342
Bums (1991) 17, (4), 342-343
Printed in Great Britain
Use of buried skin implants after recurrent failure of conventional skin grafting in a massive burn: the renewal of an old technique P. Benmeir, A. Eldad, A. Weinberg, A. Neuman, M. Rotem, S. Lusthaus and M. R. Wexler Department
of Plastic and Maxillofacial
Surgery and The Bum Unit, Hadassah University
Medical Center, Jerusalem, Israel
The technique ofbuying small pieces of skin under old granulation tissue affer recurrenf failure of convenfional skin graffing is ah-ribed in a patient with 95 per cenf full skin tkickwss burns. This method of freafwmf, which was described in fke pasf and neglected, is of vale for massive burns or grafting in difficult areas. Tke technique is described again and the relevant liferature reviewed.
Introduction Braun (1920) described a new method of skin grafting which consisted of the implantation of small pieces of skin directly into granulation tissue. During the 1930s and the 1940s this technique was widely used with success by several authors (Wangesteen, 1930; Marcks, 1941; Horton, 1942; Bors and Comarr, 1948). Most of the patients treated had suffered from chronic pressure sores, osteomyelitis cavities, and some from bums which were not responding to the conventional Thiersh skin grafting. Somehow the technique was abandoned until Sawada (1989) published details of a patient with a perineal bum not responsive to standard treatment which healed by this ‘old technique.
Technique A split thickness skin graft is taken from any available donor area and cut into ‘stamps’ of approximately 7 x 7 mm each. With a Moskito haemostat the granulation tissue is opened to create a ‘pit’ and the ‘stamp’ implanted with the epidermis down, or up, a fact that does not appear to be important in the subsequent epithelialization. The opened ‘window’ in the granulation tissue is closed by a single staple so the implant is not visible. The staples are taken out 1-2 weeks later. Following ‘take’ of the skin implant the graft grows by radial epithelial cell spread.
Case report A 17-year-old male was injured by an explosion. He sustained 95 per cent BSA bums, 87 per cent of which was full skin thickness. The only non-burned parts of the body were the scalp and the soles of the feet. During the following 6 months he was gradually 0 1991 Butterworth-Heinemann 0305-4179/91/040342-02
Ltd
Figure 1. The patient with half of his back ungrafted.
covered by 1:6 meshed autograft from his scalp and with I : 1.5 meshed homograft covering the autograft. By the end of the sixth month about 15 per cent of his body remained uncovered, namely half of his back (Figure I) and part of his buttocks. The problem was that the patient could not be nursed on his abdomen after grafting of the above areas because respiratory distress developed in this position. Six trials of ‘classical’ meshed grafting of the back failed to take so we decided to try implantation of microskin grafts into the granulation tissue. The scalp served as a donor site (altogether harvested 17 times from this patient over a period of 7.5 months). Ten days postimplantation the spreading epithelium islands were seen emerging from their nests (Figure 2) and by the third week the different islands began to converge (Figure 3). Six weeks postsurgery the back was almost closed (Figure 4) and in the light of this success the patient was operated on again. A total of 150 implants were grafted with a SO per cent ‘take’. Subsequently the patient was discharged 8 months postbum. No signs of epidermal inclusion cysts were noticed from the sites that did not ‘take’.
Discussion The technique described by Braun (1920) was widely used in the 1930s and the 1941%. Wangesteen (1930) reported the treatment of 60 patients suffering from chronic pressure
343
Benmeir et al.: Buried skin implants
Figure 2. A view of the implants at 10 days. Under each staple grafts are emerging.
Figure 3. Three weeks postimplantation. epithelialization.
Note the converging
cavities which failed to respond to ‘classical’ methods of skin grafting. Marcks (1941) reported eight patients, two of them suffering from bums resistant for years to different methods of treatment. Horton (1942) also reported the successful treatment of a full skin thickness bum of both thighs which failed to heal following three sessions of skin grafting and closed only with the implantation of microskin grafts into the granulation tissue. The last report of the 1940s was from Bars and Comarr (1948) who published their experience with 50 patients who were successfully treated by this method. The up-to-date article from Sawada (1989) dealt with the treatment of a perineal full skin thickness bum. According to Wangesteen (1930) and Marcks (1941) the advantages of the method are its simplicity and the percentage of ‘take’, around 80per cent, which we believe to be too optimistic. In our patient we had a 50 per cent take on the first implantation and about 60 per cent in the second one which is a good result compared to no ‘take’ at all in six classical mesh grafting episodes. The articles cited above reported the treatment of trochanteric and sacral pressure sores with success even with the patients continuing to lie on their sores. We presume that the main reason for the ‘take’ in those areas of pressure and maceration like the back or the buttocks is the lack of shearing forces which normally rubs the graft off its bed and the stabilization within the pit of the mini-grafts. The surrounding tissue deep in the pit has better vascular quality than the old granulation tissue and is less contaminated with microorganisms. The major disadvantage of this method is that it is time consuming. We sores and osteomyelitis
Figure 4. Six weeks postimplantation
the back wound is almost
closed.
about 90min to cut the skin, dig the tunnels and implant the chips, even when three surgeons were occupied inserting these dozens of implants. We think that this new-old method has many applications in chronic nonhealing areas.
needed
References Bors E. and Comarr A. E. (1948) The buried epidermis grafts. Sq Gynecol. Obstet. 87, 68. Braun W. (1920) Zur technik der hautpfropfung. Zmtrulb. Chir. 52,
1555. Horton W. S. (1942) Implant skin graftings. A case report. Am.J Surg. 55, 597. Marcks K. M. (1941) The use of implantation grafts in the healing of infected ulcers. Am.I. Surg. 51, 354. Sawada Y. (1989) Buried chip skin grafting for treatment of perineal bums. Burns 15, 36. Wangesteen 0. H. (1930) The implantation method of skin grafting. Surg. Gynecol. Obsfet. 50, 634.
Paper accepted 8 March 1991.
Correspondence should be addressed to: Dr P. Benmeir, Department of Plastic Surgery and Bum Unit, Hadassah Medical Center, Jerusalem, Israel.
Bums (1991) 17, (4), 342-343
Printed in Great Britain
Use of buried skin implants after recurrent failure of conventional skin grafting in a massive burn: the renewal of an old technique P. Benmeir, A. Eldad, A. Weinberg, A. Neuman, M. Rotem, S. Lusthaus and M. R. Wexler Department
of Plastic and Maxillofacial
Surgery and The Bum Unit, Hadassah University
Medical Center, Jerusalem, Israel
The technique ofbuying small pieces of skin under old granulation tissue affer recurrenf failure of convenfional skin graffing is ah-ribed in a patient with 95 per cenf full skin tkickwss burns. This method of freafwmf, which was described in fke pasf and neglected, is of vale for massive burns or grafting in difficult areas. Tke technique is described again and the relevant liferature reviewed.
Introduction Braun (1920) described a new method of skin grafting which consisted of the implantation of small pieces of skin directly into granulation tissue. During the 1930s and the 1940s this technique was widely used with success by several authors (Wangesteen, 1930; Marcks, 1941; Horton, 1942; Bors and Comarr, 1948). Most of the patients treated had suffered from chronic pressure sores, osteomyelitis cavities, and some from bums which were not responding to the conventional Thiersh skin grafting. Somehow the technique was abandoned until Sawada (1989) published details of a patient with a perineal bum not responsive to standard treatment which healed by this ‘old technique.
Technique A split thickness skin graft is taken from any available donor area and cut into ‘stamps’ of approximately 7 x 7 mm each. With a Moskito haemostat the granulation tissue is opened to create a ‘pit’ and the ‘stamp’ implanted with the epidermis down, or up, a fact that does not appear to be important in the subsequent epithelialization. The opened ‘window’ in the granulation tissue is closed by a single staple so the implant is not visible. The staples are taken out 1-2 weeks later. Following ‘take’ of the skin implant the graft grows by radial epithelial cell spread.
Case report A 17-year-old male was injured by an explosion. He sustained 95 per cent BSA bums, 87 per cent of which was full skin thickness. The only non-burned parts of the body were the scalp and the soles of the feet. During the following 6 months he was gradually 0 1991 Butterworth-Heinemann 0305-4179/91/040342-02
Ltd
Figure 1. The patient with half of his back ungrafted.
covered by 1:6 meshed autograft from his scalp and with I : 1.5 meshed homograft covering the autograft. By the end of the sixth month about 15 per cent of his body remained uncovered, namely half of his back (Figure I) and part of his buttocks. The problem was that the patient could not be nursed on his abdomen after grafting of the above areas because respiratory distress developed in this position. Six trials of ‘classical’ meshed grafting of the back failed to take so we decided to try implantation of microskin grafts into the granulation tissue. The scalp served as a donor site (altogether harvested 17 times from this patient over a period of 7.5 months). Ten days postimplantation the spreading epithelium islands were seen emerging from their nests (Figure 2) and by the third week the different islands began to converge (Figure 3). Six weeks postsurgery the back was almost closed (Figure 4) and in the light of this success the patient was operated on again. A total of 150 implants were grafted with a SO per cent ‘take’. Subsequently the patient was discharged 8 months postbum. No signs of epidermal inclusion cysts were noticed from the sites that did not ‘take’.
Discussion The technique described by Braun (1920) was widely used in the 1930s and the 1941%. Wangesteen (1930) reported the treatment of 60 patients suffering from chronic pressure
343
Benmeir et al.: Buried skin implants
Figure 2. A view of the implants at 10 days. Under each staple grafts are emerging.
Figure 3. Three weeks postimplantation. epithelialization.
Note the converging
cavities which failed to respond to ‘classical’ methods of skin grafting. Marcks (1941) reported eight patients, two of them suffering from bums resistant for years to different methods of treatment. Horton (1942) also reported the successful treatment of a full skin thickness bum of both thighs which failed to heal following three sessions of skin grafting and closed only with the implantation of microskin grafts into the granulation tissue. The last report of the 1940s was from Bars and Comarr (1948) who published their experience with 50 patients who were successfully treated by this method. The up-to-date article from Sawada (1989) dealt with the treatment of a perineal full skin thickness bum. According to Wangesteen (1930) and Marcks (1941) the advantages of the method are its simplicity and the percentage of ‘take’, around 80per cent, which we believe to be too optimistic. In our patient we had a 50 per cent take on the first implantation and about 60 per cent in the second one which is a good result compared to no ‘take’ at all in six classical mesh grafting episodes. The articles cited above reported the treatment of trochanteric and sacral pressure sores with success even with the patients continuing to lie on their sores. We presume that the main reason for the ‘take’ in those areas of pressure and maceration like the back or the buttocks is the lack of shearing forces which normally rubs the graft off its bed and the stabilization within the pit of the mini-grafts. The surrounding tissue deep in the pit has better vascular quality than the old granulation tissue and is less contaminated with microorganisms. The major disadvantage of this method is that it is time consuming. We sores and osteomyelitis
Figure 4. Six weeks postimplantation
the back wound is almost
closed.
about 90min to cut the skin, dig the tunnels and implant the chips, even when three surgeons were occupied inserting these dozens of implants. We think that this new-old method has many applications in chronic nonhealing areas.
needed
References Bors E. and Comarr A. E. (1948) The buried epidermis grafts. Sq Gynecol. Obstet. 87, 68. Braun W. (1920) Zur technik der hautpfropfung. Zmtrulb. Chir. 52,
1555. Horton W. S. (1942) Implant skin graftings. A case report. Am.J Surg. 55, 597. Marcks K. M. (1941) The use of implantation grafts in the healing of infected ulcers. Am.I. Surg. 51, 354. Sawada Y. (1989) Buried chip skin grafting for treatment of perineal bums. Burns 15, 36. Wangesteen 0. H. (1930) The implantation method of skin grafting. Surg. Gynecol. Obsfet. 50, 634.
Paper accepted 8 March 1991.
Correspondence should be addressed to: Dr P. Benmeir, Department of Plastic Surgery and Bum Unit, Hadassah Medical Center, Jerusalem, Israel.
