Use of an Autologous Heterogenous Skin Construct in the Treatment of Intractable Late-Effect Radiation Wounds: Case Series (original) (raw)
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PubMed, 2020
Split-thickness skin grafting (STSG) is the standard of care for treating deep burns. They often contract, have unpredictable cosmetic outcomes, lack dermal appendages, and result in painful, conspicuous donor sites. An autologous homologous skin construct (AHSC) has been shown to produce full-thickness skin architecture. This study examined the safety profile, engraftment, and quality of healing of a pilot group of AHSC-treated burn wounds. Following IRB approval and informed consent, patients with deep-partial/full-thickness burns requiring grafting underwent side-by-side treatment with AHSC and STSG. A 2 cm2 fullthickness harvest was processed into AHSC at an FDA-registered facility, returned within 48 hours, and applied to a 4 cm2 area alongside a STSG. AHSC donor site was closed primarily. Wounds were evaluated for healing with digital photography and investigator assessments for 90 days. All adverse events (AEs) were recorded. Eight patients with average 13.3% TBSA [range 2-58%] burn wounds were treated: 5 Caucasian and 3 African American with an average body mass index (BMI) of 26.8. Injury was due to predominantly flame burn, with additional injury from grease, scald, contact, friction and flash. Mean time between injury and AHSC treatment was 11 days [range 5-35 days]. All patients had adequate engraftment and complete epithelialization by the end of the study. Patients required one application of AHSC and no other additional surgical procedures at the application sites. The most common AEs for STSG-treated wounds included hypertrophic scarring and pruritus. One non-infected AHSC harvest site experienced a dehiscence. There were no other AEs related to AHSC treatment. AHSC treatment is feasible in deep partial and fullthickness burn wounds warranting additional investigation.
Healing of microvascular free skin flaps in irradiated recipient tissue beds
The American Journal of Surgery, 1992
This laboratory study compared the biomechanical and biochemical healing of mierovascular free skin flaps in irradiated and nonirradiated recipient areas. In the adult rat, the skin of the right groin region was exposed to a single fraction dose of 20 Gy, using a linear megavoltage accelerator. The left groin was shielded. One week after radiotherapy, the left femoral artery and vein were divided, and an anastomosis was created in situ at the site of the epigastrie pedicle. The epigastrie skin flap was crossed over to replace the central area of the irradiated skin in the contralateral right groin. The healing of the interface between the irradiated recipient skin and the transferred free epigastric flap was studied at 4 weeks. A comparison was made with the mierovascnlar free flaps of nonirradiated control av0hnals. An additional group of control animals was used to verify the retarding effect of the 20-Gy radiation dose on wound healing. In control animals, the single dose of 20 Gy decreased the tensile strength of standardized surgical wounds by 23% (p = 0.03). Clinical healing of the transferred mierovascular free flaps between the irradiated and control recipient areas was comparable, and the flaps showed no significant differences in the mechanical incorporation. The biochemical assays of the DNA, RNA-ribose, total nitrogen, and hydroxyproline contents of the flap showed an increased concentration of proteins (total nitrogen) expressed per cell count (DNA) (25%, p = 0.04), reflecting the excessive accumulation of organic matrix and a relatively deereased nnmher of cells in irradiated recipient tissues. We conclude that there are no major differences in the healing capacity of mierovasenlar free skin flaps between irradiated and nonirradiated recipient areas.
Radiation Oncology, 2012
Purpose To describe a pilot study for a novel preclinical model used to test human tissue-based therapies in the setting of cutaneous radiation injury. Methods A protocol was designed to irradiate the skin of athymic rats while sparing the body and internal organs by utilizing a non-occlusive skin clamp along with an x-ray image guided stereotactic irradiator. Each rat was irradiated both on the right and the left flank with a circular field at a 20 cm source-to-surface distance (SSD). Single fractions of 30.4 Gy, 41.5 Gy, 52.6 Gy, 65.5 Gy, and 76.5 Gy were applied in a dose-finding trial. Eight additional wounds were created using the 41.5 Gy dose level. Each wound was photographed and the percentage of the irradiated area ulcerated at given time points was analyzed using ImageJ software. Results No systemic or lethal sequelae occurred in any animals, and all irradiated skin areas in the multi-dose trial underwent ulceration. Greater than 60% of skin within each irradiated zone und...
Limb trauma: the use of an advanced wound care device in the treatment of full-thickness wounds
Strategies in Trauma and Limb Reconstruction, 2013
This is an observational case series of 15 patients with full-thickness traumatic wound defects treated with a dermal substitute. There were 8 male and 7 female patients with a mean age of 36.6 years. Eight patients had trauma to the lower limbs and 7 were of the upper limbs, with the average lesion size 104.4 cm 2 (range 6-490 cm 2 ). The time to complete healing had a mean average time of 26.8 days (range 16-60 days). All patients went on to successful repair with 6 patients requiring a second application of the substitute and 5 patients needing split thickness skin grafts. Infection was recorded in one patient.
Radiotherapy and wound healing
International Wound Journal, 2005
Radiotherapy is an invaluable weapon when treating cancer. However, the deleterious effects of radiation, both immediate and long-term, may have a significant effect on local tissues. Problematic wound healing in radiationdamaged tissue constitutes a major problem that is frequently overlooked during the management of patients who require radiotherapy, or have had radiotherapy in the past. Poor wound healing may lead to chronic ulceration, pain, secondary infection and psychological distress and compromise the outcome of general or reconstructive surgery. We discuss the pathophysiology of poor wound healing following radiotherapy, specific problems for radiation-damaged tissue and potential treatments to improve wound healing of irradiated tissues.
Guidelines For Surgical Management of Radiation Injuries
2012
Radiation therapy is being used with increasing frequency for treatment of cancer and other disease etiologies. Despite the benefits of radiotherapy, the resultant chronic changes may be lifelong and cumulative, which will need reconstruction with well vascularized, undamaged tissues. Ten patients (5 males and 5 females) with radionecrosis and osteoradionecrosis complex wounds were treated with myocutaneous flaps after radical debridement. The results revealed sound healing in seven out of the ten patients. Persistent sinus remained in two patients and major flap necrosis in one patient. In conclusion, the guidelines for surgical management of radiation injuries are debridement of necrotic tissues, coverage with myocutaneous flap, obliteration of dead space, rule out recurrence of malignancy, restore function, and keep in mind another solution if the first flap fail.
Negative pressure wound therapy as an aid to coverage of irradiated chest wounds
2012
Wounds over the irradiated chest present as a tough challenge for coverage to the reconstructive surgeon. This is due to the adverse effects of radiation on local tissue. The best option in such patients is flap coverage. Split thickness skin graft, though a simpler alternative, does not take well or breaks down easily. Case report: A patient is presented in whom flap coverage was not sought and wound bed was prepared by negative pressure wound therapy to effectively take a skin graft. Conclusions: This simple technique may be of immense value in aiding closure of problematic wounds over the irradiated chest.
New Emerging Concepts in the Medical Management of Local Radiation Injury
Health Physics, 2010
Treatment of severe radiation burns remains a difficult medical challenge. The response of the skin to ionizing radiation results in a range of clinical manifestations. The most severe manifestations are highly invalidating. Although several therapeutic strategies (excision, skin grafting, skin or muscle flaps) have been used with some success, none have proven entirely satisfying. The concept that stem cell injections could be used for reducing normal tissue injury has been discussed for a number of years. Mesenchymal Stem Cells (MSC) therapy may be a promising therapeutic approach to improve radiation-induced skin and muscle damages. Preclinical and clinical benefit of MSC injection for ulcerated skin and muscle restoration after high dose radiation exposure has been successfully demonstrated. Three first patients suffering from severe radiological syndrome were successfully treated in France based on combined autologuous human grade MSC injection to plastic surgery. Stem cell therapy must be now improved to the point that hospitals can put safe, efficient, reliable and inexpensive clinical protocols into practice.
Annals of Plastic Surgery, 2019
Background: Primary perineal closure following abdominal perineal resection (APR) is reported to have a wound complication rate as high as 66%, whereas flap reconstruction reduces wound complications to 15% to 35%. A modified de-epithelialized V-Y fasciocutaneous flap aims to further improve results in this patient population. Methods: To study the breaking force of a simple interrupted suture in either skin or subcutaneous fat, various quantitative assessments were performed in a porcine flap model using uniaxial static tensile testing with an Instron tensiometer, with a single or triple row of 3 Vicryl sutures in both skin and fat. An outcomes analysis was performed in 24 patients who underwent modified V-Y flap reconstruction after APR. Primary outcome was wound complications including infection, dehiscence, seroma, hematoma, and pelvic fluid collections. Results: Tensile strength of sutures anchored in skin was found to be up to 8 times stronger than sutures anchored in subcutaneous fat in a single row and 3 times as strong in 3 rows (breaking force, 500.2 N vs 263.7 N). In our patient cohort of 24 irradiated cancer patients, 10 (42%) had wound healing complications. Wound dehiscence of various degrees accounted for 80% of these complications. Five patients with wound complications (50%) had associated pelvic fluid collections (infection, 1; wound dehiscence, 4). Minor dehiscence was more likely to occur after suture removal and less likely to be associated with pelvic collections compared to patients with major dehiscence. Our study yields total complication rates lower than what is reported in the literature for anterolateral thigh or gracilis flap including much lower infection rates, and almost similar results to the commonly used vertical rectus myocutaneous muscle. Conclusion: Tension-free de-epithelialized V-Y flap use after APR effectively reconstructs the defect while eliminating an additional donor site. Benchtop studies suggest enhanced flap integrity yielded by layered closure. Wound complications can be managed with local care in their majority (90%). Staggering or delaying suture removal can decrease minor dehiscence. Based on analysis of our results, review of the literature and consideration of donor site morbidity, we believe that modified V-Y flap is the best approach for APR reconstruction in irradiated patients.
Radiation responses in skin and connective tissues: effect on wound healing and surgical outcome
Hernia, 2006
Radiation therapy, either alone or in combination with other types of treatment, is responsible for 40% of cancer cures and 70% of all cancer patients receive radiation therapy at some point during the course of their disease. Radiation therapy has profound eVects, both acute and long-term, on skin and connective tissues. Radiation therapy also aVects the time course and end result of wound healing, and the risk of postoperative complications. For example, radiation therapy of tumors in the abdomen or in the abdominal wall inevitably aVects the integrity of abdominal wall structures and may adversely aVect the outcome of operations on the abdominal wall, for example hernia surgery. All surgeons will encounter patients who have undergone or will receive radiation therapy. In these situations, it is important to carefully consider the optimum timing of surgery relative to radiation therapy, to decide which perioperative precautions are needed to minimize the risk of complications, to estimate and inform the patient about the increased risk of complications, and, if surgery is done before a planned course of radiation therapy, to consider how soon after surgery it is safe to commence the radiation treatment. This review will (1) describe features of acute and long term radiation-induced changes in skin and connective tissues; (2) provide a brief overview of the biological mechanisms underlying these changes; and (3) discuss practical considerations that have direct relevance to surgical decision making and postoperative outcome.