This paper presents four cases of Fournier's gangrene, including one involving a reconstructive procedure using a preputial rotation flap to cover the raw area, to reduce the period of wound healing. Since Fournier's description of Idiopathic scrotal gangrene in 1884, there have been a number of reports on this relatively rare disease but the problem of achieving early healing and epithelialisation remains.
Locally advanced or recurrent carcinoma of the breast poses difficult management problems. These fungating and discharging tumours severely impair the quality of life in these unfortunate patients. We report two cases successfully treated with omental transposition flaps and split skin grafts. The operation is described in detail and the results discussed. This technique was found to be safe, effective and rewarding.
Immediate recognition of anastomotic failure is important to ensure the viability of the vascularised fibular graft. The problems associated with post-operative bone scanning and angiography for immediate detection of anastomotic failure have been described.
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.
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.
Our objective is to determine the quality of tissue engineered human skin via immunostaining, RT-PCR and electron microscopy (SEM and TEM). Culture-expanded human keratinocytes and fibroblasts were used to construct bilayer tissue-engineered skin. The in vitro skin construct was cultured for 5 days and implanted on the dorsum of athymic mice for 30 days. Immunostaining of the in vivo skin construct appeared positive for monoclonal mouse anti-human cytokeratin, anti-human involucrin and anti-human collagen type I. RT-PCR analysis revealed loss of the expression for keratin type 1, 10 and 5 and re-expression of keratin type 14, the marker for basal keratinocytes cells in normal skin. SEM showed fibroblasts proliferating in the 5 days in vitro skin. TEM of the in vivo skin construct showed an active fibrocyte cell secreting dense collagen fibrils. We have successfully constructed bilayer tissue engineered human skin that has similar features to normal human skin.
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.
Vaginal defects can either be congenital or acquired due to tumor or trauma. The reconstructions are aimed in producing a good physical and functional result with the least donor site morbidity. The pudendal thigh flap is a sensate fasciocutaneous flap based on the terminal branch of the superficial perineal artery, the continuation of the internal pudendal artery. Although various flaps have been described for vaginal reconstruction, the pudendal thigh flap offers a very attractive alternative.
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.
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.
A major factor limiting survival following extensive thermal injury is insufficient availability of donor sites to provide enough skin for the required grafting procedures. Limitation of autologous grafting promotes the usage of allograft skin substitutes to promote wound healing. Here, we investigated the wound healing potential of allograft single layered tissue engineered skin which comprises of either keratinocytes (SLTES-K) or fibroblast (SLTES-F) with fibrin as the delivery system. Results from gross and microscopic evaluation showed our single layered tissue engineered skin constructed with keratinocytes or fibroblast after gamma radiation with the dosage of 2Gy could serve as allograft for the treatment of skin loss.
The treatment of major burn injuries are a formidable challenge to the burn surgeon. Early aggressive surgery for deep to full thickness burn injuries is vital in the prevention of infection. The ultimate goal in major burn injuries is to prevent the onset of multi-resistant organisms and achieve early wound cover. The field of tissue engineering can help to expedite the healing of these burn wounds. The development of keratinocyte culture delivery system can be used clinically to fasten the healing process and save many lives.
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).
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.
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.
Glycerol-preserved skin allograft (GPA) plays a crucial role in the management of burns. Its indications include wound-bed preparation, definitive dressing and sandwich grafting technique.
BACKGROUND: Mohs micrographic surgery (MMS) provides a combination of high cure rate and tissue conservation. Epidemiologic factors and changes in techniques may affect the way MMS is performed.
OBJECTIVE: We sought to evaluate changes over time in the type of patients and skin cancers that are treated using MMS, and the repairs used to close the defects.
METHODS: We conducted a retrospective study on patients treated with MMS at the Skin and Cancer Foundation Australia, Westmead, in 1997 against those treated in 2007. Patient demographics (age, sex), pathology of tumor, anatomic site of the tumor, preoperative tumor size, postoperative defect size, and repair method were analyzed.
RESULTS: There was a 260% increase in the number of procedures (596 in 1997 vs 1587 in 2007). The 2007 cohort was a little older (62 vs 64 years), but there were no differences in sex, anatomic site, rate of basal/squamous cell carcinoma, squamous cell carcinoma histologic subtypes, or preoperative tumor size. However, there were fewer superficial basal cell carcinomas, and the postoperative defect size was smaller in 2007 (P < .0001). There was also a decrease in the use of grafts and second-intention healing to close the defects and an increase in the number of side-to-side closures (P < .0001).
LIMITATIONS: Retrospective study at one institution is a limitation.
CONCLUSION: Although tumor size and the percentage of tumors in each anatomic site did not change over 10 years, the size of the defect created after MMS has become smaller. This reduction in defect size may explain why more defects are now repaired by side-to-side closure and flap repairs whereas fewer defects are repaired by skin grafting.
Matched MeSH terms: Skin Transplantation/utilization; Skin Transplantation/statistics & numerical data
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.
A 20- year-old female student was involved in a motor vehicle accident. She sustained a severe friction injury to the left knee that resulted in considerable soft tissue and bone loss. There was also damage to the knee extensor mechanism, tibialis anterior muscle, femoral trochlea, the anterior half of the tibial plateau extending distally to the proximal tibia and skin. However, there was no crushing of the limb or resultant neurovascular deficit but cancellous bone and the remainder of the joint were exposed. Repeated surgical debridement was performed and was followed by covering of the soft tissue using a latissimus dorsi free flap and skin grafts. The bony defect was reconstituted with antibiotic bone cement to prevent flap adherence and shrinkage, enhance stability and prevent fracture. The cement was later removed at the time of arthrodesis at which time an ipsilateral double barrel vascularised fibular graft supplemented with autogenously cancellous bone and a ring fixator was used. Computer tomography confirmed union at three months post procedure. The fixator was then removed and a tibialis posterior transfer was performed.