical negative pressure therapy (p < 0.05). Topical negative pressure significantly improved the qualitative appearance of split-thickness skin grafts as compared with standard bolster dressings.     

The use of human deceased donor skin allograft in burn care

Burns are tissue wounds caused by thermal, electrical, chemical cold or radiation injuries. Deep injuries lead to dermal damage that impairs the ability of the skin to heal and regenerate on its own. Skin autografting following burn excision is considered the current gold standard of care, but lack of patient’s own donor skin or unsuitability of the wound for autografting may require the temporary use of dressings or skin substitutes to promote wound healing, reduce pain, and prevent infection and abnormal scarring. These alternatives include deceased donor skin allograft, xenograft, cultured epithelial cells and biosynthetic skin substitutes. Allotransplantation is the transplantation of cells, tissues, or organs, sourced from a genetically non-identical member of the same species as the recipient. Human deceased donor skin allografts represent a suitable and much used temporizing option for skin cover following burn injury. The main advantages for its use include dermoprotection and promotion of reepithelialisation of the wound and their ability to act as skin cover until autografting is possible or re-harvesting of donor sites becomes available. Disadvantages of its use include the limited abundance and availability of donors, possible transmission of disease, the eventual rejection by the host and its handling storing, transporting and associated costs of provision. This paper will explore the role of allograft skin in burn care, defining the indications for its use in burn management and the future potential for allograft tissue banking.     

削痂植皮术后结合负压封闭引流在深度烧伤患者中的应用效果及对血清致痛因子及炎性因子的影响

摘要 目的：探讨削痂植皮术后结合负压封闭引流在深度烧伤患者中的应用效果及对血清致痛因子及炎性因子的影响,以此为临床治疗深度烧伤患者提供参考。方法：选取暨南大学附属第一医院在2018年1月至2022年1月期间收治的75例深度烧伤患者进行回顾性分析,所有患者均接受削痂植皮术治疗;按术后不同换药方法分为常规换药组和VSD组,其中常规换药组35例,术后常规换药;VSD组40例,术后采用VSD治疗。比较两组患者首次植皮成活率,术后1周、2周创面愈合率,创面愈合时间,疼痛程度及并发症发生率等,测定两组患者血清致痛因子、冲洗液炎性因子表达水平。结果：VSD组首次植皮成活率95.00%（38/40）,常规换药组首次植皮成活率71.43%（25/35）,差异有统计学意义（P<0.05）。VSD组术后1周、2周创面愈合率高于常规换药组,创面愈合时间、创面疼痛评分低于常规换药组,差异有统计学意义（P<0.05）。两组术后1周相关致痛因子表达较术前明显下降（P<0.05）,且VSD组致痛因子表达低于常规换药组,差异有统计学意义（P<0.05）。两组术后1周冲洗液炎性因子表达低于术前（P<0.05）,且VSD组冲洗液炎性因子表达与常规换药组比较下降明显,差异有统计学意义（P<0.05）。VSD组术后并发症发生率12.50%（5/40）低于常规换药组40.00%（14/40）,差异有统计学意义（P<0.05）。结论：削痂植皮术后结合负压封闭引流技术可提高深度烧伤患者创面愈合效果,增加首次植皮成活率,减少细菌生成、炎性因子的释放,减轻创面疼痛程度,值得临床进一步研究。     

Physical Changes of Amniotic Membranes Through Glycerolization for The Use as an Epidermal Substitute. Light and Electron Microscopic Studies

Our Department of Plastic and Reconstructive Surgery has routinely been using amnion preserved in glycerol for the treatment of debrided II° burns. This treatment is almost pain free and requires fewer changes of dressings and fewer anaesthetics. It also prevents overgrowing granulation tissue and lessens scarring. Since 1910 amnion has been used as biological wound dressing. Its advantages such as reduced loss of protein and electrolytes, fluids and energy as well as reducing the risk of infection and accelerated regeneration of the epithelium have been well documented in medical literature. In order to more closely examine the question of possible changes to the micro structure of the amnion through preservation and rehydration as well as the interaction between transplanted tissue and recipient, we have carried out several light and electron microscopic studies. Results showed that neither the treatment with glycerol, nor the pretransplantation rehydration eliminates the monolayer of surface epithelium of the amnion. Its complex architecture remains intact during the preservation process and is therefore suitable as a matrix for the growth of keratinocytes and thereby the healing process. In clinical use we found amnion to be an excellent wound dressing as it allows proper control of fluid, has sufficient permeability for gases, has good thermal properties, is impervious to micro-organisms and is free from toxic material. This revised version was published online in July 2006 with corrections to the Cover Date.     

Effect of a Synthetic Dressing Formed on a Burn Wound in Rats: a Comparison of Allografts, Collagen Sheets, and Polyhydroxyethylmethacrylate in the Control of Wound Infection

Allograft dressings to control Pseudomonas wound infections in rats were studied on surgical wounds and escharectomized burn wounds. The effects of allografts were compared with a collagen sheet (Aviderm) and a synthetic dressing, polyhydroxyethylmethacrylate (Hydron), formed on the wound by mixing the polymer and the solvent. The results indicated that infections in surgical wounds were more easily controlled by dressings than similar contaminations in burn wounds. A procedure was described for the formation of a synthetic dressing directly on the wound from a mixture of polymer and solvent. This type of preparation completely filled the wound area and sealed the edges, preventing further contamination, and gave excellent coverage of the wound. With 24 h of coverage of escharectomized burn wounds, allografts provided the best dressing for reduction of wound organisms. At 96 h of coverage, Hydron and Aviderm produce significant reductions in the Pseudomonas resident in the burn wound. The results support the thesis that suitable dressings promote local host defense processes which kill the contaminating bacteria.     

Use of Irradiated Amnion as a Biological Dressing in the Treatment of Radiation Induced Ulcers

The management of moist skin desquamation (ulceration) following radiation therapy has been a concern since the inception of this therapy. The treatment of skin reactions focuses on promoting healing, improving patient comfort preventing infection and decreasing trauma to the area. Various dressings like topical preparations, hydrocolloid and gentian violet 1 % dressing have been used for its treatment. We present our experience with the use of amnion as a biological dressing in patients with radiation induced ulceration following pelvic radiation using megavoltage beam. The preliminary experience with treatment in 14 patients proved to be cost effective due to a shorter duration of ulcer healing (median of 7 days), fewer dressing changes (median of 4 dressings) and diminished use of analgesics.     

Wound‐healing evaluation of entrapped active agents into protein microspheres over cellulosic gauzes

The use of active ingredients in wound management have evolved alongside the pharmaceutical agents and dressings used to deliver them. However, the development of gauzes, dressings with specific properties, still remains a challenge for several medical applications. A new methodology for the controlled release of active components for the healing of burn wounds is proposed herein. Cotton and non‐woven bandages have been cationised to promote the attachment of protein microspheres. The active agents, piroxicam and vegetable oil, were entrapped into the microspheres using ultrasound energy. Active agents were released from the microspheres by a change in pH. Wound healing was assessed through the use of standardised burn wounds induced by a cautery in human full‐thickness skin equivalents (EpidermFT). The best re‐epithelialisation and fastest wound closure was observed in wounds treated with proteinaceous microspheres attached to gauzes, after six days of healing, in comparison with commercial collagen dressing and other controls. Furthermore, the ability of these materials to reduce the inflammation process, together with healing improvement, makes these biomaterials suitable for wound‐dressing applications.     

Wound dressings for a proteolytic-rich environment

Wound dressings have experienced continuous and significant changes over the years based on the knowledge of the biochemical events associated with chronic wounds. The development goes from natural materials used to just cover and conceal the wound to interactive materials that can facilitate the healing process, addressing specific issues in non-healing wounds. These new types of dressings often relate with the proteolytic wound environment and the bacteria load to enhance the healing. Recently, the wound dressing research is focusing on the replacement of synthetic polymers by natural protein materials to delivery bioactive agents to the wounds. This article provides an overview on the novel protein-based wound dressings such as silk fibroin keratin and elastin. The improved properties of these dressings, like the release of antibiotics and growth factors, are discussed. The different types of wounds and the effective parameters of healing process will be reviewed.     

Promotive effects of a silk film on epidermal recovery from full-thickness skin wounds

We examined the effects of the transparent fibroin film (silk film) on full-thickness skin wounds. Full-thickness dermatotomies (15 mm x 9 mm) were prepared on the dorsal wall of CRJ:CD-1 nu/nu (ICR nu/nu) mice. The area of the wounds dressed with silk film was reduced to 10% of that made by the dermatotomy 14 days after the dermatotomy and were covered with regenerated epidermis 21 days after the dermatotomy. In contrast, less recovery and epidermal regeneration were found 14 days after dermatotomy in the wounds dressed with a conventional hydrocolloid dressing (Duro Active). Furthermore, only partial incomplete epidemal growth was obtained 21 days after dermatotomy. Most importantly, the healing time of wounds dressed with silk film was 7 days shorter than those dressed with DuoActive dressing. The silk film showed an almost similar or slightly better promotive effect as the lyophilized porcine dermis (Alloask D), which is used as a dressing for burns, ulcers, and decubitis. Histologic findings revealed that there was greater collagen regeneration and less inflammation and neutrophil-lymphocyte infiltration of the wounds dressed with silk film than with DuoActive dressing. It is clear that regeneration of the epidermis and dermis of the wound beds covered with silk film was faster than with DuoActive dressing. Finally, silk film is easily obtainable, sterilizable, and transparent, and it allows easy observation of tissue recovery. Therefore, silk film offers advantages over other dressings and may be clinically useful for wound treatment.     

Challenges in the provision of skin in the UK: the use of human deceased donor skin in burn care relating to mass incidents in the UK

This article aims to discuss the role of deceased donor skin within the treatment of burn injuries with particular reference to the management of major burn disasters. The article begins with a review of wound healing before progressing to outline the development of the current modern day approach to burns surgery from its historical origins and the role of deceased donor skin within this. A detailed review of mass disasters within the UK over the past 29 years provides an indication as to the frequency and extent of mass disasters that might be predicted to occur. Combining this with a recent review of allograft requirements within burns surgery at a regional UK centre allows for more accurate planning and stockpiling of deceased donor skin reserves. UK awareness and emergency preparedness for major burn disasters can thus be improved.     

Clinical trials of amniotic membranes in burn wound care

Four test conditions of increasing complexity were used to evaluate the clinical efficacy of amniotic membranes as biologic dressings on donor sites and burn wounds in children. These were the clean-skin donor-site wound, the uncontaminated shallow partial-thickness burn wound, the bed of freshly excised full-thickness wounds, and the granulating surface of colonized burn wounds. The rate of epithelialization under amniotic membranes was the same as that under 5% scarlet red ointment or 0.5% silver nitrate solution dressings. Preservation of a healthy excised wound bed and maintenance of a low bacterial count in contaminated wounds paralleled the experience with human allograft dressings despite technical difficulties and the absence of vascularization of amniotic membrane and its fragile structure. Tentative conclusions are drawn as to the mechanisms by which biologic dressings exert their beneficial effects.     

Cultured epidermal allografts: Quantitative evaluation of their healing effect in deep dermal burns

This study summarizes the Brno Burn Centre experience with the application of cultured epidermal allografts (CEAl) in the treatment of deep dermal burns. In a prospective randomised trial on 30 patients with deep dermal burns CEAl obtained from young healthy and examined donors and fixed on tulle grass carrier (Grasolind) were compared with empty Grasolind as the lowest layer of dressing. All the other layers were identical. Both kinds of dressing were applied simultaneously on the same deep dermal burn wound between 6th and 10th day after burn. Six days later the non-healed wound areas were recorded through painting on cellophane membrane and scanned in the computer. The percentage of wound reduction was calculated and statistically evaluated. The reduction of the non-epithelialized wound area was 86.5% when covered through CEAl and only 71.2% when covered with tulle grass (Grasolind) only. This difference is statistically significant. In conclusion it can be stated that cultured epidermal allografts strongly stimulate reepithelialisation in deep dermal burns. This revised version was published online in July 2006 with corrections to the Cover Date.     

Acute burn care

LEARNING OBJECTIVES: After studying this article and accompanying Supplemental Digital Content, the participant should be able to: 1. Explain current burn-prevention strategies and criteria for referral to a burn center. 2. Summarize the current advances made in the critical care of acute burn patients. 3. Outline the recent developments in burn depth assessment and burn wound dressing technology. 4. Describe the common psychosocial aspects of postburn rehabilitation. SUMMARY: Burn patients require interdisciplinary care in which the plastic surgeon plays a prominent role. Appropriate referral, assessment, treatment, and posttreatment supports are essential to achieving favorable outcomes following burn injury. The authors reviewed the current literature on epidemiology, prevention, referral criteria, critical care, wound assessment, wound dressings, and psychosocial aspects of burn injury. Recent advances in burn care are highlighted and have been made possible through ongoing collaborative epidemiologic, clinical, and basic biomedical research. A systematic interdisciplinary approach to the evaluation and treatment of acute burn injuries is pivotal to providing patients with the greatest chance of functional recovery. Plastic surgeons treating burn patients must remain current in a wide variety of areas, ranging from critical care to psychosocial rehabilitation.     

The use of allogeneic cultivated keratinocytes for the early coverage of deep dermal burns – indications, results and problems

Since 1995, keratinocytes are grown into cultures and used as allografts for the coverage of deep dermal defects in our burn unit. Donor skin samples are mostly acquired from other burn patients. In addition, special methods of skin preservation allow us the use of skin, which has been taken in redundancy for split thickness skin grafting from nonburned patients.Thirty five patients with deep partial thickness burns in the face were treated since 1996 according to the following concept: Dermabrasion or tangential excision was performed before the 5(th) day following trauma. If viable dermis was present, the wounds were covered with sheets of allogeneic cultivated keratinocytes. In cases of deeper defects, autologous skin grafts were applied. In 23 cases, epithelialisation was achieved within 10 days, in 8 patients, a prolonged duration until complete healing was observed. In 5 faces, coverage of residual defects with skin grafts was necessary. The mentioned problems of wound healing occurred from infection, incomplete excision of burn eschar and a depth of the wound which was retrospectively seen too deep for the treatment with keratinocytes. At follow up, patients were examined clinically and functionally with Frey's faciometer(R), which is an instrument for quantification of mimic movements. In cases of uncomplicated healing, a nearly complete restitution was found.Other indications include deep dermal burns in children and the coverage of early excised wounds in adults, with a reasonable amount of viable dermis remaining, both resulting in a significant reduction of donor-site morbidity. In severely burned adults with limited donor sites, it offers the possibility of immediate definite coverage of large areas.     

Glycerol treatment as recovery procedure for cryopreserved human skin allografts positive for bacteria and fungi

Human donor skin allografts are suitable and much used temporary biological (burn) wound dressings. They prepare the excised wound bed for final autografting and form an excellent substrate for revascularisation and for the formation of granulation tissue. Two preservation methods, glycerol preservation and cryopreservation, are commonly used by tissue banks for the long-term storage of skin grafts. The burn surgeons of the Queen Astrid Military Hospital preferentially use partly viable cryopreserved skin allografts. After mandatory 14-day bacterial and mycological culture, however, approximately 15% of the cryopreserved skin allografts cannot be released from quarantine because of positive culture. To maximize the use of our scarce and precious donor skin, we developed a glycerolisation-based recovery method for these culture positive cryopreserved allografts. The inactivation and preservation method, described in this paper, allowed for an efficient inactivation of the colonising bacteria and fungi, with the exception of spore-formers, and did not influence the structural and functional aspects of the skin allografts.     

Comparative evaluation of aloe vera in the management of burn wounds in guinea pigs

An experimental study was designed using Hartley guinea pigs, who received full-thickness burns covering 3 percent of their body surface area by direct contact with a hot plate. A total of 40 animals were equally divided among four modalities of closed burn wound management as follows: group I: silver sulfadiazine (Silvadine); group II: aloe vera gel extract (Carrington Dermal Wound Gel); group III: salicylic acid cream (aspirin); and group IV: plain gauze occlusive dressing only. The dressings were changed daily, and the size and appearance of each burn wound were recorded until complete healing. On the sixth postburn day, quantitative burn wound cultures were made. The average time to complete healing in the control group was 50 days, and the only significant difference was found in the aloe vera-treated animals, which healed on an average of 30 days (p less than 0.02). Wound bacterial counts were effectively decreased by silver sulfadiazine (p = 0.015) and by aloe vera extract (p = 0.015). From our data it appears that aloe gel extracts permit a faster healing of burn wounds.