How long can cryopreserved skin be stored to maintain adequate graft performance?

Skin graft preservation for the purpose of delayed application is still a basic tool in burn treatment and plastic and reconstructive surgery. As the demand for skin allografts has increased the responsibility for processing, storage and evaluation of graft performance of preserved skin has become an important issue of banking organizations. The present experiments were undertaken to determine how long can cryopreserved cadaveric skin be stored to maintain adequate graft performance? We applied a mouse recipient model, developed by us: Human cadaveric skin cryopreserved and stored for 5,6 or 7 years was grafted on Balb/c mice, and primary take was evaluated by gross observation and predetermined histologic criteria after 7 days. The results demonstrate that graft performance of cryopreserved skin decreased with time, as reflected in the lower percent of samples with high score of separate histologic criteria after prolonged storage. Nevertheless, paired comparison analysis between cryopreserved and fresh skin indicated that this decrease was not significant for storage of 5 years; whereas it was highly significant for 6 years of storage. Linear regression analysis indicated that there was no correlation between the score of the histologic criteria and storage period for upto 65 months. These results are in line with the paired comparison analysis. We feel that our in vivo model and analysis may be used as an evaluation procedure for transplantation performance of banked skin.

The Israel National Skin Bank: Quality Assurance and Graft Performance of Stored Tissues.

The Israel National Skin Bank (INSB) was founded jointly by the Israel Defense Forces (IDF) Medical Corps and the Ministry of Health in 1986. The prime purpose of the Skin Bank is to treat burn victims incurred at war or during mass casualty incidences. The INSB Protocol is comprised of international skin bank protocols and our previous and present research results. They provide the framework for selecting optimal guidelines for procurement, processing, preservation, storage and evaluation of transplantation performance of viable skin grafts. For evaluation and direct comparison of graft performance of glycerolized or cryopreserved skin stored for long periods, we have applied a mouse recipient model developed by us. This model assesses graft performance before the rejection process takes place. The in vivo design has inherent clinical relevance, which is especially appealing. Cryopreserved skin performed better than glycerolized skin (p > 0.027), but fresh skin performed significantly better than cryopreserved skin (p > 0.003), as analyzed by the Mann-Whitney non-parametric test. Then graft performance of skin specimens were cryopreserved by programmed or stepwise freezing and stored at -80 degrees C or in liquid nitrogen for 1 and 6-10 months was evaluated. The average score of skin preserved by programmed freezing and stored in liquid nitrogen is the highest for both storage periods. This method has a highly significant advantage (p < 0.007) over the others for 6-10 months storage, evaluated by graft adherence. Several interaction factors determine the quality of cryopreserved skin. Highly significant is the interaction factor/'combined effect' of sample variability with the method of cryopreservation or with the storage period. Finally, the results of paired comparison of selected histology criteria of cryopreserved to fresh skin indicated that storage of skin for up to 5 years did not impair significantly its performance compared to fresh skin, whereas, after six years of storage, there was a highly significant (p < 0.001) impairment in skin quality. We offer a simplified in vivo model and analysis for cryopreserved skin graft performance, suggesting that the evaluation procedures, which are issues of great interest in skin banking, may help future skin banks to make informed choices and decisions regarding quality issues.

Transposition of the great omentum for infected sternotomy wounds in cardiac surgery. Report of 16 cases and review of published reports.

The expanding indications for coronary artery bypass graft (CABG) and cardiac valves replacement have caused an increase in the number of sternal infections. The common treatment includes appropriate antibiotics, early debridement, and transposition of muscle flaps with or without skin grafts. When other treatments have proved unsatisfactory, we have used the great omentum for wound closure. During the last five years, 16 patients (10 women, six men, median age 63 years) underwent repair of infected sternotomy wounds by the transposition of the great omentum, after failure of pectoralis major or rectus abdominis muscle flaps (n = 9). Seven patients underwent transposition of the great omentum as the first choice. The omentum covers the sternal defect well and the closure was reliable.

[Plagiocephaly in children: etiology, differential diagnosis and helmet treatment].

Plagiocephaly in a head-and-neck irradiated rat model or rhomboid-shaped head, occurs in at least 1 in 300 live births. In most cases such asymmetry is not caused by synostosis of the unilateral coronal or lambdoid sutures, but is rather a deformity produced by intrauterine and/or postnatal deformational forces. Categorization and diagnosis of plagiocephaly as synostotic or deformational is reliably made by physical examination and computerized tomography. Its differential diagnosis is extremely important because prompt surgical correction is usually indicated for the synostotic type. In contrast, infants with deformational frontal or occipital plagiocephaly generally respond to helmet treatment. 10 infants with significant deformational plagiocephaly were treated with individual plastic helmets during the past 2 years and 4 other infants with plagiocephaly are currently being treated. In each instance, cranial asymmetry dramatically improved as the brain grew and the head filled out the helmet. There were no significant complications. Awareness of deformational plagiocephaly allows more accurate diagnosis and appropriate treatment, avoiding unnecessary surgical intervention in patients with positional molding.

Terra firma forme dermatosis.

New pigmented lesions with alarming properties should trigger the responsible physician to perform diagnostic procedures including biopsies, blood tests, and endocrinological evaluations. A unique pigmented dermatosis of unknown etiology, known as terra firma forme dermatosis, creates a cosmetic disturbance that might mislead experienced physicians and trigger unnecessary and expensive workups when all that is needed is a firm rubbing with 70% alcohol-impregnated applicators. We present a 17-year-old girl with such a lesion and discuss the diagnostic possibilities.

Cryopreserved cadaveric allografts for treatment of unexcised partial thickness flame burns: clinical experience with 12 patients.

Partial thickness burns (PTB) usually heal within 3 weeks. Prevention of infection and desiccation of the wounds are crucial for optimal healing. Early tangential excision of the burn eschar and allografting prevent deepening of the burns, and are therefore advocated for treatment with the best functional and aesthetic results. For superficial partial thickness burns (SPTB) conservative use of topical antimicrobial agents with frequent dressing changes are implemented. We compared the conservative treatment for PTBs and SPTBs to grafting cryopreserved cadaveric allografts with no prior excision. Twelve patients with flame PTB areas were allografted after mechanical debridement without excision of the burn wounds. The allografts were cadaveric skin cryopreserved by programmed freezing and stored at -180 degrees C for 30-48 months. Matching burns for depth and area were treated with silver sulfadiazine (SSD) one to two times daily until healing or debridement and grafting were required. It was found that 80 per cent of the cryopreserved allografts adhered well and 76 per cent of the treated areas healed within 21 days, whereas only 40 per cent of the SSD-treated burns healed within 21 days. Partial thickness burns can be treated successfully with viable human allografts (cryopreserved cadaveric skin) with no prior surgical excision. The burn wounds heal well within 3 weeks. For deep partial thickness burns (DPTB) treatment with allografts has no advantage if they have not been previously excised.

Transplantation performance of human skin cryopreserved by programmed or stepwise freezing and stored at -80 degrees C or -180 degrees C.

We developed a mouse recipient model that was used to evaluate and compare four cryopreservation procedures for human cadaveric skin stored for two time periods. Skin specimens were identically processed and preserved by programmed (1 degree C/min), or stepwise freezing, and stored at -180 degrees C or -80 degrees C for periods of 1 month and 6 to 10 months. Samples were grafted on Balb/c mice, and primary take was evaluated after 7 days. The results indicate that although all grafted specimens were initially accepted, as indicated by gross observations, histologic differences were evident and significant. The study groups were analyzed for the effect of method and skin sample variety; the effect of freezing procedure and temperature level; time effect (storage period); and advantage of method 1 (programmed freezing at -180 degrees C) over the other methods. The significance (p value) was determined for separate histologic criteria and average skin score or quality. The overall results indicate that average score of skin preserved by method 1 is highest for both storage periods. This method has an almost significant advantage (p = 0.057) over the others on quality of skin stored for 1 month, and a highly significant advantage (p = 0.007) on graft adherence of skin stored for 6 to 10 months. The effect of method and samples variety on the separate histologic criteria and average score of skin is not always significant. However, an interaction factor (between method and samples) has a highly significant effect (p < 0.001) on almost all of the histologic criteria and average skin score. The effects of freezing method is significant only on average skin score, for 1 month of storage; whereas temperature effect is seldom significant. Evaluating the effects of time, samples, and the interaction factor (between time and samples) indicated that the interaction factor is highly significant (p < 0.001). Time and samples effects are rarely significant. Thus the quality of the final product-the cryopreserved skin-is determined by many factors, and quite often they interact. Highly significant is the combined effect, or interaction factor, of sample variability with method of cryopreservation or with storage period.

Rhinoplasty patients' critical self-evaluations of their noses.

Many applicants for cosmetic rhinoplasty do not appear to have grossly deformed noses. This study was undertaken to determine the accuracy of nasal evaluations in a group of 20 female cosmetic rhinoplasty patients, before and after surgery, relative to a matched nonrhinoplasty control group composed of 25 subjects. Self-assessments and surgeon assessments were obtained for both groups. Compared with those of controls, the noses of patients were found to be more deformed before and better shaped after the operation, according to both self-assessments and surgeon assessments. Rhinoplasty patients, in contrast to controls, tended to downgrade the shape of their noses compared with surgeon assessments both before and 4 months after surgery. Faulty evaluation was not associated with sociodemographic parameters, brief symptoms index (BSI) scores, or the degree of patient satisfaction from surgical outcome. Replication and longer-term follow-up studies are needed and are anticipated.

Chest wall deformity following maximal tissue expansion for breast reconstruction.

Forty-three women, in a series of 150, participated in a prospective study that examined their chest walls for deformities 3 months after maximal tissue expansion for single-breast reconstruction. Computed tomography imaging was used for this purpose. Twenty-one patients underwent immediate breast reconstruction and the other 22 patients underwent delayed reconstruction. Fifty-three percent had some chest wall abnormality. In the delayed group, chest wall deformities were more statistically significant (p < 0.001). Our findings suggest that chest wall deformity is a common occurrence after maximal tissue expansion for breast reconstruction.

Efficacy of the topical anesthetic cream, EMLA, in alleviating both needle insertion and injection pain.

To assess the efficacy of the topical anesthetic cream, EMLA, in alleviating the pain produced by infiltration of local anesthetic prior to surgical skin biopsies, a randomized, double-blind, placebo-controlled study was performed on 54 patients undergoing 162 excisional biopsies. Both pain induced by needle insertion and pain induced by local injection were significantly diminished after topical application of EMLA cream. However, part of the effect was placebo, because the placebo ointment (Vaseline) also produced significant pain alleviation.

Treatment of extensive malignant schwannoma of the mandibular nerve.

This article describes a rare malignant schwannoma invading the left mandible in a 42-year-old man. The clinical presentation, inconclusive radiographic findings, and light microscopic histology are included. The appropriate surgical treatment could be determined only intraoperatively when frozen sections provided the exact tumor margins. The patient subsequently received adjuvant treatment by brachytherapy.

Melanoma of the scalp: the invisible killer.

A series of 20 patients (15 men and 5 women) suffering from malignant melanoma of the scalp is reported. Their epidemiologic data and outcome are described. The ages ranged from 48 to 78 years (mean 63 years). Analysis of the cases demonstrated that lesions occurring posterior to the tragal line (in hair-bearing area) have the worst prognosis. The 5-year survival rate was poor; 12 patients died within this period. Two representative cases are described, and the preventable aspects of the disease are emphasized.

Costal osteomyelitis due to an electrical burn.

This article describes the case of a patient who suffered an electrical full thickness burn of the chest wall and a concomitant osteomyelitic complication of two ribs. A review of the existing literature on bone and joint changes after burns is presented. Osteomyelitis of ribs must be kept in mind while treating patients for chest wall burns.

Rare sites of melanoma: melanoma of the external ear.

A small series of melanomas of the external ear is presented. The presentation in general was late and they varied from 2.6 mm to 4.8 mm in thickness. The outcome in most of the patients (9 patients) was bad and within 3 years only 4 survived. The fact that 9 patients remembered having a nevus that suddenly changed to melanoma emphasizes the need for early removal of such nevi.

Phosphorous burns: evaluation of various modalities for primary treatment.

White phosphorus is used in many types of military munitions, in fireworks, and in industrial and agricultural products. It ignites spontaneously and causes deep thermal injuries. It may also cause multiorgan failure because of its toxic effects on erythrocytes, liver, kidneys, and heart. Our previous studies demonstrated deleterious effects of copper sulfate. Only copious water irrigation was effective. This study examined other modalities of treatment and a free oxygen radical scavenger. One of the treatments seemed to have some beneficial effects, but simple water irrigation was much more effective. Superoxide dismutase, a free radical scavenger, reduced hepatic damage and adjacent skin flap destruction but did not prevent death of the animal receiving the high dose of white phosphorus used in the present setup.