Cherubino, M.

Maggiulli, F.

Pellegatta, I.

Scamoni, S.

Valdatta, L.

CHERUBINO, MARIO

VALDATTA, LUIGI

Archivio istituzionale della ricerca - Università dell'Insubria

Vol. 68 - No. 5 MINERVA CHIRURGICA 1The aetiology considered in the study was cover-age of defects after removal of massive skin cancer. The localization of the wounds is exemplified in the Table I.The average area grafted was 185cm2 (range from 48 to 303 cm2), and grafts were 0.2 to 0.3 cm thick.In 30 % of cases we meshed the grafts 1:3 and we used sutures stitches and staples almost in all cases.The skin graft and donor site were covered by non-adherent dressing and a secondary medication of sterile gauzes over it. Skin grafts dressing were removed 5 days after surgery.The percentage of the graft adherence was clini-cally evaluated and estimated thanks to a digital soft-ware (Bersoft Software Measurent 8.15) (Figure 1).At an average follow up of 78 days, in 28 out of 33 patients (84.8%) more than 95% of the graft dimension adhered. In 3 out of the 5 cases where graft adherence was less of 95% (Table II), the graft was positioned over skull bone, after tumour exci-sion that reached the periosteal tissue. In one case the skin graft was applied after removal of a tumour of the cheek invading the superficial lobes of the parotid gland, where salivary secretion probably impaired the adhesion of the graft and the surgi-cal sealant effectiveness. In the last case graft did not adhere completely due to the not oncologically radical excision (debulking) of the tumor and its coherent growth after skin graft application.In the 28 positive cases, the common complica-tions of skin grafting (such as necrosis, infection, sliding, haematomas and seromas) were not ob-served.TO THE EDITOR: Skin grafting is one of the most used technique for wound coverage.1 The main fac-tor in graft adherence is the condition of the wound bed, that must be well vascularized. The same im-portance has the prevention of the haematoma or seroma development in the contact between the skin graft and the wound bed. In order to avoid these conditions, classical “tie over bolster” is an ad-visable technique to achieve an optimal adhesion. For the same principles, it is also recommended to mesh the grafts and put a compressive dressing.2In case of extended wound and in difficult areas where is not easy to gain a three-dimensional recon-struction (for example in lower limb reconstruction, hand surgery, post traumatic and burn surgery), the use of the classical methods are difficult to achieve and not always satisfactory.3In these cases, wound healing could be impaired causing a partial adhesion of the graft.Nowadays more and more experimental evidenc-es 4 suggest that fibrin glue should be considered as component of skin-graft management.Human fibrin glue provides manifold advantag-es combined with skin grafting. Firstly, fibrin glue preparation is easy and fast. The solutions are ac-cessible to the operating room and easily prepared by the circulating nurse or scrub technician.We describe the use of Quixil®, a sealant based on fibrin derived from human plasma, for skin grafts fixation on large defects due to the removal of mas-sive skin cancers.We selected 33 patients with extended skin can-cer in which reconstruction with flaps was not rec-ommendable considering their comorbidities and the extension of the defect after tumour excision. We compared this group to other 61 patients, simi-lar in ages and clinical condition, where split thick-ness grafts were applied without fibrin glue.Between February 2009 and February 2012, 33 patients (20 males and 13 females) was treated with human fibrin glue combined with skin grafting. This includes patients with an average age of 83 years (range from 71 to 98 years). We chose grafts as reconstruction method instead of flaps consider-ing old ages of the patients, their comorbidities and large extension of the defects.Anno: 2013Mese: ??Volume: 68No: 5Rivista: MINERVA CHIRURGICACod Rivista: MINERVA CHIRLavoro: 5934-MCtitolo breve: USE OF HUMAN FIBRIN SEALANT IN LARGE SPLIT THICKNESS SKIN GRAFTINGprimo autore: CHERUBINOpagine: 1-25934-MCCORRESPONDENCEUse of human fibrin sealant in large split thickness skin grafting after massive skin tumour excisionMINERVA CHIRURGICA 2013;68:1-2Table I.—Sites of skin tumors.Localizazion N. of casesUpper limb  6Lower limb  6Head 15Pelvis  1Neck  2Trunk  2Buttocks  1PROOFMINERVA MEDICAPROFF ID.indd   1 10/09/10   14:282 MINERVA CHIRURGICA ?? 2013CHERUBINO USE OF HUMAN FIBRIN SEALANT IN LARGE SPLIT THICKNESS SKIN GRAFTINGFigure 2.—Seventy-eight year patient with skin tumor excision and reconstruction with split thickness skin graft and human fibrin sealant.Figure 1.—Preparation of split thickness grafts with fibrin sealant.PROOFMINERVA MEDICAPROFF ID.indd   1 10/09/10   14:28Vol. 68 - No. 5 MINERVA CHIRURGICA 3USE OF HUMAN FIBRIN SEALANT IN LARGE SPLIT THICKNESS SKIN GRAFTING CHERUBINOF. MAGGIULLIDivision of Plastic and Reconstructive Surgery, University of Insubria, Ospedale di Circolo and Fondazione Macchi, Varese, ItalyI. PELLEGATTADivision of Plastic and Reconstructive Surgery, University of Insubria, Ospedale di Circolo and Fondazione Macchi, Varese, Italyigor.pellegatta@me.comL. VALDATTADivision of Plastic and Reconstructive Surgery, University of Insubria, Ospedale di Circolo and Fondazione Macchi, Varese, Italy MINERVA MED 2013;102:1-2Received ???Accepted for publication ???References 1. Clark RA. Fibrin sealant in wound repair: a systematic survey of the literature. Expert Opin Investig Drugs 2000;9:2371-92. 2. Ogawa R, Hyakusoku H, Ono S. Useful tips for suc-cessful skin grafting. J Nippon Med Sch 2007;74:386-92. 3. Gibran N, Luterman A, Herndon D, Lozano D, Green-halgh DG, Grubbs L et al. Comparison of fibrin seal-ant and staples for attaching split-thickness autolo-gous sheet grafts in patients with deep partial- or full-thickness burn wounds: a phase 1/2 clinical study. J Burn Care Res 2007;28:401-8. 4. Currie LJ, Sharpe JR, Martin R. The use of fibrin glue in skin grafts and tissue-engineered skin replace-ments: a review. Plast Reconstr Surg 2001;108:1713-26. 5. Ali SN, Moiemen NS. Use of Quixil human surgical sealant in achieving hemostasis on a skin graft recipi-ent site of a fully heparinized patient. Plast Reconstr Surg 2006;117:339-40.During our period of observation (from February 2009 and February 2012) we followed 61 “over 65” (range from 66 to 94 years) patients who underwent extended tumor excision with reconstruction with split thickness grafts without using fibrin sealant. Patients with complete adhesion (>95%) of the graft were 72%. In the other patients (17 out of 61) the technique failed due to infection (30%, 5 patients), haematoma (17%, 3 patients), sliding of the graft (47%, 8 patients) and seroma (6%, 1 patient) (Figure 2).Analyzing the results obtained and comparing the two groups, we think that human fibrin sealant should be used in three dimensional defects (for example in anatomical fold) or when the defect is extended and fixation with staples or tie over dress-ing could be inadequate.The major problem of fibrin sealant is the addi-tional cost for the product.We believe that, in the complications of split thickness graft more common in the conditions just illustrated, the occurence of complication as infec-tion, haematoma, seroma would require a long term medication of the recipient zone increasing the total cost of the single patient management.The results observed in our patients suggest how human fibrin sealant could be taken in considera-tion in split thickness grafting reconstruction tech-nique where defect after tumour excision is extend-ed or it has a three dimensional shape.M. CHERUBINODivision of Plastic and Reconstructive Surgery, University of Insubria, Ospedale di Circolo and Fondazione Macchi, Varese, ItalyS. SCAMONIDivision of Plastic and Reconstructive Surgery, University of Insubria, Ospedale di Circolo and Fondazione Macchi, Varese, ItalyTable II.—Description of the 5 unsuccessful cases.Age Sex Diagnosis Location Grafted area cm2 Adherence (%)83 M Squamous cell carcinoma Scalp 100 8086 M Squamous cell carcinoma Scalp 160 7079 M Squamous cell carcinoma Scalp  90 8071 F Squamous cell carcinoma Cheek 130 5073 M Squamous cell carcinoma Ankle 100 50ROFMINERVA MEDICAPROFF ID.indd   1 10/09/10   14:28

Use of human fibrin sealant in large split thickness skin grafting after massive skin tumour excision.

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