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Surgical
Treatment and Reconstruction of Necrotizing Soft Tissue Infections. Marc E.
Gottlieb, MD Presented
at the Annual Meeting of the Musculoskeletal Infection Society, August 12,
2006, Squaw Valley, CA. |
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SLIDE SUMMARY:
Presentation overview.
Successful management of necrotizing fasciitis means prompt and
thorough surgical excision. Modern
skin restoration technologies are effective, dependable, and can avoid the
need for late reconstruction. ------------------------------------------------------------------------------------------------------------------------------------ This presentation assumes that the reader has
some familiarity with the subject of necrotizing fasciitis: basic concepts about the causative
bacteria, their spectrum of clinical presentation, the severity of the
illness and the urgency of treating it, and some general familiarity with
treatment principles, including surgery, antibiotics, and general patient
support. This presentation will focus on the surgical
aspects of these diseases, with two major points to be made: 1 - Surgical treatment must be prompt,
aggressive, and thorough. The disease
should be cured by one operation of drainage and excision. 2 - Surgeons who are unfamiliar with the arts of
plastic surgery need not be intimidated by excising and draining whatever is
infected. Skin loss is easy enough to
manage and reconstruct in patients whose lives have been saved. Modern skin reconstruction technologies
have advanced in the past decade, bringing unprecedented reliability and ease to the process of skin
restoration, while giving superior results which do not need later revision. ------------------------------------------------------------------------------------------------------------------------------------ LEFT - The progression of a patient with Group A
streptococcal necrotizing fasciitis, with severe toxic shock and multi-organ
failure. Prompt complete excision,
followed by good wound care saved a life (top). Wound closure and reconstruction with a
modern skin regenerative device healed the wounds without risk (middle). The final result, free of scar and
contractures, meant that followup reconstruction was unnecessary. |
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A copy of this presentation and these notes are
available on line at Arimedica.com. Arimedica is a non-commercial site strictly for
the posting of presentations and educational materials. It is not funded nor in any other way
supported by any third party or commercial interest, neither monetarily nor
administratively nor otherwise. |
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SLIDE SUMMARY:
Necrotizing fasciitis is characterized by pannicular and fascial
necrosis. However, it can be caused by
a variety of infectious agents, and each syndrome has some distinctive
pathological and therapeutic features.
If not otherwise specified, “necrotizing fasciitis” tends to imply
that due to streptococcus. Surgical
treatment by complete excision and drainage is mandatory. Later reconstruction depends on principles
related to large wounds of any cause. ------------------------------------------------------------------------------------------------------------------------------------ Numerous papers and book chapters exist to
educate you on the basic biology and clinical science behind these
infections. This presentation will
focus on the clinical arts of managing these problems for good results: for
acute life-saving treatment and for long term function-restoring management. Necrotizing fasciitis can mean any of several
forms of severe, rapidly progressive and lethal (if untreated)
infections. Much of the drama and
public attention to “necrotizing fasciitis” goes to classic Group A
streptococcal panniculitis. The
terminology is not important.
Understanding the behavior of these infections, is important: the
generic implications for life and death and urgent thorough treatment, but
also the relative differences and nuances of care that arise from the types
of organisms that are responsible. All necrotizing fasciitides have in common that
the infection causes infarction and destruction of tissue, far in excess of
the normal injury that occurs from reactive inflammation. As with most inflammatory soft tissue
pathologies, the primary target or susceptible tissues are the subcutaneous
adipose fascias. Rapid extension of
the disease, tangentially through the fascias, is the norm. Skin necrosis is typically a secondary
event, due to loss of the trans-pannicular perforators which provide blood
supply to the skin, or due to toxic chemical injury from the organism
(depending on the type of infection).
Muscular fascias are likewise more resistant, and muscles underneath,
or viscera, can be involved by extension (or they can be a primary target for
Clostridia). When the disease is active and rapidly spreading,
gross pathology can be divided into several zones which have implications for
surgical treatment (see Slide 7). General classes of rapidly progressive infectious
panniculitis, or toxic necrotizing fasciitis include these: Synergistic gangrene: This is the most common type in daily
medical practice. It is usually due to
a mixed flora of pyogenic enteric organisms, typically aerobes and anaerobes,
which create synergistic microenvironments which facilitate each others
growth and metabolism. Being due to enteric
flora, these infections are most prevalent in abdominal and pelvic related
problems, including bowel perforations, complicated genitourinary infections,
enteric contamination of skin and musculoskeletal laceration or ulceration,
perianal or perirectal abscesses, and so on - including the classic
Fournier’s gangrene. Pathologically,
there is progressive suppuration and abscess formation in the adipose
panniculus, working its way into various fascial planes, and sometimes
killing muscle. Patients can be
extremely ill from general inflammatory effects and from endotoxins and
others toxins. These patients can be
gravely ill, and prompt drainage and debridement are mandatory. However, the biology of these infections
are distinctly different than the “necrotizing fasciitis” of streptococcal
infamy. These infections are due to
organisms which are individually fairly benign, the stuff of everyday GI and
GU infections. It is in the synergy of
mixed flora that they become more destructive. There is a bit of latitude in the surgical
treatment: there is no lesser sense of
urgency, and delays in care ARE NOT excusable, and thorough debridement
remains the goal - BUT - if the exigencies of the illness and logistics of a
trip to the OR are hampered in any way, these patients have a bit more leeway
for a simpler drainage and debridement.
For example, if the problem occurred in the groin after a vascular
procedure, and the patient is on potent anti-platelet drugs, these abscesses
can be effectively managed by gross debridement of loose necrosis and pus,
and wide opening of the wound, but without incurring the bleeding of a formal
sharp excision through still viable but highly inflamed and hyperemic
tissues. This will generally arrest
progress of the infection, while maintaining a good risk-benefit balance for
the patient. Broad spectrum
antibiotics are obviously mandatory. Clostridial myofasciitis - Aka “gas gangrene”, is
often the result of ranch and soil injuries, or enteric injuries. This is a serious fulminant disease which
requires a serious expedited surgical response. Muscles as well as fascias are
targets. Exotoxins have lytic
necrotizing effects on the infected tissues, but they also have disseminated
intercurrent toxicities for other organs.
No delays in management can be tolerated. Streptococcal fasciitis. This is what people really mean when they
talk about the classic N.F. Strep
species other than in Group A, and staphylococcal species can all cause the
same syndrome. Incidental other organisms
can cause the same thing, including unexpected oddballs such as
salmonella. However, it is the
exotoxins in Group A strep which are particularly pernicious and prone to
rapid spreading and “streptococcal toxic shock syndrome” (STSS) with
intercurrent organ failure. It can
start off a bit more insidiously than some of the other types of fasciitis,
but when the diagnosis is made, the imperative for rapid surgery is the same
as for gas gangrene. These types of
fasciitis can have distinctive findings, including: non-odorous (as opposed to synergistic or
enteric gangrene); fascial necrosis and suppuration are often not lytic and
cavitary (as is the case for enteric abscesses); severe watery edema, which
is a survival and proliferative advantage for the organisms; scarlet color. Complete thorough excision is
required. See Slide 7 for more
details. Atypical infections. These are due to fungus, mycobacteria,
actinomycetes, and such atypical non-bacterial pathogens. They tend to be “slow” infections - think
TB versus pneumonia or a post-pneumonic abscess - but once vessels start to
occlude and tissues infarct, the destruction can seem to occur quickly. Typically, a relatively slow granulomatous
inflammation was cooking in the fascias prior to severe skin
involvement. Mucormycosis is
distinctive in that vascular occlusion rather than inflammation or
exotoxicity is the cause of problems.
These patients typically have a more insidious and seemingly less
urgent onset, but the implications for curative surgery and reconstruction
are the same. As discussed in later slides, surgical excision
is mandatory, and the sooner the better, with Clostridial and Streptococcal
N.F. having the most immediacy for surgery.
However, the nature of the required surgery is the same for all such
patients with any of these diseases.
Surgery is required for three components of the problem: 1 - GET RID OF THE DISEASE, by as thorough and
complete wound excision or debridement as possible. 2 - PATCH UP THE RESULTING WOUNDS, by the the
usual arts of plastic surgery, whenever wound conditions and patient
conditions permit. 3 - RECONSTRUCT LATE SEQUELAE such as scar
contractures, or amputation management, etc. The surgery is analogous to the surgery needed
for burns, deglovings, and any large or acute wound. Burns and trauma do not have the same type
of illness, and acute and critical patient management are different than N.F.
in many ways. But, the surgery of
cleaning up the mess, preparing the wounds for closure, then patching them
up, then restoring function - that is what core plastic surgery is all
about. Large wounds, small wounds - it
doesn’t make a difference - the surgical principles and methods arte the same
for all of these conditions. ------------------------------------------------------------------------------------------------------------------------------------ TOP - A young derelict paraplegic patient with
long standing pressure sores.
Synergistic fasciitis - Fournier’s gangrene - is a very infrequent
complication of ordinary ischial pressure ulcers, and in fact, it was not the
problem here. Rather the patient
developed pressure necrosis of the anus, leading to ischiorectal infection,
which then spread rapidly, involving tissues throughout the buttock, pelvis,
and thigh, including other pressure bursas.
The image here is a couple of weeks after debridement and wound care,
ready to begin closure. CENTER - A patient with severe rheumatoid and
multi-drug immunosuppression developed fairly rapid skin necrosis, leg ulceration,
and febrile toxicity. While rheumatoid
panniculitis notoriously causes extensive ulceration of the leg, that process
is relatively slow and indolent, and does not involve the muscular proximal
leg. Biopsies and cultures showed
aspergillus. BOTTOM - This is a 19 year old man who developed
fevers and malaise after a minor skin scrape.
This was followed by rapid erythroderma, edema, pain, and progressive
toxicity. This is the quintessential
Group A Strep N.F. |
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SLIDE SUMMARY:
Infections of the soft tissues are often misdiagnosed, over-diagnosed,
or diagnosis missed. These cases were
all designated “necrotizing fasciitis”, when in fact none of them had
anything to do with that disease. Safe
and effective management starts with proper diagnosis. Discriminating diagnoses are essential. ------------------------------------------------------------------------------------------------------------------------------------ “Necrotizing fasciitis” may have some breadth to
its meaning - various organisms and clinical profiles - but those words have
a specific pathological meaning and implications for prognosis and care. Not every infection is N.F. Not every necrosis is N,F. Every time there is a media report on N.F.,
then suddenly every inexperienced physician is diagnosing anything on the
skin as N.F. Wrong. Here are samples of things that are
definitely not N.F., but were advertised as such when they were referred. ------------------------------------------------------------------------------------------------------------------------------------ LEFT TOP - This is trivial, and barely qualifies
as infection. A heavy object fell on
his foot, resulting in hematoma and skin necrosis. Acute inflammation reflects a 100% lack of
wound care. Thrombus and debris were
curetted, soap and silvadene were started, and edema was controlled. Antibiotics are irrelevant, unnecessary,
and were not given. Two weeks later,
the foot is nearly healed. Not
everything red and swollen is an infection.
Not every infection needs antibiotics.
Not every infection is N.F. or needs aggressive surgery. Every wound does deserve basic competent
wound care. LEFT BOTTOM - This is a genuine infection -
staphylococcal “scalded skin syndrome”, a destructive or ulcerative form of
impetigo. The patent had several such
lesions on the lower extremities. They
healed promptly with oral antibiotics and basic wound care (simple
debridement, topical hygiene, SSD or suitable substitute, edema
control). When seen in consultation,
the problem was already a couple of weeks old, and he was not ill - real
infection, but not N.F., and surgery was not needed. RIGHT - This obese patient lost 70 lbs. As the abdominal panniculus deflated, it
became more ptotic. Ptotic obese
abdominal folds all have chronic dependent edema, which causes chronic
inflammation. Occasionally, people
develop pannicular fat necrosis or abscess in the inferior edematous
portion. her doctors declared it
“necrotizing fasciitis”, even though the patient was not ill, and the process
remained localized. They did drainage
(good), but missed the opportunity to do a simple panniculectomy, and thereby
cure all of her problems in one simple step - adequate but inexpert
management. Note the simple clean
minimally resected wound with no eschar - unlike real N.F. Moral - DON’T diagnose ever infection or every
red spot as N.F. Understand what
“necrotizing” means and what “fasciitis” means. |
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SLIDE SUMMARY:
The patient with necrotizing fasciitis must go through several
treatment phases - acute control of disease, subacute closure of wounds, and
chronic management of sequelae. The
wounds themselves have three phases of care: excise the disease, then care
for the wound until ready for closure, then close the wounds. ------------------------------------------------------------------------------------------------------------------------------------ The general overall management of necrotizing
fasciitis is like that for any serious soft tissue injury. There are three general phases: 1 - Manage the acute illness and cure the
disease. 2 - Once the patients are stable, and the wounds
meet criteria for safe closure, then the wounds are closed, and the patient
is carried through to the logical end of the acute illness. 3 - Late wound and debridement related sequelae,
such as joint contractures or missing muscles and tendons, can be
reconstructed as required or convenient. Surgery has a central role in each of these
phases: 1 - EXCISE, debride, drain (Acute, save a life
and cure the disease). 2 - REPAIR the wounds (subacute). 3 - RECONSTRUCT deficits (late). The wounds per se have their own three phases of
management: A - The acute excision for control of the
disease. B - Interim wound management, getting the wounds
ready for closure, which for N.F. means days-to-weeks. C - Close the wounds, using whatever methods are
required, meaning the usual paradigms of wound closure - repair, grafts,
flaps, and the newer paradigms of repair (in situ tissue engineering with
regenerative matrices). The wound closure issues will be the greater part
of this presentation. |
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SLIDE SUMMARY:
Necrotizing fasciitis is cured by surgery. Complete excision and drainage must be
done. The disease will have a
continuum of findings, from incipient disease at the advancing margin to skin
necrosis at the original center.
Recognizing the full extent of disease and draining or excising it all
is mandatory. The goal and standard of
good care is to CURE THE DISEASE WITH ONE OPERATION. The surgeon must be confident with this,
and the non-surgeon must expect this from the surgeon consultant. ------------------------------------------------------------------------------------------------------------------------------------ This slide focuses on Step A of managing the
wound - the acute curative debridement. It is assumed that everyone understands the
quintessential importance and central role of excision in the management of
necrotizing fasciitis. If this is a new subject for you, this is the
main lesson: CUT THE DISEASE OUT TO
CURE IT. But, there are some constraints and options. With N.F., there is usually diffuse or
multifocal disease, unlike a singular abscess. But, there is also a boundary or margin of
disease, and surgical options have some latitude in the more peripheral
zones. “Central” zone - This is where skin necrosis has
occurred, a consequence of thrombosis of the cutaneous blood supply (fascial
perforators), and advanced effects of exotoxins and inflammation. This is obvious disease, but it can be a
late finding, or it may be absent. Not
having skin changes is a common cause of naive physicians not recognizing the
disease and diagnosis and delaying proper care. If it’s there, the patient is generally
very sick. Don’t wait for these
findings to make the diagnosis and treat.
COMPLETE EXCISION mandatory. Fascial necrosis zone - Even where skin may seem
normal, the adipose fascias can be thoroughly infarcted. It will be recognized by degeneration and
suppuration of the fascias - i.e. fat necrosis and pus, “pyofascia
gangrenosum” if you will. In enteric
or synergistic gangrene, the involved tissues are typically liquefied, brown,
and putrid. With strep and staph, the
tissues have a granular pearly opacification with areas of “white”
suppuration. In either case, this is
all dead and abscessed. COMPLETE
EXCISION mandatory. Fasciitis zone - This is a more peripheral zone
where inflammatory changes are present, but necrosis and suppuration have not
yet occurred. (Remember, that one of
the things which makes clostridial and strep fasciitis so problematic is that
these areas will degenerate quickly - hour by hour changes - and the quicker
the surgery, the less damage.) These
areas need drainage and debridement, but complete excision and skin removal
can be avoided. Drainage and
debridement means that the fascial planes are complete dissected and opened
for drainage, and fat is excised piecemeal, removing suspect areas, but
leaving areas that are not necrotic, and leaving skin. Marginal edema - The above comments are true for
all N.F., but the profuse watery edema issue is more distinctive for
streptococcal and other Gram + N.F.
The profuse watery edema is obvious, and it is active disease. But bacterial loads and toxin levels are
relatively low here, and the tissues are still intrinsically healthy. Remember, that the edema is a promotional
factor for Gram + organism, and controlling edema alone can eliminate minor
infections or infection risk in many situations - one of several reasons why
edema control is one of the quintessential cornerstones of good care for all
soft tissue pathology. For N.F. simply
incising and opening the edematous areas (thoroughly), and letting the edema
run out, will arrest the disease in these marginal areas. SURGERY IS MANDATORY - good surgery. No cheating allowed. Antibiotics are required for good outcomes,
but antibiotics do not work when the surgery has not been thorough. Aggressive surgery alone can often cure
these patients - especially the mixed-enteric N.F. Antibiotics alone mean death. Good care means aggressive use of both, but
do not misunderstand the pivotal role of THOROUGH surgery. The guiding principle is that the disease should
be controlled or cured with ONE operation.
Subsequent trips to the OR for cleanup debridement are meritorious,
but if you are going back to arrest progressive disease, then the first
operation was inadequate. DON’T LET
THIS HAPPEN. Do a CURATIVE procedure
the first time. PERIOD. If this is all new to you, and you are
unfamiliar with recognizing what is and isn’t viable or what MUST be excised
versus optional areas, then BETTER to excise more, not less. Skin is easy to reconstruct on living
patients. ------------------------------------------------------------------------------------------------------------------------------------ RIGHT - Schematic illustration of the relative
zones of involvement. LEFT TOP - An incision near the peripheral margin
of strep A fasciitis. Note the high
volume watery edema “flooding” the subcutaneous panniculus. LEFT 2nd - An incision reveals necrosis and
suppuration in the adipose and muscular fascias. This is the same patient as the top
picture, but in a more central zone where actual fascial necrosis has already
ensued. Overlying skin is still
completely viable. Thorough excision
of the inflamed, abscessed, or infarcted tissues is mandatory, but if
thorough, and the circulation to the skin has not been destroyed, then the
skin can be saved. LEFT 3rd - An external view of strep
fasciitis. The bright erythroderma and
edema are characteristic, accompanied by pain and tenderness. The skin is viable and salvageable, but the
fascias underneath are actively infected and need complete
drainage-debridement-excision. LEFT BOTTOM - (Acquired image, source unknown -
credit to the originator) - Strep A fasciitis, with evolving skin
infarction. The skin in this zone
needs excision. |
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SLIDE SUMMARY:
The message cannot be overemphasized, so take it from this guy: The goal and standard of good care is to CURE THE
DISEASE WITH ONE OPERATION. Git-r-done. ------------------------------------------------------------------------------------------------------------------------------------ This is an important principle that requires repetition
and reiteration: DO A CURATIVE
OPERATION. As was stated on the last
slide: “SURGERY IS MANDATORY - good surgery. No cheating allowed. Antibiotics are required for good outcomes,
but antibiotics do not work when the surgery has not been thorough. Aggressive surgery alone can often cure
these patients - especially the mixed-enteric N.F. Antibiotics alone mean death. Good care means aggressive use of both, but
do not misunderstand the pivotal role of THOROUGH surgery. “The guiding principle is that the disease should
be controlled or cured with ONE operation.
Subsequent trips to the OR for cleanup debridement are meritorious,
but if you are going back to arrest progressive disease, then the first operation
was inadequate. DON’T LET THIS HAPPEN. Do a CURATIVE procedure the first
time. PERIOD. If this is all new to you, and you are
unfamiliar with recognizing what is and isn’t viable or what MUST be excised
versus optional areas, then BETTER to excise more, not less. Skin is easy to reconstruct on living
patients.” If you don’t believe this, maybe you’ll listen to
Larry the Cable Guy. ------------------------------------------------------------------------------------------------------------------------------------ ILLUSTRATION - This shows a patient who had strep
fasciitis of the lower extremity. He
is now stable and “healthy” after one operation. The surgery, and the companion good wound
care represent the two initial phases, A & B, of the wound management -
debridement and interim wound care. In
another week or two, the wounds will be healthy enough for closure. |
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SLIDE SUMMARY:
These slides illustrate cases of NF where one operation cured the
disease, and the patients went on to survive and heal. Here are more examples of what it means to excise
and drain the disease. Each of these
patients had just ONE operation to control the infection. Subsequent procedures were for wound
closure. ------------------------------------------------------------------------------------------------------------------------------------ LEFT UPPER - Staphylococcal N.F. arising in a leg
amputation, which progressed cephalad, then into the shoulder, the down to
the hand. LEFT LOWER - Group A strep, following a knee
arthroscopy. which extended throughout the entire trunk and both lower
extremities. RIGHT UPPER - Group A strep. This is the same patient as BOTTOM on Slide
4. Because this patient had prompt
recognition and diagnosis, and expedited surgery, the surgery was done at a
time when there was no skin necrosis.
There was more erythema, edema, and non-necrotic fasciitis than there
was necrosis and suppuration. Surgery
consisted mostly of multiple drainage incisions and subcutaneous fascial
debridement. RIGHT LOWER - Groin infection after vascular
procedure, mixed enteric flora. The
wound surface looks as expected - chocolate brown surface due to blood and
thrombus mixed with silver sulfadiazine, and reduced silver from the SSD. Note the skin margins and periwound skin:
no inflammation, no erythema, no edema; and the patient is “healthy” now. Remember, each of these potentially fatal
infections was cured with one operation.
Some were greater and some were lesser in scope - it is what it is for
each patient - but all were “cured” in one operation, regardless of how
extensive the disease was. NOTHING
LESS should be acceptable. |
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SLIDE SUMMARY:
When the disease is cured, the wounds must be cared for and then
closed. The principles of good
hygienic wound care must be adhered to.
When the wounds are ready for closure, the choice of method is based
according to the basic principles of plastic [reconstructive skin]
surgery. However, healthy wounds heal
themselves, and allowing a wound to contract on its own, with the support of
good wound care, is the preferred option in many situations. ------------------------------------------------------------------------------------------------------------------------------------ The rest of this presentation focuses on the
surgery of repair - putting the patient back together after the damage is
done and the disease controlled. The main message is simply that putting people
back together is “easy” enough. Like
any other sophisticated process in medicine and surgery, good results depend
on time, attention, and effort.
Repairing or restoring the skin is not a triviality, but the art is so
well established, and the methods are so practicable, that headache-free
treatment programs and good outcomes are predictable and dependable. Adequate initial treatment - the curative surgery
- must NEVER be compromised. With the
good methods of skin restoration that we now have, no surgeon need ever be
intimidated by the need to remove whatever needs to be removed, no matter how
extensive. How does one manage the wound or skin deficits
after the initial cure? The focus here
is on the reconstructive surgery program.
It is assumed that readers are familiar with the necessity of and
principles of good wound care, including the all-important notion that no wound
can be closed until it meets criteria for safe and dependable closure. Wound therapy Part B, the daily topical
preparatory care, glides into Part C, the repair, as the wound cleans up and
meets the closure criteria. The details of good hygienic wound management
have been alluded to on previous slides, and this art can be studied from
many other public resources. Cure the disease. Take care of the wound. Now what? There are four classic modalities of getting a
wound closed. The ordinal paradigm is to let the wound close
itself. Wounds heal. The body is programmed to do it. For many wounds and patients, surgery is
optional ... or entirely unnecessary ... or thoroughly meddlesome ... and
sometimes even counterproductive or damaging. There are many reasons to do wound closure
surgery. There are equally many
reasons NOT to do wound closure surgery.
Choices are made case by case, for each patient or wound or part of a
wound. Healthy wounds heal. Don’t meddle with a good thing. ------------------------------------------------------------------------------------------------------------------------------------ ILLUSTRATION - This shows a young man who speared
his wrist on a splinter in a lumber yard.
Septic tenosynovitis ensued.
The flexors were drained and debrided.
the wound was managed by basic hygienic care: daily bathing, SSD,
splints, edema control. The wound
contracted and closed. Therapy
restored full range of motion.
Easy. Done. Surgery to repair the wound would have
served no purpose except to spend money and resources, and perhaps delay his
therapy. |
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SLIDE SUMMARY:
When surgery is required for wound closure, there are three
conventional paradigms of wound closure surgery (based on fundamental
biological and technical differences).
The simplest paradigm is simple repair - direct coaptation of existing
skin margins. This slide illustrates
the principles and cases of fasciitis wounds eligible for simple repair. ------------------------------------------------------------------------------------------------------------------------------------ When wound closure surgery is needed, the methods
of surgery all fall into three paradigms:
simple repairs versus grafts versus flaps. These three paradigms are all distinguished
by some categorical technical and biological differences. They all share one common principle - they
all depend on a healthy wound and normal wound repair physiology. Choices for closing any wound are made on
some very basic criteria. Surgical wound closure paradigm #1: Simple repairs. This means taking the wound as is, advancing its
existing margins, and “suturing” them (sutures, staples, glues, tapes,
whatever). N.B. Any
competent wound closure surgery, regardless of method, is preceded by a
period of preparatory care, and then, at the time of closure, the existing
wound surfaces are excised, curetted, or otherwise cleaned up to a point that
the closure will heal and not have complications or failures. This a mandatory requirement of all
surgical wound closure, large and small.
These technicalities are implicit in every case presented here, and in
any discussion of wound closure. Simple repairs work when skin margins come
together easily and wound healing is normal.
This is always the theoretical first choice, but large skin injuries
create situations where it simply cannot be done. ------------------------------------------------------------------------------------------------------------------------------------ LEFT - A typical simple repair case, a dogbite
injury of a thigh. After spending a
couple of days of basic care, the wound surface was excised, and the margins
were sutured. Had it been a few
centimeters wider, this might not have been possible. RIGHT UPPER - The same strep N.F. case as on Slide
9. Because the process was drained
early, before extensive necrosis, most of the skin is still present. The gaps shown are just the normal elastic
retraction of any incision. About a
week after the initial surgery, the wounds were closed by simple straight
line repairs. RIGHT LOWER - Strep fasciitis of the lower
extremity, after drainage and debridement, and a week of good wound care,
ready for closure. Simple incisions of
the thigh and leg are closed by simple repair. Missing skin at the knee required an
alternate method (Integra CGM was used, discussed on later slides). |
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SLIDE SUMMARY:
The second paradigm of surgical wound closure is skin grafts. Pros, cons, and illustrative examples are
shown. The main purpose for skin
grafts is convenient efficient closure of large areas that have no special
concerns (such as exposed viscera or implants). ------------------------------------------------------------------------------------------------------------------------------------ When simple repairs cannot be done, an
alternative is skin grafts. A graft
has no anatomical connection to the host.
It depends entirely on a healthy host wound to nourish it and execute
the healing process. Grafts must be
suitable thin to survive, and typically they just restore missing epithelium
(epidermis). The advantages of skin
grafts are that they are extremely convenient and pragmatic. As the donor sites heal, thin split
thickness grafts are a renewable resource.
This property is highly advantageous for large burns with limited
donor sites. If grafts fail, nothing
is lost except time and effort. Since
grafts are strictly dependent on a healthy host wound, they cannot be used over
non-living or non-healing surfaces, including cartilage joints, open fractures,
hardware, any other gap or void, or over pathological
wound-healing-incompetent wounds. The main use for skin grafts is simple rapid skin
restoration on large areas, simply to get the job done. Assuming that they live and heal, their
biggest liability is that they heal with lots of scar, leading to
contractures and deformities which often require later excision and more
formal reconstruction. For most fasciitis, the net wound surface may be
huge - sometimes well in excess of total body surface area - due to the
multiple fascial planes that were opened (a tangential incision is like
opening a book - 100 sq cm of topographical area becomes 200 sq cm of open
wound). However, the net skin loss,
even in the most severe cases is typically small, as compared to burns and
degloving injuries. There are rarely
any problems or inadequacies in harvesting the required amount of skin. If for any reason, some type of interim wound
closure is desirable, this can be done with disposable resources (this is
true for any large wound of any etiology).
These include cadaver allograft, porcine xenograft, and alloplastic Biobrane® (Bertek Pharmaceuticals, Inc., West
Virginia). These provide the
advantages of skin coverage and wound closure for limited periods (days to
weeks), buying time to get the patient healthier and plan the eventual
autogenous reconstruction). ------------------------------------------------------------------------------------------------------------------------------------ LEFT
- A typical skin graft case, an ankle ulcer due to vascular disease, nursed
back to health and a healing wound after revascularization. The granulation tissue and other wound
module elements denote that the wound is healing competent and receptive to
skin grafts, which are shown fully healed. RIGHT
UPPER - A debrided leg, ready for closure.
With no special requirements or caveats for closure, simple skin
grafts were used. RIGHT
LOWER - Strep N.F. in the groin and surrounding areas. The prepared wounds are ready for closure. Skin grafts are shown, healing normally, a
week after surgery, applied to non-essential broad areas of thigh and
pubis. (The groin, a mechanically
active area, was closed with a flap, discussed on the next slide.) |
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SLIDE SUMMARY:
The third paradigm of conventional wound closure is flaps. The various indications, pros, and cons, as
well as illustrative examples are shown.
Flaps are required when coverage of exposed structures, avoidance of
contractures, or quality of the reconstruction are central concerns. ------------------------------------------------------------------------------------------------------------------------------------ The third classical paradigm of wound closure
surgery is the flap. Flaps have an
anatomical attachment to the host.
properly prepared, they have their own circulation and normal biology,
preserving their ability to execute the wound healing process. Flaps are used for several reasons: 1 - Simple convenient closure for minor daily
defects (minor trauma and skin excisions) and general plastic reconstruction. 2 - When normal quality or composite tissues are
needed for a quality reconstruction. 3 - “Essential coverage” for exposed structures
that cannot support a skin graft. 4 - Because good flaps are independently healthy
and able to heal, they are used to cover wounds which are incompetent to
heal, such as a radiation wound or an exposed implant. The advantages of a flap are the quality and
reliability of the reconstruction, and the dependability of a healed wound
(assuming the flap is done properly).
The disadvantages are various, including significant donor sites or
sacrifice (often times a lot to lose if the reconstruction fails). ------------------------------------------------------------------------------------------------------------------------------------ LEFT - A typical flap indication, an ischial
pressure ulcer. A flap is needed to:
restore composite tissues; provide thick compliant tissue (low shear modulus
over a bony contact surface); bulk filling of a large volumetric bursa;
normal durable non-fragile shear-resistant full thickness skin; extensibility
across a joint. RIGHT UPPER - An open arm and shoulder after
staphylococcal N.F. Simple repairs
cannot be done. Skin grafts would be a
late problem due to muscle tethering and joint contracture or
restriction. Rather than create large
flaps with lots of additional incision, only a small easily advanced flap was
used, right where it would do the most good - across the mechanically active
skin areas of the shoulder joint. (The
remaining areas were then closed with Integra). RIGHT LOWER - The same patient as from the
previous slide. Skin grafts across
mobile areas will contract and restrict motion, or else be subject to
repetitive fracture and chronic ulceration.
The lower abdominal fatty panniculus offered a simple solution to
avoiding any later reconstruction. A
flap was pulled across the the groin, which is the mechanically active
flexion crease of the hip joint. Late
reconstructive will not be needed (unless for cosmetic reasons). |
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SLIDE SUMMARY:
There a variety of conditions and caveats which threaten or
contraindicate the usual paradigms of wound closure surgery. repairs, grafts, flaps - all three have in
common that they depend on normal healthy wound healing. When the healing process is impaired, or
when wound and patient conditions interdict surgery, there is a need for
something more suitable. This slide
lists common challenges to conventional surgery. ------------------------------------------------------------------------------------------------------------------------------------ The first book on skin grafting was written by
Baronio, of Italy, in 1803. Flaps for
reconstructive surgery are recorded from ancient times (including the Susruta
Samhita of ancient India, 4000 years ago, documenting flaps for nose
reconstruction). Simple wound repairs
are present in many primitive cultures.
In other words, the basic paradigms of surgical wound closure have
been around awhile. Understanding the
sciences and arts of doing these things, to close wounds and reconstruct
defects, is what the “Real Plastic Surgery” is all about. BUT - these classic methods do not solve every
surgical problem. Common to all of
these is that they depend on normal healthy physiological post-inflammatory
wound repair. But not all wounds or
hosts are wound healing competent.
Various other logistical and technical factors, and factors of disease
and patient status can all hamper or disallow the use of these
modalities. The text on the slide
lists common caveats that interdict customary surgery, or create headaches
for planning and executing usual operations. ------------------------------------------------------------------------------------------------------------------------------------ RIGHT - A 60 YO woman with advanced uncontrolled
rheumatoid arthritis, and arteriosclerotic vascular insufficiency. This wound is a paradigm example of the
advanced rheumatoid wound - extensive immune panniculitis and synovitis with
immune mediated histolysis. Even when
the out-of-control rheumatoid is tamed, inflammation arrested, and active
wound pathology subsided, the arterial disease will present challenges for
getting it healed. There are no flaps
available locally. free flaps have no
place to anastomose. Flaps will be
subject to failure from persistent wound inflammation, in spite of adequate
wound preparation. Skin grafts cannot
take. Even if the wound and patient
had “good protoplasm”, skin grafts on moving tendons are disallowed. What to do? |
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SLIDE SUMMARY:
For large and unhealthy wounds, quality of care and ultimate outcomes
have undergone significant improvements in the past 10 years, due to the
advent of skin regenerative matrices. The most useful for large wounds after
burns, deglovings, and fasciitis is Integra-CGM (collagen-gag matrix). It’s many unique properties translate to
biological and clinical benefits. ------------------------------------------------------------------------------------------------------------------------------------ Remember:
The conventional paradigms of wound closure - natural contraction,
simple repairs, grafts, and flaps - all have one thing in common. They depend on normal healthy physiological
wound healing. They are also
constrained or limited when wound areas become extraordinarily large, or when
there is extensive multifocal injury and exposed structures. The new modern solution to these problem wounds
are the skin regenerative matrices.
Clinically available for only a decade, they have completely altered
the approach to complex, pathological, and extensive wounds. The most versatile of these, and the most
suitable for missing skin restoration, is Integra®
Collagen-GAG Matrix (CGM), aka Integra Artificial Skin, or just plain
“Integra” (Integra Life Sciences, Inc., Plainsboro, New Jersey). Alloderm® (LifeCell
Corporation, Branchburg, New Jersey), a highly processed cadaver dermis, has
similar biological effects, but lacking an “epidermal” barrier component, it
has become more useful for internal applications, and for anything requiring
tensile strength, such as for fascia, ligament, and tendon reconstruction
(also marketed as Graft Jacket™ by Wright Medical Technology,
Inc., Arlington, TN). Integra has become the Wizard of amazing feats of
wound closure and skin restoration for complex wounds. The remainder of this presentation will
focus on its suitability for skin closure and reconstruction after necrotizing
fasciitis. Additional extensive Integra resources are
available at arimedica.com. Integra is composed of a working layer of the CGM
matrix, overlayered with a silicone “epidermis”. The active matrix is a spongy combination
of type 1 collagen (bovine achilles tendon) and chondroitin-6 sulfate (shark
cartilage). The material is used as a sheet graft, applied to a prepared
wound. Over a period of 3-6 weeks,
regenerative new tissue fills the matrix.
When fully regenerated, the silicone is peeled off, and thin epidermal
autografts are applied to complete the reconstruction. Although it is applied to the surface and
used like a skin graft, Integra must be thought of as an implant - a “surface
implant”. Integra has remarkable biological and clinical
properties. It is recognized by the
host as normal self. Unlike
biomaterials, it is not alive, so it survives pathological conditions that
kill grafts or dissolve repairs.
Defensive reactions, inflammation, are COMPLETELY suppressed. Normal wound healing, leading to scar and
contraction, is never initiated, meaning no scar and no contraction. It induces an embryonic type of
dermatogenesis within the matrix. The
matrix will conduct new tissue tangentially, allowing for the coverage of
essential structures. These
properties, completely unique in the world of surgical and medical tools, are
the basis for Integra’s extraordinary utility and ability to solve tough
problems. IN THE SHORT RUN, Integra is a very effective
high quality skin substitute, perceived by the body as a normal epithelial boundary. It physiologically “hides” the wound from
the host. It makes wounds and patients
healthy. IN THE INTERMEDIATE, it transitions into the
agent of skin regeneration. One device
takes care of both acute biological coverage and subacute skin restoration. IN THE LONG RUN, its ability to suppress scar
means that contractures do not occur, and late reconstruction is not needed. ------------------------------------------------------------------------------------------------------------------------------------ LEFT: - The upper panels show two orthogonal views
(“Langer’s lines”) of normal dermal collagen.
Normal dermis, while tough (in its axis), is nevertheless elastic and
distensible (its orthogonal, anisotropic), due to a woven and oriented
fibrous architecture that permits gel-like deformations to a certain degree
in certain directions. - The middle panels show young scar and young
Integra. The young scar is so tightly
packed with random isotropic collagen amalgam, that no elastic motion is
possible. Integra starts off porous
and deformable. It forces collagen to
form into discrete incoherent loci with zero net tension. It moves like normal skin, right from the
beginning. - The lower panels show that, as the months and
years roll by, scar and Integra both get slowly remodeled back to a dermal
architecture. Scar takes months or
years to get there, risking contractures and reconstructive surgery in the
meantime. Integra has the mechanical
properties of skin from the beginning. RIGHT - Integra, separated to show the silicone
and CGM laminas. A biopsy shows the
matrix sitting on top of fascia. |
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SLIDE SUMMARY:
Integra’s biological effects arise from its ability to completely turn
off inflammation and supplant normal post-inflammatory wound healing with
embryonic-like dermatogenesis. This
means that inflammatory injury is arrested, care is minimized, and scar is
suppressed. ------------------------------------------------------------------------------------------------------------------------------------ This is a closer look at Integra’s biological
effects. In its role as an acute skin
substitute, it arrests inflammation and normal wound repair. The host no longer recognizes the injury,
and it ceases to be a physiological wound.
Pathological wound behavior stabilizes, and adverse events, such as
progressive necrosis and ulceration cease, and inflammatory symptoms abate. In its subacute role as a dermal or fascial
regenerant, it eliminates normal reparative scar fibroplasia, inducing instead
the embryonic process of dermatogenesis.
The result is a laminar new tissue comparable to dermis and distinct
from scar, and without scar related complications. ------------------------------------------------------------------------------------------------------------------------------------ TOP - Several days after placement, the Integra
CGM matrix has only a few cells in it.
These are small lymphoid “pioneer cells” which are the progenitors of
the subsequent histogenesis.
Leukocytes never appear in the matrix, and inflammation does not
occur. The leg ulcer is due to protein
S deficiency. Control of chronic
inflammation and ulceration was difficult in spite of relevant treatments and
good wound care. Typical of all such
patients, periwound inflammation ceases promptly upon placement of the
Integra. MIDDLE - Regenerated Integra has a pale opacified
appearance under the silicone. Having
regenerated according to embryogenic rules, vascular density is correct - the
same as normal dermis and fascias. In
a seam between pieces is some normal inflammatory wound healing,
characterized by hypervascular “granulation tissue”. In a different patient, a similar seam is
seen after healing. This recently
healed / regenerated wound has normal soft compliant dermal characteristics
in the broad Integra areas. The seam
is normal young scar, red and hypertrophic. BOTTOM - An chronic ulcer has occurred over the
anterior ankle following a burn. The
normal scar is stiff and non-compliant, fracturing with plantar flexion
(leading to more scar, and so on).
This is normal scar mechanics, which is clinically undesirable. In comparison, this Integra reconstruction,
on the dorsum of hand and wrist, is only a few weeks after completion. It is soft flat, normal color, and most
important, it is highly compliant and pliable - skin, not scar. LEFT - The reasons why the material induces
embryonic activities can be studied in other resources (at
Arimedica.com). This slide shows a key
piece of evidence - the syncytial fibroblast, which is the embryonic
dermatoblast, a cell which NEVER - not ever - appears in a normally healing
wound. |
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SLIDE SUMMARY:
The basis for Integra CGM’s biological effects is understood in many
ways. This illustrates a key
component: the matrix is developing a cluster of syncytial fibroblasts. This is the embryonic dermatoblast, a cell
which NEVER appears in normal wound post-inflammatory repair. ------------------------------------------------------------------------------------------------------------------------------------ Here is a close up of another syncytial
cluster. The small pioneer cells, seen
on the previous slide, proliferate into small clusters like this, composed of
several syncytial fibroblasts. which are starting to make young fibrillar
collagen (pale pink), nestled within a pore or domain of the matrix. Some other not-yet-transformed lymphoid
progenitor cells are also present (they must bind to the matrix to begin the
process, an effect of the aminoglycan in the material). |
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SLIDE SUMMARY:
This is a view of regenerated Integra side-by-side with normal wound
healing. Each half is completely
normal and healthy, but the differences are profound - normal wound module
versus induced dermatogenesis. ------------------------------------------------------------------------------------------------------------------------------------ This is a slide showing two distinctly different
yet entirely normal events. On the
left is a normal wound module. On the
right is normal Integra. An original
biopsy was taken a week earlier. The
biopsy site, now a normal open wound, developed normal granulation
tissue. The new biopsy was centered on
the boundary. Each half of the image
is a completely normal and paradigm demonstration of their own events -
normal post-inflammatory wound module, and normal Integra histogenesis. Absent the matrix, cells follow their
normal healing program. In the
presence of the GAG matrix, inflammation-repair is suppressed, and embryonic
histogenesis is induced. Cells, all
having the same genotype, remain pluripotential, and can be induced to one
reactive program or another depending on inputs. The histogenesis response never occurs in
normal post-parturitional injury and healing, but it can obviously be invoked
with the right trigger. |
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SLIDE SUMMARY:
At the late end of the spectrum (1 year after Integra), the
differences between wound and Integra are still dramatic: nearly normal looking dermis (right, Integra)
versus contracted non-compliant scar. ------------------------------------------------------------------------------------------------------------------------------------ Another side-by-side of normal healing versus
Integra, at the other end of the timeline.
Taken a year after Integra placement, The Integra (right) looks like
normal dermis. the conventional scar
(left) is maturing, and developing some more normal dermal characteristics
(fiber formation with interstices).
Yet the scar is what it is, highly collagenous, contracted, and
apparently stiff. (At bottom left are
glomerular ghosts, as this reconstruction was done to close a large abdominal
and flank defect, with multiple exposed viscera). |
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SLIDE SUMMARY:
Integra’s biological properties translate in to clinical
advantages. This slide illustrates
superior clinical outcomes that arose directly from these biological
properties, including suppression of inflammation, control of pathological
behavior, and tangential histoconduction.
Listed too are some of the caveats against conventional surgery (from
Slide 14), and how Integra-CGM solves those issues. ------------------------------------------------------------------------------------------------------------------------------------ Integra’s desirable clinical properties mirror
its biological properties. Suppressing
inflammation and controlling pathological wound behavior are of central
importance. The dermal regeneration in
lieu of scar has it obvious advantages.
The matrix supports tangential histoconduction, tissue creeping
through the matrix, from areas in contact with normal tissue, to other areas
that might not be in contact. This
allows new tissue to form over a non-living or non-cellular hiatus, including
cartilage, open joints and other anatomical spaces, and even alloplastic
materials. As such, Integra can
fulfill many of the purposes of conventional flaps. Recall from Slide 14 that there are many reasons
why conventional wound repair surgery may have limits, caveats, or
contraindications. If these difficult
situations are now approached with Integra or other regenerative matrices,
many of these challenges can be readily solved. Select issues and responsa are listed in
the slide text. ------------------------------------------------------------------------------------------------------------------------------------ LEFT UPPER - A persistent, persistently inflamed,
and progressively ulcerative ankle ulcer in a patient with rheumatoid and
Factor V Leiden. Inflammation ceased
immediately with Integra. A year
later, the ankle is healed (there is new Integra on the contralateral ankle,
after a rheumatoid flare caused many new ulcers; the old reconstruction
remained safe). LEFT LOWER - A chronic granulomatous ulcer of
unknown origin (presumed to be an occult atypical pathogen). It failed many skin grafts over many
years. Proteinaceous plaques appeared
shortly after re-excision (left). In spite
of the prior disappointing surgical history, use of Integra controlled wound
dynamics and pathology enough for general improvements to occur. The regenerated material (middle) is ready
for skin grafts, which have remained healed for years (right). RIGHT - This open fracture and repair was
complicated by two failed free flaps and other wound problems. No further conventional surgery is
permissible. (When seen in
consultation, a workup was done for customary underlying diagnoses,
especially immunopathic and hematological, but no problems could be
identified). Integra was used, but it
was not intended to be a skin reconstruction.
Instead, it was meant to be used as a high grade interim skin
substitute for a few months, until the fracture was healed and the hardware
could be removed. However, the
histoconductive properties of the material allowed new tissue to grow over
the implant. The patient is otherwise
normal, and the implant remains in place after 4-5 years. |
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SLIDE SUMMARY:
These cases illustrate the general use of Integra. In each of these case, disease and patient
condition assured that any conventional operation would have failed or caused
harm to the patient. Because Integra
has no donor sites, is not alive to begin with, suppresses inflammation,
bridges gaps, and does not depend on normal wound healing, it solved all of
these problems with no risk to the patients. ------------------------------------------------------------------------------------------------------------------------------------ Before moving on to fasciitis patients, here is a
gallery of challenging cases, to familiarize you with Integra’s properties
and capabilities. LEFT - Typical Arizona Native American patient
with advanced diabetes and upper extremity atherosclerosis. Long finger injury and problems on the
adjacent ring finger left a problem for covering flexor tendon and PIP
joint. Local flaps are
impossible. grafts cannot be used over
the open structures. Integra solved
the problem with no risk to the patient or hand. MID UPPER - Aorto-iliac atherosclerosis causing
foot problems, then progressive amputations.
Thigh necrosis will continue if conventional surgery is tried
again. Excision and closure with
Integra solves the problem with predictable certainty, with no risk to the
patient or local structures. MID CENTER - An achilles ulcer in a patient with
Wegener’s granulomatosis. Conventional
surgery risks wound complications, and general anesthesia has risks for this
patient. Integra healed the wound with
minimization of all risks. MID LOWER - An open phalanx and MP joint in a
patient with advanced scleroderma. All
conventional options for closure are confounded by non-compliant skin and
tissue ischemia from chronic vasculitis.
Integra heals the defect dependably, and with no risks. RIGHT - A complex foot defect from complications
of vascular disease. Although the foot
has been revascularized and is now healing, open bones and joints need
deliberate operative coverage.
Conventional flaps are either impossible or subject to significant
risks. Integra solves the problem with
no risk to foot or patient. |
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SLIDE SUMMARY:
This slide reiterates why Integra-CGM is useful when normal surgery
cannot be done. Integra represents a
new and independent paradigm of wound closure surgery - in situ tissue
engineering - a process independent of normal mature wound healing. ------------------------------------------------------------------------------------------------------------------------------------ Here are some more non-fasciitis cases. The purpose of these case studies is to
demonstrate that Integra use is unlike any other surgery. It represents a new independent paradigm of
wound repair surgery: in situ tissue
engineering. When conditions and caveats of the wound or
patient disallow a conventional repair, even when a flap is needed for
complex coverage, Integra CGM can heal the wound. Because it does not depend on conventional
wound repair (in fact, it suppresses repair), it is a distinctly different
mode of surgery than repairs, grafts, and flaps. That its response is an embryonic one that
also eliminates scar is an added bonus.
It succeeds where other options are ineligible or fail. Its easy use, unlimited procurement, lack
of donor sites, and lack of any patient risk makes is the cherry on the
sundae. ------------------------------------------------------------------------------------------------------------------------------------ LEFT - Chronic ulceration in a young man with
chronic post-phlebitic venous hypertension, and Factor V Leiden. Previous grafts, repairs, and natural
closure have been unstable, with repetitive re-ulceration. Thorough excisional debridement exposes a
long segment of tibia. A free flap is
the textbook option, but it carries substantial surgical and disability risk
in a young laboring man with a hypercoagulopathic disorder. Integra solved the problem with no risks or
hospitalization. RIGHT - An active diabetic patient had non-septic
forefoot necrosis. Basic comprehensive
care and a transtarsal amputation resolved the necrosis, leaving a wound
eligible for closure. This is a “good”
amputation because all major ankle tendons are still inserted, making a
stable useful ankle. Closure by
conventional methods is impossible: skin grafts cannot take over open joints,
no local flaps safe or available, free flaps high risk due to vascular
disease, further bone recession for simple repair will destabilize the
ankle. Integra solves the problem with
no hospitalization, no risk to the patient, and a superior result. |
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SLIDE SUMMARY:
Integra’s many properties mean that, although it is the only good
option for certain cases, it is also the preferable option for certain cases
where grafts and flaps would still be eligible. Each case illustrates a problem which would
have healed with grafts or flaps, but would have healed poorly with further
problems, but an Integra reconstruction preempted or prevented difficulties. ------------------------------------------------------------------------------------------------------------------------------------ In many of the cases presented, Integra was the
only suitable option for surgical wound closure. This means that before the advent of this
and comparable products, the conventional options were inadequate or
problem-prone, and that indeed was the case.
The general effect of Integra and similar devices has been to extend
the horizons of safety and efficacy in the management of complex wounds,
including chronic and pathological wounds as well as large acute wounds. There are, of course, many simpler cases where
conventional options are still eligible.
For many cases, most in fact, the conventional options are still most
appropriate. However, there are
healthy wounds, biologically eligible for the usual options, where Integra is
preferred - not because of biological necessity, but because of its other
desirable properties: avoid donor
sites, avoid scar, thin tissues that do not need debulking, outpatient
management, control of inflammation and wound and patient pathologies. In other words, when Integra was a novel product
in 1996, it was seen as a bailout or last ditch option for terrible
problems. Now, it is being seen as the
preferred option for many problems because it is safer and gives superior
results for many patients, wounds, and problems. And, for the big problems such as burns,
deglovings, and fasciitis, it has revolutionized management of the patients
and wounds. In these four case, Integra was not mandatory -
anything else would have healed with proper technique and care. But, it was the only suitable option in the
interest of effective or superior results. ------------------------------------------------------------------------------------------------------------------------------------ UPPER - Hand necrosis after an arterial injection
injury. In spite of the bad appearance,
most of the hand (up to the metacarpal heads) was salvageable after
aggressive wound, vascular, and soft tissue management. Preservation of length was a top
priority. Conventional options for
closure or reconstruction were inadequate or ineligible: no local flaps, no free flaps, no skin
grafts over protruding bone, etc.
Groin or abdominal flaps would have qualified, but would have left
bulky lax tissues needing revisions, with poor sensation. Integra not only got the wound closed with
no problems, but it left a mechanically superior result. LEFT - Necrobiosis lipoidica of many years
duration, with persistent active ulceration and many failed skin grafts. Excision of skin and fascias, and
resurfacing with Integra healed the problem.
The skin has remained stable for several years. It achieved thin smooth skin cosmetically
suitable for the anterior leg, and did so with no hospitalization and no
donor sites. CENTER - An ear keloid, having recurred after
prior attempts to treat. After
excision and resurfacing with Integra, there is no scar. Any other surgery, which depends on normal
fibroblastic wound healing, simply makes more keloid. RIGHT - Severe elbow, shoulder, and wrist
contractures occurred in this pre-teen girl following burns and skin
grafts. Integra resurfaces all scars
and missing skin, and completely corrects the contractures, seen here while
the Integra is in place, and several months after completing the
reconstruction. Integra SHOULD HAVE
BEEN USED as the initial wound closure during her acute care. |
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SLIDE SUMMARY:
This slide summarizes the key data and conclusions from a study of
Integra, where Integra was used for the closure of chronic and pathological
wounds which would have failed or had complications with conventional
surgical closures. The wound closure
success rate and the coverage of essential structures success rate were both
about 90% - well beyond what would have happened with repairs, grafts, and
flaps. ------------------------------------------------------------------------------------------------------------------------------------ A measure of the efficacy of Integra comes from
this paper, in which Integra was used for the closure of chronic and
pathological wounds. 120 patients were
studied over 6 years. These patients
and wounds were opted for Integra because of the caveats and conditions which
interdicted conventional surgery.
While one can never measure the “road unraveled”, the anticipated
failure rate for these patients, if conventional repairs, grafts, or flaps
had been used, was nearly 100%, which is precisely why Integra was opted for
these patients. The major diagnostic
categories are listed. Integra fully healed these complex wounds in 71%
of patients. In another 10%, it
contributed to most of the healing, paving the way for some final second
grafts. In 10% of patients, the
reconstruction contributed to a significant improvement in size of the wound
or patient status, although additional care was required for complete
closure, or small residual wounds remained open. The reconstruction failed in only 9% of
patients. The material itself
performed as it should, but failed wounds or amputations occurred anyway. In retrospect, two patient profiles were
identified as contraindicating the use of Integra-CGM. Those situations of desperately poor
arterial circulation, ABI’s around 0.3 or less, will categorically fail
attempted surgery, including Integra.
Plantar diabetic wounds also failed , but always because of compliance
and weight bearing issues, not because of any intrinsic problems with the
material’s regeneration. If the patients subsequently recognized as
fitting these contraindications are excluded, the success rate for healed
closed wounds was 92%. 90% of the
exposed essential structures (bone, tendon, joints, etc.) were successfully
closed. Integra supplanted or equaled or outperformed
flaps, in situations were flaps were nominally indicated on technical
criteria, but were contraindicated by real patient conditions. Dependable positive results, with no risk to the
patient, for problems which would have failed conventional wound closure
surgery. This is the value of in situ
tissue engineering with skin regenerative matrices. ------------------------------------------------------------------------------------------------------------------------------------ Gottlieb ME, Furman J. Successful Management and Surgical Closure
of Chronic and Pathological Wounds Using Integra®. Journal of Burns & Surgical Wound Care,
3:2, 2004. (journalofburnsandwounds.com). Gottlieb ME. Management of Complex and
Pathological Wounds with Integra. In
Lee BY, ed. The Wound Management
Manual. New York, McGraw-Hill,
2004:226-289. (ISBN 0-07-143203-5). |
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SLIDE SUMMARY: This starts a series of patients with necrotizing fasciitis. This woman had strep NF, managed by prompt drainage, then a mixed modality wound closure. ------------------------------------------------------------------------------------------------------------------------------------ And now . . . examples of patients with
necrotizing fasciitis. This young woman had strep N.F., beginning around
the knee. The extremity is shown at a
point where, after a week or two of care, the wounds are ready for
closure. Drainage incisions of the
thigh and leg are closed by simple repair.
To avoid contractures or other scar problems across a joint, Integra
was used to reconstruct the missing skin.
It is shown a week or two after placement, a few weeks later when
fully regenerated and ready for split thickness overgrafts, and a few weeks
after completing the reconstruction. The patient had full range of motion in the knee,
with no late sequelae or followup surgery. |
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SLIDE SUMMARY:
This patient had Staph NF involving lower extremity, trunk, and upper
extremity. The illustrations show
various locations and stages of skin reconstruction, with good outcomes
following mixed modality surgery. ------------------------------------------------------------------------------------------------------------------------------------ This is the same patient first shown on Slide 13,
following staphylococcal fasciitis.
The problem began in a below knee amputation wound, and progressed to
involve the trunk, neck, and upper extremity, with the most sever destruction
in the shoulder and arm, and forearm. UPPER ROW - The shoulder and arm in various
stages of wound care and reconstruction.
A readily available flap was used for the most superior reconstruction
possible across a joint. Other areas
of the shoulder and arm were closed with Integra: easy, no donor sites, and
the superior option for covering bare muscle. MIDDLE ROW - The wrist and forearm were closed
with Integra, seen on the dorsum of the hand directly over extensor
tendons. The final result has thin
pliable skin - which is why Integra is considered a preferred reconstructive
option for the dorsum of the hand.
There is no scar, and no resistance to wrist flexion. BOTTOM ROW - The tibial stump is a deep wound
with a persistent intra-osseous bursa.
Flaps and skin grafts would have been problematic, failing to get
dependable tissue-to-tissue coaptation due to local geometry and tissue
mechanics. The CGM matrix was used for
bulk filling in the bursa, then covered with a “skin” layer of Integra. New tissue eventually filled the entire
matrix, with no complications nor further surgery. |
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SLIDE SUMMARY:
More patients with NF of various causes, each showing various stages
of closure and outcome, using conventional and Integra wound closure. ------------------------------------------------------------------------------------------------------------------------------------ UPPER - Two more views of the preceding
patient. On the left is healed Integra
over what had been an open knee joint.
On the right is healed Integra over flexor tendons of the
forearm. Tendons are locked by
inter-tendinous adhesions, but not because of tethering to the skin. LOWER LEFT - A man developed Clostridial
myofasciitis “gas gangrene” after lacerating his arm in a freshly manured
garden. Available local flaps near the
elbow were used for closure directly across the joint. Integra was used over exposed muscles and
tendons of the forearm. This is an
early result, within a month or two of the wound closure, showing
preservation of full-range tendon, muscle, and joint function - a testimonial
to the superior results that accrue to prompt thorough intervention, and then
reconstruction with the most suitable options. LOWER RIGHT - A comparable problem in an older
man with who developed strep N.F. following traumatic olecranon
bursitis. Comparable to the lower
extremity on Slide 25, drainage incisions have been closed directly, and
missing skin has been reconstructed with Integra, directly across the joint
and on bare muscle. No followup
reconstructive procedures were needed. |
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SLIDE SUMMARY:
This patient had aspergillus NF.
Debridement and initial skin reconstruction are shown. This 58 yo woman had active rheumatoid and was on
multiple anti-immune therapies. The
infarction and ulceration of the leg was acute, and accompanied by
severe systemic toxicity. The primary pathogen was Aspergillus. Initial debridements were followed by
complete wound excision and closure with Integra. ------------------------------------------------------------------------------------------------------------------------------------ Prior to Integra, amputation would have been the
safest and most rational management.
Extensive bone and tendon exposure would have required a free
flap. The patient was far to sick for
an major procedure. Skin grafts would
have failed in most areas. Integra is quick and easy to place, with no
physiological load or “hit” against the patient. Intensivist physicians managing her case
were impressed by the profound physiological improvements and general
cardiodynamic and pulmonary stability that occurred promptly after placing
the Integra. This is an effect
observed and reported by others for sick burn patient (see the Gottlieb
papers for a thorough bibliography).
By arresting inflammation in the large wound, the systemic
inflammatory syndromes, aka “septic syndromes” are quenched. The patient died after amphotericin induced renal
failure and the family’s refusal to start dialysis. However, the leg was obviously headed
toward an excellent healed reconstruction. |
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SLIDE SUMMARY: This patient had streptococcal N.F. with toxic shock syndrome. His acute and reconstructive management illustrate how the most desperately ill patients can have good expeditious outcomes based on aggressive curative surgery followed by reconstruction with modern skin replacement technologies. This final example is especially illustrative of
all major points to be made about the surgical management of necrotizing
fasciitis. ------------------------------------------------------------------------------------------------------------------------------------ This 33 yo man developed classic Group A
streptococcal necrotizing fasciitis - GAS NF - after an elective knee
arthroscopy. Streptococcal toxic shock
ensued rapidly, with fulminant wildfire progression of the disease. The process ultimately involved the whole
of both lower extremities and trunk, with extension to the neck and
shoulders. When seen in consultation,
the disease was rapidly progressing despite a limited “debridement” 24 hours
before. After consultation, the
patient went to the OR again, where one operation cured the disease. No further surgery was needed for the sake
of cure. The effects of streptococcal exotoxicity and
toxic shock must be appreciated. In
this case, intercurrent organ system injury resulted in transient lung,
liver,and renal injury, all of which were relatively mild and easily managed
as the patient recovered (in other patients, they can be of lesser or greater
severity). The most serious problem
for this patient was profound bone marrow suppression. Although this too recovered eventually, it
created substantial problems for maintaining circulating red call mass, along
with platelet levels and freedom from wound bleeding. The most serious effect was on white cell
mass. Recall that no wound can be closed until it meets
certain criteria of preparedness. This
means subsidence of inflammation and control of bioburden (bacteria counts
typical of healthy wounds, usually 102 -103 organisms
per gram of tissue). These wounds were
closed starting on day 9 after the curative debridement. In this case, the wounds has been packed in
Silvadene, periwound inflammation was gone, wound cultures and counts were
negative, the wounds were starting to proliferate a healthy reparative wound
module, and by all customary criteria, these were benign healthy wounds ready
for closure. YET - the patient was acting
severely septic. Blood pressure had
become progressively unsustainable, he was on maximum multi-pressor support,
and most of his physicians were quite convinced that death was imminent. The explanation for his septic status seems to be
related to his low white blood cell counts and huge wound areas. Total wound surface was measured at 150% of
body surface area (due to multiple open planes). Low, otherwise perfectly healthy wound
counts, combined with profound neutropenia, and integrated over a massive
wound area, seemed to create significant septicemic bacterial transients in
the blood. This was the only apparent
reason for his status, and this hypothesis is supported by his rapid
favorable response to wound closure with Integra. Wound closure with skin grafts and flaps was
impossible - the patient was far too unstable for any prolonged anesthesia or
further increase in wound area. For
severely ill patients, including burns and fasciitis, Integra has that virtue
of being quick, of unlimited availability, and having no donor sites or physiological
load on the patient. Within one hour
of placing Integra on a large percentage of the wounds, vital signs
stabilized, pressors were withdrawn, and the patient’s progress was all
“downhill” from there. This response
of rapid general improvement has been reported by several authors reporting
on Integra-CGM for burns. Major points to appreciate are: 1 - The fulminant, often fatal nature of the
disease can be understood. 2 - This is no business for amateurs or the faint
of heart. ONE OPERATION should cure
the disease. Adequate surgery the
first time would have prevented progression and near catastrophe. 3 - Streptococcal exotoxicity and toxic shock are
the killers. Some patients have strep
N.F. without the toxic shock. These
patients are easier to treat and most likely to survive. All N.F. patients need rapid thorough
excision and debridement, but for the ones with STSS, failure to be thorough
and complete is likely to result in death. 4 - Integra-CGM is a very high quality artificial
skin. When criteria for closure are
met, its effects on the wound and patient, free of donor sites and risk, have
made care easier, more effective, and safer. ------------------------------------------------------------------------------------------------------------------------------------ LEFT UPPER - A small portion of the overall
wounds, just prior to closure. The
wounds are clean and meet all of the usual criteria of a healthy wound ready
for closure. Note the massive
myoedema. LEFT 2ND - Integra in place, shortly afterwards
(left), and a few days later (right).
Note the wrinkles - due to rapid resolution of edema, and reduction in
tissue volume. LEFT 3RD - About 3 weeks later, the Integra is
regenerated and ready for split thickness skin overgrafts. At this point the, patient is generally
“healthy”, well past any of the acute or critical care activities. LEFT LOWER - About 2 months after injury, the
patient is healed. Unlike what would
have happened with conventional skin grafts, there are no contractures across
joints, nor tethered scars binding skin to muscle. No late revision or reconstruction was ever
needed (it would have been otherwise had conventional skin grafts been used). RIGHT - A series of similar views of the right
knee. From the top to the middle pane
is just a 5 day interval, showing the rapid physiological corrections in the
wound, with substantial loss of myoedema.
The bottom pane shows freedom from contractures and scar problems. |
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SUMMARY This presentation focused on the surgical aspects
of treating necrotizing fasciitis.
This reiterates the two major points: 1 - Surgical treatment must be prompt,
aggressive, and thorough. The disease
should be cured by one operation of drainage and excision. 2 - Surgeons who are unfamiliar with the arts of
plastic surgery need not be intimidated by excising and draining whatever is
infected. Skin loss is easy enough to
manage and reconstruct in patients whose lives have been saved. Modern skin reconstruction technologies,
introduced in the past decade, have brought unprecedented reliability and ease to the process of skin
restoration. These products provide
high quality acute “skin” replacement, while serving as the agent of
definitive skin restoration, often with superior scar free results which do
not need later revision. |
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END |
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