L.P. Kamolz

Skin graft fixation in severe burns: use of topical negative pressure

Over the last 50 years, the evolution of burn care has led to a significant decrease in mortality. The biggest impact on survival has been the change in the approach to burn surgery. Early excision and grafting has become a standard of care for the majority of patients with deep burns; the survival of a given patient suffering from major burns is invariably linked to the take rate and survival of skin grafts. The application of topical negative pressure (TNP) therapy devices has demonstrated improved graft take in comparison to conventional dressing methods alone. The aim of this study was to analyze the impact of TNP therapy on skin graft fixation in large burns. In all patients, we applied TNP dressings covering a %TBSA of >25. The following parameters were recorded and documented using BurnCase 3D: age, gender, %TBSA, burn depth, hospital length-of-stay, Baux score, survival, as well as duration and incidence of TNP dressings. After a burn depth adapted wound debridement, coverage was simultaneously performed using split-thickness skin grafts, which were fixed with staples and covered with fatty gauzes and TNP foam. The TNP foam was again fixed with staples to prevent displacement and finally covered with the supplied transparent adhesive film. A continuous subatmospheric pressure between 75-120 mm Hg was applied (VAC®, KCI, Vienna, Austria). The first dressing change was performed on day 4. Thirty-six out of 37 patients, suffering from full thickness burns, were discharged with complete wound closure; only one patient succumbed to their injuries. The overall skin graft take rate was over 95%. In conclusion, we consider that split thickness skin graft fixation by TNP is an efficient method in major burns, notably in areas with irregular wound surfaces or subject to movement (e.g. joint proximity), and is worth considering for the treatment of aged patients.

Standardizing the complication rate after breast reduction using the Clavien-Dindo classification

Background. Published complication rates for breast reduction surgery, also known as reduction mammaplasty, vary between 4% and 54%. This wide range of complication rates could be attributable to the lack of a standardized classification of complications in plastic surgery. The aim of this study was to analyze our single‐center complication rates after reduction mammaplasty using the Clavien‐Dindo classification. Methods. We performed a retrospective chart review studying 804 patients between the ages of 18 and 81 years old who underwent breast reduction between 2005 and 2015 at our institution. Patients with a history of breast cancer, a previous breast operation, who did not undergo bilateral reduction mammaplasty, or who required systemic immunodeficiency/immunosuppressive drugs were excluded from our analysis. Complications were classified according to the Clavien‐Dindo classification from Grades I to V. Results. A total of 486 patients met the inclusion criteria for the analysis. Patients had an age (mean ± standard deviation) of 39 ± 13 years and a body mass index of 26 ± 4 kg/m2. Median follow‐up was 274 days (interquartile range: 90.5–378). The overall rate of complications of reduction mammaplasty was 63%, with the majority of those being Grades I (48%) and II (9%), comprising 92% of all the complications. Operative revisions were required in 6% (1% Grade IIIA and 5% Grade IIIB). There were no complications graded in categories IV and V. Conclusion. Although complications occurred in more than half of the cases, the majority did not require operative reintervention. The Clavien‐Dindo classification can classify the severity of complications and serve as a benchmark to compare complication rates between different practices. We believe that grading of complications should distinguish between those that do and do not require operative reinterventions.

Tissue engineering and its potential use in surgery

SummaryThe loss or failure of an organ or tissue is one of the most frequent, devastating, and costly problems in healthcare. Current treatment modalities include transplantation of organs, surgical reconstruction, use of mechanical devices, or supplementation of metabolic products. A new field, tissue engineering, applies the principles and methods of engineering, material science, and cell and molecular biology toward the development of viable substitutes, which restore, maintain, or improve the function of human tissues. In this special issue, we outline the opportunities and challenges of this emerging interdisciplinary field and its attempts to provide solutions to tissue creation and repair in different fields of surgery.

The use of Keratinocytes: Things we should keep in mind!

SummaryBackgroundCultivation of keratinocytes and their clinical application was an essential step towards the development of new treatment concepts for patients suffering from severe burns and chronic cutaneous wounds. The aim of this review is to give a current overview of keratinocyte cultivation and keratinocyte application under experimental and clinical conditions as well as to discuss their limitations, complications and future perspectives.MethodsPubmed and Medline was systematically searched for correlative publications.ResultsPromising at first, but over time its limitations became evident: demanding infrastructural requirements, high costs, lack of “ex-vitro” stability, additional requirement for dermal support, and the absence of other skin cell types or appendages have limited the introduction in daily clinical routine. Nonetheless, continuous efforts have been made in the past decades in order to improve the application of keratinocytes. Novel techniques of keratinocyte harvest and cultivation have simplified the clinical application, improved stability, and consequent outcomes.ConclusionsThe herein presented efforts despite their drawbacks during the development process and resultant clinical outcomes of keratinocyte culturing bear a solid foundation for the future. The ultimate challenge however remains, bringing any of these efforts into clinical practice while avoiding the failures of the past.

Indications for medical tattooing in breast-reconstructed patients

Skin grafting and different kinds of local flaps represent the standard technique for NAC reconstruction. We find this technique to be the ideal choice for patients that were reconstructed with autologous tissue, using the contralateral areola-skin performing an areola-sharing technique. Colour match and circumferential areola border can be achieved extremely similar to the contralateral side. After skin-sparing mastectomy, the remaining skin often is too thin to perform local flaps or even skin grafting. The risk of penetrating the skin and a following extrusion of the mamma-prosthesis is high. In these cases medical tattooing can offer a variety of benefits for example as an enhancement of contour symmetry and to restore colour mismatch (3) We aimed to analyze the beneficial effects of medical tattooing at our breast-cancer unit.1