- Email: [email protected]
An easy way to prepare microskin grafts
Bums (1994) 20, (2), 151-153
151
Pn'nted in Great Britain
An easy way to prepare microskin gratis C-S. Lai, S-D. Lin, C-C. Tsai, C-W. Tsai and C-K. Chou Division of Plastic and Reconstructive Surgery, Chung-Ho Memorial Hospital, Kaohsiung Medical College, Kaohsiung, Taiwan
The conventional technique to produce microskin grafts is a relatively time-consuming procedure. We developed an easy method by using a trimmed circular dermacarrier with the non-grooved side up and driving forward in the meshgraft instrument through six different angles that were 30 ~ apart. The tiny skin parh'cles obtained by this method not only saved operation time but also survived well in the grafted wounds.
Introduction Microskin grafting is a useful method for covering an extensive bum wound when there is only a limited amount of patient's skin available 1-4. The conventional technique to obtain microskin grafts, developed by Zhang et al. in 1986 ~, is a relatively time-consuming procedure. Herein, we present a simple technique to prepare microskin grafts (MSG) which requires much shorter operation time and is easier to handle.
//-////.//
Dermacarrier:l ~Dernlacarrier;J
V//'//-,/,,///,/,d V / / / / / / / / , ~
l 90 ~ 120 ~
60 ~
150 ~
180~ ~ . - -
Methods and results The dermacarrier (Zimmer, Snyder Labs, Dover, OH, USA) measuring 20 x 7.5 cm is cut in half with scissors. The divided rectangular dermacarrier is then trimmed into a circle measuring 7.5 cm in diameter. The circular dermacarrier is marked at the points of 0, 30, 60, 90, 120 and 150 ~ The autograft skin harvested from the patient is tailored and placed evenly on the ungrooved (smooth) side of the circular dermacarrier, and positioned firmly against the guide rail of the meshgraft instrument (Meshgraft II, Zimmer). The autograft is then cut six times through each of the previously marked angles (0, 30, 60, 90, 120 and 150 ~ by the meshgraft instrument (Figure I). The widths of the ridge and the groove of the guide rail are 0.1 mm and I mm respectively. The thickness of the split-thickness autograft is about 0.4 mm. When the skin is cut twice through 0 ~ and 90 ~ by the parallel sharp ridges of the guide rail, many square pieces measuring 1 x I x 0.4 mm (0.4 mm 3) in volume are produced. When six cuttings of the autograft at 30 ~ separations have been completed, numerous tiny skin particles with various shapes and sizes are obtained. Sufficient sterile olive oil should be applied on the guide rail circumferentially before each cutting to prevent the sliced skin particles from adhering to the mesher blades and grooves. We used three sheets of transparent plastic which are drawn with intersecting lines at 0 ~ and 90 ~ 30 ~ and 120 ~ and 60 ~ and 150 ~ respectively to indicate the possible sizes and shapes of the microskin grafts (Figure2). The largest 9 1994 Butterworth-Heinemann Ltd 0305-4179/94/020151-03
Figure 1. The rectangular dermacarrier is cut in half and trimmed into a circle. The circular dermacarrier is marked at the points 0, 30, 60, 90, 120 and 150 ~ The autograft is placed on the ungrooved side of the dermacarrier and cut six times by the meshgraft machine through the marked angles that are 30* apart.
particle is estimated to occupy about 80 per cent of the square pieces and its volume is 0.32 mm 3 (0.8 x 0.4 mm3), however, these large skin particles are present in very small numbers. The obtained skin particles are collected in a stainless container, and spread directly and randomly onto the wound using a pair of knife handles or forceps. Sheets of pigskin xenograft are then overlaid on the microskin graft and sutured into position. Conventional wound dressings and immobilization were applied. The dressing is first changed on the fifth or sixth day after grafting and then daily or on alternate days. Since the MSG obtained by the described method is a new technique, four patients with relatively low risk of complications were chosen to evaluate its 'take'. The expansion ratio ranged from 9 : 1 to 10 : 1, and the wound was resuffaced with neoepithelium within 23-26 days (Table I). Long4erm follow-up showed acceptable results
152
Burns (1994) Vol. 20/No. 2
Table I. Clinical patients Cases 1 2 3 4
Sex
Age (yr)
Causes of the lesion
Location
Expansion ratio
Healing time (days)"
Male Mate Female Male
43 28 38 21
Avulsion injury Flame burn Avulsion injury Scald burn
Right leg Both legs Right thigh Left lower extremity
10 : 1 10 : 1 10 : 1 .9 : 1
24 26 24 23
*Over 95 par cent of w o u n d resurfaced.
(Figure 3). Compared with patients previously reported by Lin et al.*, wound healing time and the quality of the grafted skin were similar to microskin grafts obtained by conventional methods. However, the required manpower and operation time were much less than the conventional one. Discussion
Figure 2. Three sheets of transparent plastic are drawn with the intersected lines of 30* and 120", 0 ~ and 90~ and 60~ and 150" respectively. They are overlapped and slid over each other to indicate the possible shapes and sizes of the obtained microskin grafts. The largest one occupies about 80 per cent of the square pieces, and the volume is 0.32 mm 3 (0,8 x 0.4 mm3).
Skin expansion is vital for grafting extensive wounds if the availability of skin autograft is limited. Since Von Mangoldt obtained epidermal particles by scraping the surface with a sharp razor in 1895 ~, various methods have been developed to harvest fine skin particles 7-9. Blair et al]o used the automated tissue slicer to obtain microscopic split thickness grafts with a 30-fold expansion. Techniques of intermingled transplantation of auto- and allografts ~ and widely meshed skin autografts ~2 have been used clinically with a high degree of success. Zhang et al.x,s introduced the technique of microskin grafting for treatment of severe bums with encouraging results; our previous works* have also shown that these microskin grafts are an effective procedure by which an extensive wound could be covered successfully with a very limited amount of autogenous skin grafts. The conventional technique of applying microskin grafts includes two main procedures: first the split thickness autograft should be minced with scissors into tiny pieces smaller than I mm3; and secondly the skin particles are floated on saline and then the suspension is sieved through a silk cloth to distinguish the epidermal side from the dermal side. We used the trimmed circular dermacarrier and the
Figure 3. a, A 43-year-old male suffered an avulsion injury over his right leg. Microskin grafts were placed on the wound, b, Pigskin
xenograft was overlaid on the microskin grafts, c, Follow-up at 100 days showed excellent wound healing with an acceptable cosmetic result.
Lai et al.: Microskin graft preparation
153
5 Zhang ML, Chang ZD, Han X et al. Microskin grafting, I, Animal experiments. Burns 1986; 12: 540. 6 Von Mangoldt F. Die Ueberhautung von Wundflachen und Wundhohlen durch Epithelaussaat; eine neue Methode der transplantation. Deutsche Med Wochnschr 1895; 21: 798. 7 Najarian JS, Crane JT and McCorkle HJ. An experimental study of the grafting of a suspension of skin particles. Surgery 1957; 42: 218. 8 Cox WA and Nichol WW. Evaluation of the fine-particlesskin autograft technique. Arch Surg 1958; 77: 870. 9 Nystrom G. Sowing of small skin graft particles as a method for epithelization especially of extensive wound surfaces. Plast Reconstr Surg 1959; 23: 226. 10 Blair SD, Nanchahal J, Backhouse CM et al. Microscopic split-skin grafts: a new technique for 30-fold expansion. Lancet 1987; ii: 483. 11 Yang CC, Shih TS, Chu TA et al. Intermingled transplantation of auto- and homograffs in severe bums. Barns 1980; 6: 141. I2 Alexander JW, MacMillan BG, Law EJ et al. Treatment of severe bums with widely meshed skin autograft and meshed skin allograft overlay. ]. Trauma 1981; 21: 433. 13 Fang CH and Alexander JW. Wound contraction following transplantation of microskin autografts with overlaid skin allograft in experimental animals. Bums 1990; 16- 190. 14 Lin SD, Chou CK, Lai CS et al. Microskin grafting of rabbits with pigskin xenograft overlay. Bums 1991; 17: 473. 15 Lin SD, Lai CS, Chou CK et al. Microskin grafting of rabbits with Biobrane overlay. Bums 1992; 18: 390.
meshgraft machine to produce microskin grafts in place of cutting with scissors, this simple technique not only saved operation time but also manpower. Although Zhang et al.2'5 and Nystrom 9 emphasized that it was essential to place the skin particles with the epidermal side upward (dermal side down) on the wound surface, Fang and Alexander ~3 and Lin et al. 14'Is have proved that microskin grafts grow well regardless of the individual orientation of the skin pieces. We spread the tiny skin particles directly and randomly onto the wound without the time-consuming procedure of separation of the epidermal side from dermal side. Successful take of the microskin grafts in clinical patients proved that harvesting the microskin graft from the meshgraft machine did not cause damage to the skin particles and the graft survived well independent of the orientation of the skin particles. This simple technique is recommended for preparing microskin graft in place of the conventional one.
References 1 Zhang ML, Wang CY, Chang ZD et al. Microskin grafting, II, Clinical report. Bums 1986; 12: 544. 2 Zhang ML, Chang ZD, Wang CY et al. Microskin grafting in the treatment of extensive bums: a preliminary report. J. Trauma 1988; 28: 804. 3 Fang CH, Yu GS, Fan YF et al. A preliminary report on transplantation of microskin autografts overlaid with sheet allograft in the treatment of large bums. ] Burn Care Rehabil 1988; 9- 629. 4 Lin SD, Lai CS, Chou CK et al. Microskin autograft with pigskin xenograft overlay: a preliminary report of studies on patients. Bums 1992; 18: 321.
We offer a reprints
Paper accepted 19 August 1993. Correspondenceshould be addressed to: Dr C-S. Lai,Division of Plastic Surgery, Chung-Ho Memorial Hospital, Kaohsiung Medical College, 100 Shih-Chuan 1st Road, Kaohsiung, Taiwan, RO China.
s e r v i c e in r e s p e c t
o f all a r t i c l e s in t h i s j o u r n a l .
Companies: a n a r t i c l e f e a t u r i n g y o u r p r o d u c t o r a n e w a p p l i c a t i o n provides its readers with an independent authoritative comment. Reprints can be used by you to inform and educate your customers and s t a f f a b o u t s c i e n t i f i c o r t e c h n i c a l a d v a n c e s in s u b j e c t s r e l e v a n t t o y o u r business. They are a cost-effective, ethical way of promoting your company and its products. For a q u o t a t i o n o n y o u r r e p r i n t r e q u i r e m e n t s ,
please contact:
The Reprints Department, Butterworth-Heinemann Ltd., Linacre House, J o r d a n Hill, O x f o r d , OX2 8DP. Tel: + 4 4 ( 0 ) 8 6 5 3 1 0 3 6 6 . Fax: + 4 4 ( 0 ) 8 6 5 3 1 4 5 1 9
I~UTTERWORTH I~IE
I N
E
M
A
N
N
151
Pn'nted in Great Britain
An easy way to prepare microskin gratis C-S. Lai, S-D. Lin, C-C. Tsai, C-W. Tsai and C-K. Chou Division of Plastic and Reconstructive Surgery, Chung-Ho Memorial Hospital, Kaohsiung Medical College, Kaohsiung, Taiwan
The conventional technique to produce microskin grafts is a relatively time-consuming procedure. We developed an easy method by using a trimmed circular dermacarrier with the non-grooved side up and driving forward in the meshgraft instrument through six different angles that were 30 ~ apart. The tiny skin parh'cles obtained by this method not only saved operation time but also survived well in the grafted wounds.
Introduction Microskin grafting is a useful method for covering an extensive bum wound when there is only a limited amount of patient's skin available 1-4. The conventional technique to obtain microskin grafts, developed by Zhang et al. in 1986 ~, is a relatively time-consuming procedure. Herein, we present a simple technique to prepare microskin grafts (MSG) which requires much shorter operation time and is easier to handle.
//-////.//
Dermacarrier:l ~Dernlacarrier;J
V//'//-,/,,///,/,d V / / / / / / / / , ~
l 90 ~ 120 ~
60 ~
150 ~
180~ ~ . - -
Methods and results The dermacarrier (Zimmer, Snyder Labs, Dover, OH, USA) measuring 20 x 7.5 cm is cut in half with scissors. The divided rectangular dermacarrier is then trimmed into a circle measuring 7.5 cm in diameter. The circular dermacarrier is marked at the points of 0, 30, 60, 90, 120 and 150 ~ The autograft skin harvested from the patient is tailored and placed evenly on the ungrooved (smooth) side of the circular dermacarrier, and positioned firmly against the guide rail of the meshgraft instrument (Meshgraft II, Zimmer). The autograft is then cut six times through each of the previously marked angles (0, 30, 60, 90, 120 and 150 ~ by the meshgraft instrument (Figure I). The widths of the ridge and the groove of the guide rail are 0.1 mm and I mm respectively. The thickness of the split-thickness autograft is about 0.4 mm. When the skin is cut twice through 0 ~ and 90 ~ by the parallel sharp ridges of the guide rail, many square pieces measuring 1 x I x 0.4 mm (0.4 mm 3) in volume are produced. When six cuttings of the autograft at 30 ~ separations have been completed, numerous tiny skin particles with various shapes and sizes are obtained. Sufficient sterile olive oil should be applied on the guide rail circumferentially before each cutting to prevent the sliced skin particles from adhering to the mesher blades and grooves. We used three sheets of transparent plastic which are drawn with intersecting lines at 0 ~ and 90 ~ 30 ~ and 120 ~ and 60 ~ and 150 ~ respectively to indicate the possible sizes and shapes of the microskin grafts (Figure2). The largest 9 1994 Butterworth-Heinemann Ltd 0305-4179/94/020151-03
Figure 1. The rectangular dermacarrier is cut in half and trimmed into a circle. The circular dermacarrier is marked at the points 0, 30, 60, 90, 120 and 150 ~ The autograft is placed on the ungrooved side of the dermacarrier and cut six times by the meshgraft machine through the marked angles that are 30* apart.
particle is estimated to occupy about 80 per cent of the square pieces and its volume is 0.32 mm 3 (0.8 x 0.4 mm3), however, these large skin particles are present in very small numbers. The obtained skin particles are collected in a stainless container, and spread directly and randomly onto the wound using a pair of knife handles or forceps. Sheets of pigskin xenograft are then overlaid on the microskin graft and sutured into position. Conventional wound dressings and immobilization were applied. The dressing is first changed on the fifth or sixth day after grafting and then daily or on alternate days. Since the MSG obtained by the described method is a new technique, four patients with relatively low risk of complications were chosen to evaluate its 'take'. The expansion ratio ranged from 9 : 1 to 10 : 1, and the wound was resuffaced with neoepithelium within 23-26 days (Table I). Long4erm follow-up showed acceptable results
152
Burns (1994) Vol. 20/No. 2
Table I. Clinical patients Cases 1 2 3 4
Sex
Age (yr)
Causes of the lesion
Location
Expansion ratio
Healing time (days)"
Male Mate Female Male
43 28 38 21
Avulsion injury Flame burn Avulsion injury Scald burn
Right leg Both legs Right thigh Left lower extremity
10 : 1 10 : 1 10 : 1 .9 : 1
24 26 24 23
*Over 95 par cent of w o u n d resurfaced.
(Figure 3). Compared with patients previously reported by Lin et al.*, wound healing time and the quality of the grafted skin were similar to microskin grafts obtained by conventional methods. However, the required manpower and operation time were much less than the conventional one. Discussion
Figure 2. Three sheets of transparent plastic are drawn with the intersected lines of 30* and 120", 0 ~ and 90~ and 60~ and 150" respectively. They are overlapped and slid over each other to indicate the possible shapes and sizes of the obtained microskin grafts. The largest one occupies about 80 per cent of the square pieces, and the volume is 0.32 mm 3 (0,8 x 0.4 mm3).
Skin expansion is vital for grafting extensive wounds if the availability of skin autograft is limited. Since Von Mangoldt obtained epidermal particles by scraping the surface with a sharp razor in 1895 ~, various methods have been developed to harvest fine skin particles 7-9. Blair et al]o used the automated tissue slicer to obtain microscopic split thickness grafts with a 30-fold expansion. Techniques of intermingled transplantation of auto- and allografts ~ and widely meshed skin autografts ~2 have been used clinically with a high degree of success. Zhang et al.x,s introduced the technique of microskin grafting for treatment of severe bums with encouraging results; our previous works* have also shown that these microskin grafts are an effective procedure by which an extensive wound could be covered successfully with a very limited amount of autogenous skin grafts. The conventional technique of applying microskin grafts includes two main procedures: first the split thickness autograft should be minced with scissors into tiny pieces smaller than I mm3; and secondly the skin particles are floated on saline and then the suspension is sieved through a silk cloth to distinguish the epidermal side from the dermal side. We used the trimmed circular dermacarrier and the
Figure 3. a, A 43-year-old male suffered an avulsion injury over his right leg. Microskin grafts were placed on the wound, b, Pigskin
xenograft was overlaid on the microskin grafts, c, Follow-up at 100 days showed excellent wound healing with an acceptable cosmetic result.
Lai et al.: Microskin graft preparation
153
5 Zhang ML, Chang ZD, Han X et al. Microskin grafting, I, Animal experiments. Burns 1986; 12: 540. 6 Von Mangoldt F. Die Ueberhautung von Wundflachen und Wundhohlen durch Epithelaussaat; eine neue Methode der transplantation. Deutsche Med Wochnschr 1895; 21: 798. 7 Najarian JS, Crane JT and McCorkle HJ. An experimental study of the grafting of a suspension of skin particles. Surgery 1957; 42: 218. 8 Cox WA and Nichol WW. Evaluation of the fine-particlesskin autograft technique. Arch Surg 1958; 77: 870. 9 Nystrom G. Sowing of small skin graft particles as a method for epithelization especially of extensive wound surfaces. Plast Reconstr Surg 1959; 23: 226. 10 Blair SD, Nanchahal J, Backhouse CM et al. Microscopic split-skin grafts: a new technique for 30-fold expansion. Lancet 1987; ii: 483. 11 Yang CC, Shih TS, Chu TA et al. Intermingled transplantation of auto- and homograffs in severe bums. Barns 1980; 6: 141. I2 Alexander JW, MacMillan BG, Law EJ et al. Treatment of severe bums with widely meshed skin autograft and meshed skin allograft overlay. ]. Trauma 1981; 21: 433. 13 Fang CH and Alexander JW. Wound contraction following transplantation of microskin autografts with overlaid skin allograft in experimental animals. Bums 1990; 16- 190. 14 Lin SD, Chou CK, Lai CS et al. Microskin grafting of rabbits with pigskin xenograft overlay. Bums 1991; 17: 473. 15 Lin SD, Lai CS, Chou CK et al. Microskin grafting of rabbits with Biobrane overlay. Bums 1992; 18: 390.
meshgraft machine to produce microskin grafts in place of cutting with scissors, this simple technique not only saved operation time but also manpower. Although Zhang et al.2'5 and Nystrom 9 emphasized that it was essential to place the skin particles with the epidermal side upward (dermal side down) on the wound surface, Fang and Alexander ~3 and Lin et al. 14'Is have proved that microskin grafts grow well regardless of the individual orientation of the skin pieces. We spread the tiny skin particles directly and randomly onto the wound without the time-consuming procedure of separation of the epidermal side from dermal side. Successful take of the microskin grafts in clinical patients proved that harvesting the microskin graft from the meshgraft machine did not cause damage to the skin particles and the graft survived well independent of the orientation of the skin particles. This simple technique is recommended for preparing microskin graft in place of the conventional one.
References 1 Zhang ML, Wang CY, Chang ZD et al. Microskin grafting, II, Clinical report. Bums 1986; 12: 544. 2 Zhang ML, Chang ZD, Wang CY et al. Microskin grafting in the treatment of extensive bums: a preliminary report. J. Trauma 1988; 28: 804. 3 Fang CH, Yu GS, Fan YF et al. A preliminary report on transplantation of microskin autografts overlaid with sheet allograft in the treatment of large bums. ] Burn Care Rehabil 1988; 9- 629. 4 Lin SD, Lai CS, Chou CK et al. Microskin autograft with pigskin xenograft overlay: a preliminary report of studies on patients. Bums 1992; 18: 321.
We offer a reprints
Paper accepted 19 August 1993. Correspondenceshould be addressed to: Dr C-S. Lai,Division of Plastic Surgery, Chung-Ho Memorial Hospital, Kaohsiung Medical College, 100 Shih-Chuan 1st Road, Kaohsiung, Taiwan, RO China.
s e r v i c e in r e s p e c t
o f all a r t i c l e s in t h i s j o u r n a l .
Companies: a n a r t i c l e f e a t u r i n g y o u r p r o d u c t o r a n e w a p p l i c a t i o n provides its readers with an independent authoritative comment. Reprints can be used by you to inform and educate your customers and s t a f f a b o u t s c i e n t i f i c o r t e c h n i c a l a d v a n c e s in s u b j e c t s r e l e v a n t t o y o u r business. They are a cost-effective, ethical way of promoting your company and its products. For a q u o t a t i o n o n y o u r r e p r i n t r e q u i r e m e n t s ,
please contact:
The Reprints Department, Butterworth-Heinemann Ltd., Linacre House, J o r d a n Hill, O x f o r d , OX2 8DP. Tel: + 4 4 ( 0 ) 8 6 5 3 1 0 3 6 6 . Fax: + 4 4 ( 0 ) 8 6 5 3 1 4 5 1 9
I~UTTERWORTH I~IE
I N
E
M
A
N
N