Allen Gabriel

Skin Substitutes and Alternatives: A Review

PURPOSE To provide the specialist in skin and wound care with a review of skin replacement alternatives and their most common uses. TARGET AUDIENCE This continuing education activity is intended for physicians and nurses with an interest in wound care and related disorders. OBJECTIVES After reading this article and taking this test, the reader should be able to: Describe characteristics of skin and skin substitutes for grafting. Identify indications for and uses of common grafting procedures and products.

Negative pressure wound therapy with instillation: a pilot study describing a new method for treating infected wounds

This data review reports the results of 15 patients who were treated with Vacuum‐Assisted Closure® (VAC) negative pressure therapy system in addition to the timed, intermittent delivery of an instilled topical solution for management of their complex, infected wounds. Prospective data for 15 patients treated with negative pressure wound therapy (NPWT)‐instillation was recorded and analysed. Primary endpoints were compared to a retrospective control group of 15 patients treated with our institution‘s standard moist wound‐care therapy. Culture‐specific systemic antibiotics were prescribed as per specific patient need in both groups. All data were checked for normality of distribution and equality of variance and appropriate parametric and non parametric analyses were conducted. Compared with the standard moist wound‐care therapy control group, patients in the NPWT‐instillation group required fewer days of treatment (36·5 ± 13·1 versus 9·9 ± 4·3 days, P < 0·001), cleared of clinical infection earlier (25·9 ± 6·6 versus 6·0 ± 1·5 days, P < 0·001), had wounds close earlier (29·6 ± 6·5 versus 13·2 ± 6·8 days, P < 0·001) and had fewer in‐hospital stay days (39·2 ± 12·1 versus 14·7 ± 9·2 days, P < 0·001). In this pilot study, NPWT instillation showed a significant decrease in the mean time to bioburden reduction, wound closure and hospital discharge compared with traditional wet‐to‐moist wound care. Outcomes from this study analysis suggest that the use of NPWT instillation may reduce cost and decrease inpatient care requirements for these complex, infected wounds.

Artificial dermis as an alternative for coverage of complex scalp defects following excision of malignant tumors

Background: Artificial dermis has been used successfully for coverage of full-thickness wounds with a well-vascularized surgical bed. However, the use of artificial dermis in the reconstruction of partial- and full-thickness scalp defects has not been well documented. Methods: Seven patients (six men and one woman; mean age, 70 ± 14 years) with partial-thickness (three patients) and full-thickness (four patients) soft-tissue defects of the scalp (mean defect area, 97 ± 58 cm2) following resection of recurrent malignant tumors and/or previous failed reconstructions underwent staged scalp reconstruction with a bilaminate skin substitute (Integra). After adequate débridement of scalp wounds, including burring the outer table of the calvaria down to bleeding bone for full-thickness defects, Integra was scored and applied unexpanded. A split-thickness skin graft (0.011 ± 0.0 inch in thickness) was placed on the operative site at postoperative day 36 ± 15 after removal of the silicone layer of the artificial dermis. Two patients required repeated applications of artificial dermis to compensate for contour deficits before skin grafting. Results: Clinically, all reconstructed areas showed well-vascularized neodermis before skin grafting. There was a 100 percent take of the skin grafts, with no infections or other complications noted. All reconstructive procedures were performed in less than 3 hours of combined operative time, with the last stage performed on an outpatient basis. Conclusions: Artificial dermis can be used successfully for reconstruction of complex scalp defects following oncologic resection, offering minimal donor-site morbidity, expedient operative time, and when needed, temporary quality closure until final pathologic results are known. Integra skin may offer another option for definitive management of extensive full-thickness scalp defects.

A clinical review of infected wound treatment with Vacuum Assisted Closure (V.A.C.) therapy: experience and case series.

Over the last decade Vacuum Assisted Closure® (KCI Licensing, Inc., San Antonio, TX) has been established as an effective wound care modality for managing complex acute and chronic wounds. The therapy has been widely adopted by many institutions to treat a variety of wound types. Increasingly, the therapy is being used to manage infected and critically colonized, difficult‐to‐treat wounds. This growing interest coupled with practitioner uncertainty in using the therapy in the presence of infection prompted the convening of an interprofessional expert advisory panel to determine appropriate use of the different modalities of negative pressure wound therapy (NPWT) as delivered by V.A.C.® Therapy and V.A.C. Instill® with either GranuFoam™ or GranuFoam Silver™ Dressings. The panel reviewed infected wound treatment methods within the context of evidence‐based medicine coupled with experiential insight using V.A.C.® Therapy Systems to manage a variety of infected wounds. The primary objectives of the panel were 1) to exchange state‐of‐practice evidence, 2) to review and evaluate the strength of existing data, and 3) to develop practice recommendations based on published evidence and clinical experience regarding use of the V.A.C.® Therapy Systems in infected wounds. These recommendations are meant to identify which infected wounds will benefit from the most appropriate V.A.C.® Therapy System modality and provide an infected wound treatment algorithm that may lead to a better understanding of optimal treatment strategies.

The evolution of breast implants.

Breast augmentation remains one of the most common procedures performed in the United States. However, shape, feel, safety, and longevity of the implants remain important areas of research. The data provided by manufacturers show the safety and efficacy of these medical devices. Clinicians should strive to provide ongoing data and sound science to continue to improve clinical outcomes in the future. This article explores the evolution of breast implants with special emphasis on the advancement of silicone implants.

Advances in Nipple-Sparing Mastectomy: Oncological Safety and Incision Selection

BACKGROUND With the evolution of breast reconstruction and oncoplastic techniques, more aesthetic mastectomies are being offered to patients. Nipple-sparing mastectomy (NSM) has been controversial, but an expanding body of published experience has allowed this concept to gain momentum. OBJECTIVES The authors review their experience with NSM. METHODS From 2007 to 2009, 112 consecutive patients (204 breasts) who were candidates for NSM presented to one of two private plastic surgery practices. All patients underwent preoperative magnetic resonance imaging to assess the size of the tumor, its distance from the nipple, and any additional disease within the ipsilateral/contralateral breast or axillae. Exclusion criteria included tumors larger than 3 cm, clinical invasion of the nipple-areolar complex, tumors within 2 cm of the nipple, evidence of multicentric disease, a positive intraoperative retroareolar frozen section, or nodal disease (excluding isolated immunohistochemistry positivity). Fourteen patients were excluded from the study for one of these reasons, leaving a total of 98 patients (186 breasts) who underwent NSM. RESULTS Risk-reducing mastectomies were performed on 45 patients. Therapeutic mastectomies were performed for Stage 0 cancer (ductal carcinoma in situ) in 26 patients, for Stage 1A in 24 patients, and for Stage 1B in three patients. Disease-free survival was calculated from the date of surgery to any local, regional, or distant relapse (whichever occurred first). As of the writing of this article, follow-up ranged from nine months to three years, and there has been no local or regional recurrence in any patient. CONCLUSIONS NSM is evolving and should be considered a good treatment option in carefully-selected patients. These findings add to the growing body of evidence showing that, with proper patient selection and operative technique, NSM is a safe and effective intervention for patients requiring therapeutic or prophylactic mastectomy.

Use of negative pressure wound therapy over clean, closed surgical incisions

The literature has reported that surgical site infections account for 17–22% of health care‐associated infections, while surgical wound dehiscence rates range from 0·25% to 3·0% (post laparatomies), 1·6% to 42·3% (post‐caesarean incisions) and 0·5% to 2·5% (sternal incisions). These types of incisional complications can become a significant cost burden to the health care system because of lengthy hospital stays and readmissions, additional nursing care and added surgical procedures. Therefore, the type of therapy used for surgical incisions plays a critical role in the healing process. The success of negative pressure wound therapy (NPWT; V.A.C.® Therapy; KCI USA, Inc., San Antonio, TX) for open wounds has been well documented and has led to its use over clean, closed surgical incisions. This review will focus on clinician experience and literature review of incisional NPWT and will include clinical cases describing NPWTs successful use over surgical incisions.

Negative-pressure wound therapy with instillation: international consensus guidelines.

Background: Negative-pressure wound therapy with instillation is increasingly utilized as an adjunct therapy for a wide variety of wounds. Despite its growing popularity, there is a paucity of evidence and lack of guidance to provide effective use of this therapy. Methods: A panel of experts was convened to provide guidance regarding the appropriate use of negative-pressure wound therapy with instillation. A face-to-face meeting was held where the available evidence was discussed and individual clinical experience with this therapy was shared. Follow-up communication among the panelists continued until consensus was achieved. The final consensus recommendations were derived through more than 80 percent agreement among the panelists. Results: Nine consensus statements were generated that address the appropriate use of negative-pressure wound therapy with instillation. The question of clinical effectiveness of this therapy was not directly addressed by the consensus panel. Conclusion: This document serves as preliminary guidelines until more robust evidence emerges that will support or modify these consensus recommendations.

Use of negative pressure wound therapy in the management of infected abdominal wounds containing mesh: an analysis of outcomes

The purpose of this study was to examine the clinical outcomes of negative pressure wound therapy (NPWT) using reticulated open‐cell foam (ROCF) in the adjunctive management of abdominal wounds with exposed and known infected synthetic mesh. A non randomised, retrospective review of medical records for 21 consecutive patients with infected abdominal wounds treated with NPWT was conducted. All abdominal wounds contained exposed synthetic mesh [composite, polypropylene (PP), or knitted polyglactin 910 (PG) mesh]. Demographic and bacteriological data, wound history, pre‐NPWT and comparative post‐NPWT, operative procedures and complications, hospital length of stay (LOS) and wound healing outcomes were all analysed. Primary endpoints measured were (1) hospital LOS prior to initiation of NPWT, (2) total time on NPWT, (3) hospital LOS from NPWT initiation to discharge and (4) wound closure status at discharge. A total of 21 patients with abdominal wounds with exposed, infected mesh were treated with NPWT. Aetiology of the wounds was ventral hernia repair (n = 11) and acute abdominal wall defect (n = 10). Prior to NPWT initiation, the mean hospital LOS for the composite, PP and PG meshes were 76 days (range: 21–171 days), 51 days (range: 32–62 days) and 19 days (range: 12–39 days), respectively. The mean hospital LOS following initiation of NPWT for wounds with exposed composite, PP and PG mesh were 28, 31 and 32 days, respectively. Eighteen of the 21 wounds (86%) reached full closure after a mean time of 26 days of NPWT and a mean hospital LOS of 30 days postinitiation of NPWT. Three wounds, all with composite mesh left in situ, did not reach full closure, although all exhibited decreased wound dimensions, granulating beds and decreased surface area exposure of mesh. During NPWT/ROCF, one hypoalbuminemic patient with exposed PP mesh developed an enterocutaneous fistula over a prior enterotomy site. This patient subsequently underwent total mesh extraction, takedown of the fistula and PP mesh replacement followed by reinstitution of NPWT and flap closure. In addition to appropriate systemic antibiotics and nutritional optimisation, the adjunctive use of NPWT resulted in successful closure of 86% of infected abdominal wounds with exposed prosthetic mesh. Patient hospital LOS (except those with PG mesh), operative procedures and readmissions were decreased during NPWT compared with treatment prior to NPWT. Future multi‐site prospective, controlled studies would provide a strong evidence base from which treatment decisions could be made in the management of these challenging and costly cases.

Prepectoral Implant-Based Breast Reconstruction: Rationale, Indications, and Preliminary Results.

Summary: Implant-based breast reconstruction is currently performed with placement of the implant in a subpectoral pocket beneath the pectoralis major muscle, by means of the dual-plane approach. Although the safety and breast aesthetics of this approach are well recognized, it is not without concerns. Animation deformities and accompanying patient discomfort, which are direct consequences of muscle elevation, can be severe in some patients. Moving the implant prepectorally may eliminate these concerns. For a successful prepectoral approach, the authors advocate use of their bioengineered breast concept, which was detailed in a previous publication. In this report, the authors discuss the rationale for prepectoral implant reconstruction, its indications/contraindications, and preliminary results from over 350 reconstructions. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.