THIS WEEK'S ARTICLES
How to Properly Manage Pressure-Induced Skin and Soft Tissue Injuries
This important process can help save your facility billions of dollars.
According to the U.S. Joint Commission on Patient Safety, pressure-induced skin and soft tissue injuries occur in 2.5 million patients in acute-care facilities annually and result in roughly 60,000 deaths each year. Another shocking statistic? The total annual cost of pressure injuries in the U.S. was estimated to be $11 billion in 2006 and $26.8 billion in 2016, with a median treatment cost of $27,000 per injury.
When it comes to the surgical management of pressure-induced skin and soft tissue injuries, an article recently published on UpToDate says providers must identify the clinical stage of the pressure injury before proceeding. Here are those six stages:
- Stage one. Skin is intact but with non-blanchable redness for greater than one hour after relief of pressure.
- Stage two. Blister or other break in the dermis with partial thickness loss of dermis, with or without infection.
- Stage three. Full-thickness tissue loss. Subcutaneous fat may be visible; destruction extends into muscle with or without infection. Undermining and tunneling may be present.
- Stage four. Full-thickness skin loss with involvement of bone, tendon or joint, with or without infection. Often includes undermining and tunneling.
- Unstageable. Full-thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed.
- Deep-tissue pressure injury. Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying tissue from pressure and/or shear.
The reconstruction of a pressure-induced injury usually involves the creation of a flap, which can be performed during the same surgery following debridement or in a subsequent procedure depending on the amount of tissue loss, completeness of debridement, presence of infection, nutritional status and general condition of the patient, and at the surgeon's discretion. Reconstructive surgery for pressure-induced injuries is known for a high rate of complications, which can be reduced with careful perioperative care and rehabilitation within a coordinated multidisciplinary system at centers accustomed to managing these difficult wounds.
When injuries occur, employ a multidisciplinary approach during the patient's episode of care, involving everyone from plastic and reconstructive surgeons, orthopedic surgeons and anesthetists to wound care and rehabilitation specialists.
How Did COVID-19 Impact Plastic Surgery?
Patients are more interested in cosmetic procedures now than before the pandemic.
The American Society of Plastic Surgeons (ASPS) recently released the 2020 results of its annual procedure survey. It gauged the perceptions of more than 1,000 American women about plastic surgery during the COVID-19 pandemic.
The survey found 11% of the women indicated they were more interested in cosmetic plastic surgery or non-surgical procedures during the pandemic than they were before COVID-19, with the number rising to 24% among women who'd already had surgery or a procedure.
Many women sought facial procedures during the first wave of pandemic, thanks to more people working from home. The pandemics' restrictions actually worked to these patients' advantage, in that they could recover "more discreetly" at home, and without having to take time off work. Tummy tucks (22%) and liposuction (17%) were among the top procedures women who are extremely or very likely to consider procedures within six months will seek, according to the survey — a possible result of "quarantine weight gain." Below are more results of the study:
- Most popular cosmetic surgical procedures in 2020: Nose reshaping (352,555 procedures), eyelid surgery (352,112 procedures), facelift (234,374 procedures), liposuction (211,067 procedures) and breast augmentation (193,073 procedures).
- Most popular cosmetic minimally invasive procedures in 2020: Botulinum toxin type A (4.4 million procedures), soft tissue fillers (3.4 million procedures), laser skin resurfacing (997,245 procedures), chemical peel (931,473 procedures) and Intense Pulsed Light (IPL) treatment (827,409 procedures).
- Most popular reconstructive procedures in 2020: Tumor removal (5.2 million procedures), laceration repair (386,710 procedures), scar revision (263,643 procedures), maxillofacial surgery (256,085 procedures) and hand surgery (206,928 procedures).
All told, 35% of women who previously had at least one cosmetic surgical procedure or minimally invasive procedure said they planned to spend more money on treatments in 2021 than they did in 2020. ASPS Past President Lynn Jeffers, MD, MBA, FACS, says that thanks to the COVID-19 vaccines, some plastic surgeons' offices are seeing higher demand.
Soft Tissue Injury Management in Plastic Surgery
The continuous external tissue expander improves surgical outcomes and patient satisfaction.
Plastic surgeons deal with a variety of complex wounds and soft tissue injuries that need careful consideration about how to treat these for the best possible outcomes. In fact, some injuries include massive soft tissue defects that may be further complicated by varying degrees of accompanying orthopedic and peripheral nerve damage. To address the severe soft tissue defect, various combinations of advanced reconstructive methods are typically required to achieve definitive wound coverage. Often surgeons need to exercise creativity when treating challenging wounds.
According to a report in the Annals of Plastic Surgery, soft tissue management with a continuous external expander has been used successfully to provide wound closure. The authors explain, "Continuous external tissue expansion has been used by our institution to significantly reduce wound burden and provide for definitive wound closure in certain blast-injured patients."1
The authors present an early series of 14 patients who suffered massive extremity soft tissue injuries and were treated with an external tissue expansion system (DERMACLOSE RC). Outcome measurements included time to definitive closure and the method of definitive wound closure. A 5-patient subset of this group was prospectively analyzed to determine measurements including initial wound surface area (WSA), percentage reduction in WSA and related complications.
According to the study, "Overall time to wound coverage ranged from 1 to 6 days, with mean time to wound coverage being 4.4 days. Of the 14 patients included in the series, 12 (85.7%) were able to undergo delayed primary closure, whereas 2 required split thickness skin grafting. In the 5-patient subgroup, WSA initially ranged from 20.25 to 1031.25 cm. Mean wound size was 262.7 cm. Decrease in WSA ranged from 44% to 93% of the initial WSA, with mean decrease being 74.3% (95% confidence interval, 57.33–91.3)."1
The results provided a tool to achieve effective wound closure. As the authors note, "In the management of large complex wounds, external tissue expansion has proven to be a valuable adjunct in achieving definitive wound closure. It can often aid in successful delayed primary closure of certain soft tissue wounds, has low associated morbidities, and can reduce the need for more complex or morbid procedures when used properly."1
Additionally, the authors propose an algorithm for the use of continuous external tissue expansion system to achieve successful wound closure, while potentially reducing the need for increased donor-site morbidities associated with more complex or larger reconstruction measures.
DERMACLOSE provides plastic surgeons with a tool to use their creativity when treating challenging wounds. Applications include:
- Fasciotomy repair
- ALT donor site wound closure
- Wound dehiscence
- Oncologic excisions
- Complex, non-healing wounds
- Scar revisions
The clinical benefits of DERMACLOSE include the following:
- Reduces time to closure
- Proven in multiple surgical specialties and applications
- Helps avoid skin grafts donor sites, and associated risks and complications
- Quickly becoming a standard of care for fasciotomy wounds
- Reduces time to closure, surgical complexity, and risk of open wound complications
- Improves surgical outcomes, cosmesis and patient satisfaction
1. Santiago, Gabriel F. MD; Bograd, Benjamin MD; Basile, Patrick L. MD; Howard, Robert T. MD; Fleming, Mark DO; Valerio, Ian L. MD, MS, MB, "Soft Tissue Injury Management With a Continuous External Tissue Expander, Annals of Plastic Surgery: October 2012 - Volume 69 - Issue 4 - p 418-421 doi: 10.1097/SAP.0b013e31824a4584
Is It Safe to Perform Plastic Surgery During a COVID-19 Surge?
The results of an online survey completed by Los Angeles plastic surgeons imply the coast is (mostly) clear.
Two great concerns held by many plastic surgeons during the initial phase of the COVID-19 pandemic was whether plastic surgery could further harm patients carrying the virus, and whether those patients would even opt for surgery as facilities began to reopen. A July 2020 online survey of board-certified Los Angeles plastic surgeons sought to take the specialty's temperature on these important issues.
More than 100 surgeons reported how many surgeries they'd performed since resuming operations (the total was more than 5,600); how many patients who tested negative preoperatively generated positive COVID-19 tests soon after surgery; and how many of their staff members had tested positive for COVID-19.
Overall, 92 percent of the surgeons had obtained preoperative COVID tests for every patient, with just 0.69% of patients testing positive preoperatively. Only seven of 5,380 surgical patients tested positive for COVID-19 within two weeks of their operation. Nine offices reported at least one staff member had developed COVID-19, but all of the cases were mild, with no hospitalizations or deaths.
Although the survey didn't cover the period in late fall and early winter when LA's COVID crisis was peaking, the results of the study are nevertheless positive for plastic surgeons and their patients. With no serious cases of postoperative COVID-19, no hospitalizations and no deaths, the survey results showed that plastic surgery could safely be performed during the pandemic. The survey results and analysis were published in the Aesthetic Surgery Journal.
Autologous Homologous Skin Constructs (AHSC) Can Regenerate Full-Thickness Skin
New technology offers promising results.
Split and full-thickness autologous skin grafts are ideal for treating large skin defects that aren't amenable to secondary healing, primary closure or local tissue rearrangement. However, it can be difficult to identify adequate donor sites for patients suffering for extensive wounds or burns. According to a recent case study, a new technology called autologous homologous skin constructs (AHSC) offers the chance of full-thickness skin regeneration from a small, full-thickness tissue sample.
AHSC reconstitutes autologous cells that remain functionally polarized, thus allowing important components of skin such as glands and hair follicles to regenerate. The study, published in the Plastic Surgery Case Studies journal, references two cases involving large pediatric wounds in which AHSC was used to regenerate functional full-thickness skin, including hair and glands, with minimal donor site morbidity.
Case one involved an 18-year-old woman who suffered an extensive degloving injury to her left dorsal foot and a left knee wound as a result of car accident. After the remainder of her trauma workup was negative, she was immediately taken to an OR for washout and debridement of the wounds. A small full-thickness skin graft was harvested from her lower abdomen and sent for processing two days after the accident. Five days after her accident, the AHSC product arrived and was applied to both injuries. The knee injury healed within four weeks postoperatively, and hair growth through the area of skin grafting was detected. After two months, the patient had nearly full epithelialization of her dorsal foot wound.
Case two involved a 10-year-old female with cerebral palsy and spastic diplegia who presented with a surgical site infection after an orthopedic procedure for leg length discrepancy. After being initially taken to the OR by orthopedics for debridement, she was left with a substantial soft tissue defect with exposed hardware. After flap reconstruction, a full-thickness skin graft was harvested from the ipsilateral thigh. Five days later, the AHSC product was applied, along with placement of a silicone gel membrane layer and wound vacuum-assisted closure (VAC). Less than two months later, the skin graft site was almost completely healed except for a 1-cm linear defect where the skin did not regenerate.
"Here, we have presented two cases of pediatric injuries in which AHSC was used to avoid donor site morbidity and regenerate functional skin," the authors concluded. "Although early case reports such as these are encouraging, additional studies are needed to determine the barrier function, longevity and long-term cosmetic outcome of this product."