Treatment of finger degloving injury with acellular dermal matrices: Functional and aesthetic results

Pre-Pectoral Tissue Expander and Acellular Dermal Matrix for a Two-Stage Muscle Sparing Breast Reconstruction: Indications, Surgical Technique and Clinical Outcomes with Histological and Ultrasound Follow-Up-A Population-Based Cohort Study

BACKGROUND

The aim of the paper is to present a single-center experience with two-stage pre-pectoral breast reconstruction using tissue expander entirely covered by acellular dermal matrix (ADM), reporting surgical indications, technique, clinical and histological outcomes.

MATERIALS AND METHODS

A prospectively maintained database of consecutive patients who had undergone immediate pre-pectoral expander-based breast reconstruction with ADM over a two years period (2019-2021) was analyzed. The primary clinical outcome measures included patients' subjective assessment of satisfaction and pain. Secondary outcomes were complication rates, the frequency of readmissions and incidence of capsular contracture. All patients underwent ultrasound examination 3 weeks postoperatively and at the end of tissue expansion completion. Histological examination of the periprosthetic tissue was performed during the second stage of the reconstructive procedure.

RESULTS

A total of 46 patients with a mean age of 46.5 years (range: 24-62) underwent collectively 54 breast reconstructions with a mean follow-up of 22.5 months after definitive implant placement. The time to reach the final volume was on average 47.2 days (range 40-58). Complications occurred in 14 (25.9%) breast reconstructions: 11 (20.4%) seromas, 2 (3.7%) infections, 1 (1.8%) flap necroses, 2(3.7%) expander removals. Overall scores for Satisfaction were all significantly increased after surgery. Histological examination revealed complete ADM integration in the host tissue, with thinner, less sclerotic tissue compared to the submuscular capsular samples.

CONCLUSIONS

Tissue expander-ADM-based breast reconstruction can be safely used in selected cases for two-stage pre-pectoral breast reconstructions and can result in significant pain-relief procedure with optimal aesthetical outcomes.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Recalcitrant Bilateral Volar Hand Burn Contracture in a Toddler Treated With Integra and Staged Full-thickness Skin Graft: A Literature Review

Background

Recurrent burn contractures on the volar aspect of the hand present a formidable challenge, especially in the pediatric patient. We used Integra followed by staged full-thickness skin grafting for recurrent bilateral volar hand burn contracture in a toddler. We reviewed the literature to appraise the utility of full-thickness skin graft (FTSG) combined with Integra used for volar hand contractures.

Methods

A systematic review of the world's literature was conducted identifying publications on the application of Integra and skin substitutes for palmar hand contractures and wounds, to include burn injuries. We describe a case of a pediatric patient with recurrent bilateral burn flexion contracture of the palm and digits treated with scar excision and application of Integra, followed by staged application of FTSG.

Results

We identified 92 publications pertaining to volar hand defects or contractures managed with skin grafts, skin substitutes, and/or flaps. Ten articles referred to the use of Integra on volar hand wounds or contractures, and only 2 articles used FTSG instead of split-thickness skin graft in combination with Integra. Our systematic review of volar burn injuries of the hand and fingers demonstrated that the use of Integra combined with FTSG for postburn flexion contracture of the hand has not been previously reported.

Conclusions

This case report suggests that application of FTSG instead of split-thickness skin graft to vascularized Integra offers protective value against recurrent burn contracture of the palmar hand, but more studies are needed to support our hypothesis.

Conventional Versus Regenerative Methods for Wound Healing: A Comparative Experimental Study on a Sheep Model

Background and Objectives: Wound healing is a complex process involving cellular, anatomical, and functional repair, often hindered in chronic wounds associated with diseases like diabetes and vascular disorders. This study investigated the efficacy of conventional and regenerative wound healing approaches in a sheep surgical wound model. Materials and Methods: Six female Bergamasca sheep underwent five full-thickness skin lesions treated with various methods: sterile gauze (control), chlorhexidine, sodium hypochlorite, micronized dermis system application, and dermal matrix. Wound healing progression was monitored over 42 days through wound dimension measurements, exudate analysis, and histopathological evaluations. Results: The results indicated that all wounds healed completely by day 42, with significant reductions in wound size and exudate over time. Notably, Micronized dermis system application and dermal matrix treatments showed a faster evolution in exudate characteristics and improved collagen reorganization compared to other treatments. Histological analysis revealed earlier neovascularization and better reconstitution of hair follicles in these groups. Despite the lack of significant differences in healing time, both regenerative approaches enhanced wound healing phases, contributing to exudate control, angiogenesis promotion, and reduced scar formation. Conclusions: The findings suggest that while micronized dermis system application and dermal matrix do not accelerate acute wound healing compared to conventional methods, they offer potential benefits in managing exudate and improving tissue regeneration, warranting further investigation in chronic wound scenarios.

Proximal toe wrap-around: a coverage technique for circumferential skin defects of the fingers

Circumferential skin defects of the fingers are a technical challenge. Although rare, their management should respect tissue organization and functional abilities. We report two cases of circumferential skin defect. Management used individually tailored "wrap-around" flaps taken from the hallux. The sample concerned the proximal cutaneous sheath of the first toe and the neurovascular pedicle of the first inter-metatarsal space. Nail and toe pad were spared. Both cases had complex circumferential skin defect of the finger, involving the neuro-vascular pedicle. Postoperative results were favorable, without functional limitation. The wrap-around technique provided skin coverage and also neurovascular pedicle reconstruction. Donor site damage was limited, with no functional consequences. This technique is a valuable option for management of circumferential skin defect of the finger.

Clinical study on the role of platelet-rich plasma in human acellular dermal matrix with razor autologous skin graft repair of giant congenital pigmented nevus in children

BACKGROUND

NA OBJECTIVE: Evaluate the safety and feasibility of platelet-rich plasma (PRP) in the treatment of giant congenital melanocytic nevi (GCMN) in children with human acellular dermal matrix (HADM) transplantation.

PATIENTS AND METHODS

A total of 22 children with GCMN were included in the study. They were divided into an experimental and a control group. The experimental group used the method of HADM with Razor Autologous Skin Graft combined with PRP to repair skin and soft tissue defects after giant nevus resection (Group A, n = 11). The control group was treated with HADM with Razor Autologous Skin Graft (Group B, n = 11) only. To compare the survival rate of skin grafts, we used the Vancouver Scar Scale (VSS) for the postoperative skin graft area and the Patient and Observer Scar Assessment Scale (POSAS) to compare the two groups of patients.

RESULTS

There was no statistically significant difference in age, gender, location of giant nevi, and pathological classification between Group A and Group (P > 0.05). The survival rate of skin grafting and the VSS and POSAS scores of scar tissue in group A were superior to those of group B (P < 0.05).

CONCLUSIONS

PRP has improved the survival rate of composite skin grafting in children with GCMN, and long-term satisfactory prognosis of scar healing. Therefore, we consider this treatment method a valuable contribution to clinical practice.

Evaluation of modulation of immunity by lymph node transfer: A preliminary histological evidence in lymphedema patients

BACKGROUND

The exact knowledge of the local biological and immunological effects of vascularized lymph node transfer (VLNT) continues to be an emerging science but a positive control positive control over infectious and immune-mediated processes is often advocated. Knowing the characterization of the inflammatory infiltrate associated with lymphedema, the aim of this paper is to verify the hypothesis that VLNT is able to modulate the inflammatory and immune microenvironment of lymphedematous tissue by evaluating any modification of the local inflammatory cell infiltrate.

PATIENTS AND METHODS

A prospectively database of patients who received VLN transfer for lower extremity lymphedema between January 2018 and December 2020 was reviewed. Nine patients diagnosed with extremities' stage II secondary lymphedema were included, with a mean age of 55.3 (range 39-66 years) years. Gastroepiploic lymph node transfer was performed in all patients and transferred heterotopically. Full thickness 6-mm skin punch biopsies were obtained from all voluntary lymph node transfer patients at identical sites of the lymphedematous limb during the surgical procedure of VLNT (T0) and 1 year later (T1). Immunohistochemistry was performed using antibodies against the following markers: anti-CD3; anti-CD4; anti-CD8; anti-CD68. Data at T0 were compared to those at T1.

RESULTS

Post-operative course was uneventful in all cases experiencing a significant reduction (almost a third) in terms of cellulitis episodes: The median duration of follow-up for patients was 28.3 months (range 12-40). The analysis of the density of the inflammatory cells as a whole revealed a significant reduction at T1 compared to T0. Specifically, CD3 expression levels turned from 16.36 ± 3.421 (cells/mm2 ) pre-operatively to 7.6 ± 1.511 (cells/mm2 ) post-operatively (p < .0001). CD4+ cells turned from 7.270 ± 3.421 (cells/mm2 ) at T0 to 4.815 ± 1.511 cells/mm2 at T1 (p = .0173). CD8 expression values decreased from 4.360 ± 3.421 (cells/mm2 ) to 2.753 ± 1.451 (cell/mm2 ) at T1 (p = .0003). Monocyte/macrophage marker CD68 varied from 8.208 ± 2.314 (cells/mm2 ) at T0 to 7.600 ± 1876 (cells/mm2 ) at T1 (p = .0003).

CONCLUSION

VLNT decreases skin and subcutaneous tissues' infiltration of inflammatory cells, providing one explanation for the positive control of lymph node transfer procedure over infectious and immune-mediated processes.

Integra® Dermal Regeneration Template as an alternative technique to treat degloving injury of fingers

Soft tissue covering of degloving injuries of fingers remains a common challenge in trauma. In this case, we report the good long-term results after the use of Integra® Dermal Regeneration Template in combination with a split-thickness skin graft as an alternative treatment option for a patient with a traumatic degloving injury of multiple fingers.

Acellular dermal matrix in reconstructive surgery: Applications, benefits, and cost

Modern tissue engineering has made substantial advancements that have revolutionized plastic surgery. Acellular dermal matrix (ADM) is an example that has gained considerable attention recently. ADM can be made from humans, bovines, or porcine tissues. ADM acts as a scaffold that incorporates into the recipient tissue. It is gradually infiltrated by fibroblasts and vascularized. Fortunately, many techniques have been used to remove cellular and antigenic components from ADM to minimize immune system rejection. ADM is made of collagen, fibronectin, elastin, laminin, glycosaminoglycans, and hyaluronic acid. It is used in critical wounds (e.g., diabetic wounds) to protect soft tissue and accelerate wound healing. It is also used in implant-based breast reconstruction surgery to improve aesthetic outcomes and reduce capsule contracture risk. ADM has also gained attention in abdominal and chest wall defects. Some studies have shown that ADM is associated with less erosion and infection in abdominal hernias than synthetic meshes. However, its higher cost prevents it from being commonly used in hernia repair. Also, using ADM in tendon repair (e.g., Achilles tendon) has been associated with increased stability and reduced rejection rate. Despite its advantages, ADM might result in complications such as hematoma, seroma, necrosis, and infection. Moreover, ADM is expensive, making it an unsuitable option for many patients. Finally, the literature on ADM is insufficient, and more research on the results of ADM usage in surgeries is needed. This article aims to review the literature regarding the application, Benefits, and costs of ADM in reconstructive surgery.

Surgical Treatment of Finger Degloving Injuries Without Usable Skin: a Case Report and Literature Review

The treatment of avulsion injuries of the fingers is complicated by the lack of universally accepted treatment guidelines and the wide variety of reconstruction techniques. The aim of this paper is to present a case and review the scientific literature to provide clear criteria for amputation and reconstruction and to present and discuss the reconstruction techniques with the best results.

Skin Reducing Mastectomy and Prepectoral Breast Reconstruction in Large Ptotic Breasts

Large and/or ptotic breasts demonstrate significant difficulty in breast reconstruction and that the rates of perioperative complications are higher compared with the general population. The authors aim to clarify some details on their previously published technique on skin reducing mastectomy and prepectoral ADM breast reconstruction. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Matriderm dermal substitute in the treatment of post traumatic hand's fingertip tissue loss

INTRODUCTION

Treatment of fingers tissue loss is particularly challenging as it often necessitates advanced reconstructive techniques such as flaps or grafts, with esthetic and functional results that are not always as good as hoped for, with long healing times. Recently, along with tissue engineering development, numerous types of dermal substitute have been commercialized, with promising possibilities of treatment in finger tissue loss. In the author's unit, Matriderm^® is the most commonly used dermal substitute. As described by the manufacturer, this scaffold is designed to be covered with a split-thickness skin graft. In using a two-step procedure, the authors realized that in most cases of fingertips injuries, at three weeks follow-up, the wound appeared in an advanced state of healing, which permitted to avoid grafting.

MATERIAL AND METHODS

Between October 2017 and October 2018, 27 fingers have been included in this study. Patients have been divided in two groups: those treated with Matriderm^® alone (15 fingers) and those who had a skin graft three weeks after the first surgery (12 fingers). At the 6-month follow-up, authors evaluated the esthetic results with the Vancouver Scar Scale (VSS), the functional results with Quick Disability of the Arm, Shoulder and Hand (qDASH) score, and sensibility by the mean of two-point discrimination test (2-PD).

RESULTS

All outcomes were overlapping in patients treated with or without skin graft: mean VSS was 2.3, mean qDASH was 13.3, and mean 2-PD was 7.7 mm.

CONCLUSIONS

The results obtained allow to consider Matriderm^® , used also without skin graft coverage, as a valid solution for treatment of fingertip tissue loss.