How Long Does A Skin Graft Take To Heal On The Lower Leg?
Eplasty. 2016; 16: e14.
Published online 2016 Mar 10.
Fast and Standardized Pare Grafting of Leg Wounds With a New Technique: Study of 2 Cases and Review of Previous Methods
Nils Hamnerius, Medico,a, b Ewa Wallin, RN,a, b Åke Svensson, Dr., PhD,a, b Pernilla Stenström, Physician, PhD,b, c and Tor Svensjö, MD, PhD 
b, c, d
Nils Hamnerius
aDepartment of Dermatology Malmö University Hospital, Malmö, Sweden
bDepartment of Clinical Sciences Lund, Lund University, Sweden
Ewa Wallin
aDepartment of Dermatology Malmö Academy Hospital, Malmö, Sweden
bSection of Clinical Sciences Lund, Lund University, Sweden
Åke Svensson
aDepartment of Dermatology Malmö Academy Hospital, Malmö, Sweden
bDepartment of Clinical Sciences Lund, Lund Academy, Sweden
Pernilla Stenström
bDepartment of Clinical Sciences Lund, Lund University, Sweden
cSection of Plastic and Reconstructive Surgery, Malmö Academy Hospital, Malmö, Sweden
Tor Svensjö
bDepartment of Clinical Sciences Lund, Lund University, Sweden
cDepartment of Plastic and Reconstructive Surgery, Malmö University Hospital, Malmö, Sweden
dSection of Surgery, Fundamental Hospital, Kristianstad, Sweden
Abstract
Background: Chronic leg ulcers remain a challenge to the treating physician. Such wounds oft need pare grafts to heal. This necessitates a readily available, fast, unproblematic, and standardized procedure for grafting. Objectives: The aim of this work was to test a novel method developed for outpatient transplant procedures. Methods: The procedure employs a handheld disposable dermatome and a roller mincer that cut the skin into standardized micrografts that can exist spread out onto a suitable graft bed. Wounds were followed until healed and photographed. Results: The device was successfully used to treat and close a traumatic lower limb wound and a persistent chronic venous leg ulcer. The donor site itself healed by secondary intent with minimal corrective impairment. Conclusion: The method was successfully used to graft 2 lower extremity wounds.
Keywords: micrograft, pare transplantation, wound healing, leg ulcers, split up thickness skin graft
Both astute and chronic wounds are major clinical problems. On the basis of population studies conducted in Sweden, the betoken prevalence of leg or foot ulcers, of any crusade, was reported to exist 0.six%.1 The lifetime menstruum prevalence in an adult population, that is, the number of adults who accept always had a leg or human foot ulcer, was estimated to exist ii.4%. This would be in Sweden, with its 9 million inhabitants, translate into approximately l,000 people having an open leg ulcer and about 150,000 people who accept a history of leg ulcers (open or healed).ane In chronic wounds, delayed or absent healing represents a major claiming. They are ofttimes complications of chronic illness such equally diabetes, connective tissue disease, vascular insufficiency, or neuropathology. The resulting leg ulcers and pressure sores not just create a personal problem and a social inconvenience but sometimes too pose a threat to the limb and life of the patient.2 , 3 In some rare instances, the nonhealing wound develops neoplasia that may transform into a malignancy.4 For these reasons, restoration of an intact skin barrier is of critical importance. Treatment is oft multifaceted and multidisciplinary. It involves correction, if possible, of the underlying illness, acceptable wound bandaging, and, many times, supply of new skin to the wound, most commonly performed past autografting.
The history of peel grafting dates back to more than 2000 years ago, every bit it is believed to have been performed by the natives of Bharat.five , 6 More recently, Reverdin provided the showtime detailed clarification of pinch grafting in 1869.5 , 6 Later, in 1895, von Mangoldt7 described a method of creating small skin grafts by pulling a razor-similar scraper over the skin to yield small skin particles. The resulting smear was applied to the surface of granulating wounds with reported success.7 The method was adopted past some clinicians,5 but it has never gained widespread employ comparable with that of pinch grafting. Variants of the pinch grafts may likewise be obtained by utilizing a punch biopsy instrument (ie, a punch graft)8 or a specialized instrument, the trigger-fired pinch graft harvester.9 The method has been found to be particularly useful and efficient as a complement to bourgeois therapy of leg ulcers.10 , 11 Drawbacks, however, include poor corrective outcome, especially at the donor sites, and a rather lengthy process.12 In 1958, Meek13 and, in 1959, Nyströmxiv presented an appliance for mincing separate-thickness skin grafts (STSGs) on a cutting apparatus that had several stainless steel lamellae run in parallel at a 1-mm distance from one another. The STSG was laid onto the lamella and cutting into strips with a scalpel blade. The strips were then lifted, turned 90°, and repositioned over the lamella again, assuasive it to be cut into small grafts with a size of 1 x i mm. The Nyström method was slightly meticulous, and a faster and more practical skin meshing technique was introduced by Vandeput and colleagues15 in 1963. The afterwards method is the nearly widespread today and represents a cornerstone in the engraftment of large skin wounds with speed and predictable effect. The method commonly relies on nondisposable dermatomes and skin meshers, and for practical reasons their utilise are express to services with equipped operating rooms. Wound practitioners come across a large number of chronic wounds that have the potential to heal faster with a pare graft. In reality, many of these wounds are managed conservatively because of lack of surgical facilities and long referral times. We believe that more wounds would be grafted with skin if there were a fast and standardized process for autologous transplantation that would exist manageable in an outpatient setting. Recently, a new transplant method that employs disposable instruments has been adult with this purpose. A case of a patient with burn injury treated with this technique was reported by Dr Danks and Lairet28 in 2010. In this article, we nowadays 2 patients with leg wounds who were treated utilizing this new method.
PATIENTS
Two patients, an 85-year-old adult female with an acute, traumatic wound on the lower leg and a 54-yr-old woman with a recurrent venous leg ulcer, were treated. Informed consent was obtained from both patients. The venous ulcer was included under a human study protocol approved by the regional upstanding review lath in Lund (www.epn.se). The patient with the acute wound arrived at the emergency department during a weekend and requested an immediate transplant procedure that could merely be offered with the help of the Xpansion MicroAutografting Kit, "Xpansion."
MATERIALS AND METHODS
The Xpansion MicroAutografting Kit (Applied Tissue Technologies LLC, Newton, Mass)* is a sterile, single-utilize disposable kit that contains a nonpowered handheld dermatome (Fig 1a) for harvesting a peel graft, a nonpowered handheld mincer for processing the graft into fine particles, as well as related supplies. The dermatome has a plastic handle with a surgical blade that is set at a fixed angle and exposure that allows for the dermatome to be held flat to the skin to harvest a graft (Fig ib) approximately 0.32 mm (0.012 in) thick. The graft was transferred with forceps to a small cutting mat. The mincer has a plastic handle with an array of round blades mounted in parallel on an axle. The device was rolled over the graft in one case to cut the graft into fine strips (Figs ic and aned), and again at a xc° angle to cut the strips into particles approximately 820 μm2 (Fig anedue east). These particles were spread evenly across the wound bed (Fig 1f). No endeavour was made to orient the particles in whatsoever item management since previous sus scrofa experiments performed by Hackl et al29 have shown that orientation of the skin grafts is not necessary. The grafts were covered with a silicone dressing (Mepitel; Mölnlycke Health Care, Gothenburg, Sweden) and a foam dressing (Allevyn, Smith and Nephew, Mölndal, Sweden, or Mepilex, Mölnlycke Health Care). The venous ulcer was too bandaged with a multilayer compression bandage system (Profore; Smith and Nephew). The acute wound was also covered with a silver dressing (Acticoat; Smith and Nephew) to prevent infection and a light compression bandage. Dressings were changed when necessary. Sterility was maintained during the initial procedure. Donor sites were located on the inductive thigh and were covered with a combined silicone foam dressing (Mepilex Border, Mölnlycke Wellness Care). Local anesthesia was managed with subcutaneous injection of Mepivakain (ten mg/mL) with epinephrine (v µg/mL). After transplantation, the patients were asked to maintain a balmy physical activity and to accept their grafted legs elevated whenever sitting or lying.
Transplantation process. (a) The handheld dermatome is run back and along with mild pressure over the skin that has been moisturized with saline. (b) An approximately 4-cm2 STSG graft has been harvested and laid onto the cutting mat, which was wetted with a few droplets of saline. (c) The handheld mincer is run outset once over the STSG and then once more in a 90° angle in relation to the first time. (d) The mincer has an array of circular blades mounted in parallel on an axle. Any peel fragments that stick to the mincer are removed with a spatula and transferred to the other fragments on the cutting mat. (east) Close-upward of the skin fragments approximately 800 × 800 µm in size. Sometimes an actress run with the mincer is necessary to obtain complete mincing. (f) The skin fragments are kept together and spread out onto the wound bed. STSG indicates split-thickness skin graft.
RESULTS
An acute wound of the lower limb
A 85-twelvemonth-old woman presented at the emergency department subsequently having a fall in her apartment and during the fall she hit a furniture with a resulting wound measuring half-dozen × viii cm (width × elevation) on her right anterior-lateral lower leg displaying exposed muscle, subcutaneous fat, and dermal tissue (Fig 2a). The wound was cleansed, subcutaneous tissues were adapted with sutures to cover the muscle, and the wound was grafted with skin harvested and processed with Xpansion (Figs 2b and 2c). The expansion charge per unit was 1:12 (donor site 2 × 2 cm), and the procedure lasted approximately 15 minutes including local anesthesia and bandaging. The patient was admitted to the hospital for 12 days to allow for daily inspections, leg superlative, and the planning for home care. Eight days posttransplantation, graft take was evident (Fig 2c). The wound healed completely at 24-hour interval 25. A follow-up at half-dozen weeks showed a wound that remained healed and that exhibited a spotty pattern of incorporated micrografts (Fig 2d). The donor site besides healed displaying redness but no hypertrophic scarring, typically what is seen in split up-thickness skin donor sites at this fourth dimension bespeak (Fig 2e).
An acute wound measuring approximately half dozen × 8 cm (width × length) with exposed muscle fascia, subcutaneous fat, and dermal tissue (a). (b) After suturing and transplantation. (c) Silicone dressing in identify on the top of grafts. (d) Eight days posttransplantation with evidence of graft accept seen equally lighter colored epithelial islands. (e) Follow-up 6 weeks postgrafting showing a spotty pattern of the skin grafts separated by red scar tissue without any hypotrophy. (f) The donor site (approximately ii × ii cm) at six weeks also showing typical redness simply no hypertrophic scarring. This redness ordinarily disappears within a year.
A chronic venous leg ulcer
An otherwise healthy 54-yr-old woman was referred to the Dermatology department with a pretibial ulcer on the right leg since 18 months (Fig 3a). Despite bourgeois therapy with compression bandages for 3 months, the ulcer failed to heal. The ankle brachial index was 0.8, claret force per unit area was 160/90 mm Hg, and the trunk mass index was 28.7. A marked insufficiency of the vena saphena magna was confirmed by Duplex investigation. There were no signs of deep venous insufficiency. Routine laboratory finding was normal (hemoglobin, erythrocyte sedimentation rate, albumin, blood glucose). The wound was clinically clean and exhibited granulation tissue; a routine wound swab showed only sparse growth of Staphylococcus aureus. Transplantation was performed with an expansion rate of 1:1.25 (donor site 2 × six cm, wound 3 × 5 cm) and the procedure lasted approximately twenty minutes including local anesthesia and bandaging. Routine visit iii days postoperatively showed grafts in place (Fig threeb). Ten days postoperatively, there were signs of partial graft have (Fig 3c), simply the wound likewise exhibited some pus and a scattered signs of folliculitis was seen in the surrounding peel. Handling was initiated with isoxazolyl penicillin 500 mg 3 times daily for ten days. On days 17 (Fig 3d) and 24 (Fig 3e), the wound showed healing and gratis of infection. On day 31, the surrounding skin once once again presented with folliculitis besides as eczema. The wound, however, continued to heal as demonstrated past expanding epithelial islands and diminishing open up wound area (Fig 3f). Treatment with isoxazolyl penicillin (in accordance with resistance pattern of cultured South aureus) and topical corticosteroids was started. On day 38, the wound nigh healed (Fig 3g), and 45 days postoperatively, the wound healed completely (Fig 3h). At follow-up (5 months postoperatively), the wound had remained healed (Fig iiii), compression stockings class 2 were continuously used, and the donor site was hardly visible (Fig iiil) as compared with mean solar day 0 (Fig 3j) and day 24 (Fig 3one thousand). The patient underwent cream sclerosing treatment of the insufficient vena saphena magna seven months postoperatively. At xix months, the patient continues with compressing stocking and her wound remains healed.
A venous ulcer transplanted with skin grafts. (a) The ulcer displaying complete granulation. (b) Three days postgrafting displaying grafts in identify. (c) X days postgrafting and complicated past a mild infection (Staphylococcus aureus) with some pus. On twenty-four hours 17 (d) and day 24 (e), the wound appeared to be healing and small epithelial islands were sparsely distributed over the wound surface. (f) On day 31, healing has progressed significantly, and on day 38 (chiliad), the wound was almost healed. (h) A completely healed wound on day 45. (i) Follow-upwards visit at 5 months and notwithstanding healed. The redness has go less pronounced. (j) Donor site (approximately 2 × 6 cm) immediately subsequently harvest, (k) at 24 days, and (fifty) at 5 months barely visible.
DISCUSSION
This report presents a standardized and fast procedure for preparation of small skin grafts. The grafts, when laid onto an astute wound and a chronic wound, were associated with complete healing of the wounds. Like and identical grafts have, in animal studies, been shown to reepithelialize total-thickness skin wounds.16 There are several mechanisms by which transplantation of small peel fragments might exert a positive effect on wound healing. Start, graft take by incorporation and revascularization of the transplanted tissues may occur. This is very likely to have happened in our study, based upon the observations of isolated epithelial islands in the grafted wounds. Second, the supply of new cells, such as keratinocytes and fibroblasts, to the wound may, together with the proliferative stimulus of the wound environment, lead to proliferation, differentiation, and migration of the grafted skin. This mechanism is supported by the observation of epithelial islands in the grafted wounds that expanded and coalesced during the healing process in this report. It is besides supported by reports that have shown accelerated healing in wounds transplanted with autologous cultured fibroblasts17 and keratinocyteseighteen - 20 as verified by sequential histologies and identification of the transplanted cells past cistron marking. Such studies take ended that the cells survive and incorporate into the tissues of the healing wound. Third, it is plausible that the grafted skin secrete ane or several growth factors into the wound milieu, which are capable of augmenting the healing process. This presumes that the growth factors work in an autocrine and/or paracrine fashion and crave that the cells of the transplanted tissues, or native cells in the wound surround, are capable of responding to growth factors or other cytokines released by the skin grafts. Our report could non determine whether such a mechanism was of any significance for the observed healing response, simply this view is supported by other studies that have demonstrated accelerated healing of man leg ulcers transplanted with allogenic keratinocytes and fibroblasts.21 , 22 Such allogeneic cells are unable to survive in the long term due to incompatibility with the host,22 although information technology was initially reported otherwise.21
The minced skin technique used in this written report is likely to exist faster than the ordinarily used pinch grafting process. A direct comparison was however not performed. The STSG harvested in this report is also thinner than a typical compression graft that often contains a significant portion of dermis. In our feel, a thin STSG donor site heals with minimal corrective harm when evaluated one half to a year postoperatively. Pinch graft donor sites at a similar time point are, on the opposite, oft highly visible every bit depigmented spotty areas exhibiting typical scar tissue.
In comparing with cultured autologous keratinocytes, we run into several advantages with the procedure studied herein. Offset, the tissue is available immediately whereas keratinocytes need typically three to 4 weeks of culture to obtain a sufficient amount of cells.23 , 24 2nd, keratinocyte culturing is very labor-intensive and relies on specialized laboratory equipment and facilities and therefore it is profanely expensive.25 Finally, keratinocyte grafting is a two-phase procedure involving harvest of the donor skin necessitating a small surgical procedure and, at a subsequently stage, when the cultures are gear up, a transplant procedure must be performed. The advantage with cultured keratinocytes is, however, the virtually unlimited amounts of cells that may be obtained by serial propagation and subculture of the keratinocytes in vitro. For the relatively pocket-sized wound, this is probably non necessary and information technology is quite possible that donor site size may exist kept low by spreading the minced skin grafts extensively, thereby obtaining a loftier expansion factor. This remains to be studied in detail.
Some other possible advantage of minced skin grafts is that they as well contain a dermal support. The importance of a dermal tissues for the enhancement of transplantation of cultured keratinocytes has previously been stressed,17 , 24 , 26 , 27 and, if absent, the take rate of keratinocytes is oft poor.
In relation to traditional separate-thickness pare grafting and meshing,15 the minced peel technique offers the possibility of greater expansion. Greater expansion volition, yet, as well lead to longer healing times and lower efficiency. We therefore exercise not believe that the minced pare procedure presented here would exclude traditional grafting, just we may consider it as a commencement line of treatment in the outpatient clinic as it offers a standardized and hands available handling option for therapy-resistant pare ulcers.
Footnotes
* The Xpansion MicroAutografting Kit is distributed by SteadMed Medical LLC, Fort Worth, Tex.
Acknowledgment
Xpansion was supplied by Practical Tissue Technologies, Newton, Mass.
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How Long Does A Skin Graft Take To Heal On The Lower Leg?,
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