Kevin P. Yakuboff

The 1999 clinical research award. Cultured skin substitutes combined with Integra Artificial Skin to replace native skin autograft and allograft for the closure of excised full-thickness burns.

Prompt and permanent closure of excised full-thickness burns remains a critical factor in a patients recovery from massive burn injuries. Hypothetically, Integra Artificial Skin (Integra) may replace the need for allografts for immediate wound coverage, and cultured skin substitutes (CSS) that contain stratified epithelium may replace the need for autografts for definitive wound closure. To test this hypothesis, 3 patients with full-thickness burns of greater than 60% of their total body surface areas had their eschar excised within 14 days of admission. Integra was applied, and a skin biopsy was collected from each patient for the preparation of CSS. At 3 weeks or more after the application of the Integra and the collection of skin biopsies, the outer silastic cover of the Integra was removed and CSS were grafted. The CSS were irrigated with nutrients and antimicrobials for 6 days and then dressed with antimicrobial ointment and cotton gauze. Treated wounds were traced on days 14 and 28 after the grafting of CSS for determination of engraftment and wound closure, respectively. Cost analysis was not performed. Engraftment on postoperative day (POD) 14 was 98%+/-1% (mean +/- standard error of the mean), the ratio of closed:donor areas on POD 28 was 52.3+/-5.2, and no treated sites required regrafting. The histology of the closed wounds showed stable epithelium that covered a layer of newly formed fibrovascular tissue above the reticulated structure of the degrading Integra. The clinical outcomes of the closed wounds after POD 28 demonstrated smooth, pliable, and hypopigmented skin. Two patients who had received CSS grafts over Integra on their backs were positioned supine on air beds from POD 8 or POD 9 with minimal graft loss because of mechanical loading. One patient with a full-thickness burn of 88% of the total body surface area was covered definitively at 55 days postburn. These results demonstrate that the combination of CSS and Integra can accomplish functionally stable and cosmetically acceptable wound closure in patients with extensive full-thickness burns. This combination of alternatives to the conventional grafting of split-thickness skin permits the substitution of cadaveric allograft with Integra and the substitution of donor autograft with CSS. This approach to the closure of excised full-thickness burns is expected to reduce greatly the time to definitive closure of burn wounds and to reduce the morbidity associated with the harvesting of donor sites for split-thickness skin autografts.

Cultured Skin Substitutes Reduce Donor Skin Harvesting for Closure of Excised, Full-Thickness Burns

ObjectiveComparison of cultured skin substitutes (CSS) and split-thickness skin autograft (AG) was performed to assess whether donor-site harvesting can be reduced quantitatively and whether functional and cosmetic outcome is similar qualitatively in the treatment of patients with massive cutaneous burns. Summary Background DataCultured skin substitutes consisting of collagen-glycosaminoglycan substrates populated with autologous fibroblasts and keratinocytes have been shown to close full-thickness skin wounds in preclinical and clinical studies with acceptable functional and cosmetic results. MethodsQualitative outcome was compared between CSS and AG in 45 patients on an ordinal scale (0, worst; 10, best) with primary analyses at postoperative day 28 and after about 1 year for erythema, pigmentation, pliability, raised scar, epithelial blistering, and surface texture. In the latest 12 of the 45 patients, tracings were performed of donor skin biopsies and wounds treated with CSS at postoperative days 14 and 28 to calculate percentage engraftment, the ratio of closed wound:donor skin areas, and the percentage of total body surface area closed with CSS. ResultsMeasures of qualitative outcome of CSS or AG were not different statistically at 1 year after grafting. Engraftment at postoperative day 14 exceeded 75% in the 12 patients evaluated. The ratio of closed wound:donor skin areas for CSS at postoperative day 28 was significantly greater than for conventional 4:1 meshed autografts. The percentage of total body surface area closed with CSS at postoperative day 28 was significantly less than with AG. ConclusionsThe requirement for harvesting of donor skin for CSS was less than for conventional skin autografts. These results suggest that acute-phase recovery of patients with extensive burns is facilitated and that complications are reduced by the use of CSS together with conventional skin grafting.

Tissue Expanders in the Lower Face and Anterior Neck in Pediatric Burn Patients: Limitations and Pitfalls

Radovans 1982 landmark work on the clinical use of tissue expanders was felt to be a panacea for multiple reconstructive problems. We have used and probably overused tissue expanders for reconstruction of many complicated pediatric facial burn problems. This has enlightened us to some of the limitations of their use, and we have, therefore, reassessed our indications for their use. From 1984 through 1990, 52 tissue expanders were used in 37 pediatric patients for face and anterior neck burn scar resurfacing. This experience, combined with the unique problems encountered with face and neck tissue expansion, provided the groundwork for operative guidelines. The long-term effects of gravity, growth, and scarring on facial features adjacent to expanded skin led to the following principles. (1) Caution should be used in advancing expanded neck skin beyond the border of the mandible. The risk of scar widening or possible lip or eyelid ectropion needs to be considered when planning these flaps. Extreme overexpansion is necessary to advance unburned neck flaps over the mandibular border to avoid these problems. (2) After advancement or rotational flaps neck flaps to the face, vertically directed suture lines in the neck may need redirection to prevent linear contracture. This correction may be performed during the primary operation or during revisions. (3) Expanded cheek or neck skin should preferably replace burned areas, but at the same time, not violate unburned facial aesthetic units. (4) To counteract the affects of gravity, expanded cheek skin in conjunction with expanded neck skin, if unburned, may be the best choice for face or mandibular border scar replacement.(ABSTRACT TRUNCATED AT 250 WORDS)

Current management of purpura fulminans: a multicenter study.

Seven burn centers performed a 10-yr retrospective chart review of patients diagnosed with purpura fulminans. Patient demographics, etiology, presentation, medical and surgical treatment, and outcome were reviewed. A total of 70 patients were identified. Mean patient age was 13 yr. Neisseria meningitidis was the most common etiologic agent in infants and adolescents whereas Streptococcus commonly afflicted the adult population. Acute management consisted of antibiotic administration, volume resuscitation, ventilatory and inotropic support, with occasional use of corticosteroids (38%) and protein C replacement (9%). Full-thickness skin and soft-tissue necrosis was extensive, requiring skin grafting and amputations in 90% of the patients. One fourth of the patients required amputations of all extremities. Fasciotomies when performed early appeared to limit the level of amputation in 6 of 14 patients. Therefore, fasciotomies during the initial management of these patients may reduce the depth of soft-tissue involvement and the extent of amputations.

Total eyelid reconstruction with free dorsalis pedis flap after deep facial burn.

A case of severe facial and corneal burns with complete loss of upper and lower eyelids is reported together with the acute management and surgical options for total eyelid defects secondary to thermal injury. An acutely burned man with 78 percent total burn surface area presented with complete exposure of the left cornea. Because of the severe thermal injury, no facial tissues were available as donor sources for reconstructing the eyelid. A free dorsalis pedis flap was used to cover the exposed cornea after bilateral conjunctival advancement flaps, with septal cartilage graft for structural support. A conjunctivodacryocystorhinostomy was performed at the time of the coverage. The patient was unable to perform an exact visual acuity test; however, his gross vision was intact.

Use of free fasciocutaneous and muscle flaps for reconstruction of the foot

Seventeen free flaps were used to reconstruct severe injuries to the foot over the last 36 months at the University of Cincinnati College of Medicine. The type of free flaps used included six fasciocutaneous free flaps and eleven free muscle flaps with split-thickness skin grafts. The fasciocutaneous flaps were either radial forearm or scapular flaps. The muscle flaps used were gracilis, rectus, or latissimus dorsi muscle flaps. Each type, with their specific advantages, disadvantages, and indications for use as they apply to the anatomical areas of the foot, are described. Regardless of the type of free flap used, careful preoperative planning, attention to the size and location of the anatomical defect, and correct contouring and insetting should allow for maximal functional result and minimize postoperative morbidity.

Multimodal quantitative analysis of early pulsed-dye laser treatment of scars at a pediatric burn hospital.

BACKGROUND The pulsed‐dye laser (PDL) is a potential adjunctive therapy for treatment of hyperemic and hypertrophic scars. OBJECTIVE To compare the effects of early PDL treatment plus compression therapy (CT) with those of CT alone in patients undergoing burn scar reconstruction with split‐thickness grafts on an extremity. METHODS Laser treatments were applied to one half of the graft seam. Standard CT was applied to both halves. Laser treatment was repeated at 6‐week intervals until one half reached sufficient clinical improvements. Each half was evaluated just before treatments using quantitative measures of color, scar height, biomechanical properties and clinical features using the Vancouver Scar Scale (VSS). RESULTS Less quantitative scar erythema and height and greater tissue elasticity were observed after two or three treatments for PDL plus compression than with compression alone. VSS scores showed greater improvement for vascularity, pliability, pigmentation, and height for PDL plus compression than for compression alone. CONCLUSION PDL treatment in combination with CT appears to reduce scar hyperemia and height and normalize the biomechanical properties of burn‐related scars.

An 18-Year Experience in the Management of Congenital Nevomelanocytic Nevi

Background:Children with giant congenital nevomelanocytic nevi (CNN) are referred to our pediatric burn center for the surgical management of this disfiguring and potentially malignant skin disorder. Use of tissue expanders has contributed significantly in limiting donor site morbidity associated with treatment of giant CNN. Cultured skin substitutes (CSS) have also shown promise as an alternative wound coverage. With recent controversy regarding the effectiveness of excision in preventing melanoma risk, we wished to review our surgical management of giant CNN and to determine the incidence of malignancy in these patients. Methods:A retrospective chart review of patients with giant CNN was performed from 1985 to 2003. Charts were reviewed for age, sex, percentage total body surface area (TBSA) involved, age at initiation and completion of treatment, surgical treatment, complications, histopathology, and length of follow-up. Results:Of the 40 patients treated at our facility, the mean extent of skin involvement was 10% TBSA (range: 0.5%–75%). The mean age at initial operation was 5.1 years, and the majority of surgical interventions were completed within a mean of 1.3 years. Twenty-two patients (55%) required more than 1 surgical procedure. Excision and split-thickness skin grafting was the most common surgical procedure (n = 22) followed by excision with primary closure (n = 18). Ten patients were treated with tissue expansion, while 4 received cultured skin replacements. One patient died of extracutaneous melanoma during the course of surgical treatment. Three patients demonstrated histopathologic evidence of cytoatypia but remained clinically free of malignancy during a mean follow-up of 11 years. Conclusions:Giant CNN are both important cosmetic and medical problems. With an associated lifetime risk of melanoma in 4%–10% of patients, excision of CNN is recommended despite the fact that 50% of melanomas arise extracutaneously. Depending on the extent of body surface area involvement, wound closure can be obtained with conventional split- or full-thickness skin grafts, tissue expansion, and/or cultured autologous cultured skin substitutes. The latter 2 modalities provide improved cosmetic results, with minimal donor site morbidity.

Treatment outcomes for keloid scar management in the pediatric burn population

INTRODUCTION Keloids scars are challenging problems facing many reconstructive surgeons and have proven to be resistant to many treatments. This is evident by the broad range of treatments available and implemented with inconsistent results. We reviewed our experience to better define the disorder and to evaluate the impact of specific treatment options as related to our patient population. METHODS After obtaining Institutional Review Board approval, we examined the medical records of pediatric patients who were evaluated at our pediatric burn center between 2000 to 2008. All study subjects were identified as having keloid scars confirmed by clinical evaluation (raised scar extending beyond the margins of the original wound [1,2]). Treatments included excision and grafting [split thickness autograft (STAG) or full thickness autograft (FTAG)], excision and grafting with steroid injection, excision and primary closure, or excision and primary closure with steroid injection. Patients were included only if there was follow-up of 12 months or greater. RESULTS One hundred and ten subjects with a diagnosis of a keloid scar were identified. Twenty-six were treated with excision and skin grafting and 8 were treated with a steroid and surgery regimen. Of the patients treated with surgery and steroids, the treatment varied from an intra-operative injection to post-operative injections at 6-week intervals. The number of injections was determined by the administering surgeon and varied from one to three. Clinical end points were determined by the administering surgeon and included: (1) no further improvement in scar maturation or (2) absence of improvement. Recurrence was defined as return of a raised scar consistent with a keloid scar. The recurrence rate was 87.5% for patients treated with surgery and steroids and 80.0% for surgery only. This difference was not statistically significant. CONCLUSIONS Our data demonstrate that steroids do not significantly decrease recurrence in pediatric burn related keloids as compared to previously published series involving non-burn related keloids [3,5]. This further emphasizes that burn related keloids respond differently to conventional treatments that have proven successful in keloid scars from other mechanisms of injury. A consistent and effective treatment algorithm should be implemented in treating keloid scars from burn wounds.

Randomized, Paired-Site Comparison of Autologous Engineered Skin Substitutes and Split-Thickness Skin Graft for Closure of Extensive, Full-Thickness Burns.

Stable closure of full-thickness burn wounds remains a limitation to recovery from burns of greater than 50% of the total body surface area (TBSA). Hypothetically, engineered skin substitutes (ESS) consisting of autologous keratinocytes and fibroblasts attached to collagen-based scaffolds may reduce requirements for donor skin, and decrease mortality. ESS were prepared from split-thickness skin biopsies collected after enrollment of 16 pediatric burn patients into an approved study protocol. ESS and split-thickness autograft (AG) were applied to 15 subjects with full-thickness burns involving a mean of 76.9% TBSA. Data consisted of photographs, tracings of donor skin and healed wounds, comparison of mortality with the National Burn Repository, correlation of TBSA closed wounds with TBSA full-thickness burn, frequencies of regrafting, and immunoreactivity to the biopolymer scaffold. One subject expired before ESS application, and 15 subjects received 2056 ESS grafts. The ratio of closed wound to donor areas was 108.7 ± 9.7 for ESS compared with a maximum of 4.0 ± 0.0 for AG. Mortality for enrolled subjects was 6.25%, and 30.3% for a comparable population from the National Burn Repository (P < .05). Engraftment was 83.5 ± 2.0% for ESS and 96.5 ± 0.9% for AG. Percentage TBSA closed was 29.9 ± 3.3% for ESS, and 47.0 ± 2.0% for AG. These values were significantly different between the graft types. Correlation of % TBSA closed with ESS with % TBSA full-thickness burn generated an R 2 value of 0.65 (P < .001). These results indicate that autologous ESS reduce mortality and requirements for donor skin harvesting, for grafting of full-thickness burns of greater than 50% TBSA.