A Narrative Review of the History of Skin Grafting in Burn Care

Barriers and prospects for skin grafting in burn treatment across African countries

INTRODUCTION

The current standard management of full-thickness or deep dermal burns is early tangential excision and skin grafting. A conservative approach to deep burns without the option of skin grafting results in delayed wound healing, possibly leading to wound infection and is associated with hypertrophic scarring and increased morbidity and mortality. The aim of this study was to improve the understanding of the management and availability to perform skin grafting for burns on the African continent. It also sought to identify challenges and perceived improvements.

METHODS

A web-based, structured, closed-formatted, multinational survey was designed to gather information on the current state and availability of skin grafting of burn wounds on the African continent. The questionnaire consisted of 27 questions, available in English and French. It was reviewed within the GAP-Burn collaboration network and sent to 271 health care professionals who had participated in a previous study and had initially been recruited by means of the snowball system.

RESULTS

The questionnaire was completed 84 times (response rate: 31.0%), of which 3 were excluded. Responses originated from 22 African countries. The majority 71 (87.7%) resulted from countries with a low Human Development Index (HDI), 7 (8.6%) from medium HDI countries. Split thickness skin grafting (STSG) is performed in 51 (63.0%) centers. The majority considers STSG to reduce length of stay (72.8%) and improve scarring (54.3%), yet some indicated that STSG is associated with increased risk of donor site infection (8.6%) and severe bleeding (7.4%). Factors preventing increased grafting included lack of equipment and training.

CONCLUSION

Skin grafting is not performed in a significant number of hospitals treating burns. The majority of the staff believe that more skin grafting would lead to a better outcome. Advocacy and improved infrastructure, human resources coupled with introduction to well-structured health coverage for all in African countries could help to better access and affordability in burn care.

Histological assessment of a novel de-epithelialization method for connective tissue grafts harvested from the palate. An experimental study in cadavers

OBJECTIVES

This study aims to compare the histological outcomes of three distinct de-epithelialization methods used in (connective tissue grafts) CTG harvested from the palate.

MATERIALS AND METHODS

An experimental study using nine cadaver head specimens was carried out to compare 3 different de-epithelialization techniques for CTG. Eighteen samples were randomly allocated to three study groups: bone scraper, diamond bur and extraoral removal with a scalpel. The main outcome variable was the graft surface percentage without epithelium remains. Additionally, the time employed, and the graft thickness were also measured.

RESULTS

Sixteen CTGs were analyzed. The extraoral scalpel group presented a total surface area with no epithelium of 58.84% (22.68) and a mean de-epithelialization time of 3.7 min; the intraoral diamond bur group had 88.24% (41.3) of the surface with no epithelium and took 1.455 min, and the intraoral bone scraper showed 97.98% (5.99) of surface without epithelium and a mean time of 0.815 min (P < 0.05). Histological analysis showed significant differences between the bone scraper and the extraoral group (P = 0.009).

CONCLUSION

The de-epithelialization technique with a bone scraper seems to be the most effective and fastest de-epithelialization technique for CTG. These findings need to be confirmed in future clinical studies with larger samples.

CLINICAL RELEVANCE

The use of bone scrapers, could be a simple, effective and fast technique to de-epithelialize connective tissue grafts harvested from the palatal area for both novice and experienced surgeons.

A New Technique for Harvesting Limbal Stem Cell Tissue for Transplantation Using an Automated Microkeratome and a Novel Globe-Fixation System

PURPOSE

To introduce an unprecedented technique, instrumentation, and setup for the superficial limbus harvest from the human cadaver donor whole globe.

METHODS

We studied several superficial limbus harvest alternatives, developed a preferred approach with our available instruments, and optimized it on a handful of (seropositive) cadaver donors of whole globes.

RESULTS/TECHNIQUE

The globe was pressurized to about normal intraocular pressure by viscoelastic injection through the optic nerve stump. The globe was then mounted on a dynamic globe fixator that maintained a negative pressure in its stabilizing socket. Exertion of the negative pressure effectively elevated globe intraocular pressure (to over 40 mm Hg) and made the corneoscleral wall tight. The socket was then held tilted to the left side for about 35 to 40 degrees to put the limbal zone horizontally and mildly "chin-up." Next, the microkeratome was put on the uppermost and exposed limbus of the globe and activated, and the socket was rotated clockwise under the microkeratome head and its oscillating blade, allowing an effective 360-degree revolution of the microkeratome head around the limbal belt (for a right-handed operator and a counterclockwise cut).

CONCLUSIONS

We consistently succeeded in peeling intact 360-degree strips of the smooth superficial limbus by using blades with varying depths. Our method can be further equipped and optimized and be used by the eye banks and the surgeons for keratolimbal grafting as a more efficient limbal stem cell tissue harvest technique.

Evolution of Burn Care: Past, Present, and Future

Burn care evolved slowly from primitive treatments depicted in cave drawings 3500 years ago to a vibrant medical specialty which has made remarkable progress over the past 200 years. This evolution involved all areas of burn care including superficial dressings, wound assessment, fluid resuscitation, infection control, pathophysiology, nutritional support, burn surgery, and inhalation injury. Major advances that contributed to current standards of care and improved outcomes are highlighted in this article. New innovations are making possible a future where severe burn injuries will require less morbid interventions for acute care and outcomes will restore patients more closely to their pre-injury condition.

Skin Substitutes and Autograft Techniques: Temporary and Permanent Coverage Solutions

Coverage of burn wounds is crucial to prevent sequalae including dehydration, wound infection, sepsis, shock, scarring, and contracture. To this end, numerous temporary and permanent options for coverage of burn wounds have been described. Temporary options for burn coverage include synthetic dressings, allografts, and xenografts. Permanent burn coverage can be achieved through skin substitutes, cultured epithelial autograft, ReCell, amnion, and autografting. Here, we aim to summarize the available options for burn coverage, as well as important considerations that must be made when choosing the best reconstructive option for a particular patient.

Enhancing Lower Extremity Defect Coverage: High Viability Ultra-Thin Split-Thickness Skin Grafts Obtained from the Scalp

BACKGROUND

Repairing lower extremity defects presents challenges due to the scarcity of available local tissue. Skin grafting is a widely employed technique for addressing non-healing ulcers, improving the quality of life of patients and minimizing discomfort. However, using traditional donor sites, such as the thigh, can hinder mobility and result in noticeable scarring and pigmentation changes.

OBJECTIVES

This study aims to assess the effectiveness of a novel approach utilizing autologous ultra-thin split-thickness skin grafts (STSGs) harvested from the scalp using a disposable, commercially available razor blade named DermaBlade.

METHODS

Fifteen patients (median age: 72 years, eight males and seven females) with diverse lower limb lesions, including carcinomas and ulcers of varying etiologies, were prospectively enrolled. Donor sites included the sideburn extending to the hairy temporal skin (nine cases) and hairy occipital skin (six cases). Ultra-thin skin strips (<0.2 mm thick) were obtained from the scalp through the use of the disposable flexible blade DermaBlade. The strips were positioned over the receptor area with no sutures in most cases and secured using dressings. A substantial majority of patients (90%) achieved successful graft take with no complications. Swift re-epithelialization occurred within a median of 12 days for the donor site and 24 days for the receptor site. No hair transfer or alopecic scars were noted.

CONCLUSIONS

In contrast to traditional grafting methods, DermaBlade-assisted scalp grafting yields highly viable STSGs that adhere to wound beds without the need for sutures. Notable advantages of this technique encompass rapid wound healing, minimal complications, and superior cosmetic outcomes. Furthermore, it avoids scarring and alopecia, making it a promising approach for addressing lower extremity defects.

Lipoaspirate fluid derived factors and extracellular vesicles accelerate wound healing in a rat burn model

Background: The regenerative capabilities of derivatives derived from the fat layer of lipoaspirate have been demonstrated. However, the large volume of lipoaspirate fluid has not attracted extensive attention in clinical applications. In this study, we aimed to isolate the factors and extracellular vesicles from human lipoaspirate fluid and evaluate their potential therapeutic efficacy. Methods: Lipoaspirate fluid derived factors and extracellular vesicles (LF-FVs) were prepared from human lipoaspirate and characterized by nanoparticle tracking analysis, size-exclusion chromatography and adipokine antibody arrays. The therapeutic potential of LF-FVs was evaluated on fibroblasts in vitro and rat burn model in vivo. Wound healing process was recorded on days 2, 4, 8, 10, 12 and 16 post-treatment. The scar formation was analyzed by histology, immunofluorescent staining and scar-related gene expression at day 35 post-treatment. Results: The results of nanoparticle tracking analysis and size-exclusion chromatography indicated that LF-FVs were enriched with proteins and extracellular vesicles. Specific adipokines (adiponectin and IGF-1) were detected in LF-FVs. In vitro, LF-FVs augmented the proliferation and migration of fibroblasts in a dose-dependent manner. In vivo, the results showed that LF-FVs significantly accelerated burn wound healing. Moreover, LF-FVs improved the quality of wound healing, including regenerating cutaneous appendages (hair follicles and sebaceous glands) and decreasing scar formation in the healed skin. Conclusion: LF-FVs were successfully prepared from lipoaspirate liquid, which were cell-free and enriched with extracellular vesicles. Additionally, they were found to improve wound healing in a rat burn model, suggesting that LF-FVs could be potentially used for wound regeneration in clinical settings.

Optimization of human skin keratinocyte culture protocols using bioactive molecules derived from olive oil

Skin damage due to severe burns can compromise patient life. Current tissue engineering methods allow the generation of human skin substitutes for clinical use. However, this process is time-consuming, as the keratinocytes required to generate artificial skin have a low proliferation rate in culture. In this study, we evaluated the pro-proliferative effects of three natural biomolecules isolated from olive oil: phenolic extract (PE), DL-3,4-dihydroxyphenyl glycol (DHFG), and oleuropein (OLP), on cultured human skin keratinocytes. The results showed that PE and OLP increased the proliferation of immortalized human skin keratinocytes, especially at concentrations of 10 and 5 µg/mL, respectively, without altering cell viability. In contrast, DHFG did not produce a significant improvement in keratinocyte proliferation. In normal human skin keratinocytes obtained from skin biopsies, we found that PE, but not OLP, could increase the number of keratinocyte colonies and the area occupied by these cells. Furthermore, this effect was associated with increased KI-67 and Proliferating cell nuclear antigen (PCNA) gene expression. Thus, we propose that PE positively affects keratinocyte proliferation and could be used in culture protocols to improve bioartificial skin generation by tissue engineering.

Beauty Borne out of Chaos: Molding a Surgical Subspecialty Through the World Wars

The chaos during the Great Wars provided the impetus for the genesis of modern plastic surgery. Collectively, the World Wars caused disfiguring injuries to thousands of American soldiers, which challenged their acceptance into society. The Wars, however, propelled 2 leaders in the field of plastic surgery-Vilray P. Blair and James Barrett Brown. These two American pioneers used their surgical acumen and artistic skills to heal the wounds of the soldiers. During World War I, the wounds of injured soldiers were often poorly managed by inadequately trained surgeons and dentists. Upon return to the United States, these soldiers underwent specialized treatment under Blair's supervision. During World War II, James Barrett Brown, a disciple of Blair, was appointed as a consultant in the war. He spearheaded the establishment of several plastic surgery centers in Europe. Upon his return from the War, he led the plastic surgery service at Valley Forge General Hospital in Phoenixville, PA, where thousands of soldiers were sent after their initial operations in the war zones. Care of war wounds served as an impetus for the development of new techniques in reconstructive and plastic surgery. These techniques included a delayed transfer of long pedicled flaps and split-thickness skin grafts. Through our archival research at the Bernard Becker Medical Library at Washington University in St. Louis, we provide evidence for how reconstructive surgical approaches were advanced during the Great Wars and helped restore some form of normalcy to the lives of the injured soldiers.

Getting Into One's Skin: The History of Skin Autografting

Surgeons who treat and manage complex wounds rely on many techniques and modalities to properly close their wounds. In modern times, the concept of the reconstructive ladder helps practitioners make decisions on which method to employ to create the best result. Skin autografting is a part of that algorithm, but few know of the arduous history of this field. Dating back thousands of years ago, the history of skin autografting is complex and spans several continents and eras. This article discusses the history and nuance of a surgical technique that has had years of refinement. The discussion begins with ancient times and delves into how skin autografting made a resurgence during the renaissance and the late 1800s and the influence that World War I posed on the advancement of this surgical principle.

Evaluation of Magnesium-Phosphate Particle Incorporation into Co-Electrospun Chitosan-Elastin Membranes for Skin Wound Healing

Major challenges facing clinicians treating burn wounds are the lack of integration of treatment to wound, inadequate mechanical properties of treatments, and high infection rates which ultimately lead to poor wound resolution. Electrospun chitosan membranes (ESCM) are gaining popularity for use in tissue engineering applications due to their drug loading ability, biocompatibility, biomimetic fibrous structure, and antimicrobial characteristics. This work aims to modify ESCMs for improved performance in burn wound applications by incorporating elastin and magnesium-phosphate particles (MgP) to improve mechanical and bioactive properties. The following ESCMs were made to evaluate the individual components’ effects; (C: chitosan, CE: chitosan-elastin, CMg: chitosan-MgP, and CEMg: chitosan-elastin-MgP). Membrane properties analyzed were fiber size and structure, hydrophilic properties, elastin incorporation, MgP incorporation and in vitro release, mechanical properties, degradation profiles, and in vitro cytocompatibility with NIH3T3 fibroblasts. The addition of both elastin and MgP increased the average fiber diameter of CE (~400 nm), CMg (~360 nm), and CEMg (565 nm) compared to C (255 nm). Water contact angle analysis showed elastin incorporated membranes (CE and CEMg) had increased hydrophilicity (~50°) compared to the other groups (C and CMg, ~110°). The results from the degradation study showed mass retention of ~50% for C and CMg groups, compared to ~ 30% seen in CE and CEMg after 4 weeks in a lysozyme/PBS solution. CMg and CEMg exhibited burst-release behavior of ~6 µg/ml or 0.25 mM magnesium within 72 h. In vitro analysis with NIH3T3 fibroblasts showed CE and CEMg groups had superior cytocompatibility compared to C and CMg. This work has demonstrated the successful incorporation of elastin and MgP into ESCMs and allows for future studies on burn wound applications.

Analysis of the Effect of Wound-Edge Microgranular Skin Grafting in the Treatment of Various Small Wounds

Objective

To explore the clinical effect of wound edge microgranular skin grafting in the treatment of various small wounds.

Methods

From September 2018 to September 2021, Yueqing people's Hospital of Wenzhou City, Zhejiang Province collected and recorded the data of 12 patients with chronic wounds and third degree burns. The method of skin grafting with particles at the edge of the wound was used to graft skin on the wound. Scar evaluation scale was used to evaluate the wound. The patients were followed up for 12 months. The preoperative and postoperative data, scar index and patient satisfaction after healing were recorded and statistically analyzed.

Results

All patients in this group were followed up for 3-12 months, and the results showed that SCAR Scale score decreased gradually over time, with patient satisfaction ranging from 80% to 96%. The patient gradually healed, scar hyperplasia gradually improved, functional activities gradually returned to normal, clinical effect is satisfactory.

Conclusion

Microparticle skin grafting at the edge of wound avoids skin grafting at different skin donor sites. It has the characteristics of simple anesthesia, small trauma and convenient operation. This method can be considered when treating patients with chronic wounds and burns who need skin grafting.

Overview of Biologic Agents Used in Skin and Soft Tissue Reconstruction

Wound healing is a highly complex process mediated by cellular interactions at the microscopic level. Increased understanding of wound healing physiology has served as the foundation for translational research to develop biologic wound care technologies that have profoundly affected patient care. As the reader will see throughout this series in Seminars in Plastic Surgery , biologic wound technologies have broad applications and have greatly impacted the reconstructive ladder. Despite their frequent use, many surgeons lack familiarity with the myriad of products available on the market along with each product's relative advantages and shortcomings. This overview will discuss the classification of biologic wound agents used to reconstruct defects of the skin and soft tissue along with the advantages and disadvantages associated with their use.

High Risk of Failed Skin Graft on Major Burn Patients with Complication of Hypernatremia

The rate of failed skin graft in Dr. Soetomo General Academic Hospital Surabaya was around 26% of the cases, and it became a concern because skin graft was the main procedure to close large burn wounds. Many problems might affect this event; one of them was electrolyte imbalance. Hypernatremia was found in major burn patients. This condition disrupted the wound healing process of skin graft. This cross-sectional study evaluated patients with burns admitted to the Burn Centre of Dr. Soetomo Hospital between January 2014 and December 2018. 143 subjects participated in this study. Hypernatremia was found in 16% of all subjects (23 subjects), 19% with hypernatremia (28 subjects), and the majority of it, 65% with normonatremia (92 subjects). This study found that the risk of failed skin graft was higher on hypernatremia than normonatremia subjects. This risk was higher if the skin graft procedure took more than 10%.