practice
The use of a dermal substitute for simultaneous flap delay and donor site coverage in two cases l Objective: Lower extremity traumatic wounds can be difficult to treat owing to limb ischaemia and large zones of injury. Often, muscle or fasciocutaneous flaps are used in the presence of severe open orthopaedic injuries with soft tissue defects. Sometimes local flaps may be the preferred or only option, but may not tolerate being rotated or advanced owing to resulting flap ischaemia. One well-studied technique that can increase the survival of various flaps involves the delay phenomenon. l Method: In these case reports, Integra Dermal Regeneration Template was used to simultaneously create delayed flaps and to cover the wound and flap donor site so that the donor site could be skin grafted at the time of flap inset. l Results: These cases demonstrate that use of Integra can enhance the delay phenomenon while simultaneously providing coverage of soft tissue defects in preparation for ultimately insetting delayed flaps and better covering donor areas. l Conclusion: This technique may be applicable to many different flaps in many different anatomic locations and should be considered an option when reconstructing complicated wounds. l Declaration of interest: none
Lower extremity reconstruction; flap delay; local regional flap; Integra; Dermal Regeneration Template; open orthopaedic fracture
treatment of the wound is still required during this maturation period. Occasionally, intraoperative ischaemia of a flap is noted and an unplanned flap delay may be required. More recently, skin substitutes have emerged as an additional option for wound coverage. One commonly used dermal substitute is Integra (Integra Dermal Regeneration Template, Integra Lifesciences, Plainsboro, NJ). Skin substitutes can be used to prepare wound beds for accepting and retaining grafts and flaps, and may serve as definitive closure in some instances. Integra is an artificial bilayer skin substitute consisting of a dermal regeneration layer and temporary epidermal components. It was developed in 1981 and FDA approved in 1996, to close excisional burn wounds.5,6 The dermal layer is composed of bovine collagen and chondroitin-6-sulfate derived from shark cartilage. The epidermal replacement layer is made of silicon rubber (Silastic) bound to the dermal layer which prevents fluid loss and mechanically protects the wound.7,8 In these case reports, Integra was used to assist the formation of delayed flaps when ischaemia was noted intraoperatively, while simultaneously helping to cover the wound as well as the donor site to be created when the flap is moved. This has
j o u r n a l o f wo u n d c a r e A P W H S u pp l e m e n t v o l 2 3 , n o 7 J u ly 2 0 1 4
Brittany J Behar,1 MD Hamid Abdollahi, 2 MD Bharat Ranganath,1 MD Azra Ashraf,2 MD Paul M Glat,1 MD Chief of Plastic Surgery Drexel University College of Medicine, Department of Surgery, Division of Plastic Surgery Philadelphia, USA Email: Paul.glat@ tenethealth.com 2 Temple University Hospital, Philadelphia, Pennsylvania, USA 1
s
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P
lastic surgeons continue to search for the ideal method for addressing complex wounds. Providing coverage of these wounds is dependent on the location and extent of the defect. Options for wound coverage include skin grafts, primary closure, local flaps, regional flaps and free tissue transfers. A flap is tissue that is elevated from its tissue bed and moved to an adjacent area while maintaining its blood supply. Local flaps can be divided into axial and random flaps. However, random flaps are restricted in size by their length-to-width ratio. These options can be even more limited in the lower extremity after severe traumatic wounds. Fasciocutaneous flaps are an option, but are notoriously unpredictable around and below the knee. One well-studied method used to increase flap viability is the delay phenomenon. This process allows for an increase in blood flow and thus the potential size of a flap and mobility. This is especially useful in lower extremity trauma. In flap delay, ischaemia of the flap is intentionally created by ligating major feeding vessels or by partially elevating, undermining, and replacing a given area of a flap several days to weeks before flap transposition.1-3 This promotes the development of more optimal circulation and increased flap survival. 1,2,4 However,
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fig 1. foot prior to flap elevation
fig 2a. Integra, including silicone layer, inset under medial plantar flap and across wound
fig 2b.Medial plantar flap after delay process and Integra placement, prior to rotation over the calcaneous.
fig 3. left medial plantar flap after delay prior to rotation with neodermis present
fig 4. Medial plantar flap rotated to cover exposed hardware and split thickness skin graft placed to cover remaining wound and donor site
fig 5. eighteen months postoperatively after reconstruction using delayed medial plantar flap and Integra
fig 6. Initial soft tissue injury over comminuted proximal tibial fracture prior to fixation and initial coverage
fig 7a. Initial hardware placement over tibial fracture
fig 7b. Gastrocnemius flap covered with split thickness skin graft (right)
fig 10. flap rotated over neodermis which is covering the donor area and the hardware
fig 11a. Postoperative results at 2 weeks
fig 11b. Postoperative results at four months (right)
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fig 8. exposed hardware after fig 9.Two weeks after Integra incision and drainage of abscess placement, the 4 months later fasciocutaneous flap is reelevated, but not rotated into position (note the presence of good Integra neodermis throughout the wound including under the flap donor area, as well as over the previously exposed hardware)
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practice not been previously reported in the literature. We present two cases involving successful treatment of severe traumatic wounds to the lower extremities using Integra during maturation of delayed flaps.
Cases A 55-year-old male presented to a university hospital trauma centre after sustaining a crush injury to his lower extremities from a cement block. He sustained a traumatic amputation of the right lower extremity, as well as a limb-threatening and critically disabling injury to the left lower extremity. This included degloving of the dorsum of the foot with traumatic amputations of the first and fifth digits, an exposed open calcaneal fracture and left knee injury. He was treated initially with an external fixator for the calcaneal fracture. Twelve days after the patient was stabilised by the vascular and orthopaedic surgery, the plastics service proceeded to the operating room to address the degloving injury and soft tissue injury. Devitalised tissue of the plantar surface of the foot was debrided leaving exposed the medial plantar nerve, as well as bone. The patient was treated with negative pressure wound therapy, with repeated operative trips for further debridement (Fig 1). A medial plantar flap was planned to cover the fractured calcaneous and other exposed structures. Before flap elevation, a Doppler signal was identified in the flap. However, as the flap was elevated and rotated it became ischaemic and signal was lost. At this point it was felt the flap did not have a major vascular supply and was actually a random fasciocutaneous flap. It was decided to delay the flap and to place Integra underneath the elevated portion of the flap and over the remaining open portion of the wound. The silicone layer was left in place and interposed between the tip of the flap and the adjacent wound edge to prevent vascular ingrowth into the flap. The raw surface of the raised flap was treated with a non-adherent petrolatum gauze dressing, which was changed daily (Fig 2). Fourteen days later the patient was returned to the operating room where the flap was re-raised and was safely rotated into position and inset over the calcaneus (Figs 2–3). Split-thickness skin grafts were applied to the remaining areas, including the flap donor area, now covered with Integra neodermis, after removal of the silicone layer (Fig 4). Following surgery, the flap remained viable and the skin grafts took well. The patient continued to progress and 6 months postoperatively his wounds were completely healed and he was bearing weight as tolerated on his remaining foot (Fig 5).
A 33-year-old male presented after sustaining a motorcycle accident with open comminuted right proximal tibial and fibular fractures, and devitalised skin (Fig 6). After multiple debridements, the tibial fracture was plated and treated with antibiotic beads (Fig 7). The exposed hardware was then covered with a medial gastrocnemius flap and split-thickness skin graft (Fig 7). The patient initially did well, however, he presented 4 months after his initial surgery to the emergency room with increasing oedema and pain on right anterior lower leg. An abscess was found on imaging and he was taken to the operating room for drainage and washout of the lower extremity, which left him with exposed hardware of the tibia (Fig 8). In order to provide local coverage of the hardware a superiomedially-based fasciocutaneous flap was used. The patient chose this flap, with its inherent greater risk of amputation, because he was unwilling to sacrifice muscle for a free flap. During the procedure, it was noted that the flap was compromised once it had been rotated. It was therefore decided to delay the flap. The entire open area, including the hardware, was then covered with Integra and the flap was sutured down over the top of the Integra to maintain the length and width. The Integra was simultaneously placed under the elevated flap and remaining open wound. The patient was taken back to the operating room 15 days later, at which point the Integra neodermis was viable (including over the hardware) and able to be grafted. The flap was inset and placed over the previously exposed hardware, now covered with Integra neodermis (Figs 9–10). A split-thickness skin graft was then placed over the remaining exposed neodermis. The patient was discharged home with visiting nursing and local wound care. He was followed as an outpatient with local wound care. The flap remained intact and viable throughout this process and the patient healed completely (Fig 11). At 1-year follow-up, X-rays demonstrated healing and no signs of osteomyelitis.
Discussion Integra provides a non-antigenic, non-inflammatory covering, allowing fibroblasts and vessels to grow into the material, as well as prevent colonisation and infection of the wound bed. This induces regeneration of dermis by providing a scaffolding for new collagen deposition, creating a ‘neodermis’ and preventing scar tissue infiltration and wound contraction.7 Although originally intended for use in closure of burn wounds, Integra has been used to accelerate healing and close various other wound types successfully.9–15 In the lower extremity, Gravvanis et al. describe the use of Integra to provide bulk to free flaps in weight-bearing areas, a necessary consideration for lower limb reconstruction.16 Barnett and Shilt report the successful use of Integra alone in
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Case 1
Case 2:
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a free flap, leaving a local flap as the only option. In case 1, a lateral calcaneal flap was not available, owing to the location of the injuries; instead a fasciocutaneous flap using the tissue of the medial plantar region of the foot was used. In case 2, a medial gastrocnemius muscle flap with split-thickness skin graft was originally chosen because of the location of the injury and the greater length it allows compared to a lateral fasciocutaneous flap. Short-term prognosis of these limbs is determined by the length of time from wound recognition to coverage, in order to minimise the risk of infection and maximise the survival of any flap coverage. Long-term prognosis is determined by the integrity of the sciatic and posterior tibial nerve function. Monitoring of the flap and sensory nerve distribution is necessary over time to ensure success. The delay phenomenon using Integra is novel because it takes advantage of the presence of the silicone outer layer of the product to prevent vascular ingrowth back into the flap while it is maturing. In addition, it provides immediate physiologic wound closure while the flap is being delayed and avoids creation of a donor site wound in the initial period when the patient is least able to tolerate another physiologic insult. It also provides good quality neodermis both under the donor flap and recipient sites. This may allow for increased success of the methods used to close the flap donor area. The potential benefit of increased survival must be balanced against the risks associated with the greater time period required for reconstruction completion. This can be optimised if flap transfer is completed within 2–4 weeks after delay. In addition, as seen in our cases, flap delay may be the only option available to the patient. The risks that accompany delay, including infection and ischaemia, are decreased when Integra is used under the raised delayed flap and over the wound bed. Despite the potential success of delayed flaps in the long term, they also create additional stress with the need for additional operations and increased length of hospital stay. This risk should be weighed against any potential benefits. It should not be a first choice for reconstruction, but should be used as a means to salvage a compromised raised flap and ensure its usefulness and success in the future. It is also efficacious in situations where a commonly used flap is chosen but may not have adequate length to reach and cover the defect. In such cases, the delay phenomenon may allow the surgeon to create a longer length flap that would ordinarily not survive based on standard length-to-width ratios. We believe that Integra is a novel choice for enhancing the delay phenomenon while simultaneously providing coverage of soft tissue defects in preparation for ultimately insetting delayed flaps. This technique may be applicable to many different flaps in many different anatomic locations. n
© 2014 MA Healthcare
treatment of paediatric severe lower extremity wounds without need for local or free flaps.17 Integra use creates a dilemma for patient care, because it may require two operations, one for positioning and one for skin graft placement. However, it seems that the many potential benefits of this dermal substitute outweigh this potential downside. Lower extremity injuries are often the result of high-energy forces. Limb salvage should be considered whenever possible. However, lower extremity traumatic injuries involving vascular damage, especially to the popliteal and tibial arteries, carry a 10% rate of mortality and morbidity, including acute amputation.18 Unfortunately, uncovered and untreated soft tissue injuries involving or exposing neurovascular structures can also result in amputations and other morbidities after the acute injury is treated. However, there are no means available to predict which defects will be amenable to treatment. Coverage of soft tissue damage with well-vascularised tissue sources is critical to prevent these sequelae and potentially restore functionality to these patients. Current practice dictates that local muscular and musculocutaneous flaps provide the most sound coverage for proximal soft tissue defects of the lower extremities when available. Free flaps and local fascia may be the only option for distal leg and foot wounds.19,20 However, implementation of these may require innovative techniques.21 First described in the 16th century, the use of delayed random flaps is an effective means of obtaining coverage of defects when ordinary flaps are inadequate. The delay phenomenon not only greatly assists in coverage of any defects, but also in survival of the flap. This technique derives its greatest utility when distal ischaemia occurs during the undermining of a flap but proximal blood flow is adequate. These are especially effective in patients who are obese, have a history of cigarette smoking, radiation therapy or previous scars.2 Theories behind the effectiveness of this phenomenon include conditioning cells to better survive hypoxia, increasing angiogenesis and collateralisation within the flap with reorientation of vessel to a more longitudinal pattern, and creation of ‘choke’ vessels that are normally closed.1-4,22,23 The flaps described in these cases are good examples of flaps that clearly benefitted from delay. These types of flaps have proven effective for coverage of the damaged soft tissue regions noted in both cases. In both patient cases, free flaps were potential options, but were not chosen for several reasons. In case 1, the patient had already sustained a traumatic amputation of the opposite leg and would not well tolerate sacrifice of any core or upper extremity muscles for the flap. In addition, he was a poor candidate for free flap as a result of his obesity and vasculopathy. In case 2, the patient outright refused to consider
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practice 1. Holzbach T, Neshkova I,Vlaskou D, et al. Searching for the right timing of surgical delay: angiogenesis, vascular endothelial growth factor and perfusion changes in a skin-flap model. J Plast Reconstr Aesthet Surg 2009; 62: 11, 1534-1542. 2. Lineaweaver WC, Lei MP, Mustain W, et al..Vascular endothelium growth factor, surgical delay, and skin flap survival. Ann Surg 2004; 239: 6, 866-873; Discussion 873-865. 3. Erdmann D, Sundin BM, Moquin KJ, et al. Delay in unipedicled TRAM flap reconstruction of the breast: a review of 76 consecutive cases. Plast Reconstr Surg 2002; 110: 3, 762-767. 4. Parrett BM, Pribaz JJ, Matros E, et al. Risk analysis for the reverse sural fasciocutaneous flap in distal leg reconstruction. Plast Reconstr Surg 2009; 123: 5, 1499-1504. 5. Yannas IV, Burke JF, Gordon PL, et al.. Design of an artificial skin. II. Control of chemical composition. J Biomed Mater Res 1980; 14: 2, 107-132. 6. Yannas IV, Burke JF. Design of an artificial skin. I. Basic design principles. J Biomed Mater Res 1980; 14: 1, 65-81.
7. Burke JF,Yannas IV, Quinby WC, Jr., et al. Successful use of a physiologically acceptable artificial skin in the treatment of extensive burn injury. Ann Surg 1981; 194: 4, 413-428. 8. Michaeli D, McPherson M. Immunologic study of artificial skin used in the treatment of thermal injuries. J Burn Care Rehabil 1990; 11: 1, 21-26. 9. Besner GE, Klamar JE. Integra® Artificial Skin as a useful adjunct in the treatment of purpura fulminans. J Burn Care Rehabil 1998; 19: 4, 324-329. 10. Wang JC, To EW. Application of dermal substitute (Integra®) to donor site defect of forehead flap. Br J Plast Surg 2000; 53: 1, 70-72. 11. Shermak MA, Wong L, Inoue N, et al. Reconstruction of complex cranial wounds with demineralized bone matrix and bilayer artificial skin. J Craniofac Surg 2000; 11: 3, 224-231. 12. Giovannini UM, Teot L. Aesthetic complex reconstruction of the lower leg: application of a dermal substitute (Integra®) to an adipofascial flap. Br J Plast Surg 2002; 55: 2, 171-172.
13. Sardesai MG, Tan AK. Artificial skin for the reconstruction of cutaneous tumour resection. J Otolaryngol 2002; 31: 4, 248-252. 14. Khan MA, Ali SN, Farid M, et al. Use of dermal regeneration template (Integra®) for reconstruction of full-thickness complex oncologic scalp defects. J Craniofac Surg 2010; 21: 3, 905-909. 15. Jeng JC, Fidler PE, Sokolich JC, et al. Seven years’ experience with Integra® as a reconstructive tool. J Burn Care Res 2007; 28: 1, 120-126. 16. Gravvanis A, Deliconstantinou I, Tsoutsos D. Reconstruction of the weight-bearing surface of the foot with Integra®-grafted latissimus dorsi muscle flap. Microsurgery. 2011; 31: 2, 162-163. 17. Barnett TM, Shilt JS. Use of vacuum-assisted closure and a dermal regeneration template as an alternative to flap reconstruction in pediatric grade IIIB open lower-extremity injuries. Am J Orthop (Belle Mead NJ) 2009; 38: 6, 301-305. 18. Kauvar DS, Sarfati MR, Kraiss LW. National trauma databank analysis of mortality and limb loss
in isolated lower extremity vascular trauma. J Vasc Surg 2011; 53: 6, 1598-1603. 19. Greene TL, Beatty ME. Soft tissue coverage for lowerextremity trauma: current practice and techniques. A review. J Orthop Trauma 1988; 2: 2, 158-173. 20. Hallock GG. Utility of both muscle and fascia flaps in severe lower extremity trauma. J Trauma 2000; 48: 5, 913-917. 21. Higgins TF, Klatt JB, Beals TC. Lower Extremity Assessment Project (LEAP)--the best available evidence on limb-threatening lower extremity trauma. Orthop Clin North Am. 2010; 41: 2, 233-239. 22. Erdmann D, Gottlieb N, Humphrey JS, et al. Sural flap delay procedure: a preliminary report. Ann Plast Surg 2005; 54: 5, 562-565. 23. Reavis KM, Chang EY, Hunter JG, et al. Utilization of the delay phenomenon improves blood flow and reduces collagen deposition in esophagogastric anastomoses. Ann Surg 2005; 241: 5, 736-745; Discussion 745-737.
Trends in Wound Care Volume V
field has progressed in recent years,
About the author
and helps busy clinicians keep
on of chapters shows how this appraised of important researc h.
Keith Cutting It offers something for those with practical as well as is Principaa l Lecture r in Tissue Viability infocus the Faculty of Society and Health, Buckinghamshire New Univers ity. He has been involved in tissue viability for a number of years and worked in what has now become covered science and theoretical debate. Topics include: the Wound Healing Researc h Unit in Cardiff. Apart from lecturing on wound care manage
ment he has maintained clinical and research roles and has supported these activities via a number of publications. Keith is also Clinical Editor of Wound Journal and is a member of a number s-UK of wound healing societies. He is a Fellow of the Academy of Higher Education and a Regiona l Fellow of the Royal Society of Medicine, and he works closely with various international medica l device, pharmaceutical, biotech nology and publishing compan as an independent consultant. ies
• Wound survey and audit
• Bacterial profiling and biofilms
Trends in Wound Care Volume V
This highly reputable source monographs has become a Aboutof the book This highly reputable source of up-to-date monographs has become a standar seeking to keep in d text forareas standard text for those seeking to touch with key those touchkeep with key areasin of clinical and scientific research. This volume eclectic miscellany of chapters, contains an each based upon published (and so, peer-reviewed) articles from the Journal of Wound Care. Where importa of clinical and scientific research. Edited by Keith Cutting, this nt new information has been published, chapter been updated accordingly. Topics s have included in this volume are: wound survey/ audit, topical negative pressure, bacterial profiling and biofilms, wound pH, scar assessm ent, fibroblast senescence, the volume maintains the established role of nitric oxide, andstandard. theories on wound contraction. This collecti
Trends in Wound Care Volume V Edited by Keith Cutting
• Wound pH • Scar assessment • Fibroblast senesence • The role of nitric oxide
ltd
ISBN-13: 978-1-85642-374-8; 234 x 156 mm; paperback; 120 pages; published 2009; £29.99 9
Order your copies by visiting
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781856 423748
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or call our Hotline 1
A Journal of Wound Care Mono
graph
+44(0)1722 716 935 s
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ISBN 1-85642-374-3
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• Wound contraction theories
11/2/09 13:11:33
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03/07/2014 14:52
The use of a dermal substitute for simultaneous flap delay and donor site coverage in two cases l Objective: Lower extremity traumatic wounds can be difficult to treat owing to limb ischaemia and large zones of injury. Often, muscle or fasciocutaneous flaps are used in the presence of severe open orthopaedic injuries with soft tissue defects. Sometimes local flaps may be the preferred or only option, but may not tolerate being rotated or advanced owing to resulting flap ischaemia. One well-studied technique that can increase the survival of various flaps involves the delay phenomenon. l Method: In these case reports, Integra Dermal Regeneration Template was used to simultaneously create delayed flaps and to cover the wound and flap donor site so that the donor site could be skin grafted at the time of flap inset. l Results: These cases demonstrate that use of Integra can enhance the delay phenomenon while simultaneously providing coverage of soft tissue defects in preparation for ultimately insetting delayed flaps and better covering donor areas. l Conclusion: This technique may be applicable to many different flaps in many different anatomic locations and should be considered an option when reconstructing complicated wounds. l Declaration of interest: none
Lower extremity reconstruction; flap delay; local regional flap; Integra; Dermal Regeneration Template; open orthopaedic fracture
treatment of the wound is still required during this maturation period. Occasionally, intraoperative ischaemia of a flap is noted and an unplanned flap delay may be required. More recently, skin substitutes have emerged as an additional option for wound coverage. One commonly used dermal substitute is Integra (Integra Dermal Regeneration Template, Integra Lifesciences, Plainsboro, NJ). Skin substitutes can be used to prepare wound beds for accepting and retaining grafts and flaps, and may serve as definitive closure in some instances. Integra is an artificial bilayer skin substitute consisting of a dermal regeneration layer and temporary epidermal components. It was developed in 1981 and FDA approved in 1996, to close excisional burn wounds.5,6 The dermal layer is composed of bovine collagen and chondroitin-6-sulfate derived from shark cartilage. The epidermal replacement layer is made of silicon rubber (Silastic) bound to the dermal layer which prevents fluid loss and mechanically protects the wound.7,8 In these case reports, Integra was used to assist the formation of delayed flaps when ischaemia was noted intraoperatively, while simultaneously helping to cover the wound as well as the donor site to be created when the flap is moved. This has
j o u r n a l o f wo u n d c a r e A P W H S u pp l e m e n t v o l 2 3 , n o 7 J u ly 2 0 1 4
Brittany J Behar,1 MD Hamid Abdollahi, 2 MD Bharat Ranganath,1 MD Azra Ashraf,2 MD Paul M Glat,1 MD Chief of Plastic Surgery Drexel University College of Medicine, Department of Surgery, Division of Plastic Surgery Philadelphia, USA Email: Paul.glat@ tenethealth.com 2 Temple University Hospital, Philadelphia, Pennsylvania, USA 1
s
© 2014 MA Healthcare
ltd
P
lastic surgeons continue to search for the ideal method for addressing complex wounds. Providing coverage of these wounds is dependent on the location and extent of the defect. Options for wound coverage include skin grafts, primary closure, local flaps, regional flaps and free tissue transfers. A flap is tissue that is elevated from its tissue bed and moved to an adjacent area while maintaining its blood supply. Local flaps can be divided into axial and random flaps. However, random flaps are restricted in size by their length-to-width ratio. These options can be even more limited in the lower extremity after severe traumatic wounds. Fasciocutaneous flaps are an option, but are notoriously unpredictable around and below the knee. One well-studied method used to increase flap viability is the delay phenomenon. This process allows for an increase in blood flow and thus the potential size of a flap and mobility. This is especially useful in lower extremity trauma. In flap delay, ischaemia of the flap is intentionally created by ligating major feeding vessels or by partially elevating, undermining, and replacing a given area of a flap several days to weeks before flap transposition.1-3 This promotes the development of more optimal circulation and increased flap survival. 1,2,4 However,
S15
Journal of Wound Care.Downloaded from magonlinelibrary.com by 157.211.003.015 on January 19, 2015. For personal use only. No other uses without permission. . All rights reserved. JWC 2014_23_7_S4, S6-S12, S14-S19_APWH SUPPLEMENT.indd 15
03/07/2014 14:52
practice
fig 1. foot prior to flap elevation
fig 2a. Integra, including silicone layer, inset under medial plantar flap and across wound
fig 2b.Medial plantar flap after delay process and Integra placement, prior to rotation over the calcaneous.
fig 3. left medial plantar flap after delay prior to rotation with neodermis present
fig 4. Medial plantar flap rotated to cover exposed hardware and split thickness skin graft placed to cover remaining wound and donor site
fig 5. eighteen months postoperatively after reconstruction using delayed medial plantar flap and Integra
fig 6. Initial soft tissue injury over comminuted proximal tibial fracture prior to fixation and initial coverage
fig 7a. Initial hardware placement over tibial fracture
fig 7b. Gastrocnemius flap covered with split thickness skin graft (right)
fig 10. flap rotated over neodermis which is covering the donor area and the hardware
fig 11a. Postoperative results at 2 weeks
fig 11b. Postoperative results at four months (right)
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fig 8. exposed hardware after fig 9.Two weeks after Integra incision and drainage of abscess placement, the 4 months later fasciocutaneous flap is reelevated, but not rotated into position (note the presence of good Integra neodermis throughout the wound including under the flap donor area, as well as over the previously exposed hardware)
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03/07/2014 14:52
practice not been previously reported in the literature. We present two cases involving successful treatment of severe traumatic wounds to the lower extremities using Integra during maturation of delayed flaps.
Cases A 55-year-old male presented to a university hospital trauma centre after sustaining a crush injury to his lower extremities from a cement block. He sustained a traumatic amputation of the right lower extremity, as well as a limb-threatening and critically disabling injury to the left lower extremity. This included degloving of the dorsum of the foot with traumatic amputations of the first and fifth digits, an exposed open calcaneal fracture and left knee injury. He was treated initially with an external fixator for the calcaneal fracture. Twelve days after the patient was stabilised by the vascular and orthopaedic surgery, the plastics service proceeded to the operating room to address the degloving injury and soft tissue injury. Devitalised tissue of the plantar surface of the foot was debrided leaving exposed the medial plantar nerve, as well as bone. The patient was treated with negative pressure wound therapy, with repeated operative trips for further debridement (Fig 1). A medial plantar flap was planned to cover the fractured calcaneous and other exposed structures. Before flap elevation, a Doppler signal was identified in the flap. However, as the flap was elevated and rotated it became ischaemic and signal was lost. At this point it was felt the flap did not have a major vascular supply and was actually a random fasciocutaneous flap. It was decided to delay the flap and to place Integra underneath the elevated portion of the flap and over the remaining open portion of the wound. The silicone layer was left in place and interposed between the tip of the flap and the adjacent wound edge to prevent vascular ingrowth into the flap. The raw surface of the raised flap was treated with a non-adherent petrolatum gauze dressing, which was changed daily (Fig 2). Fourteen days later the patient was returned to the operating room where the flap was re-raised and was safely rotated into position and inset over the calcaneus (Figs 2–3). Split-thickness skin grafts were applied to the remaining areas, including the flap donor area, now covered with Integra neodermis, after removal of the silicone layer (Fig 4). Following surgery, the flap remained viable and the skin grafts took well. The patient continued to progress and 6 months postoperatively his wounds were completely healed and he was bearing weight as tolerated on his remaining foot (Fig 5).
A 33-year-old male presented after sustaining a motorcycle accident with open comminuted right proximal tibial and fibular fractures, and devitalised skin (Fig 6). After multiple debridements, the tibial fracture was plated and treated with antibiotic beads (Fig 7). The exposed hardware was then covered with a medial gastrocnemius flap and split-thickness skin graft (Fig 7). The patient initially did well, however, he presented 4 months after his initial surgery to the emergency room with increasing oedema and pain on right anterior lower leg. An abscess was found on imaging and he was taken to the operating room for drainage and washout of the lower extremity, which left him with exposed hardware of the tibia (Fig 8). In order to provide local coverage of the hardware a superiomedially-based fasciocutaneous flap was used. The patient chose this flap, with its inherent greater risk of amputation, because he was unwilling to sacrifice muscle for a free flap. During the procedure, it was noted that the flap was compromised once it had been rotated. It was therefore decided to delay the flap. The entire open area, including the hardware, was then covered with Integra and the flap was sutured down over the top of the Integra to maintain the length and width. The Integra was simultaneously placed under the elevated flap and remaining open wound. The patient was taken back to the operating room 15 days later, at which point the Integra neodermis was viable (including over the hardware) and able to be grafted. The flap was inset and placed over the previously exposed hardware, now covered with Integra neodermis (Figs 9–10). A split-thickness skin graft was then placed over the remaining exposed neodermis. The patient was discharged home with visiting nursing and local wound care. He was followed as an outpatient with local wound care. The flap remained intact and viable throughout this process and the patient healed completely (Fig 11). At 1-year follow-up, X-rays demonstrated healing and no signs of osteomyelitis.
Discussion Integra provides a non-antigenic, non-inflammatory covering, allowing fibroblasts and vessels to grow into the material, as well as prevent colonisation and infection of the wound bed. This induces regeneration of dermis by providing a scaffolding for new collagen deposition, creating a ‘neodermis’ and preventing scar tissue infiltration and wound contraction.7 Although originally intended for use in closure of burn wounds, Integra has been used to accelerate healing and close various other wound types successfully.9–15 In the lower extremity, Gravvanis et al. describe the use of Integra to provide bulk to free flaps in weight-bearing areas, a necessary consideration for lower limb reconstruction.16 Barnett and Shilt report the successful use of Integra alone in
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a free flap, leaving a local flap as the only option. In case 1, a lateral calcaneal flap was not available, owing to the location of the injuries; instead a fasciocutaneous flap using the tissue of the medial plantar region of the foot was used. In case 2, a medial gastrocnemius muscle flap with split-thickness skin graft was originally chosen because of the location of the injury and the greater length it allows compared to a lateral fasciocutaneous flap. Short-term prognosis of these limbs is determined by the length of time from wound recognition to coverage, in order to minimise the risk of infection and maximise the survival of any flap coverage. Long-term prognosis is determined by the integrity of the sciatic and posterior tibial nerve function. Monitoring of the flap and sensory nerve distribution is necessary over time to ensure success. The delay phenomenon using Integra is novel because it takes advantage of the presence of the silicone outer layer of the product to prevent vascular ingrowth back into the flap while it is maturing. In addition, it provides immediate physiologic wound closure while the flap is being delayed and avoids creation of a donor site wound in the initial period when the patient is least able to tolerate another physiologic insult. It also provides good quality neodermis both under the donor flap and recipient sites. This may allow for increased success of the methods used to close the flap donor area. The potential benefit of increased survival must be balanced against the risks associated with the greater time period required for reconstruction completion. This can be optimised if flap transfer is completed within 2–4 weeks after delay. In addition, as seen in our cases, flap delay may be the only option available to the patient. The risks that accompany delay, including infection and ischaemia, are decreased when Integra is used under the raised delayed flap and over the wound bed. Despite the potential success of delayed flaps in the long term, they also create additional stress with the need for additional operations and increased length of hospital stay. This risk should be weighed against any potential benefits. It should not be a first choice for reconstruction, but should be used as a means to salvage a compromised raised flap and ensure its usefulness and success in the future. It is also efficacious in situations where a commonly used flap is chosen but may not have adequate length to reach and cover the defect. In such cases, the delay phenomenon may allow the surgeon to create a longer length flap that would ordinarily not survive based on standard length-to-width ratios. We believe that Integra is a novel choice for enhancing the delay phenomenon while simultaneously providing coverage of soft tissue defects in preparation for ultimately insetting delayed flaps. This technique may be applicable to many different flaps in many different anatomic locations. n
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treatment of paediatric severe lower extremity wounds without need for local or free flaps.17 Integra use creates a dilemma for patient care, because it may require two operations, one for positioning and one for skin graft placement. However, it seems that the many potential benefits of this dermal substitute outweigh this potential downside. Lower extremity injuries are often the result of high-energy forces. Limb salvage should be considered whenever possible. However, lower extremity traumatic injuries involving vascular damage, especially to the popliteal and tibial arteries, carry a 10% rate of mortality and morbidity, including acute amputation.18 Unfortunately, uncovered and untreated soft tissue injuries involving or exposing neurovascular structures can also result in amputations and other morbidities after the acute injury is treated. However, there are no means available to predict which defects will be amenable to treatment. Coverage of soft tissue damage with well-vascularised tissue sources is critical to prevent these sequelae and potentially restore functionality to these patients. Current practice dictates that local muscular and musculocutaneous flaps provide the most sound coverage for proximal soft tissue defects of the lower extremities when available. Free flaps and local fascia may be the only option for distal leg and foot wounds.19,20 However, implementation of these may require innovative techniques.21 First described in the 16th century, the use of delayed random flaps is an effective means of obtaining coverage of defects when ordinary flaps are inadequate. The delay phenomenon not only greatly assists in coverage of any defects, but also in survival of the flap. This technique derives its greatest utility when distal ischaemia occurs during the undermining of a flap but proximal blood flow is adequate. These are especially effective in patients who are obese, have a history of cigarette smoking, radiation therapy or previous scars.2 Theories behind the effectiveness of this phenomenon include conditioning cells to better survive hypoxia, increasing angiogenesis and collateralisation within the flap with reorientation of vessel to a more longitudinal pattern, and creation of ‘choke’ vessels that are normally closed.1-4,22,23 The flaps described in these cases are good examples of flaps that clearly benefitted from delay. These types of flaps have proven effective for coverage of the damaged soft tissue regions noted in both cases. In both patient cases, free flaps were potential options, but were not chosen for several reasons. In case 1, the patient had already sustained a traumatic amputation of the opposite leg and would not well tolerate sacrifice of any core or upper extremity muscles for the flap. In addition, he was a poor candidate for free flap as a result of his obesity and vasculopathy. In case 2, the patient outright refused to consider
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practice 1. Holzbach T, Neshkova I,Vlaskou D, et al. Searching for the right timing of surgical delay: angiogenesis, vascular endothelial growth factor and perfusion changes in a skin-flap model. J Plast Reconstr Aesthet Surg 2009; 62: 11, 1534-1542. 2. Lineaweaver WC, Lei MP, Mustain W, et al..Vascular endothelium growth factor, surgical delay, and skin flap survival. Ann Surg 2004; 239: 6, 866-873; Discussion 873-865. 3. Erdmann D, Sundin BM, Moquin KJ, et al. Delay in unipedicled TRAM flap reconstruction of the breast: a review of 76 consecutive cases. Plast Reconstr Surg 2002; 110: 3, 762-767. 4. Parrett BM, Pribaz JJ, Matros E, et al. Risk analysis for the reverse sural fasciocutaneous flap in distal leg reconstruction. Plast Reconstr Surg 2009; 123: 5, 1499-1504. 5. Yannas IV, Burke JF, Gordon PL, et al.. Design of an artificial skin. II. Control of chemical composition. J Biomed Mater Res 1980; 14: 2, 107-132. 6. Yannas IV, Burke JF. Design of an artificial skin. I. Basic design principles. J Biomed Mater Res 1980; 14: 1, 65-81.
7. Burke JF,Yannas IV, Quinby WC, Jr., et al. Successful use of a physiologically acceptable artificial skin in the treatment of extensive burn injury. Ann Surg 1981; 194: 4, 413-428. 8. Michaeli D, McPherson M. Immunologic study of artificial skin used in the treatment of thermal injuries. J Burn Care Rehabil 1990; 11: 1, 21-26. 9. Besner GE, Klamar JE. Integra® Artificial Skin as a useful adjunct in the treatment of purpura fulminans. J Burn Care Rehabil 1998; 19: 4, 324-329. 10. Wang JC, To EW. Application of dermal substitute (Integra®) to donor site defect of forehead flap. Br J Plast Surg 2000; 53: 1, 70-72. 11. Shermak MA, Wong L, Inoue N, et al. Reconstruction of complex cranial wounds with demineralized bone matrix and bilayer artificial skin. J Craniofac Surg 2000; 11: 3, 224-231. 12. Giovannini UM, Teot L. Aesthetic complex reconstruction of the lower leg: application of a dermal substitute (Integra®) to an adipofascial flap. Br J Plast Surg 2002; 55: 2, 171-172.
13. Sardesai MG, Tan AK. Artificial skin for the reconstruction of cutaneous tumour resection. J Otolaryngol 2002; 31: 4, 248-252. 14. Khan MA, Ali SN, Farid M, et al. Use of dermal regeneration template (Integra®) for reconstruction of full-thickness complex oncologic scalp defects. J Craniofac Surg 2010; 21: 3, 905-909. 15. Jeng JC, Fidler PE, Sokolich JC, et al. Seven years’ experience with Integra® as a reconstructive tool. J Burn Care Res 2007; 28: 1, 120-126. 16. Gravvanis A, Deliconstantinou I, Tsoutsos D. Reconstruction of the weight-bearing surface of the foot with Integra®-grafted latissimus dorsi muscle flap. Microsurgery. 2011; 31: 2, 162-163. 17. Barnett TM, Shilt JS. Use of vacuum-assisted closure and a dermal regeneration template as an alternative to flap reconstruction in pediatric grade IIIB open lower-extremity injuries. Am J Orthop (Belle Mead NJ) 2009; 38: 6, 301-305. 18. Kauvar DS, Sarfati MR, Kraiss LW. National trauma databank analysis of mortality and limb loss
in isolated lower extremity vascular trauma. J Vasc Surg 2011; 53: 6, 1598-1603. 19. Greene TL, Beatty ME. Soft tissue coverage for lowerextremity trauma: current practice and techniques. A review. J Orthop Trauma 1988; 2: 2, 158-173. 20. Hallock GG. Utility of both muscle and fascia flaps in severe lower extremity trauma. J Trauma 2000; 48: 5, 913-917. 21. Higgins TF, Klatt JB, Beals TC. Lower Extremity Assessment Project (LEAP)--the best available evidence on limb-threatening lower extremity trauma. Orthop Clin North Am. 2010; 41: 2, 233-239. 22. Erdmann D, Gottlieb N, Humphrey JS, et al. Sural flap delay procedure: a preliminary report. Ann Plast Surg 2005; 54: 5, 562-565. 23. Reavis KM, Chang EY, Hunter JG, et al. Utilization of the delay phenomenon improves blood flow and reduces collagen deposition in esophagogastric anastomoses. Ann Surg 2005; 241: 5, 736-745; Discussion 745-737.
Trends in Wound Care Volume V
field has progressed in recent years,
About the author
and helps busy clinicians keep
on of chapters shows how this appraised of important researc h.
Keith Cutting It offers something for those with practical as well as is Principaa l Lecture r in Tissue Viability infocus the Faculty of Society and Health, Buckinghamshire New Univers ity. He has been involved in tissue viability for a number of years and worked in what has now become covered science and theoretical debate. Topics include: the Wound Healing Researc h Unit in Cardiff. Apart from lecturing on wound care manage
ment he has maintained clinical and research roles and has supported these activities via a number of publications. Keith is also Clinical Editor of Wound Journal and is a member of a number s-UK of wound healing societies. He is a Fellow of the Academy of Higher Education and a Regiona l Fellow of the Royal Society of Medicine, and he works closely with various international medica l device, pharmaceutical, biotech nology and publishing compan as an independent consultant. ies
• Wound survey and audit
• Bacterial profiling and biofilms
Trends in Wound Care Volume V
This highly reputable source monographs has become a Aboutof the book This highly reputable source of up-to-date monographs has become a standar seeking to keep in d text forareas standard text for those seeking to touch with key those touchkeep with key areasin of clinical and scientific research. This volume eclectic miscellany of chapters, contains an each based upon published (and so, peer-reviewed) articles from the Journal of Wound Care. Where importa of clinical and scientific research. Edited by Keith Cutting, this nt new information has been published, chapter been updated accordingly. Topics s have included in this volume are: wound survey/ audit, topical negative pressure, bacterial profiling and biofilms, wound pH, scar assessm ent, fibroblast senescence, the volume maintains the established role of nitric oxide, andstandard. theories on wound contraction. This collecti
Trends in Wound Care Volume V Edited by Keith Cutting
• Wound pH • Scar assessment • Fibroblast senesence • The role of nitric oxide
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