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1.  Epidermal Micrografts Produced via an Automated and Minimally Invasive Tool Form at the Dermal/Epidermal Junction and Contain Proliferative Cells That Secrete Wound Healing Growth Factors 
Advances in Skin & Wound Care  2015;28(9):397-405.
The aim of this scientific study was to assess epidermal micrografts for formation at the dermal-epidermal (DE) junction, cellular outgrowth, and growth factor secretion. Epidermal harvesting is an autologous option that removes only the superficial epidermal layer of the skin, considerably limiting donor site damage and scarring. Use of epidermal grafting in wound healing has been limited because of tedious, time-consuming, and inconsistent methodologies. Recently, a simplified, automated epidermal harvesting tool (CelluTome Epidermal Harvesting System; Kinetic Concepts Inc, San Antonio, Texas) that applies heat and suction concurrently to produce epidermal micrografts has become commercially available. The new technique of epidermal harvesting was shown to create viable micrografts with minimal patient discomfort and no donor-site scarring.
This study was a prospective institutional review board–approved healthy human study.
This study was conducted at the multispecialty research facility, Clinical Trials of Texas, Inc, in San Antonio, Texas.
The participants were 15 healthy human volunteers.
Epidermal micrografts formed at the DE junction, and migratory basal layer keratinocytes and melanocytes were proliferative in culture. Basement membrane–specific collagen type IV was also found to be present in the grafts, suggesting that the combination of heat and vacuum might cause partial delamination of the basement membrane. Viable basal cells actively secreted key growth factors important for modulating wound healing responses, including vascular endothelial growth factor, hepatocyte growth factor, granulocyte colony-stimulating factor, platelet-derived growth factor, and transforming growth factor α.
Harvested epidermal micrografts retained their original keratinocyte structure, which is critical for potential re-epithelialization and repigmentation of a wound environment.
PMCID: PMC4892759  PMID: 26258460
epidermal micrograft; split-thickness skin graft; cellular outgrowth
2.  Novel expansion techniques for skin grafts 
The quest for skin expansion is not restricted to cover a large area alone, but to produce acceptable uniform surfaces, robust engraftment to withstand mechanical shear and infection, with a minimal donor morbidity. Ease of the technique, shorter healing period and reproducible results are essential parameters to adopt novel techniques. Significant advances seen in four fronts of autologous grafting are: (1) Dermal–epidermal graft expansion techniques, (2) epidermal graft harvests technique, (3) melanocyte-rich basal cell therapy for vitiligo and (4) robust and faster autologous cell cultures. Meek's original concept that the sum of perimeter of smaller grafts is larger than the harvested graft, and smaller the graft size, the greater is the potential for regeneration is witnessed in newer modification. Further, as graft size becomes smaller or minced, these micrografts can survive on the wound bed exudate irrespective of their dermal orientation. Expansion produced by 4 mm × 4 mm sized Meek micrografts is 10-folds, similarly 0.8 mm × 0.8 mm size micrografts produce 100-fold expansion, which becomes 700-fold with pixel grafts of 0.3 mm × 0.3 mm size. Fractional skin harvest is another new technique with 700 μ size full thickness graft. These provide instant autologous non-cultured graft to cover extensive areas with similar quality of engraftment surface as split skin grafts. Newer tools for epidermal blister graft harvest quickly, with uniform size to produce 7-fold expansions with reproducible results. In addition, donor area heals faster with minimal scar. Melanocyte-rich cell suspension is utilised in vitiligo surgery tapping the potential of hair root melanocytes. Further advances in the cell culture to reduce the cultivation time and provide stronger epidermal sheets with dermal carrier are seen in trials.
PMCID: PMC4878244  PMID: 27274117
Epidermal grafts; micrografts; skin culture; skin expansion; skin graft
3.  An Automated and Minimally Invasive Tool for Generating Autologous Viable Epidermal Micrografts 
Advances in Skin & Wound Care  2016;29(2):57-64.
A new epidermal harvesting tool (CelluTome; Kinetic Concepts, Inc, San Antonio, Texas) created epidermal micrografts with minimal donor site damage, increased expansion ratios, and did not require the use of an operating room. The tool, which applies both heat and suction concurrently to normal skin, was used to produce epidermal micrografts that were assessed for uniform viability, donor-site healing, and discomfort during and after the epidermal harvesting procedure.
This study was a prospective, noncomparative institutional review board–approved healthy human study to assess epidermal graft viability, donor-site morbidity, and patient experience.
These studies were conducted at the multispecialty research facility, Clinical Trials of Texas, Inc, San Antonio.
The participants were 15 healthy human volunteers.
The average viability of epidermal micrografts was 99.5%. Skin assessment determined that 76% to 100% of the area of all donor sites was the same in appearance as the surrounding skin within 14 days after epidermal harvest. A mean pain of 1.3 (on a scale of 1 to 5) was reported throughout the harvesting process.
Use of this automated, minimally invasive harvesting system provided a simple, low-cost method of producing uniformly viable autologous epidermal micrografts with minimal patient discomfort and superficial donor-site wound healing within 2 weeks.
PMCID: PMC4718186  PMID: 26765157
donor site; epidermal graft; split-thickness skin graft; suction blister
4.  The real expansion rate of meshers and micrografts: things we should keep in mind 
Skin graft expansion techniques (mesh and micrograft) are widely used, but there is ample evidence that skin graft meshers do not provide their claimed expansion rates. Although this finding might not be new for the majority of surgeons, less is known about surgeons’ actual knowledge of expansion rates. The aim of this study was to evaluate the true expansion rates of commonly used expansion techniques with regard to claimed, achieved, and polled results. In the first part of the study, 54 surgeons were polled during an annual burns meeting regarding the most commonly used expansion techniques and expansion ratios; in the second step the true (achievable) expansion rates of the most widely used meshers and micrografts were analysed; and in third step, a poll involving 40 surgeons was conducted to estimate the true expansion rates of the most frequently used skin expansion techniques. The skin meshers (1:1.5 / 1:3) did not achieve their claimed values: (1:1.5) 84.7% of the claimed expansion (mean ± SD: 1:1.27 ± 0.15) and (1:3) 53.1% of the 1:3 (1:1.59 ± 0.15) mesher. The use of the micrografting technique resulted in 99.8% of the 1:3 (1:2.99 ± 0.09), 93.6% of the 1:4 (1:3.74 ± 0.12) and 93.8% of the 1:6 (1:5.63 ± 0.12) claimed expansion rates, respectively. In general the surgeons overestimated the achievable expansion rates. In general the achieved expansion rate was lower than the estimated and claimed expansion rates. The micrografting technique provided reliable and valid expansion rates compared to the skin meshers. We recommend using the micrograft technique when large expansion ratios are required, for example in severe extensive burns.
PMCID: PMC3741003  PMID: 23966895
skin transplantation; skin graft; mesh; micrografting; Meek’s technique
5.  Epidermal Grafting for Chronic Complex Wounds in India: A Case Series 
Cureus  null;8(3):e516.
In India, the high cost of medical treatments and limited resources can deter patients from receiving available care, leading to the development of chronic wounds. We evaluated the use of epidermal grafting in patients with complex, long-term chronic wounds.
Eighteen patients with complex wounds were treated with epidermal micrografts between September 2014 and March 2015 at a state-run, community health center in Mahe, Puducherry, India. Wound re-epithelialization was monitored for up to 14 weeks.
Comorbidities in the patient group (nine females and nine males; mean age 54.1 ± 10.8 years, range 32–70 years) included diabetes mellitus, hypertension, obesity (body mass index (BMI) >30 kg/m2), and peripheral vascular disease. The wound types included diabetic and nondiabetic foot, pressure, and venous leg ulcers. The average wound age prior to treatment was 36.8 ± 48.5 months (range 2–180 months) in the majority of patients. All wounds measured less than 7 cm × 7 cm. The mean time to wound epithelialization was 3.7 ± 1.8 weeks (range 2–9 weeks). The majority of wounds healed following epidermal grafting (n=16, 88.9%). One patient developed infection following removal of the dressing under non-sterile conditions against the advice of the healthcare providers. Another patient developed wound hypergranulation after grafting. Both wounds healed completely after treatment with antibiotic therapy and tissue resection, respectively. All donor sites healed without complications.
In patients with small- to medium-sized chronic wounds, epidermal grafting offered a viable wound closure option for wounds requiring only the epidermal layer. Additionally, epidermal grafting was performed in the clinic without anesthesia or a surgeon, making the procedure more accessible in resource-challenged regions.
PMCID: PMC4818076  PMID: 27054051
epidermal skin grafts; wound healing; chronic wounds
6.  Negative Pressure Wound Therapy 
Executive Summary
This review was conducted to assess the effectiveness of negative pressure wound therapy.
Clinical Need: Target Population and Condition
Many wounds are difficult to heal, despite medical and nursing care. They may result from complications of an underlying disease, like diabetes; or from surgery, constant pressure, trauma, or burns. Chronic wounds are more often found in elderly people and in those with immunologic or chronic diseases. Chronic wounds may lead to impaired quality of life and functioning, to amputation, or even to death.
The prevalence of chronic ulcers is difficult to ascertain. It varies by condition and complications due to the condition that caused the ulcer. There are, however, some data on condition-specific prevalence rates; for example, of patients with diabetes, 15% are thought to have foot ulcers at some time during their lives. The approximate community care cost of treating leg ulcers in Canada, without reference to cause, has been estimated at upward of $100 million per year.
Surgically created wounds can also become chronic, especially if they become infected. For example, the reported incidence of sternal wound infections after median sternotomy is 1% to 5%. Abdominal surgery also creates large open wounds. Because it is sometimes necessary to leave these wounds open and allow them to heal on their own (secondary intention), some may become infected and be difficult to heal.
Yet, little is known about the wound healing process, and this makes treating wounds challenging. Many types of interventions are used to treat wounds.
Current best practice for the treatment of ulcers and other chronic wounds includes debridement (the removal of dead or contaminated tissue), which can be surgical, mechanical, or chemical; bacterial balance; and moisture balance. Treating the cause, ensuring good nutrition, and preventing primary infection also help wounds to heal. Saline or wet-to-moist dressings are reported as traditional or conventional therapy in the literature, although they typically are not the first line of treatment in Ontario. Modern moist interactive dressings are foams, calcium alginates, hydrogels, hydrocolloids, and films. Topical antibacterial agents—antiseptics, topical antibiotics, and newer antimicrobial dressings—are used to treat infection.
The Technology Being Reviewed
Negative pressure wound therapy is not a new concept in wound therapy. It is also called subatmospheric pressure therapy, vacuum sealing, vacuum pack therapy, and sealing aspirative therapy.
The aim of the procedure is to use negative pressure to create suction, which drains the wound of exudate (i.e., fluid, cells, and cellular waste that has escaped from blood vessels and seeped into tissue) and influences the shape and growth of the surface tissues in a way that helps healing. During the procedure, a piece of foam is placed over the wound, and a drain tube is placed over the foam. A large piece of transparent tape is placed over the whole area, including the healthy tissue, to secure the foam and drain the wound. The tube is connected to a vacuum source, and fluid is drawn from the wound through the foam into a disposable canister. Thus, the entire wound area is subjected to negative pressure. The device can be programmed to provide varying degrees of pressure either continuously or intermittently. It has an alarm to alert the provider or patient if the pressure seal breaks or the canister is full.
Negative pressure wound therapy may be used for patients with chronic and acute wounds; subacute wounds (dehisced incisions); chronic, diabetic wounds or pressure ulcers; meshed grafts (before and after); or flaps. It should not be used for patients with fistulae to organs/body cavities, necrotic tissue that has not been debrided, untreated osteomyelitis, wound malignancy, wounds that require hemostasis, or for patients who are taking anticoagulants.
Review Strategy
The inclusion criteria were as follows:
Randomized controlled trial (RCT) with a sample size of 20 or more
Human study
Published in English
Summary of Findings
Seven international health technology assessments on NPWT were identified. Included in this list of health technology assessments is the original health technology review on NPWT by the Medical Advisory Secretariat from 2004. The Medical Advisory Secretariat found that the health technology assessments consistently reported that NPWT may be useful for healing various types of wounds, but that its effectiveness could not be empirically quantified because the studies were poorly done, the patient populations and outcome measures could not be compared, and the sample sizes were small.
Six RCTs were identified that compared NPWT to standard care. Five of the 6 studies were of low or very low quality according to Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. The low and very low quality RCTs were flawed owing to small sample sizes, inconsistent reporting of results, and patients lost to follow-up. The highest quality study, which forms the basis of this health technology policy assessment, found that:
There was not a statistically significant difference (≥ 20%) between NPWT and standard care in the rate of complete wound closure in patients who had complete wound closure but did not undergo surgical wound closure (P = .15).
The authors of this study did not report the length of time to complete wound closure between NPWT and standard care in patients who had complete wound closure but who did not undergo surgical wound closure
There was no statistically significant difference (≥ 20%) in the rate of secondary amputations between the patients that received NPWT and those that had standard care (P = .06)
There may be an increased risk of wound infection in patients that receive NPWT compared with those that receive standard care.
Based on the evidence to date, the clinical effectiveness of NPWT to heal wounds is unclear. Furthermore, saline dressings are not standard practice in Ontario, thereby rendering the literature base irrelevant in an Ontario context. Nonetheless, despite the lack of methodologically sound studies, NPWT has diffused across Ontario.
Discussions with Ontario clinical experts have highlighted some deficiencies in the current approach to wound management, especially in the community. Because NPWT is readily available, easy to administer, and may save costs, compared with multiple daily conventional dressing changes, it may be used inappropriately. The discussion group highlighted the need to put in place a coordinated, multidisciplinary strategy for wound care in Ontario to ensure the best, continuous care of patients.
PMCID: PMC3379164  PMID: 23074484
7.  Fast and Standardized Skin Grafting of Leg Wounds With a New Technique: Report of 2 Cases and Review of Previous Methods 
Eplasty  2016;16:e14.
Background: Chronic leg ulcers remain a challenge to the treating physician. Such wounds often need skin grafts to heal. This necessitates a readily available, fast, simple, and standardized procedure for grafting. Objectives: The aim of this work was to test a novel method developed for outpatient transplant procedures. Methods: The procedure employs a handheld disposable dermatome and a roller mincer that cut the skin into standardized micrografts that can be spread out onto a suitable graft bed. Wounds were followed until healed and photographed. Results: The device was successfully used to treat and close a traumatic lower limb wound and a persistent chronic venous leg ulcer. The donor site itself healed by secondary intent with minimal cosmetic impairment. Conclusion: The method was successfully used to graft 2 lower extremity wounds.
PMCID: PMC4793303  PMID: 27004083
micrograft; skin transplantation; wound healing; leg ulcers; split thickness skin graft
8.  Protocol for a systematic review of the efficacy of epidermal grafting for wound healing 
Systematic Reviews  2016;5:92.
Autologous skin grafting is an important modality for wound coverage; however, it can result in donor site morbidity. Epidermal grafting is an emerging option to overcome this challenge. Furthermore, it can be done in an outpatient setting with minimal or no pain. To date, the evidence on the efficacy of this technique for wound healing has yet to be outlined. We aim to synthesise the current evidence on epidermal grafting for wound healing to establish the efficacy of this technique.
We will conduct a comprehensive search in the MEDLINE, EMBASE, and CENTRAL databases (up to May 2016) to identify studies on epidermal grafting for wound healing. We will include any primary studies (excluding case reports or case series lesser than three patients) or systematic reviews of such studies to assess the outcome of epidermal grafting for wound healing either on its own or compared to other methods. The expected primary outcome measures are the efficacy of epidermal grafting for wound healing (measured by the proportion of wounds healed at 6 weeks) and the mean wound-healing time (time for complete re-epithelialisation). Secondary outcome measures are the mean donor site-healing time, need for anaesthesia, costs associated with resource use, health-related quality of life, and proportion of patients with adverse event. Subgroup analysis will be performed for the proportions of wounds healed based on wound aetiology.
This is a timely systematic review, and the finding of this systematic review is expected to guide research and clinical practice aimed at improving wound care.
Systematic review registration
PROSPERO CRD42016033051
Electronic supplementary material
The online version of this article (doi:10.1186/s13643-016-0268-7) contains supplementary material, which is available to authorized users.
PMCID: PMC4891844  PMID: 27255327
Epidermal graft; Skin graft; Wound healing; Systematic review
9.  Recent advances in topical wound care 
There are a wide variety of dressing techniques and materials available for management of both acute wounds and chronic non-healing wounds. The primary objective in both the cases is to achieve a healed closed wound. However, in a chronic wound the dressing may be required for preparing the wound bed for further operative procedures such as skin grafting. An ideal dressing material should not only accelerate wound healing but also reduce loss of protein, electrolytes and fluid from the wound, and help to minimize pain and infection. The present dictum is to promote the concept of moist wound healing. This is in sharp contrast to the earlier practice of exposure method of wound management wherein the wound was allowed to dry. It can be quite a challenge for any physician to choose an appropriate dressing material when faced with a wound. Since wound care is undergoing a constant change and new products are being introduced into the market frequently, one needs to keep abreast of their effect on wound healing. This article emphasizes on the importance of assessment of the wound bed, the amount of drainage, depth of damage, presence of infection and location of wound. These characteristics will help any clinician decide on which product to use and where,in order to get optimal wound healing. However, there are no ‘magical dressings’. Dressings are one important aspect that promotes wound healing apart from treating the underlying cause and other supportive measures like nutrition and systemic antibiotics need to be given equal attention.
PMCID: PMC3495389  PMID: 23162238
Moist healing; topical wound care; wet dressings
10.  Epidermal grafting versus split-thickness skin grafting for wound healing (EPIGRAAFT): study protocol for a randomised controlled trial 
Trials  2016;17:245.
Split-thickness skin grafting (SSG) is an important modality for wound closure. However, the donor site becomes a second, often painful wound, which may take more time to heal than the graft site itself and holds the risk of infection and scarring. Epidermal grafting (EG) is an alternative method of autologous skin grafting that harvests only the epidermal layer of the skin by applying continuous negative pressure on the normal skin to raise blisters. This procedure has minimal donor site morbidity and is relatively pain-free, allowing autologous skin grafting in an outpatient setting. We plan to compare EG to SSG and to further investigate the cellular mechanism by which each technique achieves wound healing.
EPIGRAAFT is a multicentre, randomised, controlled trial that compares the efficacy and wound-healing mechanism of EG with SSG for wound healing. The primary outcome measures are the proportion of wounds healed in 6 weeks and the donor site healing time. The secondary outcome measures include the mean time for complete wound healing, pain score, patient satisfaction, health care utilisation, cost analysis, and incidence of adverse events.
This study is expected to define the efficacy of EG and promote further understanding of the mechanism of wound healing by EG compared to SSG. The results of this study can be used to inform the current best practise for wound care.
Trial registration identifier, NCT02535481. Registered on 11 August 2015.
Electronic supplementary material
The online version of this article (doi:10.1186/s13063-016-1352-y) contains supplementary material, which is available to authorized users.
PMCID: PMC4869340  PMID: 27185033
Epidermal graft; Split-thickness skin graft; CelluTome; Wound healing
11.  Scar-free healing: from embryonic mechanisms to adult therapeutic intervention. 
In man and domestic animals, scarring in the skin after trauma, surgery, burn or sports injury is a major medical problem, often resulting in adverse aesthetics, loss of function, restriction of tissue movement and/or growth and adverse psychological effects. Current treatments are empirical, unreliable and unpredictable: there are no prescription drugs for the prevention or treatment of dermal scarring. Skin wounds on early mammalian embryos heal perfectly with no scars whereas wounds to adult mammals scar. We investigated the cellular and molecular differences between scar-free healing in embryonic wounds and scar-forming healing in adult wounds. Important differences include the inflammatory response, which in embryonic wounds consists of lower numbers of less differentiated inflammatory cells. This, together with high levels of morphogenetic molecules involved in skin growth and morphogenesis, means that the growth factor profile in a healing embryonic wound is very different from that in an adult wound. Thus, embryonic wounds that heal without a scar have low levels of TGFbeta1 and TGFbeta2, low levels of platelet-derived growth factor and high levels of TGFbeta3. We have experimentally manipulated healing adult wounds in mice, rats and pigs to mimic the scar-free embryonic profile, e.g. neutralizing PDGF, neutralizing TGFbeta1 and TGFbeta2 or adding exogenous TGFbeta3. These experiments result in scar-free wound healing in the adult. Such experiments have allowed the identification of therapeutic targets to which we have developed novel pharmaceutical molecules, which markedly improve or completely prevent scarring during adult wound healing in experimental animals. Some of these new drugs have successfully completed safety and other studies, such that they have entered human clinical trials with approval from the appropriate regulatory authorities. Initial trials involve application of the drug or placebo in a double-blind randomized design, to experimental incision or punch biopsy wounds under the arms of human volunteers. Based on encouraging results from such human volunteer studies, the lead drugs have now entered human patient-based trials e.g. in skin graft donor sites. We consider the evolutionary context of wound healing, scarring and regeneration. We hypothesize that evolutionary pressures have been exerted on intermediate sized, widespread, dirty wounds with considerable tissue damage e.g. bites, bruises and contusions. Modem wounds (e.g. resulting from trauma or surgery) caused by sharp objects and healing in a clean or sterile environment with close tissue apposition are new occurrences, not previously encountered in nature and to which the evolutionary selected wound healing responses are somewhat inappropriate. We also demonstrate that both repair with scarring and regeneration can occur within the same animal, including man, and indeed within the same tissue, thereby suggesting that they share similar mechanisms and regulators. Consequently, by subtly altering the ratio of growth factors present during adult wound healing, we can induce adult wounds to heal perfectly with no scars, with accelerated healing and with no adverse effects, e.g. on wound strength or wound infection rates. This means that scarring may no longer be an inevitable consequence of modem injury or surgery and that a completely new pharmaceutical approach to the prevention of human scarring is now possible. Scarring after injury occurs in many tissues in addition to the skin. Thus scar-improving drugs could have widespread benefits and prevent complications in several tissues, e.g. prevention of blindness after scarring due to eye injury, facilitation of neuronal reconnections in the central and peripheral nervous system by the elimination of glial scarring, restitution of normal gut and reproductive function by preventing strictures and adhesions after injury to the gastrointestinal or reproductive systems, and restoration of locomotor function by preventing scarring in tendons and ligaments.
PMCID: PMC1693363  PMID: 15293811
12.  The Use of Split-Thickness Skin Grafts on Diabetic Foot Ulcerations: A Literature Review 
Plastic Surgery International  2012;2012:715273.
Diabetic foot ulcerations are historically difficult to treat despite advanced therapeutic modalities. There are numerous modalities described in the literature ranging from noninvasive topical wound care to more invasive surgical procedures such as primary closure, skin flaps, and skin grafting. While skin grafting provides faster time to closure with a single treatment compared to traditional topical wound treatments, the potential risks of donor site morbidity and poor wound healing unique to the diabetic state have been cited as a contraindication to its widespread use. In order to garner clarity on this issue, a literature review was undertaken on the use of split-thickness skin grafts on diabetic foot ulcers. Search of electronic databases yielded four studies that reported split-thickness skin grafts as definitive means of closure. In addition, several other studies employed split-thickness skin grafts as an adjunct to a treatment that was only partially successful or used to fill in the donor site of another plastic surgery technique. When used as the primary closure on optimized diabetic foot ulcerations, split-thickness skin grafts are 78% successful at closing 90% of the wound by eight weeks.
PMCID: PMC3361270  PMID: 22666573
13.  Reconstruction of Alar Nasal Cartilage Defects Using a Tissue Engineering Technique Based on a Combined Use of Autologous Chondrocyte Micrografts and Platelet-rich Plasma: Preliminary Clinical and Instrumental Evaluation 
Developing cartilage constructs with injectability, appropriate matrix composition, and persistent cartilaginous phenotype remains an enduring challenge in cartilage repair. The combined use of autologous chondrocyte micrografts and platelet-rich plasma (PRP) is an alternative that opens a new era in this field.
At the Department of Plastic and Reconstructive Surgery, University of Rome Tor Vergata, Italy, 11 patients underwent nasal alar reconstruction with chondrocyte micrografts gently poured onto PRP in solid form. A computed tomographic scan control was performed after 12 months. Pearson’s Chi-square test was used to investigate difference in cartilage density between native and newly formed cartilages.
The constructs of chondrocyte micrografts–PRP that were subcutaneously injected resulted in a persistent cartilage tissue with appropriate morphology, adequate central nutritional perfusion without central necrosis or ossification, and further augmented nasal dorsum without obvious contraction and deformation.
This report demonstrated that chondrocyte micrografts derived from nasal septum poured onto PRP in solid form are useful for cartilage regeneration in patients with external nasal valve collapse.
PMCID: PMC5096517  PMID: 27826462
14.  Glycerin-Based Hydrogel for Infection Control 
Advances in Wound Care  2012;1(1):48-51.
Infection is a major problem in the health and wellbeing of patients in hospitals, nursing homes, and other medical facilities as well as the homecare patients and the general public. According to Scientia Advisors, wound care costs the healthcare system over $7 billion in 2009. After adding the cost associated with potential complications such as infections, extended physician care, and lengthy hospital stays, the annual wound care expenditures well exceeded over $20 billion.1 There are 20 million reported cases of diabetes per year and more every day. Because of the fact that leg ulcers are the number one health problem of men coupled with the rise in drug resistance of infections, the importance of providing the professional and the public with relatively simple and affordable wound care is of extreme importance. Often the wounds can become chronic wounds, which then result in long-term nursing expense in time and supplies or, worse yet, can result in expensive amputations ranging from $5000 to $40,000 per patient.
There are many dressing options now available for treating wounds with components such as glycerin, honey, salt, and many other natural products, with some dressings being more appropriate than others. In 1988, a patented glycerin-based dressing was introduced to the market, called Elasto-Gel™.2
New Technology
Elasto-Gel™ is a glycerin-based gel sheet (65%) combined with a hydrophilic polymer that causes the sheet to absorb the exudate from the wound and simultaneously release the glycerin from the gel, which adds many benefits to the wound for excellent healing outcomes. The gel sheet is 1/8th of an inch thick with a four-way stretch backing. It has the ability to absorb 3–4 times its own weight of fluids. The dressing will not dry out or allow the exudate to dry out, thus keeping the dressing from becoming bonded to the wound or the surrounding tissue. It does not have adhesive properties and, therefore, will not cause damage to the wound bed or periwound area upon dressing removal. Because of the thickness, the product provides excellent cushion and padding support. It has been also proven to be bacteriostatic/fungistatic. (Bacteriostatic is the ability to restrain the development or reproduction of bacteria.3)
Product Technology
Glycerin is a huamectant by definition and has been recognized by the U.S. Food and Drug Administration (FDA). Humectants attract, bind, and hold moisture to the site of application. The actual concentration of glycerin in a wound dressing is indicative of the ability to absorb excess moisture. Exudate management is an important function of topical treatment. The ability to absorb drainage and prevent pooling of exudate in the wound or on the surrounding skin are attributes specific to high glycerin content. Perhaps, the most significant advantage of the glycerin-based hydrogel sheet is its impact on wound bioburden and pathogenic organisms.4 Glycerin is a simple three-carbon tri-alcohol and is a natural humectant. It is used as a carrier in many medicines and as plasticizer in gelatin gel capsules. Glycerin is a component of cosmetics, conditioners, soaps, foods, and other common products. It is a component of mono-, di-, and triglycerides naturally occurring in the body. These glycerides and glycerin are constantly reacted with each other by the natural enzymes and reversed with the natural metabolic processes already present in the body. Any glycerin that may be absorbed into the body fluid is rapidly diluted in these fluids and is no longer toxic but is metabolized as another component of the food chain. It is well known that glycerin in high concentration will exhibit dehydrating effect on many systems including living cells by the commonly known process of osmosis. (Osmosis: the flow or diffusion that takes place through a semipermable membrane, as of living cell, typically separating a solvent such as water, thus bringing about equilibrium conditions.5) It has been shown that glycerin at high concentration will be cytotoxic to all cells that have been tested if they are exposed long enough. These properties of glycerin have been recognized by the European Skin Bank, where they use 85% glycerin solutions to store cadaver skin at ∼42F, and can be used for potential wound coverings. The cadaver skin that has been prepared by this method has been available since 1994.6 The concern for safety resulted in a three-day international synmposium7 with emphasis on glycerin-preserved cadaver skin providing healthy environment for the preserved skin to be successfully accepted without rejection, having no complications of infection and providing excellent healing outcomes and minimal scaring. Additional research by Dr. David P. Mackie of the Red Cross Hospital, The Netherlands, reported that using 85% glycerin solutions had slow bactericidal effects and also showed virocidal activity on several types of viruses.8 Dr. Hoekstra has observed that within 2 hours after application of Elasto-Gel™, the inflammatory reaction is reduced.9 Vandeputte, Belgium, showed that wounds covered with Elasto-Gel™ had fewer myofibroblasts than those covered with hydrocolloid.10 It has been proposed that myofibroblasts in high concentrations contribute to the formation of hypertrophic and keloid scars. As noted earlier, there is less scar formation when glycerin-based gel sheets are used. The data sited here have shown that glycerin and glycerin-based products are effective antimicrobial agents with less side effects. Many verbal reports along with personal communications have indicated that applying glycerin-based gel sheets to stalled wounds, some 15–20-year-old chronic wounds, resulted in healing in 1–20 weeks (data/case studies on file).
Indications for Use
Elasto-Gel™ has been approved for all types of wounds, that is, pressure ulcers, acute and chronic wounds, diabetic wounds, traumatic wounds, dermatology wounds, cancer tumors, and first- and second-degree burns, to name a few. Because of the product's features and benefits, it may be used on a variety of wounds. Because of its padding properties, it may be also used as a preventative product over bony prominence areas so that wounds do not occur. The glycerin properties act as a skin substitute and may also be used for scar reduction.
Elasto-Gel™ is not approved for third-degree burns as no dressing has been approved by the FDA for this type of wound.
PMCID: PMC3839013  PMID: 24527279
15.  Reconstructive Hair Transplantation of the Face and Scalp 
Seminars in Plastic Surgery  2005;19(2):159-166.
Quantum leap advancements in hair transplantation have occurred in the past 10 to 15 years, particularly the use of micrografts (one- to two-hair follicular unit grafts) and minigrafts (three- to four-hair follicular unit grafts) used in large numbers (> 1000 grafts) in a single session (megasession). This was initially described for the treatment of male pattern baldness. Since that time I have found many other applications, particularly in facial and scalp reconstruction. Common causes for aesthetic reconstructive hair restoration in my experience include: hair loss due to facelift and forehead lift procedures, revision of unsatisfactory results from previous hair transplantation, burn alopecia, congenital reasons, postoncological resections, and idiopathic. The basic technique is described in detail, including the variations for each of the challenging anatomic areas including sideburns and temporal hairline, eyebrows, eyelashes, mustache, beard, and remaining scalp. Especial attention is given to the direction of hair growth, texture, aesthetic planning, and absence of detectable scars, so as to mimic nature. The use of micrografts and minigrafts in the aesthetic reconstruction of the face and scalp has been found to be safe and predictable and has provided a high level of patient satisfaction.
PMCID: PMC2884705
Reconstructive; hair transplantation; micrografting; minigrafting
16.  Clinical Impact Upon Wound Healing and Inflammation in Moist, Wet, and Dry Environments 
Advances in Wound Care  2013;2(7):348-356.
Successful treatment of wounds relies on precise control and continuous monitoring of the wound-healing process. Wet or moist treatment of wounds has been shown to promote re-epithelialization and result in reduced scar formation, as compared to treatment in a dry environment.
Recent Advances
By treating wounds in a controlled wet environment, delivery of antimicrobials, analgesics, other bioactive molecules such as growth factors, as well as cells and micrografts, is allowed. The addition of growth factors or transplantation of cells yields the possibility of creating a regenerative wound microenvironment that favors healing, as opposed to excessive scar formation.
Critical Issues
Although several manufacturers have conceived products implementing the concept of moist wound healing, there remains a lack of commercial translation of wet wound-healing principles into clinically available products. This can only be mitigated by further research on the topic.
Future Directions
The strong evidence pointing to the favorable healing of wounds in a wet or moist environment compared to dry treatment will extend the clinical indications for this treatment. Further advances are required to elucidate by which means this microenvironment can be optimized to improve the healing outcome.
PMCID: PMC3842869  PMID: 24587972
17.  A porcine model of full-thickness burn, excision and skin autografting 
Acute burn wounds often require early excision and adequate coverage to prevent further hypothermia, protein and fluid losses, and the risk of infection. Meshed autologous skin grafts are generally regarded as the standard treatment for extensive full-thickness burns. Graft take and rate of wound healing, however, depend on several endogenous factors. This paper describes a standardized reproducible porcine model of burn and skin grafting which can be used to study the effects of topical treatments on graft take and re-epithelialization.
Procedures provide a protocol for successful porcine burn wound experiments with special focus on pre-operative care, anesthesia, burn allocation, excision and grafting, postoperative treatment, dressing application, and specimen collection. Selected outcome measurements include percent area of wound closure by planimetry, wound assessment using a clinical assessment scale, and histological scoring.
The use of this standardized model provides burn researchers with a valuable tool for the comparison of different topical drug treatments and dressing materials in a setting that closely mimics clinical reality.
PMCID: PMC2637517  PMID: 18617332
Burn; Burn excision; Wound healing; Reconstruction; Autograft
18.  Which dressing do donor site wounds need?: study protocol for a randomized controlled trial 
Trials  2011;12:229.
Donor site wounds after split-skin grafting are rather 'standard' wounds. At present, lots of dressings and topical agents for donor site wounds are commercially available. This causes large variation in the local care of these wounds, while the optimum 'standard' dressing for local wound care is unclear. This protocol describes a trial in which we investigate the effectiveness of various treatment options for these donor site wounds.
A 14-center, six-armed randomized clinical trial is being carried out in the Netherlands. An a-priori power analysis and an anticipated dropout rate of 15% indicates that 50 patients per group are necessary, totaling 300 patients, to be able to detect a 25% quicker mean time to complete wound healing. Randomization has been computerized to ensure allocation concealment. Adult patients who need a split-skin grafting operation for any reason, leaving a donor site wound of at least 10 cm2 are included and receive one of the following dressings: hydrocolloid, alginate, film, hydrofiber, silicone dressing, or paraffin gauze. No combinations of products from other intervention groups in this trial are allowed. Optimum application and changes of these dressings are pursued according to the protocol as supplied by the dressing manufacturers. Primary outcomes are days to complete wound healing and pain (using a Visual Analogue Scale). Secondary outcomes are adverse effects, scarring, patient satisfaction, and costs. Outcome assessors unaware of the treatment allocation will assess whether or not an outcome has occurred. Results will be analyzed according to the intention to treat principle. The first patient was randomized October 1, 2009.
This study will provide comprehensive data on the effectiveness of different treatment options for donor site wounds. The dressing(s) that will prevail in effectiveness, satisfaction and costs will be promoted among clinicians dealing with such patients. Thus, we aim to contribute a well-designed trial, relevant to all clinicians involved in the care for donor site wounds, which will help enhance uniformity and quality of care for these patients.
Trial registration, NTR1849. Date registered: June 9, 2009
PMCID: PMC3219559  PMID: 21999705
In the study of the action of non-antiseptic substances on the rate of cicatrization, the chief obstacle encountered is the facility with which wounds become reinfected under an aseptic dressing. At the beginning of Experiment 1 the wound was sterile. It was subjected to flushing with distilled water for 2 hours, then to flushing with 30 per cent sodium chloride solution for another 2 hours. During that time no special precaution was taken to sterilize the wound and the dressing was left intact until the following morning. It was then found that the wound contained from 30 to 50 bacteria per field. The following day, after the wound had been subjected to the same treatment, the number of bacteria had increased to 50 and 100 per field, and as an immediate consequence the surface of the wound increased from 12 to 12.6 sq. cm. in 2 days. The wound was then dressed antiseptically and was found to be sterile 3 days later. Reinfection again took place the following day in spite of antiseptic dressing with chloramine paste 4 parts per 1,000, which was applied for 20 hours. In Experiment 2 similar results were observed. After 2 days of flushing with distilled water, the number of bacteria had increased to 50 per field. The wound was thereupon sterilized, but new reinfection ensued a few days later. Another wound on the same patient became reinfected under the same conditions after 1 day of sterile dressing. In none of the patients could the wounds be kept in a sterile condition throughout the whole experiment. It was impossible to maintain the sterility of a wound under aseptic dressing. Dakin's solution was therefore injected every 4 hours, or less often, according to the degree of infection, or chloramine paste was applied during the night. If there were 3 or 4 bacteria per field, the experiment was discontinued in order that the wound might be sterilized again. The cicatrization and bacteriological curves of Experiment 4 show that by the application of chloramine paste a wound may be maintained in an appropriately bacteriological condition for carrying out an experiment. Nevertheless, in spite of the antiseptic precautions taken, it was necessary to interrupt this experiment on two occasions, on December 13 to 15 and on December 18 to 22, in order that a complete sterilization of the wound might be effected. When the sterilization was performed as soon as the bacteria were discovered, little retardation occurred in the process of cicatrization. Moreover, the reinfection from the skin was often due to fine bacilli which have but mild retarding action on the rate of healing. The use of at least six flushings in 2 hours with Dakin's solution or of 12 hours' dressing with chloramine paste 10 parts per 1,000, was necessary to keep the wound in a condition of surgical asepsis. The action of distilled water was studied in Experiments 1, 2, and 3. In Experiment 1 the wound was subjected to flushing with distilled water first for 2 hours, then 4 hours, and later for 8 hours per day. The wound was maintained in a condition of mild infection. No marked modification, either acceleration or retardation, was noted in the rate of repair during the period that the treatment was applied. From November 21 to 25 the wound was almost clean and the observed curve remained parallel to the calculated curve, showing that distilled water did not retard the rate of healing. In Experiment 2 the wound was subjected to uninterrupted flushing with distilled water, first for 2 and 8 hours, then for 24 hours. It was continued from November 24 to 30; viz., for 112 hours out of 120, without the occurrence of any marked modification of the course of healing. The bacteriological curve showed that from November 22 to 27 inclusive the wound was kept aseptic. The slight retardation which occurred afterwards was probably brought about by the infection. In Experiment 3 the wound was subjected to flushing with distilled water, first for 2, then for 4, 6, and 8 hours, a total of 20 hours in 4 days. From November 21 to 24 the wound remained surgically aseptic. No modification in the rate of healing occurred. The action of the hypertonic sodium chloride solution was studied in a similar way. In Experiment 4 the wound was flushed at first with 40 per cent sodium chloride solution, from December 4 to 9 for 12 hours a day, and from December 10 to 13 for 24 hours a day, making a total of 144 hours out of 240 hours. At the end of this time the surface area of the wound coincided exactly with the calculated area. Owing to reinfection the experiment was suspended. From December 24 to 29 the wound was kept in contact with 50 per cent sodium chloride solution for 54 hours, and after December 30 flushing with 80 per cent solution for 24 hours a day was resorted to. The total amount of time involved in the above treatments was 174 hours with 40 per cent solution, 72 hours with 50 per cent solution, and 120 hours with 80 per cent solution. On January 1, the surface measured 11 sq. cm. and the calculated surface was 11.3 sq. cm. On January 5 the. surface observed was 10 sq. cm. and the calculated surface was 9 sq. cm. It should be noticed that on January 5 the bacteria numbered 4 per field, which might account for the difference. In Experiment 5 the wound was flushed for 24 hours every day with 50 per cent sodium chloride solution from December 11 to 18, a total of 192 hours. From December 18 to 24 the wound was dressed with agar-agar cakes containing 40 per cent sodium chloride. The concentration was raised to 50 per cent from December 24 to 27. The cicatrization curve indicates only a slight retardation of the repair which can be attributed to infection when both cicatrization and infection curves are compared. The temporary acceleration on the 13th may have been due to the influence of the dressing, but as it did not occur again an experimental error is probably the cause of the change observed in the curve. In Experiment 6 two practically identical wounds at a distance of but a few centimeters from each other were located on the right thigh of Patient 721. The areas of the wounds were respectively 40 and 33 sq. cm. One of the wounds was flushed with distilled water only. The other was subjected to the action of 40 per cent sodium chloride solution. From December 20 to 25 both wounds were in a condition of surgical asepsis. However, the cicatrization curves show that in spite of the difference of treatment the rate of healing was not modified. The rate of healing of the wounds did not therefore apparently undergo any measurable modification under the influence of distilled water or hypertonic salt solution. It is well known that the osmotic changes of the medium have a marked influence on tissues deprived of circulation. But it seems that a tissue with normal circulation is protected by it against the changes of the osmotic pressure occurring at its surface. The above experiments show that apparently the conditions of the tissues of a wound are not modified by the changes of the osmotic pressure of the dressing. The beneficial effects of hypertonic sodium chloride solution on the sterilization of wounds and on the rate of healing recently described by various surgeons are possibly an illusion due to lack of precise technique.
PMCID: PMC2125649  PMID: 19868150
20.  Therapy of acute wounds with water-filtered infrared-A (wIRA) 
Water-filtered infrared-A (wIRA) as a special form of heat radiation with a high tissue penetration and with a low thermal load to the skin surface acts both by thermal and thermic as well as by non-thermal and non-thermic effects. wIRA produces a therapeutically usable field of heat in the tissue and increases tissue temperature, tissue oxygen partial pressure, and tissue perfusion. These three factors are decisive for a sufficient tissue supply with energy and oxygen and consequently as well for wound healing and infection defense.
wIRA can considerably alleviate the pain (with remarkably less need for analgesics) and diminish an elevated wound exudation and inflammation and can show positive immunomodulatory effects. wIRA can advance wound healing or improve an impaired wound healing both in acute and in chronic wounds including infected wounds. Even the normal wound healing process can be improved.
A prospective, randomized, controlled, double-blind study with 111 patients after major abdominal surgery at the University Hospital Heidelberg, Germany, showed with 20 minutes irradiation twice a day (starting on the second postoperative day) in the group with wIRA and visible light VIS (wIRA(+VIS), approximately 75% wIRA, 25% VIS) compared to a control group with only VIS a significant and relevant pain reduction combined with a markedly decreased required dose of analgesics: during 230 single irradiations with wIRA(+VIS) the pain decreased without any exception (median of decrease of pain on postoperative days 2-6 was 13.4 on a 100 mm visual analog scale VAS 0-100), while pain remained unchanged in the control group (p<0.001). The required dose of analgesics was 57-70% lower in the subgroups with wIRA(+VIS) compared to the control subgroups with only VIS (median 598 versus 1398 ml ropivacaine, p<0.001, for peridural catheter analgesia; 31 versus 102 mg piritramide, p=0.001, for patient-controlled analgesia; 3.4 versus 10.2 g metamizole, p=0.005, for intravenous and oral analgesia). During irradiation with wIRA(+VIS) the subcutaneous oxygen partial pressure rose markedly by approximately 30% and the subcutaneous temperature by approximately 2.7°C (both in a tissue depth of 2 cm), whereas both remained unchanged in the control group: after irradiation the median of the subcutaneous oxygen partial pressure was 41.6 (with wIRA) versus 30.2 mm Hg in the control group (p<0.001), the median of the subcutaneous temperature was 38.9 versus 36.4°C (p<0.001). The overall evaluation of the effect of irradiation, including wound healing, pain and cosmesis, assessed on a VAS (0-100 with 50 as indifferent point of no effect) by the surgeon (median 79.0 versus 46.8, p<0.001) or the patient (79.0 versus 50.2, p<0.001) was markedly better in the group with wIRA compared to the control group. This was also true for single aspects: Wound healing assessed on a VAS by the surgeon (median 88.6 versus 78.5, p<0.001) or the patient (median 85.8 versus 81.0, p=0.040, trend) and cosmetic result assessed on a VAS by the surgeon (median 84.5 versus 76.5, p<0.001) or the patient (median 86.7 versus 73.6, p=0.001). In addition there was a trend in favor of the wIRA group to a lower rate of total wound infections (3 of 46, approximately 7%, versus 7 of 48, approximately 15%, p=0.208) including late infections after discharge, caused by the different rate of late infections after discharge: 0 of 46 in the wIRA group and 4 of 48 in the control group. And there was a trend towards a shorter postoperative hospital stay: 9 days in the wIRA group versus 11 days in the control group (p=0.037). The principal finding of this study was that postoperative irradiation with wIRA can improve even a normal wound healing process.
A prospective, randomized, controlled, double-blind study with 45 severely burned children at the Children’s Hospital Park Schönfeld, Kassel, Germany, showed with 30 minutes irradiation once a day (starting on the first day, day of burn as day 1) in the group with wIRA and visible light VIS (wIRA(+VIS), approximately 75% wIRA, 25% VIS) compared to a control group with only VIS a markedly faster reduction of wound size. On the fifth day (after 4 days with irradiation) decision was taken, whether surgical debridement of necrotic tissue was necessary because of deeper (second degree, type b) burns (11 of 21 in the group with wIRA, 14 of 24 in the control group) or non-surgical treatment was possible (second degree, type a, burns). The patients treated conservatively were kept within the study and irradiated till complete reepithelialization. The patients in the group with wIRA showed a markedly faster reduction of wound area: a median reduction of wound size of 50% was reached already after 7 days compared to 9 days in the control group, a median reduction of wound size of 90% was already achieved after 9 days compared to 13 days in the control group. In addition the group with wIRA showed superior results till 3 months after the burn in terms of the overall surgical assessment of the wound, cosmesis, and assessment of effects of irradiation compared to the control group.
In a prospective, randomized, controlled study with 12 volunteers at the University Medical Center Charité, Berlin, Germany, within each volunteer 4 experimental superficial wounds (5 mm diameter) as an acute wound model were generated by suction cup technique, removing the roof of the blister with a scalpel and a sterile forceps (day 1). 4 different treatments were used and investigated during 10 days: no therapy, only wIRA(+VIS) (approximately 75% wIRA, 25% VIS; 30 minutes irradiation once a day), only dexpanthenol (= D-panthenol) cream once a day, wIRA(+VIS) and dexpanthenol cream once a day. Healing of the small experimental wounds was from a clinical point of view excellent with all 4 treatments. Therefore there were only small differences between the treatments with slight advantages of the combination wIRA(+VIS) and dexpanthenol cream and of dexpanthenol cream alone concerning relative change of wound size and assessment of feeling of the wound area. However laser scanning microscopy with a scoring system revealed differences between the 4 treatments concerning the formation of the stratum corneum (from first layer of corneocytes to full formation) especially on the days 5-7: fastest formation of the stratum corneum was seen in wounds treated with wIRA(+VIS) and dexpanthenol cream, second was wIRA(+VIS) alone, third dexpanthenol cream alone and last were untreated wounds. Bacterial counts of the wounds (taken every 2 days) showed, that wIRA(+VIS) and the combination of wIRA(+VIS) with dexpanthenol cream were able to inhibit the colonisation with physiological skin flora up to day 5 when compared with the two other groups (untreated group and group with dexpanthenol cream alone). At any investigated time, the amount of colonisation under therapy with wIRA(+VIS) alone was lower (interpreted as more suppressed) compared with the group with wIRA(+VIS) and dexpanthenol cream.
During rehabilitation after hip and knee endoprosthetic operations the resorption of wound seromas and wound hematomas was both clinically and sonographically faster and pain was reduced by irradiation with wIRA(+VIS).
wIRA can be used successfully for persistent postoperative pain e.g. after thoracotomy.
As perspectives for wIRA it seems clinically prudent to use wIRA both pre- and postoperatively, e.g. in abdominal and thoracic operations. wIRA can be used preoperatively (e.g. during 1-2 weeks) to precondition donor and recipient sites of skin flaps, transplants or partial-thickness skin grafts, and postoperatively to improve wound healing and to decrease pain, inflammation and infections at all mentioned sites. wIRA can be used to support routine pre- or intraoperative antibiotic administration or it might even be discussed to replace this under certain conditions by wIRA.
PMCID: PMC2831241  PMID: 20204084
water-filtered infrared-A (wIRA); wound healing; acute wounds; prospective, randomized, controlled, double-blind studies; reduction of pain; problem wounds; wound infections; infection defense; wound exudation; inflammation; thermal and non-thermal effects; thermic and non-thermic effects; energy supply; oxygen supply; tissue oxygen partial pressure; tissue temperature; tissue blood flow; visual analog scales (VAS); quality of life
21.  Cultural Understanding of Wounds, Buruli Ulcers and Their Management at the Obom Sub-district of the Ga South Municipality of the Greater Accra Region of Ghana 
PLoS Neglected Tropical Diseases  2016;10(7):e0004825.
This study was conducted with the aim to understand some of the cultural belief systems in the management of wounds and patients practices that could contaminate wounds at the Obom sub-district of the Ga South Municipality of Ghana.
This was an ethnographic study using in-depth interviews, Focus Group Discussions and participant observation techniques for data collection. Observations were done on Buruli ulcer patients to document how they integrate local and modern wound management practices in the day-to-day handling of their wounds. Content analysis was done after the data were subjected to thematic coding and representative narratives selected for presentation.
It was usually believed that wounds were caused by charms or spirits and, therefore, required the attention of a native healer. In instances where some patients’ wounds were dressed in the hospital by clinicians whose condition/age/sex contradict the belief of the patient, the affected often redress the wounds later at home. Some of the materials often used for such wound dressing include urine and concoctions made of charcoal and gunpowder with the belief of driving out evil spirits from the wounds.
Clinicians must therefore be aware of these cultural beliefs and take them into consideration when managing Buruli ulcer wounds to prevent redressing at home after clinical treatment. This may go a long way to reduce secondary infections that have been observed in Buruli ulcer wounds.
Author Summary
The study revealed a number of cultural practices and beliefs which influenced patients' wound care and health seeking behaviour. These included the beliefs that prohibit certain category of people such as pregnant women, lactating mothers and women who menstruate from dressing wounds. Respondents believed that some wounds were caused by charms or spirits and, therefore, required the attention of a traditional healer. In instances where patients’ wounds were dressed in the hospital by clinicians and the patients observed that the condition, age or sex of the clinician contradict their belief, they often redressed the wounds later at home for fear of the wound not healing. Some of the materials often used for such wound dressing include urine and concoctions made of charcoal and gunpowder with the belief of driving out evil spirits from the wounds. These practices may cause secondary infection of wounds considering the conditions under which the mixtures (concoctions) are prepared. It may require collaborative efforts of clinicians, public health promoters and the affected communities to find a common ground to manage Buruli ulcer wounds in a mutually acceptable way to aid healing.
PMCID: PMC4954709  PMID: 27438292
22.  Meshed skin grafts placed upside down can “take” if desiccation is prevented 
Plastic and reconstructive surgery  2010;125(3):855-865.
The role of the wet environment in wound healing has been investigated in various studies. The current study explores the role of the wet wound environment in promoting healing of skin grafts. We hypothesized that survival of the skin grafts is not only dependent on the orientation of transplantation, but also on the environment into which the skin is transplanted.
The study included 72 full-thickness (2.5×2.5cm) wounds in 6 Yorkshire pigs. The wounds were grafted with autologous split-thickness skin grafts (meshed or sheet), placed either regularly (dermal-side-down) or inverted (dermal-side-up), and treated in wet or dry environment. Behavior of the skin grafts and healing were analyzed in histologies collected on days 4, 6, 9 and 12 postwounding. Wound contraction was quantified by photoplanimetry.
In the wet environment, not only did inverted meshed skin grafts survive, but also they proliferated to accelerate reepithelialization. In this environment, wounds transplanted with inverted and regular meshed grafts showed no significant difference in reepithelialization rate and contraction. In contrast, in the dry environment, wounds transplanted with inverted meshed grafts showed a significantly lower reepithelialization and higher contraction than wounds transplanted with regular grafts. Inverted meshed grafts in dry environment and inverted sheet grafts did not survive.
The wound environment has an important role in the survival and proliferation of skin grafts, as demonstrated by survival of inverted meshed grafts in the wet environment and their contribution to accelerated reepithelialization, equal to the regularly placed grafts.
PMCID: PMC2848958  PMID: 20195112
23.  The Use of Growth Factors and Other Humoral Agents to Accelerate and Enhance Burn Wound Healing 
Eplasty  2011;11:e41.
Objective: Certain cytokines, especially those known as growth factors, have been demonstrated to mediate or modulate burn wound healing. Experimental and clinical evidence suggests that there are therapeutic advantages to the wound healing process when these agents are utilized. Positive effects have been reported for 4 types of wounds seen in the burn patient: partial-thickness wounds, full-thickness wounds, interstices of meshed skin grafts, and skin graft donor sites. Methods: A comprehensive literature search was performed using the MEDLINE, Ovid, and Web of Science databases to identify pertinent articles regarding growth factors and other cytokines in burns and wound healing. Results: The current knowledge about cytokine growth factors and their potential therapeutic applications in burn wound healing are discussed and reviewed. Conclusions: Platelet-derived growth factor, fibroblast growth factors, epidermal growth factors, transforming growth factor alpha, vascular endothelial growth factor, insulin-like growth factor I, nerve growth factor, transforming growth factor beta, granulocyte-macrophage colony-stimulating factor, and amnion-derived cellular cytokine solution have all been suggested to enhance the rate and quality of healing in 1 or more of these wounds encountered in burn care.
PMCID: PMC3212033  PMID: 22084646
24.  Chimeric Human Skin Substitute Tissue: A Novel Treatment Option for the Delivery of Autologous Keratinocytes 
Advances in Wound Care  2012;1(2):57-62.
For patients suffering from catastrophic burns, few treatment options are available. Chimeric coculture of patient-derived autologous cells with a “carrier” cell source of allogeneic keratinocytes has been proposed as a means to address the complex clinical problem of severe skin loss.
The Problem
Currently, autologous keratinocytes are harvested, cultured, and expanded to form graftable epidermal sheets. However, epidermal sheets are thin, are extremely fragile, and do not possess barrier function, which only develops as skin stratifies and matures. Grafting is typically delayed for up to 4 weeks to propagate a sufficient quantity of the patient's cells for application to wound sites.
Basic/Clinical Science Advances
Fully stratified chimeric bioengineered skin substitutes could not only provide immediate wound coverage and restore barrier function, but would simultaneously deliver autologous keratinocytes to wounds. The ideal allogeneic cell source for this application would be an abundant supply of clinically evaluated, nontumorigenic, pathogen-free, human keratinocytes. To evaluate this potential cell-based therapy, mixed populations of a green fluorescent protein-labeled neonatal human keratinocyte cell line (NIKS) and unlabeled primary keratinocytes were used to model the allogeneic and autologous components of chimeric monolayer and organotypic cultures.
Clinical Care Relevance
Relatively few autologous keratinocytes may be required to produce fully stratified chimeric skin substitute tissue substantially composed of autologous keratinocyte-derived regions. The need for few autologous cells interspersed within an allogeneic “carrier” cell population may decrease cell expansion time, reducing the time to patient application.
This study provides proof of concept for utilizing NIKS keratinocytes as the allogeneic carrier for the generation of bioengineered chimeric skin substitute tissues capable of providing immediate wound coverage while simultaneously supplying autologous human cells for tissue regeneration.
PMCID: PMC3839016  PMID: 24527281
25.  Complications in Brief: Quadriceps and Patellar Tendon Tears 
Effective treatment of knee extensor mechanism disruptions requires prompt diagnosis and thoughtful decision-making with surgical and nonsurgical approaches. When surgery is chosen, excellent surgical technique can result in excellent outcomes. Complications and failures arise from missed or delayed diagnoses and from technical problems in the operating room. In particular, inappropriate surgical timing (especially late surgery), misplaced patellar drill holes, and failure to address concomitant injuries can result in complications seen when repairing a patellar or quadriceps tendon tear. We review the complications that can occur during treatment of these injuries (Table 1).Table 1Errors and complications in the treatment of quadriceps and patellar tendon tearsError/complicationClinical effectPreventionDetectionRemedyJudgment errors Missed diagnosis: patella tendon tearPatient seen in the emergency room, presumed to have a patella dislocation; sent home; delay in treatment leads to chronic extensor mechanism disruption, which can cause disability and be more difficult to treatCareful history and physical examination(1) Physical examination Infrapatellar pain Infrapatellar gap Inability to maintain full active extension Unable to perform straight leg raise Gait abnormalities: stiff knee gait or exaggerated hip elevation for swing through circumduction(2) Radiographs Abnormal patella height (alta)(3) MRI/ultrasoundEducation of physicians and ancillary staff; high index of suspicion; thorough history and physical examination Missed diagnosis: quadriceps tendon tearVery common, especially in obese patients; delay in treatment leading to chronic extensor mechanism disruption, which can cause disability and be more difficult to treatCareful history and physical examination(1) Physical examination Suprapatellar pain Suprapatellar gapInability to maintain full active extension Gait abnormalities: stiff knee gait or exaggerated hip elevation for swing through circumduction(2) Radiographs Abnormal patella height (baja)(3) MRI/ultrasoundEducation of physicians and ancillary staff; high index of suspicion; thorough history and physical examination Missed diagnosis: intact retinaculum but torn quadriceps tendonPatient able to perform weak straight leg raise as a result of intact retinaculum, but quadriceps tendon actually completely torn; lack of power leading to altered gait and joint kinematics, joint breakdown and potential subsequent traumatic injuries(1) Careful physical examination: check for extensor lag(2) Aspirate blood from knee and inject with lidocaine; then reexamine(3) Additional imaging: MRI(1) Palpable defect in soft tissues proximal to patella(2) MRIEducation of physicians and ancillary staff; high index of suspicion Missed diagnosis: multiligament knee injury, failure to recognize extensor mechanism disruptionWith severe traumatic knee injuries, clinicians may focus on ligament/bony injury and may miss extensor mechanism disruption, leading to incomplete care of injuries and significant disability(1) Careful review of imaging, particularly sagittal views(2) Thorough physical examination(1) Palpable defect in soft tissues proximal/distal to patella(2) MRIEducation of physicians and ancillary staff; high index of suspicion; thorough history and physical examination; careful review all imaging Delayed diagnosis: delayed surgeryOperating too late after injury; tendon becomes scarred down and retracted; may be difficult to perform primary repair; may require tissue grafting and multiple surgeriesPerforming surgery as soon as possible, preferably within first weekProper detection and early management; if noted too late, consider V-Y or Scuderi technique Incorrect diagnosis: partial tendon tearTendon only partially disrupted (< 10 mm separation of the tendon from bone); will heal without surgery; in one study, nonsurgical management resulted in 93% success rate [5](1) MRI(2) Ultrasound(3) Physical examination(1) Patient should be able to maintain full active extension(2) Radiographs: normal patellar heightThis individual can be treated nonoperatively with immobilization until the tendon has healed Incorrect diagnosis: retinaculum torn, but quadriceps tendon intactAs long as the tendon is intact, the retinaculum should heal nonoperatively(1) Careful physical examination(2) Aspirate blood from knee and inject with lidocaine; then reexamine(3) Additional imaging: MRI or ultrasound Incorrect diagnosis: inability to extend knee or perform straight leg raise, but extensor mechanism is intactMultiple reasons:(1) Femoral nerve palsy(2) Pain(3) Intraarticular pathology: locked knee (loose body, bucket handle meniscal tear, etc)(1) Thorough history and careful physical examination(2) Additional imaging: MRIConsider aspiration/injection of local anesthetic and reexaminationPotential judgment errors Performing definitive surgery in open injuryConsider staged procedure if contaminated wound(1) Irrigation and debridement(2) Definitive fixationThorough history and careful physical examinationSingle stage management of contaminated or chronically open injuries potentially leads to infection and repair failure Failure to account for diabetesPoor tissue quality that should be accounted for. Delayed wound and tendon healingThorough history and careful physical examination. Tight perioperative glycemic controlLaboratory studies. Patient’s glycemic historyConsultation with patient’s primary care provider/internal medicineAdequate diseased tendon debridement.Delayed postoperative motion to account for expected delayed healingTechnical errors Positioning and preparing(1) Supine, bump under ipsilateral hip to internally rotate lower extremity(2) Consider full muscle paralysis to aid in reduction Inadequate exposureGenerous midline incision needed to see extent of injury (retinacular injury) and define injury pattern (midsubstance tear versus avulsion from patella) Failure to identify correct injury pattern: patellar tendonThree injury patterns based on location:(1) Avulsion (with/without bone) from inferior pole patella(2) Midsubstance rupture(3) Distal avulsion from tibial tubercle(1) Preoperative imaging(2) Adequate exposureCorrectly identifying injury pattern will dictate fixation method Failure to identify correct injury pattern: quadriceps tendonThree injury patterns based on location:(1) Avulsion (with/without bone) from superior pole patella(2) Midsubstance rupture(3) Mixed(1) Preoperative imaging(2) Adequate exposureCorrectly identifying injury pattern will dictate preoperative planning and fixation method Failure to débride patella/quadriceps tendon stumpFailure to débride scar or devascularized tissue may predispose to failure of the repair and/or chronic weaknessRongeur scar tissue from patellaPrepare bleeding bone bed: curette or burr a trough Failure to débride/prepare patella bone bedFailure to débride patella bone bed may predispose to poor healingRongeur scar tissue from patellaPrepare bleeding bone bed: curette or burr a trough Tendon repair: inadequate tissue for repair of midsubstance rupturesCan be challenging, especially with severely disrupted patella tendonsConsider augmentation with contralateral hamstring autograft or allograft; role for other biologics (dermal patches, etc)? Tendon repair: appropriate tension for midsubstance rupturesCan be challenging, especially with severely disrupted patella tendonsLateral radiograph of contralateral leg can help determine appropriate tension Transosseous tendon repair: divergent tunnelsDivergent tunnels lead to asymmetric reduction of tendon to bone; may lead to poor contact and therefore poor healing or maltracking(1) Adequate exposure of entire patella(2) Parallel pin drill guide(3) Consider use of fluoroscopy Transosseous tendon repair: tunnel penetration into articular surfaceIatrogenic articular cartilage injury(1) Adequate exposure of entire patella(2) Parallel pin drill guide Transosseous tendon repair: drill breakageBroken drill bit in tunnel(1) Careful drilling technique(2) Do not attempt to change direction of drill hole once started drilling(3) Do not torque drill(4) Use stout drill bit Transosseous tendon repair: anterior placement of tunnelsMay lead to downward tilting of the patella and increase patellofemoral contact forces and pain(1) Place drill holes in center of patella (with respect to AP)(2) If have to cheat, cheat toward articular surface Transosseous tendon repair: overtightening repairMay lead to patella alta or baja(1) Prepare opposite leg to assist with tensioning(2) Obtain intraoperative radiograph and compare with contralateral side Transosseous tendon repair: undertightening repair(1) May lead to patella alta or baja(2) Poor tendon to bone contact may interfere with healing(1) When tying knots, make sure to remove all the slack and that the tendon is pulled snuggly into patella bone trough(2) Adequate retinacular repair Transosseous tendon repair: prominent proximal suture knotsMay lead to skin irritationAttempt to bury knots and cover with surrounding soft tissue Suture anchor tendon repairAdvantages:(1) Less dissection(2) Decreased surgical time(3) More accurate suture placement(4) Low profile Suture anchor tendon repair: anchor pulloutCauses:(1) Poorly placed anchors(2) Poor bone quality(3) Weak anchors(1) Anchors should be placed in center of patella [2](2) Not to be used in osteoporotic bone(3) Two 5.0-mm corkscrew titanium anchors (equivalent pullout to transosseous tunnels) [1] Suture anchor tendon repair: proud anchorsProud anchors will not allow the tendon edge to be pulled into the bone trough in the patella, possibly leading to a gap at the bone-tendon junction and poor healingAnchors should be slightly countersunk to pull tendon firmly into bone trough in patella Failure to repair retinacular tissueMay lead to increased stress on central repair(1) Adequate exposure(2) Suture medial and lateral retinaculumAdditional complications Infection(1) Open injury(2) Comorbidities  Diabetes  Smoking  Chronic disease(1) Irrigation and debridement (consider delayed repair)(2) Timely administration preoperative antibiotics(3) Tight glucose control(4) Smoking cessation Wound complications(1) Open injury(2) Comorbidities  Diabetes  Smoking  Chronic disease(3) Prominent sutures(1) Irrigation and débridement (consider delayed repair)(2) Timely administration preoperative antibiotics(3) Tight glucose control(4) Smoking cessation Nerve injuryExtremely rareRehabilitation complications Prolonged immobilizationLeads to stiffness and decreased ROMIntraoperative assessment of maximum flexion before gapping between bone and tendon is observedEarly ROM (10–14 days): active flexion, passive extension to limits determined intraoperatively Inadequate immobilization(1) Wound complications(2) Failure of repairROM bracing locked in extension Overly aggressive physical therapyNeed time for tendon-to-bone healing to occurNo forced flexion or active extension in first 6 weeks
PMCID: PMC3916631  PMID: 24338040

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