Foot ulcers due to diabetes or/and arteriosclerosis obliterans frequently result in an intractable condition which is refractory to treatment. In order to overcome such a condition, establishing a treatment modality based on the tissue, infection/inflammation, moisture balance, and edge of wound (TIME) concept to clinically perform wound bed preparation (WBP), as advocated by Schulz, is important. Therefore, the following steps are essential: 1) control and treat the disease-causing chronic wounds and 2) evaluate the wounds as per the TIME concept and perform local treatment at the proper timing. The core of this treatment concept is considered to be debridement. Debridement is a procedure carried out to protect the surrounding tissue by cleaning the wound of infectious and necrotic tissues, and this is crucial for chronic foot diseases. Our current strategy consists of two steps: initial medical treatment and subsequent aggressive treatment of the lesion. Our method of performing maintenance debridement, using trafermin spray and aggressive conservative therapy using NPWT, makes TIME-based wound bed preparation possible. Proper debridement at the proper time contributes to the success of this treatment. In this paper, we report the essential factors for debridement and our methods of debridement.
Background: Progress in multidisciplinary therapy has led to a trend to avoid below-knee amputation for critical limb ischemia. However, there are still serious cases in which such amputation must be performed. In typical below-knee amputation cases, the surgical wound is most commonly closed using anterior and posterior skin flaps, but delayed healing is not unusual in critical limb ischemia cases. One cause for the delayed healing of wound margins is thought to be the difference in the length and thickness of the wound margins between the anterior and posterior skin flaps. Methods: Four critical limb ischemia patients who were receiving hemodialysis for diabetic renal failure were treated with below-knee amputation using medial and lateral skin flaps of similar lengths and thicknesses. Result: All patients achieved satisfactory healing by wound closure. Conclusions: In critical limb ischemia patients undergoing maintenance hemodialysis for diabetic renal failure, medial and lateral flaps may be a viable option in below-knee amputation provided the patients are not candidates for postoperative prosthesis, such as elderly patients with preoperative gait difficulty.
Background: In old patients or in patients with conditions unfavorable for wound healing, complete reepithelialization of the donor site of the split-thickness skin graft takes considerably more time, and the donor site develops chronic ulcers sometimes. Thus, reduction of the time for reepithelialization of the donor site is important. To achieve this, we developed two new methods to reduce the raw surface area of the donor site. Methods: We applied the two methods in 7 patients who needed split-thickness skin grafting. Four patients were treated with recruited skin grafting; and three, with chipped skin grafting. The split-thickness skin graft, 350 \u000000b5m in thickness, was harvested using an electronic dermatome. The donor sites were sutured either by excision or by folding with dermostitches. Results: The reepithelialization was completed from 7 to 15 days after the operation. None of the patients showed persistent erosion or ulcers. Conclusions: By reducing the donor area using the suturing technique, the wounds tended to heal faster. Reepithelialization at the donor site was completed faster by recruited and chipped skin grafting. We named this method SHIGE (split-thickness skin harvest site incision or inverted folding-in with dermostitches and grafting back to the donor site using an electronic dermatome).
Introduction: Calciphylaxis is a serious life-threatening skin condition, which mainly affects dialysis patients. The mortality rate is reported to be as high as 50–80%, mainly due to severe wound infection. Thus, appropriate wound care is critical for its management, but still there is no consensus on the optimal method for this purpose. Materials and methods: The purpose of this study was to provide an insight into the treatment of calciphylaxis wounds by describing our case series. Retrospective data analysis was performed using data on calciphylaxis patients and their wounds. All patients were treated with the same protocol, including application of negative pressure wound therapy with instillation and dwell time (NPWTi-d) by our multi-disciplinary wound care team. Results: In the study period, nine wounds in seven patients with calciphylaxis underwent our treatment. On the first day of NPWTi-d, each wound was covered with 35.2% of necrotic tissue, on average. The mean duration of the therapy was 27.8 days, and later, good granulation and reduction of necrotic tissue was achieved in all cases. None of the cases showed clinical infection during treatment, and complete resolution was achieved in seven of the nine wounds. Conclusion: Our approach was useful for facilitating healing of calciphylaxis wounds without causing infection even with a high presence of necrotic tissue. NPWTi-d was beneficial in terms of gentle debridement and suppression of bacterial growth, in addition to promotion of good granulation.
Background: In the abdominal reconstruction of soft tissue sarcoma (STS), a consistent operative method has not been previously reported. This retrospective case-control study aimed to investigate the characteristics of abdominal STS compared to other areas and to created an algorithm for abdominal reconstruction after STS resection. Methods: We reviewed the cases of 425 STS patients. Patients were stratified into two groups (abdominal area vs. other areas). We also investigated our reconstruction procedures. Results: The resection of abdominal STS was performed in 43 cases (10.5%). The reconstruction rate in the abdominal area group was significantly higher than that in the other areas group (33 cases [76.7%] vs. 119 cases [31.2%], p<0.001); similarly, the local or pedicled flap rate was higher in the abdominal area group than in the other areas group (27 cases [81.8%] vs. 48 cases [40.3%], p<0.001). Our algorithm was as follows: Abdominal wall was reconstructed using fascia graft. In the groin region only, pedicled tensor fasciae latae flap (TFL) was performed. In the upper abdominal area, we first tried to perform pedicled rectus abdominis musculocutaneous flap (RAM). In the lower abdominal area, we first tried to perform pedicled muscle sparing transverse RAM and considered performing pedicled anterior lateral thigh + TFL in abdominal wall defect cases. Conclusions: Since patients commonly need reconstruction of the abdominal wall, the reconstruction rate was high. In all cases, reconstruction could be performed using pedicled flaps and/or fascia graft.
Giant congenital melanocytic nevus (GCMN) must be treated from the point of view of either cosmetics or the risk of malignancy. Since 2016, cultured epidermal autograft (JACE®) for GCMN has been covered by insurance in Japan, but there are few reports on its usefulness and postoperative course. We performed excision of the nevus with electric dermatome and CO2 laser excision, followed by cultured epidermal autograft in seven cases and 11 sites of GCMN in the extremities and trunks. In all cases, 90% of the grafts engrafted and became epithelialized in about one week. All cases showed a reduction in the brown color of the nevus. Recurrence occurred in one site, and hypertrophic scar formation was found in the wound after transplantation in six cases. While cultured epidermal transplantation for GCMN can more safely reduce color tone with a small donor size compared to the conventional procedure, it remains necessary to determine how to reduce the risk of complications such as recurrent nevi and hypertrophic scar formation.
Lymphatic malformations that occur in the head and neck are often difficult to treat. Sclerotherapy using polidocanol, which has little tissue damage, can be treated with minimal dysfunction and complications. In particular, it is considered an effective treatment for superficial lesions that bleed from the mucosal surface. In this study, we performed sclerotherapy using polidocanol for a 17-year-old woman with lymphatic malformations with blood containing lymphorrhea in the pharynx and larynx. A total of 3 sclerotherapy treatments were performed, and lesion reduction and bloody lymphorrhea control were observed. At 1 year after treatment, the course of treatment was good with no re-enlargement of the lesions.
Minor amputations for critical limb ischemia have been reported to confer an increased risk of postoperative skin necrosis or poor wound healing secondary to poor vascularity. Predicting wound healing in patients with critical limb ischemia is a focus of ongoing research. Indocyanine green fluorescence angiography is used to visualize tissue perfusion in various surgical fields. We sought to address this challenge and introduced indocyanine green fluorescence angiography during minor amputation in a patient with critical limb ischemia to evaluate perfusion of the wound tissue. Before wound closure, the parts of the skin flaps exhibiting fluorescence were preserved, while the non-fluorescent edges of the skin flaps were trimmed off. The trimmed skin was reused as a full-thickness skin graft. The postoperative course was uneventful. There was no wound dehiscence or flap necrosis, and the graft was completely incorporated. Indocyanine green fluorescence angiography was suggested to be effective for preventing postoperative wound dehiscence after minor amputation in a patient with critical limb ischemia.