Comparison of Efficacy among Three Dermal Substitutes in the Management of Critical Lower-Limb Wounds: The Largest Biases-Reduced Single-Center Retrospective Cohort Study in Literature

Background and objectives: The skin recently became the main focus of regenerative medicine and, in this context, skin substitutes are fully entering into the plastic surgeon’s armamentarium. Among the various types of skin substitutes, dermal substitutes (DSs) are the most used. Our study aims to retrospectively compare three renowned and extremely similar DS in the management of critical lower limb wounds in the largest cohort analysis currently present in literature. Materials and Methods: We followed a strict protocol of application and evaluation of the DS for each patient and wound and, after a meticulous bias reduction process, we compared final outcomes in terms of efficacy and speed in achieving the defect coverage. Results: Among patients who did not receive a skin graft after the DS, we registered a wound healed surface of 50% for Pelnac, 52% for Integra, and 19% for Nevelia, after 30 days from the external silicon layer removal; among those who received a skin graft after the DS, we observed a significantly lower mean percentage of graft take after 7 days with Pelnac (53%) compared to Integra and Nevelia (92% and 80%, respectively). The overall percentage of wound healed surface obtained after 30 days from the external silicon sheet removal, either with or without skin graft, was 71% for Pelnac, 63% for Integra and 63% for Nevelia. We also ran a sub-group analysis only including grafted wounds with a negative microbiological test and the mean percentage of graft take was similar this time. Eventually, we assessed the influence of the wound’s “chronicity” on its healing, comparing the mean graft take only in “acute” wounds who received a skin graft and it resulted 63% for Pelnac, 91% for Integra and 75% for Nevelia. Conclusions: Integra demonstrates the highest rate of skin graft viability and the highest rate of skin graft takes after 7 days. Pelnac shows the quickest induction of secondary healing in acute wounds. Nevelia is not different from Integra and shows a superior graft take compared to Pelnac, but features the lowest secondary healing induction rate. No differences exist between the three DSs in terms of wound healing after 30 days from the skin graft or from the removal of the external silicon layer.

Skin Oncoplasties: Is Z-Plasty A Technique of Choice In Situation of Limited Resources? Case of Burkina Faso.

Background: In developing countries, the long delays in consultation lead to a delay in diagnosis and management of the skin tumours. The lesions are often large and brings the problem of skin coverage after their resections. Several reconstruction techniques allow skin coverage. The objective of this study is to describe the place of Z-plasty in the surgical treatment of skin cancers in Ouagadougou.Patients and methods: It was a two-centre, retrospective, descriptive study on Z-plasty in skin cancers. It included patients who underwent surgery between January 1st, 2013 and March 30th, 2021 in Ouagadougou. Scar quality and healing time in Z-plasty were compared with those of secondary healing. Results: In 8 years and 3 months, 171 skin cancers were identified. The mean time to consultation was 13.6 months. The average size of the tumours was 9 cm. A Z-plasty was performed in 42 cases, being 58.3% of the patients operated on. The average healing time was 15 days. It was four and a half times shorter in Z-plasty than in secondary healing. Ischaemic necrosis of the Z-corner was noted in 7 cases. The recurrence rate in Z-plasty and secondary healing was 7.1% and 9.1% respectively. Hypertrophic or keloidal scars were noticed in 7 cases and hypochromia in 2 cases.Conclusion: Z-plasty is a technique of choice for skin coverage after large resections in surgical oncology. It reduces the healing time and the cost of postoperative care without increasing the risk of tumour recurrence.

Conservative Technique Using Oral Dressing Material for Wound Dehiscence after Ridge Augmentation: A Technical Report with a Case Series

Wound dehiscence is the most frequent complication after ridge augmentation and causes postoperative infection, inadequate bone healing, or graft failure. In the oral cavity, conservative treatment for dehiscence is difficult to maintain until secondary healing occurs because of its normal flora, dynamic masticatory muscle movement, and humid environment. This paper reports an effective conservative method using an oral wound dressing material with an omnivec splint and presents three wound dehiscence cases: (1) autogenous tooth bone graft material with a collagen membrane, with dehiscence occurring at postoperative 5 days. (2) Autogenous bone graft covering titanium mesh, with dehiscence occurring at postoperative three weeks. The mesh was removed after 10 weeks with histologic analysis. (3) Autogenous bone and autogenous tooth bone graft covering a titanium mesh, with dehiscence occurring at postoperative 1 week. The exposed titanium mesh was maintained for 6 months after the graft. All cases achieved secondary healing and acceptable outcomes for a dental implant by conservative treatment without infection after the dehiscence after ridge augmentation.

Punch Incision with Secondary Healing (PISH) Technique for Benign Facial Lesions: An Institutional Experience in 307 Patients

Background Multiple or solitary facial lesions pose a unique challenge to the attending surgeon in terms of delivering the best cosmetic outcome. There are various methods in dealing with them and the preference of using them is based on the surgeon’s experience, patient expectations, and availability of instruments. One such tool, skin-punch, primarily designed for a biopsy can play a very important therapeutic role in this era of keyhole surgery. In this paper, we assess the technique of punch incision with its combination of secondary healing for various facial lesion. Methods This observational study, a total of 307 patients with solitary or multiple benign facial lesions were treated with punch incision technique using 2 to 6 mm sterile, disposable skin biopsy punches. Subsequently, the wounds were managed with healing with secondary intention. Results In our series all superficial wounds epithelized by 7 to 14 days while the deeper lesions epithelized by 14 to 28 days. We had three recurrences which were managed by fusiform excision and one patient had surgical site infection which was managed conservatively. On application of our self-devised facial scar scoring system (SCAR or Scar Cosmesis Assessment and Rating)3 on all the scars, the mean score was 6 at 1 year followup. Conclusion Punch incision with healing by secondary intention is a relatively easy, effective, single-stage office procedure. This method can be considered as an alternative method for the removal of various skin lesions, especially on face, thus providing a simple solution to complex problems.

An unusual case of childhood osteoarticular tuberculosis from the Árpádian Age cemetery of Győrszentiván-Révhegyi tag (Győr-Moson-Sopron county, Hungary)

Ancient human remains exhibiting bony changes consistent with osteoarticular tuberculosis (OATB) indicate that the disease has afflicted mankind for millennia. Nonetheless, not many pediatric OATB cases have been published in the paleopathological literature–from Hungary, only three cases have been described up to now. In our paper, we demonstrate a child (S0603) from the Árpádian Age cemetery of Győrszentiván-Révhegyi tag (northwestern Hungary), who represents a unique case of OATB regarding both the pattern and severity of the observed bony changes. During the macromorphological and radiological investigations, the most serious alterations were discovered in the upper thoracic spine–the development of osteolytic lesions led to severe bone loss and consequent collapse and fusion of several adjacent vertebrae. The pathological process terminated in a sharp, rigid angular kyphosis. Disruption of the normal spine curvature resulted in consequent deformation of the whole thoracic wall–it became “rugby-ball-shaped”. The overall nature and pattern of the detected alterations, as well as their resemblance to those of described in previously published archaeological and modern cases from the pre-antibiotic era indicate that they are most consistent with OATB. Based on the severity and extent of the lesions, as well as on the evidence of secondary healing, S0603 suffered from TB for a long time prior to death. Besides body deformation, OATB resulted in consequent disability in daily activities, which would have required regular and significant care from others to survive. It implies that in the Árpádian Age community of Győrszentiván-Révhegyi tag, there was a willingness to care for people in need. Detailed archaeological case studies can give us a unique insight into the natural history and different presentations of OATB. Furthermore, they can provide paleopathologists with a stronger basis for diagnosing TB and consequently, with a more sensitive means of assessing TB frequency in past populations.

Age-Related Palatal Wound Healing: An Experimental In Vivo Study

We assessed age-related excisional palatal mucoperiosteal wound closure in rats. A 4.2 mm diameter punch was used to create a secondary healing defect in the palate of Wistar rats. Study group—21, 18-month-old vs. control 21, 2-month-old males. The 2-dimensional area, maximum length and width of the soft tissue defect served as clinical outcome parameters. The dynamics of the initial three healing weeks were assessed. Semi-quantitative histomorphometric analysis of inflammation and myofibroblasts served for the evaluation of the inflammatory and proliferative wound healing phases. Complete wound closure was faster in the old rats. A dimensional related wound closure was observed in the young rats versus a symmetrical wound closure in the old rats. Inflammatory response was significantly delayed and of lower intensity in the old rats. Myofibroblastic response, representing the proliferative stage, was delayed and of lower intensity in the old rats, albeit not statistically significant. Reduced initial tissue damage due to decreased and delayed inflammatory response in the old rats ultimately led to faster clinical wound healing compared to the young rats, despite a statistically non-significant lower proliferative response in the old rats.

Analysis of Outcomes in Adolescents and Young Adults With Pilonidal Disease

Purpose: Numerous definitive surgical techniques exist for the treatment of pilonidal disease with varied recurrence rates and wound complications. Due to the wide array of techniques and lack of consensus on the best approach, we proposed to study our experience treating pilonidal disease in adolescents and young adults.Methods: A retrospective analysis was conducted of patients 10–24 years old treated at a tertiary medical center from 2011 to 2016. Data including demographics, management, and outcomes were collected and analyzed. Primary outcome was recurrence of disease.Results: One hundred and thirty three patients with pilonidal disease underwent operative management. Fifty one percent underwent primary closure and 49% healed by secondary intention with no significant difference in recurrence rates (primary 18%, secondary 11%; p = 0.3245). Secondary healing patients had significantly lower wound complication rates (primary 51%, secondary 23%; p = 0.0012). After accounting for sex, race, weight, and operative technique, age was predictive of disease recurrence with an adjusted odds ratio (OR) of 0.706 (0.560–0.888; p = 0.003). Age and sex were both predictive of wound complications. Older patients had decreased risk of wound complication (adjusted OR 0.806, 95% CI 0.684–0.951; p = 0.0105), and male patients had increased risk of wound complication (adjusted OR 2.902, 95% CI 1.001–8.409; p = 0.0497).Conclusion: In summary, there is no significant difference in the recurrence rates between operative techniques for pilonidal disease. Older patients have decreased risk of recurrence following intervention. Wound complication rates are lower in patients undergoing secondary healing, though this may be better explained by differences in age and sex. Additional research investigating newer, minimally-invasive techniques needs to be pursued.

Reconstruction of Achilles region defects: a single-center experience

Background: Reconstruction of Achilles tendon and the overlying tissue defects is a challenging undertaking. The spectrum of available repair methods range from secondary healing to use of free flaps. Method: In this study, we retrospectively evaluated 14 patients who underwent reconstruction of Achilles region defect between 2016 and 2019 at a single center. Results: Reconstructions were performed with secondary healing (n=2), negative pressure wound therapy and skin grafting (n=2), free flaps (n=6), and local and distant flaps (n=4). Satisfactory aesthetic and functional outcomes were achieved in all patients. One patient developed partial skin graft loss. Marginal necrosis occurred in one of the local flaps. Wound dehiscence and flap retraction occurred in one of the free (superficial circumflex iliac artery perforator) flaps. One patient undergoing reconstruction with ulnar artery perforator flap developed intraoperative atrial fibrillation; the operation was terminated and reconstruction completed with skin grafting. Conclusion: Orthoplastic reconstruction should be kept in mind for Achilles tendon defects. Use of special digital imaging techniques facilitates flap surgery and helps minimize the risk of flap complications. Conventional approaches are suitable for shallow small skin lesions. Local flaps are good options for deeper skin defects owing to superior aesthetic outcomes. Superthin free flaps offer a distinct advantage in skillful hands. Use of multi-content free chimeric flaps for reconstruction of complex defects facilitates better anatomical repair. Cross leg or flow-through flaps may be considered in patients with compromised distal circulation. Selection of the most reliable approach for Achilles reconstruction is a key imperative to achieve favorable outcomes.

Simplified protocol for horizontal and vertical post-extractive GBR with intentionally exposed PTFE membrane - Case series

Purpose: Post-extractive sites often need soft and hard tissue regeneration in order to place implants with optimal functional and aesthetic conditions. The author proposed several techniques for bone preservation and regeneration: most of them requires release incisions and coronally advanced flap to obtain primary closure, so regain a correct alignment of keratinized gingiva makes mandatory a further surgery with a connective tissue graft from secondary surgical site. Case report: Since May 2018 we applied with some adjustments Open Barrier Technique (proposed by E. Funakoshi, 2005) in 152 post-extractive alveolar preservation and GBR; after 3-6 months we placed 194 implants, with 100% success and survival rate. Conclusions: Our simplified protocol allows performing vertical and horizontal GBR in post-extractive sites without release incisions: non resorbable PTFE membrane protects wound and bone graft for 6-8 week; secondary healing ensures thick keratinized tissue and bone maturation, suitable to place implants after 3-6 months.