ABSTRACT Pyoderma Gangrenosum (PG) is a neutrophilic dermatosis characterized by chronic painful ulcerations most commonly on the lower extremities. Current treatment options for PG are largely nonsurgical and include the use of systemic and topical immunomodulators and wound care. Wake Forest University School of Medicine Institutional Review Board Approval was obtained to perform a retrospective medical record review of PG patients from 2010 to 2023. Five patients, primarily female (80%) and Caucasian (60%), with a mean age of 68 ± 16 years at the time of first surgery met inclusion criteria. The average PG duration from diagnosis to STSG was 54 months (range of 9–20 months). Two patients required multiple grafts due to multiple PG lesions. Percent graft take ranged from 95% − 100% and the average time for total healing was 9 ± 5 weeks. While the sample size of this study may be limited due to controversial concerns with surgical intervention, it appears select patients may benefit from STSG for PG.

BACKGROUND:Skin cell suspension autograft (SCSA) is a point-of-care approach to wound management facilitating epithelialization while reducing burden associated with conventional autografting. Despite growing clinical use of SCSA across diverse wound etiologies, the global clinical evidence describing its use has not yet been comprehensively synthesized. METHODS:A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA) guidelines to identify studies between January 2000 and December 2024 reporting clinical use of SCSA for wound closure. Data on patient demographics, wound characteristics, and treatment methods were extracted. Clinical, safety, and health economic outcomes were extracted for comparative studies evaluating SCSA against control treatments. RESULTS:Ninety-nine studies across 13 countries were included. Across the overall dataset, SCSA was used alone or in combination with autografting for burns, surgical wounds, traumatic injuries, inflammatory conditions, and chronic wounds. Among comparative studies (n=27), SCSA consistently reduced donor skin, and healing outcomes favored SCSA in 61%, while 39% reported equivalent outcomes. Pain and esthetic outcomes more frequently favored SCSA, while safety outcomes were generally similar, with some studies favoring comparators. Health-economic outcomes suggested potential reductions in length of stay and resource utilization, although findings were variable across studies. CONCLUSION:The available global evidence supports SCSA as a versatile modality for supporting epidermal coverage across wound types and clinical contexts. However, the findings should be interpreted in the context of the limitations of this review, which include heterogenous study designs, variable outcome reporting, predominance of non-randomized data, and the absence of a formal quantitative analysis. Nevertheless, the demonstrated clinical and economic benefits in comparative studies reinforce the role of SCSA as an evidence-based innovation for burn and wound treatment.

Life- and limb-threatening musculoskeletal injuries are common in the trauma patient. These injuries frequently involve complex bone and soft tissue defects requiring reconstruction to minimize future functional impairment. The management of the patient with musculoskeletal injuries in tandem with other traumatic injuries necessitates multidisciplinary efforts to maximize patient outcomes. Flap reconstruction is indicated for injuries with large areas of exposed or denuded critical structures such as bone, tendon, neurovascular structures, and reconstructive hardware. The type and technique of tissue transfer is dependent on the characteristics of the wound itself, the status of periwound tissues, and the presence or absence of flap donor sites. Operative timing of flap procedures is dependent on the patient’s comorbidities, type and timing of other life-sustaining interventions, adequacy of wound débridement/preparation, flap type, and transfer technique planned. All of the above, in combination with appropriate postflap rehabilitation, results in high flap success rates and improved patient functionality.

BACKGROUND Traumatic insults, infection, and surgical procedures can leave skin defects that are not amenable to primary closure. Split-thickness skin grafting (STSG) is frequently used to achieve closure of these wounds. Although effective, STSG can be associated with donor site morbidity, compounding the burden of illness in patients undergoing soft tissue reconstruction procedures. With an expansion ratio of 1:80, autologous skin cell suspension (ASCS) has been demonstrated to significantly decrease donor skin requirements compared with traditional STSG in burn injuries. We hypothesized that the clinical performance of ASCS would be similar for soft tissue reconstruction of nonburn wounds. METHODS A multicenter, within-patient, evaluator-blinded, randomized-controlled trial was conducted of 65 patients with acute, nonthermal, full-thickness skin defects requiring autografting. For each patient, two treatment areas were randomly assigned to concurrently receive a predefined standard-of-care meshed STSG (control) or ASCS + more widely meshed STSG (ASCS+STSG). Coprimary endpoints were noninferiority of ASCS+STSG for complete treatment area closure by Week 8, and superiority for relative reduction in donor skin area. RESULTS At 8 weeks, complete closure was observed for 58% of control areas compared with 65% of ASCS+STSG areas ( p = 0.005), establishing noninferiority of ASCS+STSG. On average, 27.4% less donor skin was required with ASCS+ STSG, establishing superiority over control ( p < 0.001). Clinical healing (≥95% reepithelialization) was achieved in 87% and 85% of Control and ASCS+STSG areas, respectively, at 8 weeks. The treatment approaches had similar long-term scarring outcomes and safety profiles, with no unanticipated events and no serious ASCS device-related events. CONCLUSION ASCS+STSG represents a clinically effective and safe solution to reduce the amount of skin required to achieve definitive closure of full-thickness defects without compromising healing, scarring, or safety outcomes. This can lead to reduced donor site morbidity and potentially decreased cost associated with patient care. Clincaltrials.gov identifier: NCT04091672 LEVEL OF EVIDENCE Therapeutic/Care Management; Level I.

Current treatments for deep tissue burns are limited, and most serve only to enhance hydration or prevent bacterial growth. This leaves burn healing dependent on slow natural processes to debride the wound and reestablish the epidermal and dermal layers of the skin. Infections are well known to destabilize this process through a variety of mechanisms, most notably through increased inflammation and the resulting oxidative stress. In this study, we show that ARAG (an antioxidant-rich antimicrobial gel) can suppress the growth of multiple bacteria commonly found to infect burns (Klebsiella pneumoniae, Proteus vulgaris, Pseudomonas aeruginosa, and Staphylococcus aureus). This inhibition is comparable to that conferred by silver ion release from burn dressings such as Mepilex-Ag. We further show, using a porcine model for deep partial-thickness burns, that ARAG allows for enhanced wound healing over Mepilex-Ag, the current standard of care. Histological findings indicate this is likely due to increased wound debridement and dampening of late inflammatory processes, leading to more balanced physiologic healing. Taken together, these findings show promise for ARAG as a superior alternative to the current standard of care.

Introduction:The aim of this study was to evaluate effectiveness of sterified hyaluronic acid matrix (eHAM) for treating chronic wounds.Hyaluronic acid (HA) is an extra cellular polysaccharide found in every human tissue and body fluid.The benefits of using eHAM for chronic wounds still needs to be investigated. Methods:We are presenting the patients we have treated in our wound care center.Choice of patients was based on clinical grounds where clinic an felt that tissue growth needed to be stimulated and based on availability of the product in clinic and failure of routine treatment modalities.We recorded patient demographics, associated health conditions, wound measurements and characteristics.eHAM was used for full thickness wound safterad quated ebridement and making sure the wound is free of infection.Patients were followed weekly and were corded wound dimensions, pain level, comfort and tolerability.Digital photography was used to document wound progress.

Bioprinting is a promising alternative method to generate skin substitutes because it can replicate the structural organization of the skin into biomimetic layers in vitro. In this study, six primary human skin cell types were used to bioprint a trilayer skin construct consisting of epidermis, dermis, and hypodermis. Transplantation of the bioprinted skin with human cells onto full-thickness wounds of nu/nu mice promoted rapid vascularization and formation of epidermal rete ridges analogous to the native human epidermis, with a normal-looking extracellular matrix. Cell-specific staining confirmed the integration of the implanted cells into the regenerated skin. Using a similar approach, a 5 centimeter–by–5 centimeter bioprinted autologous porcine skin graft was transplanted onto full-thickness wounds in a porcine excisional wound model. The bioprinted skin graft improved epithelialization, reduced skin contraction, and supported normal collagen organization with reduced fibrosis. Differential gene expression demonstrated pro-remodeling protease activity in wounds transplanted with bioprinted autologous skin grafts. These results demonstrate that bioprinted skin can support skin regeneration to allow for nonfibrotic wound healing and suggest that the skin bioprinting technology may be applicable for human clinical use.

INTRODUCTION:Identifying a bioindicator of healing capacity would be beneficial in guiding treatment of and reducing morbidity in patients with DFU. Hypoalbuminemia is a well-established risk factor for amputation and, thus, a promising candidate. OBJECTIVE:This study was conducted to examine whether albumin values over a 12-week treatment course for DFU correlated with ulcer size and outcomes. MATERIALS AND METHODS:A retrospective review was conducted of 793 patients who presented to the Atrium Health Wake Forest Baptist Wound Care and Hyperbaric Center between 2010 and 2022. Sixty-two patients met the inclusion criteria. Albumin values and wound size data were collected monthly over a 12-week treatment course. RESULTS:Initial albumin values were not significantly different between patients healed by 12 weeks compared with nonhealed patients. Healed proportion and average initial ulcer size in patients with at least 1 hypoalbuminemia value (<3.0 g/dL) were not significantly different from those in patients with normal albumin levels. Patients who trended from normoalbuminemia to hypoalbuminemia displayed significantly increased wound sizes compared to patients with albumin changes within the normal range (0.04 cm² and -1.17 cm², respectively; P < .05). Monthly changes in albumin correlated poorly with wound healing (r = 0.144, P = .240), and large negative albumin trends (>0.5 g/dL per month) did not correlate with increased wound sizes compared with stable or positive trends. CONCLUSION:Albumin's utility as a bioindicator of short-term healing capability is limited to below-normal values.

BACKGROUND:Exposing a healthy wound bed for skin grafting is an important step during burn surgery to ensure graft take and maintain good functional outcomes. Currently, the removal of non-viable tissue in the burn wound bed during excision is determined by expert clinician judgment. Using a porcine model of tangential burn excision, we investigated the effectiveness of an intraoperative multispectral imaging device combined with artificial intelligence to aid clinician judgment for the excision of non-viable tissue. METHODS:Multispectral imaging data was obtained from serial tangential excisions of thermal burn injuries and used to train a deep learning algorithm to identify the presence and location of non-viable tissue in the wound bed. Following algorithm development, we studied the ability of two surgeons to estimate wound bed viability, both unaided and aided by the imaging device. RESULTS:The deep learning algorithm was 87% accurate in identifying the viability of a burn wound bed. When paired with the surgeons, this device significantly improved their abilities to determine the viability of the wound bed by 25% (p = 0.03). Each time a surgeon changed their decision after seeing the AI model output, it was always a change from an incorrect decision to excise more tissue to a correct decision to stop excision. CONCLUSION:This study provides insight into the feasibility of image-guided burn excision, its effect on surgeon decision making, and suggests further investigation of a real-time imaging system for burn surgery could reduce over-excision of burn wounds.

Clinical application of skin substitute is typically a two-stage procedure with application of skin substitute matrix to the wound followed by engraftment of a split-thickness skin graft (STSG). This two-stage procedure requires multiple interventions, increasing the time until the wound is epithelialised. In this study, the feasibility of a one-stage procedure by combining bioengineered collagen-chondroitin-6-sulfate (DS1) or decellularised fetal bovine skin substitute (DS2) with autologous skin cell suspension (ASCS) in a porcine full-thickness wound healing model was evaluated. Twelve full-thickness excisional wounds on the backs of pigs received one of six different treatments: empty; ASCS; DS1 with or without ASCS; DS2 with or without ASCS. The ASCS was prepared using a point-of-care device and was seeded onto the bottom side of DS1, DS2, and empty wounds at 80 000 cells/cm(2). Wound measurements and photographs were taken on days 0, 9, 14, 21, 28, 35, and 42 post-wounding. Histological analysis was performed on samples obtained on days 9, 14, 28, and 42. Wounds in the empty group or with ASCS alone showed increased wound contraction, fibrosis, and myofibroblast density compared with other treatment groups. The addition of ASCS to DS1 or DS2 resulted in a marked increase in re-epithelialisation of wounds at 14 days, from 15 +/- 11% to 71 +/- 20% (DS1 vs DS1 + ASCS) or 28 +/- 14% to 77 +/- 26 (DS2 vs DS2 + ASCS) despite different mechanisms of tissue regeneration employed by the DS used. These results suggest that this approach may be a viable one-stage treatment in clinical practice.

Facial burns present a challenge in burn care, as hypertrophic scarring and dyspigmentation can interfere with patients' personal identities, ocular and oral functional outcomes, and have long-term deleterious effects. The purpose of this study is to evaluate our initial experience with non-cultured, autologous skin cell suspension (ASCS) for the treatment of deep partial-thickness (DPT) facial burns. Patients were enrolled at a single burn center during a multicenter, prospective, single-arm, observational study involving the compassionate use of ASCS for the treatment of large total BSA (TBSA) burns. Treatment decisions concerning facial burns were made by the senior author. Facial burns were initially excised and treated with allograft. The timing of ASCS application was influenced by an individual's clinical status; however, all patients were treated within 30 days of injury. Outcomes included subjective cosmetic parameters and the number of reoperations within 3 months. Five patients (4 males, 1 female) were treated with ASCS for DPT facial burns. Age ranged from 2.1 to 40.7 years (mean 18.2 +/- 17.3 years). Average follow-up was 231.2 +/- 173.1 days (range 63-424 days). Two patients required reoperation for partial graft loss within 3 months in areas of full-thickness injury. There were no major complications and one superficial hematoma. Healing and cosmetic outcomes were equivalent to, and sometimes substantially better than, outcomes typical of split-thickness autografting. Non-cultured, ASCS was successfully used to treat DPI facial burns containing confluent dermis with remarkable cosmetic outcomes. Treatment of DPT burns with ASCS may be an alternative to current treatments, particularly in patients prone to dyspigmentation, scarring sequelae, and with limited donor sites.

BACKGROUND: Reconstruction of facial skin defects remains a clinical challenge. With aging, ptosis of tissue over fixed structures creates an important facial feature known as the tear trough. This study aimed to evaluate the efficacy and aesthetic outcome of a novel surgical technique that reproduced this facial feature while avoiding ectropion during midfacial skin defect repair. METHODS: Nineteen patients with midfacial skin defects received local flap reconstruction combined with an anchoring suture. The flap was designed in a unilateral pedicled V-Y pattern. When the flap was advanced to cover the defect, one or two sutures that connected the dermis of the flap with the infraorbital periosteum were made to reproduce the tear trough line. RESULTS: Midfacial defects were successfully repaired with the V-Y flap in all 19 patients. No lower eyelid ectropion or conspicuous scars were noted in any of the patients. Further, the tear trough was successfully reconstructed in each patient. Facial symmetry was maintained with static positioning and animation. CONCLUSIONS: The combination of local V-Y flap reconstruction with anchoring sutures to reproduce facial feature lines is an effective technique in midfacial skin defect repair.

Vitamin A is a general term for retinoids. Vitamin A deficiency leads to a variety of cutaneous manifestations. It also functions as a hormone through retinoic acid receptors altering the activity of multiple cell lines. Pancreatic vitamin A levels are critical for retinoid signaling and normal pancreatic control of glucose. Vitamin A deficiency is more common during infection, and supplementation reduces severe morbidity and mortality from infectious diseases. Vitamin A modulates activities at the cellular level and, via its interrelationship with hormones such as thyroid, insulin, and corticosteroids, has diffuse metabolic effects on the body. It plays an important role in all stages of wound healing. Vitamin A is known for its ability to stimulate epithelial growth, fibroblasts, granulation tissue, angiogenesis, collagen synthesis, epithelialization, and fibroplasia. Local (topical) and systemic supplementation with vitamin A has been proven to increase dermal collagen deposition. There are numerous animal studies and limited human studies regarding physiologic effect of vitamin A on acute or chronic wounds via systemic or topical administration. The most common use of vitamin A supplementation is to offset steroids’ effect. When considering supplementation, the potential benefits must be weighed against the risk of harm. Vitamin A toxicity can be critical and even result in death. The evidence for supplementation with vitamin A is currently limited to expert opinion and is not backed up by rigorous trials. There is an acute need for therapeutic trials with vitamin A supplementations.

BACKGROUND Hydrotherapy plays an important role in the management of surgical patients, and especially so in those that have sustained burns to their skin. Different centers practice hydrotherapy differently. At the University Teaching Hospital in Lusaka, Zambia, patients with burns in surgical wards use a common bathtub for cleaning their wounds. This breaches patient isolation and increases risk of cross-infection. Audit records from the department of surgery show that burn wound colonization and infection is an important source of morbidity and mortality. However, there is no evidence yet that the hydrotherapy as practiced at our institution does lead to cross infection among patients with burns. OBJECTIVE The general objective was to determine if the hydrotherapy practice plays a role in cross-infection. We also wanted to characterize these organisms being spread by cross-infection. METHODS This was a prospective analytical study. Patients meeting the admission criteria were recruited. Swabs from the burn wounds were collected on admission (day 0), day 4 and day 7. Weekly swabs of the bathtub were also collected, after the tub had been cleaned and declared ready for the next patient. Weekly water samples were also collected. Selected results, for Staphylococcus aureus and Klebsiella pneumoniae, were subjected to further analysis and PCR. Results were analyzed using statistics software, SPSS version 23. RESULTS In this study, there were 96 participants of which 51 (53.1%) were males and 45 (46.9%) were females. Age distribution ranged from 5months old to 91 years old. The modal age range was 1 to 2 years old. The modal burn percentage was 6% to 10%, followed by 11 to 15%. Hot water was the cause of burns in 65.6%. Staphylococcus aureus and Klebsiella pneumoniae were the commonest organisms isolated. These came from wounds that looked clinically clean. Others were enteric organisms. In terms of readily available antibiotics, there was more sensitivity to Amikacin and Chloramphenicol than Ciprofloxacin (our commonly used antibiotic). The bathtub also had Staphylococcus aureus and Klebsiella pneumoniae, besides enteric organisms. Sixty five point four percent (65.4%) of the Klebsiella were ESBL v producers. The tub had samples that were both ESBL producers as well as widely resistant Klebsiella by other means. Of the ESBLs, 29.4% had the SHV gene, 23.5% had the TEM gene and 47.1% had both SHV and TEM. There was no CTX gene identified. MRSA accounted for 30.6% of all the Staphylococcus in this study. The PVL gene was detected in 11.8%, SPA gene in 35.3%, while 5.9% of the Staphylococcus had both PVL and SPA genes. No growth was obtained from the water samples. Seventy-two point nine percent (72.9%) of the patients were discharged, 19.8% died, while 7.3% left against medical advice. CONCLUSION Hydrotherapy as currently practiced at the University Teaching Hospital does contribute significantly to cross-infection among burns patients. The organisms transmitted are widely resistant…