Carbon dioxide laser resurfacing and thin skin grafting in the treatment of "stable and recalcitrant" vitiligo

Various surgical methods have been used in the treatment of small stable vitiliginous areas, but there is no established surgical approach for larger vitiligo areas and therapy-resistant anatomic sites, such as the hands. Two years ago, we successfully treated large burn scar depigmentation areas at different anatomic sites using carbon dioxide laser resurfacing and thin (0.2 to 0.3 mm) skin grafting. The purpose of this study was to investigate the effectiveness of our method in treating large, stable, and recalcitrant vitiligo areas. Thirteen anatomic sites of seven male patients, whose ages ranged from 20 to 22 years, were treated. The locations of the treated areas were as follows: seven areas on the dorsum of the hands, two areas on the forearms, two areas in the pretibial region, one area on the lateral thigh, and one area in the presternal region. The surface area of treated vitiligo sites ranged from 0.5 to 6 percent of total body surface area (mean, 2.5 percent). Skin graft take was excellent in all patients except for one. The follow-up period for these patients ranged from 6 to 18 months, with an average follow-up period of 14 months. Early and complete repigmentation was achieved and the color match was good or excellent in all patients. No depigmentation occurred again in the treated areas or graft donor sites. In conclusion, with careful patient selection and delicate surgical technique, our method was effective in treating large areas of vitiligo over the extremities and dorsum of hands, which were refractory to other therapies and could not be hidden.     

A comparison of scar revision with the free electron and carbon dioxide resurfacing lasers

Laser scar revision was studied to measure the effects of targeting extracellular matrix protein versus tissue water on scar revision. We compared the free electron laser used at 7.7 microm (the amide III protein absorption band) to the carbon dioxide (CO2) laser and dermabrasion.Nude mice (n = 40) that had rejected skin grafts on their dorsal surface and developed mature scars were used as a model for scar revision. One-half of each scar was revised with either the free electron laser at 7.7 microm (32 to 38 mJ, nonoverlapping pulses delivered with a computerized adjustable pattern generator at 30 Hz, and two to three passes), a 100-microsec CO2 resurfacing laser (500 mJ, 5.0 Hz, and two to five passes), or dermabrasion. The untreated portion of each scar served as an internal control. Evaluation was by measurement of the clinical size of the scar using photography with quantitative computer image analysis to compare the data and histology to evaluate the quality and depth of the scars.The free electron laser at 7.7 microm was significantly better than the CO2 laser and dermabrasion for scar size reduction (p < 0.046 and p < 0.018). The CO2 laser and a highly skilled dermabrader were not statistically significantly different (p < 0.44). The result seen with less skilled dermabraders was significantly worse than all other methods (p < 0.009).The free electron laser at 7.7 microm, which is preferentially absorbed by the proteins of the extracellular matrix, provided better scar reduction than the CO2 resurfacing laser and dermabrasion. Dermabrasion by a skilled operator resulted in improvement similar to the results obtained with the CO2 resurfacing laser, but less skilled operators had significantly poorer results.     

Effectiveness and Safety of the PEGT/PBT Copolymer Scaffold as Dermal Substitute in Scar Reconstruction Wounds (Feasibility Trial)

Skin defects left after excision of hypertrophic scars were treated with a dermal substitute and split-thickness skin grafts transplanted after vascularisation of the substitute. The used substitute was a synthetic porous scaffold made from the biodegradable copolymer polyethyleneglycol-terephtalate and polybuthylene-terephtalate. The study was designed to assess the rate of granulation tissue formation, graft take, and after 3 and 12 months the quality of life (pain, comfort of treatment, cosmetic or functional nuisance), scar formation and wound contraction. In addition, scaffold biodegradation and scar tissue formation were evaluated histologically. Seven patients with different causes of burn injury were enrolled, of which 5 completed the study. In the first 4 patients the time between scaffold application and split-thickness skin overgrafting was in between 17 and 24 days. The time point of overgrafting was significantly reduced to 10–12 days by meshing of the dermal scaffold as evidenced in the last 3 patients. Histological evaluation at 3 months revealed normal generation of dermal tissue, however, the collagen bundles were parallel organized like in scar tissue. In the deeper layers of the neodermis, fragments of the dermal substitute were present, causing a mild inflammatory response. One year post-treatment, some fragments of the copolymer were still observed. The extent of wound contraction after successful overgrafting ranged from 30% to 57% after 1 year. All 5 patients showed an improvement in the total Vancouver Scar Score compared to the value before scar removal being similar to what can be expected when treated with split-thickness skin grafts alone. No unanticipated adverse effects due to application of the substitute were observed. We conclude that although this synthetic dermal substitute can be safely used in humans, the presence of 3D dermal template in a full-thickness skin defect will not automatically improve the skin tissue regeneration process or inhibit wound contraction. This revised version was published online in July 2006 with corrections to the Cover Date.     

Reconstruction of the burned palm: full-thickness versus split-thickness skin grafts--long-term follow-up

The long-term results of full-thickness (N = 11) and split-thickness (N = 14) skin grafts for reconstitution of the palmar surface following release of palmar burn scar contractures in pediatric patients are compared. Patients treated with full-thickness skin grafts required 1.2 +/- 0.4 operations (mean +/- SD). Patients treated with split-thickness skin grafts required 1.3 +/- 0.6 operations (mean +/- SD). No significant difference in the number of operative procedures was noted. No functional difference existed between the two groups. The use of split-thickness skin grafts provided comparable function without increased operative procedures and was less deforming. Increased use of split-thickness skin grafts following release of palmar burn scar contractures in pediatric patients should be considered.     

The treatment of burn scar hypopigmentation and surface irregularity by dermabrasion and thin skin grafting

Scar tissue and leukoderma-type discoloration of the skin due to deep burns are treated by dermabrasion and thin split-thickness skin-graft application. This method was applied to 18 patients on whom the treated lesion sites were located as follows: 8 in the facial area, 9 on the extremities, and 1 on the neck. Adequate repigmentation and flat surfaces were obtained in all patients at the end of 6 months, and results persist at the end of a considerable follow-up period (1 to 4 years). The technique, advantages, disadvantages, and results are discussed.     

Fist position for skin grafting on the dorsal hand: II. Clinical use in deep burns and burn scar contractures

The fundamental problem in all types of hand burns is a loss of skin and subsequent deformities. The goal of skin grafting on the dorsal hand is to graft a sufficient amount of skin, as much as the original amount, and to restore normal hand function without secondary deformities. The safe, or Michigan, position commonly has been used for immobilizing the hand. However, this position is to protect hand function rather than to provide for adequate skin grafting. This institution has developed a new hand position (the fist position) for grafting the greatest amount of skin on the dorsal side of the hand. In the fist position, the hand is positioned flexing all joints of the wrist and the fingers and maximally stretching the dorsal surface of the hand before skin grafting. Ten hands with deep second- or third-degree burn (n = 6) and burn scar contracture (n = 4) of the dorsal hand in eight patients were treated with split-thickness skin grafting after immobilizing in the fist position. The burns and contractures involved nearly the total area of the dorsal hand. The hand was kept in the fist position for 7 to 9 days after skin grafting. Excellent functional and cosmetic results were observed in all cases during the follow-up period of 6 months to 2 years. Complications resulting from hand immobilization for a short period did not occur. The fist position may be a proper hand position for skin grafting to reconstruct the dorsal hand.     

Free tensor fasciae latae perforator flap for the reconstruction of defects in the extremities

In the three cases presented in this study, free tensor fasciae latae perforator flaps were used successfully for the coverage of defects in the extremities. This flap has no muscle component and is nourished by muscle perforators of the transverse branch of the lateral circumflex femoral system. The area of skin that can by nourished by these perforators is larger than 15 x 12 cm. The advantages of this flap include minimal donor-site morbidity, the preservation of motor function of the tensor fasciae latae muscle and fascia lata, the ability to thin the flap by removing excess fatty tissue, and a donor scar that can be concealed. In cases that involve transection of the perforator above the deep fascia, the operation can be completed in a very short period of time. This flap is especially suitable as a free flap for young women and children who have scars in the proximal region of the lateral thigh or groin region that were caused by split-thickness skin grafting or full-thickness skin grafting during previous operations.     

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.     

早期整形手术在深Ⅱ度烧伤患者治疗中的作用

为了探讨早期整形外科手术治疗对深Ⅱ度烧伤创面愈合后瘢痕挛缩畸形及功能障碍的影响,本研究选择深Ⅱ度烧伤患者60例作为研究对象,对患者进行早期功能性部位整形手术,其中研究组34例,对照组26例。对照组患者使用常规治疗和功能锻炼;研究组在对照组的基础上,使用瘢痕组织切除术、中厚皮肤移植术和术后功能锻炼,比较2组治疗后疗效的差异。研究结果表明,研究组34例烧伤患者接受整形手术后,各部位平均植皮成活率均达90%以上。术后第3个月和半年2组关节功能恢复效果不显著。研究组患者术后1年的关节功能恢复和疗效均显著优于对照组(p<0.05)。初步结论表明,研究组总有效率(100%)显著高于对照组(81.25%, p<0.05)。深Ⅱ度烧伤患者创面愈合后进行早期功能部位整形手术治疗能有效改善患处瘢痕挛缩导致的关节功能障碍。     

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.     

Rice cooker steam hand burn in the pediatric patient

Burn injuries often lead to significant cosmetic and functional deformity. In the Orient, household electric rice cookers have caused a significant number of steam burns to infant hands. The clinical course and treatment outcome of these burns have been studied retrospectively in a review of the medical records of 79 pediatric patients treated for acute hand steam burns and of 38 other patients who underwent correction for postburn contracture. Electric rice cookers caused all of the acute pediatric steam burns treated at our institute. Of the 81 hands treated between 1995 and 1998, 38.3 percent healed with conservative treatment and 61.7 percent required skin grafting. The volar aspects of the index and middle fingers were those most frequently involved. Eighteen of 36 hands (50 percent) grafted with split-thickness skin developed late contractures requiring additional procedures. Among the 38 patients who underwent correction for postburn deformity, initial treatment was split-thickness grafting for 60.5 percent, full-thickness skin grafting for 7.9 percent, and spontaneous healing for 31.6 percent. Awareness among medical personnel and continued public education should be promoted to help prevent this unique type of pediatric steam burn from occurring.     

Cultured epithelial autografts for giant congenital nevi

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

Outcome of scalp donor sites in 450 consecutive pediatric burn patients

The scalp is a useful and reliable donor site in pediatric burn patients that can be multiply harvested with minimal morbidity. Healing complications, however, may include alopecia and chronic folliculitis. To investigate scalp donor-site morbidity, a consecutive series of 2478 pediatric burn patients treated over a 10-year period were reviewed. A total of 450 of these patients had scalp donor sites for wound closure. Percent of total body surface area burned was 46+/-23 percent (mean+/-standard deviation), and the mean number of sequential scalp donor-site harvests was 2.2+/-2 (range, 1 to 10) with mean intervals between harvesting of 6+/-0.6 days. Ten patients (2.2 percent) had related complications. Eight patients developed scalp folliculitis, with Staphylococcus sp as the predominant organism (80 percent). Two patients were managed successfully with wound care alone; the other six patients required surgical debridement and split-thickness skin grafting to achieve wound healing. These eight patients developed varying degrees of alopecia. Two patients developed alopecia without previous folliculitis. Six patients required reconstructive surgery, which consisted of primary closure (3), staged excision (1), and tissue expansion (2). A number of variables were examined to determine any differences in the group that had complications compared with the group of patients that did not. No differences in age, sex, race, burn type, burn size, septic episodes, time to wound closure, or number of times the scalp was harvested were detected. Healed second-degree burns to the scalp that were subsequently taken as donor sites seemed to be a risk factor (p < 0.05) for folliculitis and alopecia. Our study confirms that scalp donor sites are reliable with low morbidity. Complications include alopecia and chronic folliculitis that can be avoided by meticulous technique and avoidance of previously burned areas.     

Graft survival and effectiveness of dermal substitution in burns and reconstructive surgery in a one-stage grafting model

Survival of the autograft and objective parameters for scar elasticity were evaluated after dermal substitution for acute burns and reconstructive surgery. The dermal substitute, which was based on bovine type I collagen and elastin-hydrolysate, was evaluated by intraindividual comparison in a clinical trial. The substitute was applied in a one-step procedure in combination with a split-thickness autograft. This treatment was compared with the conventional treatment, the split-thickness antograft. After 1 week, the percentage of autograft survival was assessed. The Cutometer SEM 474 was used to obtain objective measurements of skin elasticity parameters 3 to 4 months postoperatively. Forty-two pairs of wounds (31 patients, age 32.9 +/- 19.3 years; burned surface area, 19.8 +/- 14.5 percent) were treated because of acute burns. Reconstructive surgery was performed on 44 pairs of wounds (31 patients, age 33.9 +/- 17.5 years). Autograft survival was not altered by the substitute for reconstructive wounds, although a slight but significant reduction (p = 0.015) was established in the burn category for substituted compared with nonsubstituted wounds. However, the necessity for regrafting was not increased by substitution. Cutometer measurements of reconstructive wounds with a dermal substitute demonstrated a significant increase of pliability (50 percent, p < 0.001), elasticity (defined as immediate extension, 33 percent, p = 0.04), maximal extension (33 percent, p = 0.002), and immediate retraction (31 percent, p = 0.01), as compared with nonsubstituted wounds. After burn surgery, no improvement was found for the different elasticity parameters. Dermal substitution in a one-stage grafting model seems feasible with respect to graft survival. Skin elasticity was considerably improved by the collagen/elastin dermal substitute after reconstructive surgery.     

Combined erbium:YAG laser resurfacing and face lifting

Facial aging occurs secondary to gravity-induced tissue ptosis and photoaging. Combined face lifting and carbon dioxide laser resurfacing provides a comprehensive one-stage approach to facial rejuvenation but is condemned by many plastic surgeons due to the nonspecific thermal effects of the laser and risk of skin necrosis. Newer high-energy erbium:YAG lasers allow precise tissue ablation with minimal thermal effect. In this study, various facial rejuvenation techniques were combined with simultaneous erbium:YAG laser resurfacing to assess results and complications. A total of 257 patients from Florida, Melbourne, Australia, and Tel Aviv, Israel, underwent combined erbium:YAG laser resurfacing and surgical facial rejuvenation. Various face-lift methods were used, including endoscopic, deep plane, and subcutaneous. Simultaneous, full-facial laser resurfacing was performed using a variety of erbium:YAG lasers. It was found that combined laser resurfacing and face lifting was successful in greater than 95 percent of patients with minimal morbidity. Two patients (1 percent) (both heavy smokers) developed small areas of skin necrosis that healed with minor pigment changes. Five patients (2 percent) developed synechia that was treated with no residual effect. Two additional patients (1 percent) developed temporary ectropion. There were no other cases of scarring, infection, or cosmetically obvious hypopigmentation. Although larger studies are necessary, it seems that the lack of thermal injury from the erbium:YAG laser makes it possible to safely perform laser resurfacing with surgical facial rejuvenation in nonsmokers. However, the authors caution that familiarity with the nuances of erbium:YAG laser resurfacing be obtained before performing combined laser resurfacing and face lifting.     

丹参酮IIA磺酸钠对烧伤植皮创面愈合及瘢痕形成的影响

目的:探讨丹参酮IIA磺酸钠注射液对烧伤患者植皮创面愈合及瘢痕形成情况的影响。方法:选取2014年3月至2014年12月我院收治的烧伤植皮患者62例,根据临床用药分为试验组(使用丹参酮IIA磺酸钠注射组)与对照组(未使用丹参酮IIA磺酸钠注射液)。比较两组创面愈合情况,术后植皮成活率及愈合后瘢痕形成情况。结果:1经治疗,两组创面均愈合,试验组患者植皮成活率为(97.12±1.89)%,高于对照组(89.96±1.86)%,差异具有统计学意义(P0.01);试验组愈合时间较对照组短,试验组创面愈合时间为10.1±1.9天,对照组为14.3±2.3天,两组比较差异具有统计学意义(P0.001);瘢痕形成评价试验组均优于对照组,差异具有统计学意义,其中血肿面积(1.50±0.03 vs.3.04±0.08,P0.01)、畸形率[2(6.45)vs.8(25.81),P0.05]、感染率[2(6.45)vs.9(29.03),P0.05]。结论:丹参酮IIA磺酸钠注射液对于烧伤植皮创面的患者,能够提高植皮成活率,促进创面愈合,减轻瘢痕形成,改善创面愈合质量。     

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.     

Conchal transposition flap for postburn ear deformities

Severe thermal injuries to the external ear often lead to extensive loss of peripheral structures such as helix and lobule but frequently spare the more central parts of the ear, even though they may be grossly deformed by scar contracture. The use of spared conchal structures as a transposition flap in combination with remodeling of the residual auricle and release of surrounding scar when indicated has been a useful technique in the reconstruction of a frequently occurring type of postburn ear deformity. Twenty-four ears have been reconstructed in 18 patients over the past 5 years using a conchal transposition flap. The residual concha with its overlying skin can be transposed superiorly, based on a very narrow pedicle in the area of the crus helicis. The raw central area remaining is then resurfaced with a split-thickness skin graft. This technique maximally utilizes the unique remaining auricular elements and can provide a satisfactory reconstruction in selected patients without resorting to more complex and extensive procedures. There have been no significant complications in this series, and patient acceptance of the results has been excellent.     

Breast reconstruction with the internal mammary artery pedicled fasciocutaneous island flap: description of a new flap

Postburn skin contracture of the inframammary sulcus is a commonly encountered problem, especially in pubescent girls. Release of these contractures is commonly performed by split-thickness skin grafts, which necessitate further operations as the child grows. If the contracture of the inframammary sulcus is only one-sided, then the inframammary tissues of the contralateral breast can be used for reconstruction with the fasciocutaneous island flap. The donor site can be closed primarily without disrupting the appearance of the healthy breast, and the skin incision is hidden in the inframammary sulcus. The flap described here is a fasciocutaneous island flap based on the internal mammary artery and the perforating branches to the skin and subcutaneous tissues that the artery gives off as it leaves the thoracic cavity through the seventh intercostal space. After being supported by fresh cadaver and angiographic studies, the flap was applied to seven female patients (four of whom were pubescent) with burn contracture of the breast; satisfactory results were obtained. In defects of the mammary region that required volume or for which repair by skin grafting was planned, in sternal defects, or in young patients, this flap seems to be the best choice.