Buried Chip Skin Grafting in Neuropathic Diabetic Foot Ulcers Following Vacuum-Assisted Wound Bed Preparation: Enhancing a Classic Surgical Tool with Novel Technologies

[Buried chipped skin grafts for patients in failure of treatment]

Local conditions can lead to a failure of traditional skin grafts. We propose here our technique about the realization of autologous skin graft using it buried chipped grafts, for wounds in failure of treatments or at risk of failure. The protocol includes cutting the skin graft within little squared pieces of a few millimeters of length, that are then buried directly deep into the wound. We can then obtain little islands of epidermisation on the random places of the wound that will heal by confluence of those epidermal islands.

The Value of Negative-Pressure Wound Therapy and Flap Surgery in Hidradenitis Suppurativa – A Single Center Analysis of Different Treatment Options

Background

Hidradenitis suppurativa is manifested by painful abscesses and scarring of sweat glands. Axillary, inguinal and genital regions are mostly affected. Multiple options exist in the treatment of hidradenitis suppurativa. The aim of this retrospective, mono-center cohort study was to analyze the outcome of different treatment methods after radical excision of hidradenitis suppurativa.

Methods

We retrospectively evaluated the treatment strategy and recurrence rate of hidradenitis suppurativa. We included all eligible patients of legal age between February 2003 and October 2021, with the diagnosis of Hidradenitis suppurativa and the necessity for surgical treatment. All patients with surgical treatment and direct wound closure by suture were excluded. Bacterial load and flora were analyzed for primary and secondary reconstruction in combination with negative-pressure wound therapy. Patient data were analyzed for recurrence rate and remission time according to different reconstructive techniques.

Results

In 44 affected anatomical sites (n = 23 patients) we treated 15 patients with negative-pressure wound therapy. Bacterial load and flora were lower in the last wound swab of patients with multi-surgical procedures (22 localizations) compared to the first wound swab independent of the use of negative-pressure wound therapy.

Wound closure, independent of a direct and multi-stage procedure was achieved by local fasciocutaneous flaps (n = 12), secondary intention healing (n = 7), secondary intention healing with buried chip skin grafts (n = 10), or split-thickness skin grafts (n = 15). Radical excision combined with split-thickness skin grafts showed the lowest recurrence rate in the follow-up (16%; n = 4).

Conclusion

Radical excision of hidradenitis suppurativa as gold standard for surgical treatment combined with negative-pressure wound therapy as multi-stage procedures ultimately reduced bacterial load and flora in our study. The use of split-thickness skin grafts showed the lowest recurrence rate.

Biomechanical modeling of novel high expansion auxetic skin grafts

Over 20 million burn injuries are reported every year, with severe cases requiring skin grafting. Traditionally, split thickness skin grafts are prepared by excising a small portion of healthy skin and its incision patterning using a suitable meshing device, which allows the graft to be expanded beyond its capacity. To date, the maximum expansion achieved through skin grafting has been reported to be less than three times, which is not sufficient for covering large burn sites with limited donor site skin. In this work, we have attempted to study skin graft expansion potential with novel auxetic patterns, which are known to exhibit negative Poisson's effect. Two-layer skin graft models were developed using eight different auxetic incision patterns, and subjected to uniaxial and biaxial tensile strains. The Poisson's ratio, meshing ratio, and induced stresses were characterized for all graft models. The numerical results indicated expansion potentials greater than that of traditional skin grafts across all loads. Extremely high expansions (i.e., >30 times) were estimated for the I-Shaped Re-entrant and Rotating Triangles shaped auxetic models without rupture. Such pioneering findings are anticipated to initiate ground-breaking advances towards skin graft research and improved outcomes in burn surgeries.

[Reconstruction of oncological defects of the perianal region]

In addition to the progressive development of surgical oncological techniques for malignant tumors of the rectum, anal canal and vulva, reconstructive procedures after oncological interventions in the perianal region represent a cornerstone in the postoperative quality of life of patients. Modern treatment modalities for rectal cancer with neoadjuvant chemoradiotherapy increase the survival rate and simultaneously reduce the risk of local recurrence to 5-10%, especially by cylindrical extralevatory extirpation of the rectum. The price for increased surgical radicality and improved oncological safety is the acceptance of larger tissue defects. Simple suture closure of perineal wounds often does not primarily heal, resulting in wound dehiscence, surgical site infections and formation of chronic fistulas and sinuses. The interdisciplinary one-stage or two-stage reconstruction of the perianal region with well-vascularized tissue has proven to be a reliable procedure to prevent or control such complications.

Novel application of autologous micrografts in a collagen-glycosaminoglycan scaffold for diabetic wound healing

BACKGROUND

Therapeutic strategies that successfully combine two techniques-autologous micrografting and biodegradable scaffolds-offer great potential for improved wound repair and decreased scarring. In this study we evaluate the efficacy of a novel modification of a collagen-glycosaminoglycan scaffold with autologous micrografts using a murine dorsal wound model.

METHODS

db/db mice underwent dorsal wound excision and were treated with a collagen-glycosaminoglycan scaffold (CGS), a modified collagen-glycosaminoglycan scaffold (CGS+MG) or simple occlusive dressing (Blank). The modified scaffold was created by harvesting full thickness micrografts and transplanting these into the collagen-glycosaminoglycan membrane. Parameters of wound healing, including cellular proliferation, collagen deposition, keratinocyte migration, and angiogenesis were assessed.

RESULTS

The group treated with the micrograft-modified scaffold healed at a faster rate, showed greater cellular proliferation, collagen deposition, and keratinocyte migration with higher density and greater maturity of microvessels. The grafts remained viable within the scaffold with no evidence of rejection. Keratinocytes were shown to migrate from the wound border and from the micrograft edges towards the center of the wound, while cellular proliferation was present both at the wound border and wound bed.

CONCLUSION

We report successful treatment of diabetic wounds with a novel collagen-glycosaminoglycan scaffold modified with full-thickness automicrografts. Differences in cellular migration and proliferation offer maiden evidence on the mechanisms of wound healing. Clinically, the successful scaffold engraftment, micrograft viability and improved wound healing offer promising results for the development of a new therapeutic modality for wound repair.

Deferoxamine enhances the regenerative potential of diabetic Adipose Derived Stem Cells

INTRODUCTION

Diabetes mellitus remains a significant public health problem, consuming over $400 billion every year. While Diabetes itself can be controlled effectively, impaired wound healing still occurs frequently in diabetic patients. Adipose-derived mesenchymal stem cells (ASCs) provide an especially appealing source for diabetic wound cell therapy. With autologous approaches, the functionality of ASCs largely underlie patient-dependent factors. Diabetes is a significant diminishing factor of MSC functionality. Here, we explore a novel strategy to enhance diabetic ASC functionality through deferoxamine (DFO) preconditioning.

MATERIAL AND METHODS

Human diabetic ASCs have been preconditioned with 150 µM and 300 µM DFO in vitro and analyzed for regenerative cytokine expression. Murine diabetic ASCs have been preconditioned with 150 µM DFO examined for their in vitro and in vivo vasculogenic capacity in Matrigel assays. Additionally, a diabetic murine wound healing model has been performed to assess the regenerative capacity of preconditioned cells.

RESULTS

DFO preconditioning enhances the VEGF expression of human diabetic ASCs through hypoxia-inducible factor upregulation. The use of 150 µM of DFO was an optimal concentration to induce regenerative effects. The vasculogenic potential of preconditioned diabetic ASCs is significantly greater in vitro and in vivo. The enhanced regenerative functionality of DFO preconditioned ASCs was further confirmed in a model of diabetic murine wound healing.

CONCLUSION

These results demonstrate that DFO significantly induced the upregulation of hypoxia-inducible factor-1 alpha and VEGF in diabetic ASCs and showed efficacy in the treatment of diabetes-associated deficits of wound healing. The favorable status of DFO as a small molecule drug approved since decades for multiple indications makes this approach highly translatable.

Topical negative-pressure wound therapy: emerging devices and techniques

Introduction: The treatment of chronic wounds constitutes a massive financial burden to society and our health-care system. Therefore, efficient wound care is of great importance to all kinds of medical fields. The implementation and modification of negative-pressure wound therapy can be seen as a major improvement in wound healing. Many different NPWT applications evolved trying to address various wound etiologies.Areas covered: This review aims to give an overview of various NPWT applications, show its effects on wound healing, and discuss future modifications.Expert opinion: NPWT as a delivery device for cold plasma, growth factors, or targeted stem cells to the wound bed and the ability to monitor the inflammatory activity, bacterial load and wound healing factors can be seen as possible future steps to individualized wound care. In addition, it requires high-quality experimental studies to develop the ideal foam in terms of microstructure, pore size, and material properties.

Principles of STAGE Management for Diabetic Foot Ulcers Based on the Wagner and Texas Classification Systems

The current Wagner and Texas classifications of diabetic foot ulcers (DFUs) are used worldwide to assess the extent of foot lesions, but wound treatment principles based on both the classification systems are lacking. We have summarized the STAGE principles of wound treatment for clinical practice based on the Wagner and Texas classification systems. The STAGE principles refer to the principles of surgical intervention during wound treatment of DFUs and emphasize that "based on anatomical layers, the management focuses on blood supply and includes layer-by-layer incision to the infected area, maintenance of effective wound drainage, and step-by-step treatment of the wound." During treatment, microcirculation improvement and microvascular angiogenesis (A) are essential for granulation tissue formation in the bone (skeleton, S) and tendons (T) and healing of the wound with reepithelialization (E). We defined the above mentioned steps as the STAGE principles, namely, layer-by-layer incision and step-by-step management (Phase A is essential for the treatments in Phases S-T and G-E). Ulcers or gangrene formed during Phases S-T or T should be treated according to the STAGE or TAGE principles, respectively. Similar treatment principles are applied in the other phases. However, treatments at each phase are not isolated and can be performed simultaneously. The STAGE principle can be combined with the tissue, infection, moisture, and wound edge (TIME) and TIME-H chronic wound treatment principles to eliminate the shortcomings of a single principle in wound management.

Anatomic basis and clinical application of the distally based medialis pedis flaps

BACKGROUND

Soft-tissue defects of the forefoot are difficult to cover adequately, particularly, although multiple options for reconstruction are available. This study especially focused on the vascularization of the medial side of the foot and the determination of the contribution of the nutrient vessels to medialis pedis flap viability.

METHODS

Thirty cadavers were available for this anatomical study. Microdissection was conducted under a microscope, and details of the course and distribution and the communication of the first plantar metatarsal artery with the fascial vascular network of the medial side of the foot were recorded. Clinically, six cases of soft-tissue defects at the forefoot region were reconstructed with distally based medialis pedis flap.

RESULTS

The perforator of the first plantar metatarsal artery pierces in the superficial fascia of the medial aspect of the foot 2.2 ± 0.7 cm proximal to the first metatarsophalangeal joint, vascularize the skin of the medial plantar region. The anatomical study showed that the vasculature pattern could roughly be classified into two types. In terms of clinical application, all flaps completely survived, and one patient had partial loss of skin graft.

CONCLUSION

The perforators of the medialis pedis flap are presented constant. The forefoot region can be repaired by the distally based medialis pedis flap on the perforator of the medial plantar artery of the hallux or the first plantar metatarsal artery perforator with medial plantar vein, medial plantar cutaneous nerve and nutrient vessels.

Vessel transformation in chronic wounds under topical negative pressure therapy: an immunohistochemical analysis

The underlying physiological mechanism of topical negative pressure (TNP) therapy is not yet completely understood. This prospective clinical study aims to clarify a potential influence of TNP therapy on vessel proliferation and hypoxia in chronic wounds. TNP was applied on chronic wounds of 16 patients (-125 mmHg) to prepare them for a plastic-surgical reconstruction using free or pedicled flaps. Tissue biopsies were taken from the wound edge and wound bed at different time points. All samples were stained with haematoxylin and eosin, hypoxia-induced factor-1α and endothelial cell markers (CD31 and CD34) for the immunohistological analysis of inflammation, hypoxia and vessel proliferation. Between day 5 and day 8 of treatment, a considerable increase in blood vessel density could be observed, reaching a maximum of approximately 200% in contrast to the vessel density prior to treatment. In addition, the number of hypoxic and inflammatory cells was found to be increased at particular time points. This study demonstrates a stimulating effect on vessel proliferation under TNP treatment. TNP appears to support (neo-) angiogenesis and transformation of chronic non-healing wounds in a physiological wound healing process when combined with surgical debridement. This effect underlines the positive influence of TNP in the treatment of chronic wounds as shown by various clinical reports.

Versatile use of vacuum-assisted healing in fifty patients

Context:

Wound management can often be a challenging experience, especially in the presence of diabetes mellitus, vascular or immunological compromise. While no single technique can be considered by itself to be ideal, vacuum-assisted healing, which is a recent innovation, is fast becoming a necessary addition as adjuvant therapy to hasten wound healing.

Aims:

To determine the efficacy of vacuum-assisted healing.

Settings and Design:

Plastic surgery centre. Ministry of Health Hospital, Kuwait.

Materials and Methods:

Patients from Kuwait in a wide variety of clinical situations were chosen for study: Patients (n=50) were classified by diagnosis: Group 1: pressure sore- sacral (n= 3), trochanteric (n=6), ischial (n= 2); Group 2: ulcers (n= 11); Group 3: traumatic soft tissue wounds (n =15); Group 4: extensive tissue loss from the abdominal wall perineum, thigh and axilla (n =5); Group 5: sternal dehiscence wounds (n =4) and Group 6: wounds from flap necrosis (n =4). All wounds were subjected to vacuum by wall unit or portable unit, using pressure of 100-125 mm - continuous or intermittent. Closure of wounds, significant reduction in size and refusal by patient for continuation of vacuum-assisted closure therapy were end points of vacuum application.

Results:

Sixteen per cent of patients showed complete healing of the wound. Seventy per cent of patients showed 20-78% reduction in wound size. In 14% of patients treatment had to be discontinued. All patients showed improvement in granulation tissue and reduction in bacterial isolates and tissue oedema.

Conclusions:

The application of subatmospheric pressure or negative pressure promotes healing in a wide range of clinical settings and is an advanced wound healing therapy that can optimize patient care, promote rapid wound healing and help manage costs. It may be used in most instances in both hospital and community settings.

Reconstruction of a child's forefoot defect using a distally based pedicled medial plantar flap

This report describes a case of a 10-year-old boy who received a distally based, pedicled medial plantar artery flap to cover a defect on the distal lateral side of his right foot. The defect resulted from amniotic constriction. The flap served as defect coverage and was kept viable solely by the distal medial plantar vessels. Use of this particular kind of flap proves advantageous in that it provides good protection in the weight-bearing area of the foot, while causing only a minor donor site defect.

Solving acne inversa (hidradenitis suppurativa) in Crohn disease with buried chip skin grafts

BACKGROUND

Acne inversa is a progressive chronic inflammatory disease associated with abscess and fistula formation and subsequent scarring. In recent years, an increasing number of reports have been published about acne inversa and concomitantly occurring Crohn disease. Extensive anogenitoperineal soft tissue defects represent an enormous challenge to therapy. Common treatment strategies of reconstructive surgery such as local flaps, free flaps, or split-thickness skin grafts are frequently problematic and associated with poor outcomes.

OBJECTIVE

The aim of this case report is to demonstrate the clinical problem of extensive anogenitoperineal soft tissue defects and to present a surgical technique that can be successfully used in such difficult cases.

METHODS

In both cases, extensive excision of the affected areas was carried out down to the gluteal muscles followed by intramuscular grafting of buried skin chip grafts.

RESULTS

In both cases, the final postoperative results after numerous surgeries were very good, with complete wound closure resulting in complete recovery and social reintegration.

CONCLUSION

The technique of buried skin chip grafting has long been ignored since split-thickness skin grafting and different techniques of flap coverage evolved, but it may constitute a highly efficient treatment strategy in challenging reconstructive situations.

The effect of vacuum-assisted closure on lymph vessels in chronic wounds

INTRODUCTION

Chronic wounds come in various forms and result from a multitude of factors that play a detrimental role in the wound-healing process. A breakthrough in wound management came with the introduction of vacuum-assisted closure (VAC). Although numerous papers have been published suggesting that VAC is based upon its unique ability to accelerate the rate of granulation tissue production, enhance angiogenesis and remove excess chronic wound fluid, no attempts have been made to investigate its effect on lymph vessels.

PATIENTS AND METHODS

From April 2005 to April 2006, 80 patients with chronic wounds were treated with VAC therapy and prospectively studied. The parameters included: the length of VAC treatment, the number of dressing changes, the number of days of hospitalisation and immunocytochemical lymphatic vessel density assessments.

RESULTS

Lymph vessel proliferation was noted in all types of wounds, up to the first dressing change, but as VAC therapy continued it was apparent that patients exhibiting the same type of wounds did not exhibit the same results. Additionally, the duration of VAC therapy, dressing changes and average number of days of hospitalisation were significantly less in some cases but also prolonged in others.

CONCLUSION

VAC therapy seems to be inducing morphological and quantitative alterations on the lymph vessel network in a wound. The effect of VAC therapy varies greatly depending on the presence of underlying diseases and risk factors impairing wound healing. An increase in the density of lymph vessels manifested histologically correlates with a better clinical outcome, in terms of healing rates and hospitalisation time.