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The temporary use of allograft for complicated wounds in plastic surgery
Burns 28 (2002) S13–S15
The temporary use of allograft for complicated wounds in plastic surgery E. Moerman a , E. Middelkoop b,c , D. Mackie b,c,∗ , F. Groenevelt a a
Department of Plastic and Reconstructive Surgery, 1942 LE Beverwijk, The Netherlands b Burn Centre, Red Cross Hospital, 1942 LE Beverwijk, The Netherlands c Dutch Burns Foundation, 1940 EA Beverwijk, The Netherlands
Abstract A retrospective analysis was performed on the use of glycerol-preserved allografts (GPA) in the preparation of complicated wounds for secondary wound closure. All files from the plastic surgery department in the period 1992–1998 were screened. Thirty-three patients within a total 85 GPA treatments were selected and screened for indication of use of GPA, frequency of GPA changes, duration of treatment and whether or not subsequent autografting was possible. GPA was used as a biological cover for the following indications: problematic wound healing, 13 cases; non-healing burns, 12 cases; carcinoma, 4 cases; unstable scar, 2 cases; shortage of skin, 2 cases. The average frequency of GPA application was 2.6 times, with a mean duration of 5 days per application. In 84 cases (32 patients) the wound was successfully covered with autograft. In conclusion, GPA was used with good results as a temporary cover for complicated wounds. We postulate that angiogenic effects of this biological dressing may have contributed to the improved healing conditions and successful secondary wound closure. © 2002 Elsevier Science Ltd and ISBI. All rights reserved. Keywords: Glycerol-preserved allografts; Biological cover; Angiogenic effects
1. Introduction Glycerol-preserved allografts (GPA) have been used in the Red Cross Hospital, Beverwijk, since 1984. Two important indications for GPA in our hospital are in the treatment of partial thickness burns and as an overlay for widely meshed autografts in extensive full-thickness burns [1–4]. In recent years, we have used GPA more frequently in poorly vascularised wounds to improve the condition of the wound bed before autografting. For this indication, wound coverage using GPA seems a good alternative to the use of synthetic dressing or biomaterials. The use of glycerolised donor skin is easy and does not require complicated preparations, other than proper preparation of the wound bed. Certain advantages of the use of GPA are noted. • Close adherence of the graft to the wound bed provides protection against further desiccation and colonisation. • The low antigenicity results in a decreased rejection reaction; repeated applications are possible without the occurrence of second set reactions.
∗
Corresponding author. Tel.: +31-251-27-55-26. E-mail address: [email protected] (D. Mackie).
• Enhancing revascularisation is perceived as one of the most important features of GPA. The exact mechanism of the GPA as an angiogenetic stimulus on the epithelial cells to migrate and induce the development of granulation tissue is unknown. Our experience includes the management of exposed calvarial electrical burn wounds of the skull [5]. In a series of four patients, we noted a marked shortening of healing time compared with the results shown in the literature. This experience prompted us to review retrospectively those patients attending the plastic surgical department who were treated with GPA to achieve secondary wound closure.
2. Patients and methods All operation files of the Department of Plastic and Reconstructive Surgery from the period January 1992 to 1999 were reviewed for the use of GPA. During this period 33 patients were treated with a total of 85 glycerol-preserved human allografts, provided by the Euro Skin Bank, Beverwijk, The Netherlands. Nineteen patients of the population are male and 14 female. The patients ranged in age from 1 to 88 years (average 45 years).
0305-4179/02/$22.00 © 2002 Elsevier Science Ltd and ISBI. All rights reserved. PII: S 0 3 0 5 - 4 1 7 9 ( 0 2 ) 0 0 0 8 6 - 4
S14
E. Moerman et al. / Burns 28 (2002) S13–S15
Fig. 1. Use of GPA for complicated wounds in plastic surgery.
Fig. 2. Frequency of changing GPA (# applications).
Parameters collated included the aetiology of wounds treated by GPA, the frequency of changes of GPA until autografting was possible, the number of days GPA was left on the wound and the percentage of cases in which autografting was possible. In practice, the ability of the allograft to adhere to the wound bed has a diagnostic value, referred to as a ‘take-test’ [6]. If the GPA does not adhere, one must consider an infection or non-viable wound surface. If the GPA adheres to the wound bed and causes bleeding when removed, then the wound bed is suitable for autografting. Frequent changing of the GPA also allows inspection of the condition of the wound. The use of GPA in complicated wounds is illustrated by a case of an electrical burn of the skull.
Fig. 3. Duration of application of GPD (days).
Fig. 4. (A) and (B) Appearance of the burn injury caused by high voltage at 1 day post injury, mainly necrotic tissue is present; (C) and (D) extensive debridement, drilling of burr holes and osteotomies; (E) application of split-skin autografts; (F) wound closure after 60 days.
E. Moerman et al. / Burns 28 (2002) S13–S15
S15
3. Results
4. Conclusions
From January 1992 to 1999, 33 patients were treated with GPA in the plastic and reconstructive surgery department (Fig. 1). Allograft was used as a biological cover in 13 patients with wound healing problems, 12 patients with non-healing burn wounds, 4 patients with carcinoma (biological cover until histology was known), 2 patients with an unstable scar and 2 patients with shortage of skin. In all patients meshed allograft was used. It was meshed in a ratio of 1:1.5 in order to allow sufficient drainage from the wound. In 17 cases (51.5%), a viable wound bed, identified by a positive ‘take-test’, was achieved by a single application of GPA. In five cases GPA was applied twice. The average frequency of application was two to three times (Fig. 2). GPA was left on the wound for an average of 5 days (range 1–10) (Fig. 3). Good vascularisation was obtained in 84 cases (32 patients), allowing definitive closure of the wound by autografting. Failure to achieve wound closure was reported in only one case following limb amputation resulting from a complicated fracture. The use of GPA to achieve closure in a difficult wound is illustrated in the case of an electrical burn of the skull, caused by contact with a high voltage overhead cable. Damage was due to direct heat, progressive electroporation and rupture of small blood vessels, resulting in ischemia and thrombosis of soft tissue and bone. We performed early excision of the full-thickness burned skin and non-viable underlying soft tissue (Fig. 4A and B) and multiple aggressive debridement of dead bone, performed by drilling burr holes and osteotomies of the outer table of the cortex (Fig. 4C and D). The defects were temporarily covered by GPA, resulting in the gradual development of sufficient granulation tissue prior to proceed to definitive split-skin autografting and wound closure (Fig. 4E and F).
GPA can be used as a biological dressing for complicated wounds which for some reason cannot be closed immediately. There appears to be a better preparation of the wound bed prior to autograft transplantation, which might be attributed to enhanced fibroblast and/or capillary ingrowth. The formation of granulation tissue was stimulated by the use of GPA, thus creating a viable wound bed before the final reconstruction was performed. In our study, autografting after allografting was possible in 32 of 33 patients with open wounds. The use of allograft as a temporary coverage can shorten the healing time from many months to several weeks. References [1] Hermans MHE. Clinical experience with glycerol-preserved donor skin treatment in partial thickness burns. Burns 1989;15:57– 60. [2] Kreis RW, Vloemans AFPM, Hoekstra MJ, Mackie DP, Hermans RP. The use of non-viable glycerol-preserved cadaver skin combined with widely expanded autografts in the treatment of extensive third-degree burns. J Trauma 1989;29:51–4. [3] Kreis RW, Hoekstra MJ, Mackie DP, Vloemans AFPM, Hermans RP. Historical appraisal of the use of skin allografts in the treatment of extensive full thickness burns at the Red Cross Hospital Burns Centre, Beverwijk, The Netherlands. Burns 1992;18:19. [4] Brans TA, Hoekstra MJ, Vloemans AFPM, Kreis RW. Long-term results of treatment of scalds in children with glycerol-preserved allografts. Burns 1994;20(1):10–3. [5] Groenevelt F, van Trier AJM, Khouw YLN. The use of allografts in the management of exposed calvarial electrical burn wounds of the skull. Ann N Y Acad Sci 1999;888:109–12. [6] Mackie DP. The Euro Skin Bank: development and application of glycerol-preserved allografts. J Burn Care Rehab 1997;18(1):7– 9.
The temporary use of allograft for complicated wounds in plastic surgery E. Moerman a , E. Middelkoop b,c , D. Mackie b,c,∗ , F. Groenevelt a a
Department of Plastic and Reconstructive Surgery, 1942 LE Beverwijk, The Netherlands b Burn Centre, Red Cross Hospital, 1942 LE Beverwijk, The Netherlands c Dutch Burns Foundation, 1940 EA Beverwijk, The Netherlands
Abstract A retrospective analysis was performed on the use of glycerol-preserved allografts (GPA) in the preparation of complicated wounds for secondary wound closure. All files from the plastic surgery department in the period 1992–1998 were screened. Thirty-three patients within a total 85 GPA treatments were selected and screened for indication of use of GPA, frequency of GPA changes, duration of treatment and whether or not subsequent autografting was possible. GPA was used as a biological cover for the following indications: problematic wound healing, 13 cases; non-healing burns, 12 cases; carcinoma, 4 cases; unstable scar, 2 cases; shortage of skin, 2 cases. The average frequency of GPA application was 2.6 times, with a mean duration of 5 days per application. In 84 cases (32 patients) the wound was successfully covered with autograft. In conclusion, GPA was used with good results as a temporary cover for complicated wounds. We postulate that angiogenic effects of this biological dressing may have contributed to the improved healing conditions and successful secondary wound closure. © 2002 Elsevier Science Ltd and ISBI. All rights reserved. Keywords: Glycerol-preserved allografts; Biological cover; Angiogenic effects
1. Introduction Glycerol-preserved allografts (GPA) have been used in the Red Cross Hospital, Beverwijk, since 1984. Two important indications for GPA in our hospital are in the treatment of partial thickness burns and as an overlay for widely meshed autografts in extensive full-thickness burns [1–4]. In recent years, we have used GPA more frequently in poorly vascularised wounds to improve the condition of the wound bed before autografting. For this indication, wound coverage using GPA seems a good alternative to the use of synthetic dressing or biomaterials. The use of glycerolised donor skin is easy and does not require complicated preparations, other than proper preparation of the wound bed. Certain advantages of the use of GPA are noted. • Close adherence of the graft to the wound bed provides protection against further desiccation and colonisation. • The low antigenicity results in a decreased rejection reaction; repeated applications are possible without the occurrence of second set reactions.
∗
Corresponding author. Tel.: +31-251-27-55-26. E-mail address: [email protected] (D. Mackie).
• Enhancing revascularisation is perceived as one of the most important features of GPA. The exact mechanism of the GPA as an angiogenetic stimulus on the epithelial cells to migrate and induce the development of granulation tissue is unknown. Our experience includes the management of exposed calvarial electrical burn wounds of the skull [5]. In a series of four patients, we noted a marked shortening of healing time compared with the results shown in the literature. This experience prompted us to review retrospectively those patients attending the plastic surgical department who were treated with GPA to achieve secondary wound closure.
2. Patients and methods All operation files of the Department of Plastic and Reconstructive Surgery from the period January 1992 to 1999 were reviewed for the use of GPA. During this period 33 patients were treated with a total of 85 glycerol-preserved human allografts, provided by the Euro Skin Bank, Beverwijk, The Netherlands. Nineteen patients of the population are male and 14 female. The patients ranged in age from 1 to 88 years (average 45 years).
0305-4179/02/$22.00 © 2002 Elsevier Science Ltd and ISBI. All rights reserved. PII: S 0 3 0 5 - 4 1 7 9 ( 0 2 ) 0 0 0 8 6 - 4
S14
E. Moerman et al. / Burns 28 (2002) S13–S15
Fig. 1. Use of GPA for complicated wounds in plastic surgery.
Fig. 2. Frequency of changing GPA (# applications).
Parameters collated included the aetiology of wounds treated by GPA, the frequency of changes of GPA until autografting was possible, the number of days GPA was left on the wound and the percentage of cases in which autografting was possible. In practice, the ability of the allograft to adhere to the wound bed has a diagnostic value, referred to as a ‘take-test’ [6]. If the GPA does not adhere, one must consider an infection or non-viable wound surface. If the GPA adheres to the wound bed and causes bleeding when removed, then the wound bed is suitable for autografting. Frequent changing of the GPA also allows inspection of the condition of the wound. The use of GPA in complicated wounds is illustrated by a case of an electrical burn of the skull.
Fig. 3. Duration of application of GPD (days).
Fig. 4. (A) and (B) Appearance of the burn injury caused by high voltage at 1 day post injury, mainly necrotic tissue is present; (C) and (D) extensive debridement, drilling of burr holes and osteotomies; (E) application of split-skin autografts; (F) wound closure after 60 days.
E. Moerman et al. / Burns 28 (2002) S13–S15
S15
3. Results
4. Conclusions
From January 1992 to 1999, 33 patients were treated with GPA in the plastic and reconstructive surgery department (Fig. 1). Allograft was used as a biological cover in 13 patients with wound healing problems, 12 patients with non-healing burn wounds, 4 patients with carcinoma (biological cover until histology was known), 2 patients with an unstable scar and 2 patients with shortage of skin. In all patients meshed allograft was used. It was meshed in a ratio of 1:1.5 in order to allow sufficient drainage from the wound. In 17 cases (51.5%), a viable wound bed, identified by a positive ‘take-test’, was achieved by a single application of GPA. In five cases GPA was applied twice. The average frequency of application was two to three times (Fig. 2). GPA was left on the wound for an average of 5 days (range 1–10) (Fig. 3). Good vascularisation was obtained in 84 cases (32 patients), allowing definitive closure of the wound by autografting. Failure to achieve wound closure was reported in only one case following limb amputation resulting from a complicated fracture. The use of GPA to achieve closure in a difficult wound is illustrated in the case of an electrical burn of the skull, caused by contact with a high voltage overhead cable. Damage was due to direct heat, progressive electroporation and rupture of small blood vessels, resulting in ischemia and thrombosis of soft tissue and bone. We performed early excision of the full-thickness burned skin and non-viable underlying soft tissue (Fig. 4A and B) and multiple aggressive debridement of dead bone, performed by drilling burr holes and osteotomies of the outer table of the cortex (Fig. 4C and D). The defects were temporarily covered by GPA, resulting in the gradual development of sufficient granulation tissue prior to proceed to definitive split-skin autografting and wound closure (Fig. 4E and F).
GPA can be used as a biological dressing for complicated wounds which for some reason cannot be closed immediately. There appears to be a better preparation of the wound bed prior to autograft transplantation, which might be attributed to enhanced fibroblast and/or capillary ingrowth. The formation of granulation tissue was stimulated by the use of GPA, thus creating a viable wound bed before the final reconstruction was performed. In our study, autografting after allografting was possible in 32 of 33 patients with open wounds. The use of allograft as a temporary coverage can shorten the healing time from many months to several weeks. References [1] Hermans MHE. Clinical experience with glycerol-preserved donor skin treatment in partial thickness burns. Burns 1989;15:57– 60. [2] Kreis RW, Vloemans AFPM, Hoekstra MJ, Mackie DP, Hermans RP. The use of non-viable glycerol-preserved cadaver skin combined with widely expanded autografts in the treatment of extensive third-degree burns. J Trauma 1989;29:51–4. [3] Kreis RW, Hoekstra MJ, Mackie DP, Vloemans AFPM, Hermans RP. Historical appraisal of the use of skin allografts in the treatment of extensive full thickness burns at the Red Cross Hospital Burns Centre, Beverwijk, The Netherlands. Burns 1992;18:19. [4] Brans TA, Hoekstra MJ, Vloemans AFPM, Kreis RW. Long-term results of treatment of scalds in children with glycerol-preserved allografts. Burns 1994;20(1):10–3. [5] Groenevelt F, van Trier AJM, Khouw YLN. The use of allografts in the management of exposed calvarial electrical burn wounds of the skull. Ann N Y Acad Sci 1999;888:109–12. [6] Mackie DP. The Euro Skin Bank: development and application of glycerol-preserved allografts. J Burn Care Rehab 1997;18(1):7– 9.