- Email: [email protected]
An external use of a tissue expander
1154
Correspondence and communications
same size as the defect; the second lobe was made almost twice as long as the first flap but half the width of the primary flap. Donor site tissues were assessed for suitable laxity and an appropriate arc of rotation for the flaps was chosen. The flaps were raised with the underlying fascia, undermining was necessary to allow tensionless closure. The patient was finally placed in a resting cast with the hand and wrist in the position of function. At review at two weeks in clinic both flaps had survived with good colour match, minimal bulk and no distortion to the surrounding tissues. There was 1 cm2 area of epidermolysis at the tip of second flap however no distal flap necrosis. There was also no evidence of wound dehiscence. At 4 weeks the wounds had fully healed. Although the bilobed flap is well described, its use is uncommon in the upper limb. This is the first description of the use of this flap as a reconstructive option on the dorsum of the forearm in an adult patient. In scenarios such as this where reconstructive options are limited and significant patient comorbidities exist, it can be considered as a robust and quickly executed lifeboat flap.
Conflicts of interest None.
Funding None.
Ethical approval N/A.
An external use of a tissue expander Dear Sir, We have observed an increasing number of pressure sores of the hand secondary to flexion contractures in our practice over the past number of years. They typically occur in elderly patients and can be quite problematic to dress as well as painful for the patient. The risk of infection is also quite high as the area is not easily cleaned and is frequently macerated due to pressure necrosis. These patients often require frequent trips to the dressing clinic or outpatients for wound care. We have previously treated several patients by placing a wool roll in the hand to separate the spastic digits from the palm. However, insertion of the wool roll can be painful for the patient and it has to be changed quite frequently, especially if it gets wet or dirty. Other treatment modalities described in the literature include release of tendons at the wrist but this is a drastic measure as many of these patients are nursing home residents who are not ideal surgical candidates. Botulinum toxin injections into the superficialis and profundus injections have also been described but these are not a long term solution. In our institution, we now treat these patients by inserting a crescentic tissue expander in between the fingers and the palm (Figures 1 and 2). The device is gradually expanded to open up the hand and relieve the pressure. The carers of the patient are educated on how to remove and replace the fluid so the device can be cleaned. We find it to be a very simple technique to treat pressure sores in
References 1. Onishi K, Maruyama Y, Okada E. Bilobed fasciocutaneous flap for primary repair of a large upper arm defect with secondary closure of the donor site without a skin graft. Ann Plastic Surg 1997;39(2):205e9. 2. Evans DM, Gateley DR, Lewis JS. The use of a bilobed flap in the correction of radial club hand. J Hand Surg 1995;20(3):333e7. 3. Hsieh CH, Kuo YR, Yao SF, Liang CC, Jeng SF. Primary closure of radial forearm flap donor defects with a bilobed flap based on the fasciocutaneous perforator of the ulnar artery. Plastic Reconstr Surg 2004;113(5):1355e60. 4. Behan FC. The Keystone design perforator island flap in reconstructive surgery. ANZ J Surg 2003;73(3):112e20.
Dariush Nikkhah Martin Jones The Queen Victoria Hospital, UK E-mail addresses: [email protected], [email protected] ª 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2015.03.022
Figure 1 The spastic hand with a dressing overlying pressure necrosis of the thumb.
Correspondence and communications
1155
Allosensitization following skin allografts in acute burn management: Are burns patients suitable face transplant candidates? Dear Sir,
Figure 2 inserted.
The crescentic tissue expander with 50 cc of fluid
the hand and much more patient-friendly than tendon release. We also obtain non-sterile tissue expanders directly from the manufacturer, thereby keeping costs to a minimum. Tissue expanders can have their external uses too! Yours sincerely, Cormac W. Joyce Padraic J. Regan
Financial interest None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this manuscript.
Conflicts of interest None.
Ethical approval N/A. Cormac W. Joyce Padraic J. Regan Department of Plastic Surgery, University Hospital Galway, Ireland E-mail address: [email protected] ª 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2015.04.001
Composite tissue allotransplantation has become a recognized reconstructive option for patients with extensive facial burns. Of 27 facial transplants carried out worldwide, 10 have been performed for severe facial burns. Despite advances in transplant medicine, the greatest barrier to both access to and success of transplantation remains sensitization to human leucocyte antigens (HLAs). During the acute management of extensive burns, deceased donor skin allografts without HLA-matching, are used as temporary dressings. HLA-mismatched skin allografts are known to be highly immunogenic, and can consequently prompt development of anti-HLA antibodies. As more patients are surviving previously nonsurvivable burns, it has become increasingly important to examine the long-term consequences of skin allografts. An important, and as yet unanswered question is, to what extent the success of future transplantation is jeopardized by the use of skin allografts in acute burn management. St. Andrew’s Centre is one of the largest burn centers in the UK, and routinely uses cryopreserved skin allografts for extensive burns.1 We evaluated the presence of circulating HLA-specific alloantibodies using Luminex single antigen HLA antibody detection beads (One Lambda) in patient serum at 2e8 years following cryopreserved skin allografting (n Z 14). Burn patients who had received autografts served as negative controls (n Z 2). The impact of these anti-HLA antibodies on the access to transplants was estimated by measuring calculated panel-reactive antibody (cPRA). cPRA defines the percentage of a standardized panel of 10,000 consecutive deceased organ donors that is incompatible with the alloantibody profile of a potential transplant recipient.2 Therefore, cPRA reflects the chance of identifying a suitable donor for a given recipient. Data regarding demographics, total burns surface area (TBSA%), number of skin donors, and additional potential allosensitizing events (transfusion of blood products, pregnancy, transplant) was collected (Table 1). As expected, average TBSA (%) of skin allografted patients is significantly higher [47.5 13% allografted vs 21.5 6.3% autografted; p Z 0.017]. Of note, 12 of 14 allografted patients also received multiple blood products [32.1 26.3 units allografted vs 0 unit autografted] (Table 1). All patients who received skin allografts, including the two patients who did not receive any blood products (Table 1) or had any other allosensitizing events (pregnancy, or other form of transplant), had high level of circulating anti-HLA antibodies. The level of sensitization (cPRA) was
Correspondence and communications
same size as the defect; the second lobe was made almost twice as long as the first flap but half the width of the primary flap. Donor site tissues were assessed for suitable laxity and an appropriate arc of rotation for the flaps was chosen. The flaps were raised with the underlying fascia, undermining was necessary to allow tensionless closure. The patient was finally placed in a resting cast with the hand and wrist in the position of function. At review at two weeks in clinic both flaps had survived with good colour match, minimal bulk and no distortion to the surrounding tissues. There was 1 cm2 area of epidermolysis at the tip of second flap however no distal flap necrosis. There was also no evidence of wound dehiscence. At 4 weeks the wounds had fully healed. Although the bilobed flap is well described, its use is uncommon in the upper limb. This is the first description of the use of this flap as a reconstructive option on the dorsum of the forearm in an adult patient. In scenarios such as this where reconstructive options are limited and significant patient comorbidities exist, it can be considered as a robust and quickly executed lifeboat flap.
Conflicts of interest None.
Funding None.
Ethical approval N/A.
An external use of a tissue expander Dear Sir, We have observed an increasing number of pressure sores of the hand secondary to flexion contractures in our practice over the past number of years. They typically occur in elderly patients and can be quite problematic to dress as well as painful for the patient. The risk of infection is also quite high as the area is not easily cleaned and is frequently macerated due to pressure necrosis. These patients often require frequent trips to the dressing clinic or outpatients for wound care. We have previously treated several patients by placing a wool roll in the hand to separate the spastic digits from the palm. However, insertion of the wool roll can be painful for the patient and it has to be changed quite frequently, especially if it gets wet or dirty. Other treatment modalities described in the literature include release of tendons at the wrist but this is a drastic measure as many of these patients are nursing home residents who are not ideal surgical candidates. Botulinum toxin injections into the superficialis and profundus injections have also been described but these are not a long term solution. In our institution, we now treat these patients by inserting a crescentic tissue expander in between the fingers and the palm (Figures 1 and 2). The device is gradually expanded to open up the hand and relieve the pressure. The carers of the patient are educated on how to remove and replace the fluid so the device can be cleaned. We find it to be a very simple technique to treat pressure sores in
References 1. Onishi K, Maruyama Y, Okada E. Bilobed fasciocutaneous flap for primary repair of a large upper arm defect with secondary closure of the donor site without a skin graft. Ann Plastic Surg 1997;39(2):205e9. 2. Evans DM, Gateley DR, Lewis JS. The use of a bilobed flap in the correction of radial club hand. J Hand Surg 1995;20(3):333e7. 3. Hsieh CH, Kuo YR, Yao SF, Liang CC, Jeng SF. Primary closure of radial forearm flap donor defects with a bilobed flap based on the fasciocutaneous perforator of the ulnar artery. Plastic Reconstr Surg 2004;113(5):1355e60. 4. Behan FC. The Keystone design perforator island flap in reconstructive surgery. ANZ J Surg 2003;73(3):112e20.
Dariush Nikkhah Martin Jones The Queen Victoria Hospital, UK E-mail addresses: [email protected], [email protected] ª 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2015.03.022
Figure 1 The spastic hand with a dressing overlying pressure necrosis of the thumb.
Correspondence and communications
1155
Allosensitization following skin allografts in acute burn management: Are burns patients suitable face transplant candidates? Dear Sir,
Figure 2 inserted.
The crescentic tissue expander with 50 cc of fluid
the hand and much more patient-friendly than tendon release. We also obtain non-sterile tissue expanders directly from the manufacturer, thereby keeping costs to a minimum. Tissue expanders can have their external uses too! Yours sincerely, Cormac W. Joyce Padraic J. Regan
Financial interest None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this manuscript.
Conflicts of interest None.
Ethical approval N/A. Cormac W. Joyce Padraic J. Regan Department of Plastic Surgery, University Hospital Galway, Ireland E-mail address: [email protected] ª 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2015.04.001
Composite tissue allotransplantation has become a recognized reconstructive option for patients with extensive facial burns. Of 27 facial transplants carried out worldwide, 10 have been performed for severe facial burns. Despite advances in transplant medicine, the greatest barrier to both access to and success of transplantation remains sensitization to human leucocyte antigens (HLAs). During the acute management of extensive burns, deceased donor skin allografts without HLA-matching, are used as temporary dressings. HLA-mismatched skin allografts are known to be highly immunogenic, and can consequently prompt development of anti-HLA antibodies. As more patients are surviving previously nonsurvivable burns, it has become increasingly important to examine the long-term consequences of skin allografts. An important, and as yet unanswered question is, to what extent the success of future transplantation is jeopardized by the use of skin allografts in acute burn management. St. Andrew’s Centre is one of the largest burn centers in the UK, and routinely uses cryopreserved skin allografts for extensive burns.1 We evaluated the presence of circulating HLA-specific alloantibodies using Luminex single antigen HLA antibody detection beads (One Lambda) in patient serum at 2e8 years following cryopreserved skin allografting (n Z 14). Burn patients who had received autografts served as negative controls (n Z 2). The impact of these anti-HLA antibodies on the access to transplants was estimated by measuring calculated panel-reactive antibody (cPRA). cPRA defines the percentage of a standardized panel of 10,000 consecutive deceased organ donors that is incompatible with the alloantibody profile of a potential transplant recipient.2 Therefore, cPRA reflects the chance of identifying a suitable donor for a given recipient. Data regarding demographics, total burns surface area (TBSA%), number of skin donors, and additional potential allosensitizing events (transfusion of blood products, pregnancy, transplant) was collected (Table 1). As expected, average TBSA (%) of skin allografted patients is significantly higher [47.5 13% allografted vs 21.5 6.3% autografted; p Z 0.017]. Of note, 12 of 14 allografted patients also received multiple blood products [32.1 26.3 units allografted vs 0 unit autografted] (Table 1). All patients who received skin allografts, including the two patients who did not receive any blood products (Table 1) or had any other allosensitizing events (pregnancy, or other form of transplant), had high level of circulating anti-HLA antibodies. The level of sensitization (cPRA) was