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Fulltext Outcome of Islanded Gastrocnemius Musculocutaneous Flap in Orthopaedic Practice

Yusof MN, Ahmad-Alwi AA

Malays Orthop J, 2019 Mar;13(1):25-29.
PMID: 31001380 DOI: 10.5704/MOJ.1903.004

Introduction: Large wounds in the leg require combination of local flaps or free flap for wound coverage. Gastrocnemius musculocutaneous flap (GMCF) allows a large wound to be covered by a single local flap. However, the conventional GMCF is often associated with donor site morbidity where the exposed soleus raphe causes poor uptake of the skin graft. Islanding the skin on the muscles allows the donor site to be closed primarily, thus avoiding the donor site morbidity. Materials and Methods: Medical records of twelve patients who underwent islanded GMCF surgery from 2004 till 2018 were reviewed retrospectively. Results: The mean age was 31 years old. Eight cases were with open fracture of the tibia, two degloving injury exposing the patella, one open fracture of patella and necrotising soft tissue infection. The wound size ranged from 12cm2 to 120cm2. All flaps survived. Three patients required skin grafting at the donor site while in the rest the donor sites were able to be closed primarily. Four patients developed deep infection, one healed after vacuum dressing, one after bone transport and one after split thickness skin graft. One patient ended up with below knee amputation after developing chronic osteomyelitis of the tibia. Conclusion: Islanded gastrocnemius musculocutaneous flap is an effective simple alternative for coverage of large soft tissue defects from the knee to half of the leg distally with minimal donor site morbidity. Aggressive debridement of unhealthy tissue is necessary to prevent infection following wound coverage with this flap.

Matched MeSH terms: Skin Transplantation
Laminated pedicled latissimus dorsi myocutaneous flap for single-stage reconstruction of a composite anterior neck and tracheal defect

Wu LY, Halim AS, Sain AH

J Otolaryngol, 2005 Feb;34(1):69-72.
PMID: 15966482
Matched MeSH terms: Skin Transplantation/methods*
The effect of a small triangular skin flap on vermillion height after cleft lip repair: a photogrammetry study

Wong LS, Lu TC, Chen PK

Int J Oral Maxillofac Surg, 2019 Oct;48(10):1313-1316.
PMID: 30898431 DOI: 10.1016/j.ijom.2019.02.021

During primary cleft lip repair, a small triangular flap of about 2mm is sometimes required to achieve better symmetry of Cupid's bow. The aim of this study was to evaluate the symmetry of Cupid's bow, with and without the use of a small triangular skin flap (STSF). Forty-five children who underwent the repair of unilateral cleft lip between January 1999 and December 2000 were recruited. Twenty children had a STSF included in the repair (STSF group) an d 25 children underwent the same repair without the STSF (NSTSF group). Vermillion height was measured on the cleft and non-cleft sides using reference points. The t-test was used to compare the vermillion height ratio between the two groups. The mean age at surgery was 4±1.3months in the STSF group and 4.3±0.6years in the NSTSF group. There was no significant difference in vermillion height ratio at 5 years of age between the patients in the two groups. Thus, there is no difference in vermillion height ratio with or without a STSF in cleft lip repair. The use of a small triangular skin flap needs to be assessed carefully, as it will create an unsightly scar over the philtrum area.

Matched MeSH terms: Skin Transplantation
Effect of keratin-gelatin and bFGF-gelatin composite film as a sandwich layer for full-thickness skin mesh graft in experimental dogs

Thilagar S, Jothi NA, Omar AR, Kamaruddin MY, Ganabadi S

J Biomed Mater Res B Appl Biomater, 2009 Jan;88(1):12-6.
PMID: 18161832

Skin grafts are indicated when there is a major loss of skin. Full-thickness skin graft is an ideal choice to reconstruct defect of irregular surface that is difficult to immobilize. Full-thickness mesh grafts can be applied to patch large skin defect when there is less donor site in extensively traumatized and burned surgical patients. The concept of using natural biomaterials such as keratin, basic fibroblast growth factor is slowly gaining popularity in the field of medical research to achieve early healing. The main objective of this study is to evaluate the efficacy of gelatin conjoined with keratin processed from the poultry feather and commercially available basic fibroblast growth factor (bFGF) as a sandwich layer in promoting the viability of full-thickness skin mesh grafts. The efficacy was assessed from the observation of clinical, bacteriological, and histopathological findings in three groups of experimental dogs. The clinical observations such as color, appearance and discharge, and hair growth were selected as criteria which indicated good and early acceptance of graft in keratin-gelatin (group II). On bacteriological examination, Staphylococcus aureus and Proteus was identified in few animals. Histopathological study of the patched graft revealed early presences of hair follicles; sebaceous gland, and normal thickness of the epidermis in keratin-gelatin in group II treated animals compared with other group (group I-control, group III-bFGF-gelatin).

Matched MeSH terms: Skin Transplantation/instrumentation*; Skin Transplantation/methods
Adjunctive use of superoxidized solution in chest wall necrotizing soft tissue infection

Tata MD, Kwan KC, Abdul-Razak MR, Paramalingam S, Yeen WC

Ann Thorac Surg, 2009 May;87(5):1613-4.
PMID: 19379926 DOI: 10.1016/j.athoracsur.2008.10.019

A 39-year-old Indian man presented with necrotizing soft tissue infection of his right forearm and previously undiagnosed diabetes mellitus. The infection progressively worsened to involve his right lateral chest wall despite multiple debridements and systemic antibiotics. His right arm was eventually disarticulated along with wide debridement of the surrounding tissue. Aggressive wound debridement, mechanical scrubbing, and irrigation were then initiated every 8 hours. A superoxidized solution was later introduced as a wound irrigant and dressing agent. The large defect was suitable for split-thickness skin grafting after 16 days of a strict wound management routine with the superoxidized solution.

Matched MeSH terms: Skin Transplantation*
Fulltext Reconstruction of Secondary Type Congenital Hallux Varus with Modification of the Farmer Technique for Cover of Skin Defect: Report of Three Cases

Sulaiman AR, Munajat I, M-Yusuf H, Nik-Jaffar N, Zarullail NH, Mohd EF, et al.

Malays Orthop J, 2019 Nov;13(3):72-76.
PMID: 31890115 DOI: 10.5704/MOJ.1911.013

The reconstruction of hallux varus deformity involves the release of contracted medial structure and realignment of the phalange, leaving a significant skin defect which requires cover. Farmer described proximal based rotational skin flap from the first web space to cover the defect. This technique may compromise the circulation to the flap and risk to the lateral digital vessels. We modified his technique to address these issues. We report a successful reconstruction using the Farmer's technique on one patient and a modified technique on three patients. We used the excess skin from the extra digit to cover the medial defect. We found this modified technique of skin cover safe without risk of injuring the neurovascular bundle. There was no recurrence of deformity at last foolow-up. All patients were able to wear normal shoes.

Matched MeSH terms: Skin Transplantation
Fulltext Abdominal flap: a reconstructive option for hand defect in rural setting

Sinnasamy, Shankari, B Mohd Shakir, Vijayashingam, Naveen, Mustaqim Afifi @ Apipi, Prakash, Doddaballapur Ramaiah

Borneo Journal of Medical Sciences, 2018;12(3):63-67.
MyJurnal

Reconstruction of hand injury is the challenge for the surgeon especially in rural settings. This case report is about a 10-year-old boy, who sustained large degloving wound of dorsum of right hand with extensor tendon injury following a road traffic accident. We performed a staged abdominal flap with tensor fascia lata graft for tendon reconstruction as microsurgery facilities was not available. Post-operatively he was subjected to physiotherapy and he has a functional right hand. This case report aimed to highlight abdominal flap as reconstructive option as compared to skin grafting which is reproducible with limited resources. Besides that, overall exposure to all surgical options is of paramount importance in the training of trainees to equip them with skills to serve in rural setting.

Matched MeSH terms: Skin Transplantation
Fulltext Modified vacuum-assisted closure

Sia, S.F., Fong, E.P.

JUMMEC, 2006;9(2):24-27.
MyJurnal

The treatment of large ulcers is a problem. Closure with flaps and even skin grafts in compromised patients is often fraught with risks. Dressing these large wounds is also a problem, as they are often heavily exudative. We report our experience using the vacuum-assisted closure technique in managing difficult ulcers in four patients. A modification of the technique using cheap, easily available materials is described. The vacuum-assisted suction is an effective treatment for large ulcers in compromised patients. It facilitates considerable contraction of the wound, and in smaller wounds; the vacuum-assisted closure allows sufficient contracture to enable delayed primary closure. We recommend the use of this method of wound dressing and closure in large wounds particularly, in high-risk patients where extensive flap coverage or even split skin graft would incur considerable risk.

Matched MeSH terms: Skin Transplantation
Fulltext Shelf-life evaluation of bilayered human skin equivalent, MyDerm™

Seet WT, Manira M, Maarof M, Khairul Anuar K, Chua KH, Ahmad Irfan AW, et al.

PLoS One, 2012;7(8):e40978.
PMID: 22927903 DOI: 10.1371/journal.pone.0040978

Skin plays an important role in defense against infection and other harmful biological agents. Due to its fragile structure, skin can be easily damaged by heat, chemicals, traumatic injuries and diseases. An autologous bilayered human skin equivalent, MyDerm™, was engineered to provide a living skin substitute to treat critical skin loss. However, one of the disadvantages of living skin substitute is its short shelf-life, hence limiting its distribution worldwide. The aim of this study was to evaluate the shelf-life of MyDerm™ through assessment of cell morphology, cell viability, population doubling time and functional gene expression levels before transplantation. Skin samples were digested with 0.6% Collagenase Type I followed by epithelial cells dissociation with TrypLE Select. Dermal fibroblasts and keratinocytes were culture-expanded to obtain sufficient cells for MyDerm™ construction. MyDerm™ was constructed with plasma-fibrin as temporary biomaterial and evaluated at 0, 24, 48 and 72 hours after storage at 4°C for its shelf-life determination. The morphology of skin cells derived from MyDerm™ remained unchanged across storage times. Cells harvested from MyDerm™ after storage appeared in good viability (90.5%±2.7% to 94.9%±1.6%) and had short population doubling time (58.4±8.7 to 76.9±19 hours). The modest drop in cell viability and increased in population doubling time at longer storage duration did not demonstrate a significant difference. Gene expression for CK10, CK14 and COL III were also comparable between different storage times. In conclusion, MyDerm™ can be stored in basal medium at 4°C for at least 72 hours before transplantation without compromising its functionality.

Matched MeSH terms: Skin Transplantation
Fulltext Necrotising fasciitis: a life-threatening complication of acupuncture in a patient with diabetes mellitus

Saw A, Kwan MK, Sengupta S

Singapore Med J, 2004 Apr;45(4):180-2.
PMID: 15094988

Acupuncture is used for some conditions as an alternative to medication or surgical intervention. Several complications had been reported, and they are generally due to physical injury by the needle or transmission of diseases. We report a case of life-threatening necrotising fasciitis that developed after acupuncture treatment for osteoarthritis of the knee in a 55-year-old diabetic woman. She presented with multiple discharging sinuses over the right knee. As the patient did not respond to intravenous antibiotics, extensive debridement was performed. She made a good recovery. Since many old diabetic patients with degenerative joint diseases may consider this mode of treatment, guidelines on cleanliness and sterility of this procedure should be developed and practiced.

Matched MeSH terms: Skin Transplantation
Use of dermal regeneration template (INTEGRA) in reconstructive burn surgery

Sasidaran R, Dorai AA, Sulaiman WA, Halim AS

Med J Malaysia, 2008 Jul;63 Suppl A:29.
PMID: 19024967

We present our two year experience with a dermal regeneration template (INTEGRA) in burn reconstructive surgery for contracture release as well as a reconstructive tool for management of soft tissue loss.

Matched MeSH terms: Skin Transplantation/instrumentation*; Skin Transplantation/methods
Fulltext Low-grade liquid silicone injections as a penile enhancement procedure: Is bigger better?

Sasidaran R, Zain MA, Basiron NH

Urol Ann, 2012 Sep;4(3):181-6.
PMID: 23248528 DOI: 10.4103/0974-7796.102672

To report our experience with 5 cases of complications of penile enhancement procedures secondary to liquid silicone injections and our method of management of its debilitating effects. All five patients were treated with excision of penile shaft skin down to buck's fascia followed by resurfacing with split thickness skin grafting. We conclude that penile enhancement procedures with liquid silicone by non-medical personnel could result in devastating consequences. We also demonstrate that a simple method of excision of the entire penile shaft skin and resurfacing with split skin grafting showed improvement in cosmetic as well as functional outcome.

Matched MeSH terms: Skin Transplantation
Fulltext Surgical Techniques for Correction of Penile Paraffinoma

Salauddin SA, Ghazali H

Malays J Med Sci, 2019 Nov;26(6):137-142.
PMID: 31908595 MyJurnal DOI: 10.21315/mjms2019.26.6.14

Background: Penile augmentation using injection of a foreign body into penile skin was mainly performed by non-medical personnel. Majority of these patients end up with complication of an abnormal mass formation known as penile paraffinoma.
Methods: We described three different surgical techniques for correction of penile paraffinoma based on our single-centre experience. Informed consents were obtained from patients whose photographs were taken during the operation step.
Results: In general, three patients had simple excision biopsy with primary suturing, four patients underwent single stage excision of circumferential granuloma with bilateral scrotal skin flap reconstruction and one patient experienced dual stage procedure. Three of them were injected with paraffin, one with silicone and the remaining four were unable to identify the substance used. All patients successfully underwent the surgical procedure and four of them had minor post-operative surgical site infection and wound gapping.
Conclusion: All patients recovered well and the mean International Index of Erectile Function (IIEF-5) score obtained was 24.25. In our experience, excision biopsy was adequate for focal mass and reconstructive surgery using bilateral scrotal flap was suitable for circumferential mass.

Matched MeSH terms: Skin Transplantation
The use of glycerol-preserved skin allograft in conjunction with reconstructive and flap surgery: seven years of experience

Saad AZ, Halim AS, Khoo TL

J Reconstr Microsurg, 2011 Feb;27(2):103-8.
PMID: 20976667 DOI: 10.1055/s-0030-1268208

Major reconstructive surgery may be extensive and prolonged, and it may cause edema and compromise the flap pedicle if closed under tension. Glycerol-preserved skin allograft (GPA) can provide a means for tension-free closure and temporary cover of the wound. Seven years of analysis on GPA used in conjunction with major reconstruction was undertaken to highlight its indications, results, and outcomes. Forty-seven patients were included, aged between 9 and 73 years. Majority of patients had reconstruction following tumor resection and trauma. The main indication for use of GPA was temporary, loose cover of the wound in 44% of cases; flap pedicle protection in 31% of cases; donor site wound cover in 10%; flap monitoring in one case; and management of flap-related complications in 6% of cases. Free flap reconstruction was performed in 72% of cases. In conclusion, GPA is a useful adjunct in reconstructive surgery. It can be used temporarily to allow tension-free wound closure, as well as to protect the flap pedicle until edema subsides and the pedicle becomes stable. This latter approach allows secondary wound closure and good esthetic outcome.

Matched MeSH terms: Skin Transplantation/adverse effects; Skin Transplantation/methods*
Autologous human fibrin as the biomaterial for tissue engineering

Ruszymah BH

Med J Malaysia, 2004 May;59 Suppl B:30-1.
PMID: 15468804

Patient own fibrin may act as the safest, cheapest and immediate available biodegradable scaffold material in clinical 1 tissue engineering. This study investigated the feasibility of using patient own fibrin isolated from whole blood to construct a new human cartilage, skin and bone. Constructed in vitro tissues were implanted on the dorsal part of the nude mice for in vivo maturation. After 8 weeks of implantation, the engineered tissues were removed for histological analysis. Our results demonstrated autologous fibrin has great potential as clinical scaffold material to construct various human tissues.

Matched MeSH terms: Skin Transplantation*
Successful free omental flap and skin graft reconstruction of scalp avulsion injury

Ramzisham AR, Somasundaram S, Nasir ZM, Ali F, Das S

Clin Ter, 2010;161(5):453-5.
PMID: 20949243

For the management of a full-thickness scalp avulsion injury, thorough wound debridement and immediate primary revascularization or a split-thickness skin graft may be necessary. Graft failure may be common situation thereby predisposing the individuals to unnecessary multiple operations. In the recent times, the use of omental graft has gained much popularity. In the present study, we describe an interesting case of chronic non healing scalp ulcer in a young woman who eventually underwent a free omental flap reconstruction with split-thickness skin graft and had satisfactory outcome.

Matched MeSH terms: Skin Transplantation*
A prospective study evaluating wound healing with sea cucumber gel compared with hydrogel in treatment of skin graft donor sites

Poh Yuen Wen A, Halim AS, Mat Saad AZ, Mohd Nor F, Wan Sulaiman WA

Complement Ther Med, 2018 Dec;41:261-266.
PMID: 30477850 DOI: 10.1016/j.ctim.2018.10.006

BACKGROUND: Gamat (sea-cucumber) is a natural occurring fauna which is popularly used as traditional medication in Southeast Asian countries. There have been many animal studies done on its' biochemical properties and its' effects in vivo. The effect of gamat on human cutaneous wounds was studied using a split-skin graft donor site wound.
METHODS: This was a comparative case-control study done on patients in Hospital Universiti Sains Malaysia (Hospital USM), requiring split-thickness skin grafting, whereby, the skin graft donor site was divided to almost equal halves, and applied with both gamat-based gel on one side, with Duoderm® hydrogel on the other side. The epithelialization of the wounds was observed and compared on days 10, 14 and 21. Pain score, and pruritus score were also observed. Repeated measure analysis of variance (ANOVA) test and Paired t-test was used to test statistical significance accordingly.
RESULTS: No significant differences were seen in rates of epithelialization of wounds on days 10, 14 and 21 (p > 0.01). No significant difference was also seen in the pain score and pruritus score (p > 0.01).
CONCLUSIONS: A gamat-based gel is comparable to conventional hydrogels in treatment of split-skin graft donor site. No adverse effects were observed in either group.

Matched MeSH terms: Skin Transplantation*
Correlation of donor age and telomerase activity with in vitro cell growth and replicative potential for dermal fibroblasts and keratinocytes

Ng MH, Aminuddin BS, Hamizah S, Lynette C, Mazlyzam AL, Ruszymah BH

J Tissue Viability, 2009 Nov;18(4):109-16.
PMID: 19632116 DOI: 10.1016/j.jtv.2009.06.003

Previous studies suggested telomerase activity as a determinant of cell replicative capacity by delaying cell senescence. This study aimed to evaluate the feasibility of adopting telomerase activity as a selection criterion for in vitro expanded skin cells before autologous transplantation. Fibroblasts and keratinoctyes were derived from the same consenting patients aged 9-69 years, and cultured separately in serum-supplemented and serum-free media, respectively. Telomerase activity of fresh and cultured cells were measured and correlated with cell growth rate, donor age and passage number. The results showed that telomerase activity and cell growth were independent of donor age for both cell types. Telomerase was expressed in freshly digested epidermis and dermis and continued expressing in vitro. Keratinocytes consistently showed 3-12 folds greater telomerase activity than fibroblast both in vivo and in vitro. Conversely, growth rate for fibroblast exceeded that of keratinocyte. Telomerase activity decreased markedly at Passage 6 for keratinocytes and ceased by Passage 3 for fibroblasts. The decrease or cessation of telomerase activity coincided with senescence for keratinocyte but not for fibroblast, implying a telomerase-regulated cell senescence for the former and hence a predictor of replicative capacity for this cell type. Relative telomerase activity for fibroblasts from the younger age group was significantly higher than that from the older age group; 69.7% higher for fresh isolates and 31.1% higher at P0 (p<0.05). No detectable telomerase activity was to be found at later subcultures for both age groups. Similarly for keratinocytes, telomerase activity in the younger age group was significantly higher (p<0.05) compared to that in the older age group; 507.7% at P0, 36.8% at P3 and the difference was no longer significant at P6. In conclusion, the study provided evidence that telomerase sustained the proliferation of keratinocytes but not fibroblasts. Telomerase activity is an important criterion for continued survival and replication of keratinocytes, hence its positive detection before transplantation is desirable. Inferring from our results, the use of keratinocytes from Passage 3 or lesser for construction of skin substitute or cell-based therapy is recommended owing to their sustained telomerase expression.

Matched MeSH terms: Skin Transplantation*
Antibiotic Irrigation: A Promising Unconventional Method for Facial Carbuncle

Ng JJ, Gendeh H, Ong HY, Gopalan S, Abdul Karaf JH

Cureus, 2021 Apr 27;13(4):e14710.
PMID: 34079672 DOI: 10.7759/cureus.14710

Carbuncle is conventionally treated with combinations of intravenous antibiotics and surgical intervention; be it saucerization or incision and drainage. Cosmesis outcome might be unfavorable following surgical intervention, especially when the facial region is involved. Skin grafting surgery may even be needed as a second-stage procedure for a larger wound. We reported a series of three facial carbuncles treated successfully with a new improvised method. Our method includes performing a stab incision prior to draining of pus, coupled with minimal wound debridement, followed by regular irrigation of the wound with antibiotics containing solution. Based on the three cases reported in this article, we conclude that this method is more superior as there is more skin preservation, better patient tolerance, shorter hospital stays, and favorable cosmesis outcome.

Matched MeSH terms: Skin Transplantation
The effects of age on monolayer culture of human keratinocytes for future use in skin engineering

Muhd Fakhruddin BH, Aminuddin BS, Mazlyzam AL, Ruszymah BH

Med J Malaysia, 2004 May;59 Suppl B:182-3.
PMID: 15468878

Skin is the largest organ in human system and plays a vital role as a barrier against environment and pathogens. Skin regeneration is important in tissue engineering especially in cases of chronic wounds. With the tissue engineering technology, these skins equivalent have been use clinically to repair burns and wounds. Consented redundant skin samples were obtained from patients aged 9 to 65 years old. Skin samples were digested with dispase, thus separating the epidermis and the dermis layer. The epidermis layer was trypsinized and cultured in DKSFM in 6-well plate at 37 degrees C and 5% CO2. Once confluent, the culture were trypsinized and the cells were pooled. Cells were counted using haemacytometer. Doubling time and viability were calculated and analysed. From the result, we conclude that doubling time and viability of in vitro keratinocytes cultured in DKSFM media is not age dependant.

Matched MeSH terms: Skin Transplantation*

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