Original Article Submitted: 27.2.2017 Accepted: 13.6.2017 Conflict of interest None.
DOI: 10.1111/ddg.13337
Superiority of occipital donor sites for split-thickness skin grafting in dermatosurgery: Results of a prospective randomized controlled study
Maximilian Kovacs1,*, Syrus Karsai1, 2,*, Maurizio Podda1, 3 (1) Hautklinik, Klinikum Darmstadt GmbH Heidelberger Landstra.e 379 D-64297 Darmstadt (2) Klinik und Poliklinik für Hautkrankheiten Universitätsmedizin Greifswald Ferdinand Sauerbruchstraße D-17475 Greifswald (3) Klinik für Dermatologie Venerologie und Allergologie Universitätsklinik Frankfurt am Main Theodor-Stern-Kai 1 D- 60596 Frankfurt am Main *Both authors contributed equally to this manuscript.
Summary Background: Split-thickness skin grafts are commonly used in dermatosurgery. For occipital donor sites, retrospective studies have shown good results with respect to graft take and healing rates. Nevertheless, the majority of grafts in dermatosurgery are harvested from the thigh. To date, there has been no prospective randomized controlled study comparing occipital versus femoral donor sites. Patients and methods: Following micrographically controlled R0 tumor resection, 108 patients were randomized prior to undergoing split-thickness skin grafting (donor site: occiput vs. thigh). Follow-up examinations were carried out on day 3, 5, 7, and 14, as well as one month and three months after surgery. Documented data included graft take rates, re-epithelialization rates at the donor site, pain, cosmetic outcome, Vancouver Scar Scale (VSS), and complications. Results: Occipital donor sites showed significantly faster reepithelization, less pain, fewer complications, a better cosmetic outcome, and better results on the VSS. With regard to graft take rates, grafts harvested from the occiput were significantly superior on days 3 and 5. Conclusions: This is the first randomized controlled trial showing a significant superiority of occipital compared to femoral donor sites regarding re-epithelialization, pain, cosmetic outcome and the Vancouver Scar Scale.
Introduction As early as 3,000 years ago, the first successful skin grafts were described in the “Sushrata Samhita” texts in India. In modern times, the Marburg-based anatomist and surgeon Christian Heinrich Bünger was the first to describe a successful surgery involving skin grafting in humans: In 1817, he performed nasal reconstruction in a 33-year-old woman using an autologous skin graft from the inner thigh [1]. Given the easy harvesting technique and the low risk of infection, the extensor aspect of the thigh and the buttocks have been predominantly used as donor sites despite the fact that, since the 1960s, case series as well as retrospective studies on the use of occipital donor sites for split-thickness skin grafts have demonstrated good outcomes with regard to graft
take and complication rates as well as patient satisfaction [2–9]. To date, occipital donor sites have become established in the management of children and burn patients [3–5, 9]. In addition, they are used for combined defect closure [10, 11]. When using free skin grafts, rapid, complication-free re-epithelialization of the donor site and prompt graft take at the acceptor site are desirable. A donor site that combines these positive features would thus be preferable. Published data and the few non-controlled clinical observations suggest that split-thickness skin grafts harvested from the occiput are associated with faster healing rates, less pain, and a lower risk of scarring [2–10]. Given that there are still no controlled studies on donor site selection, we set out to conduct a prospective randomized controlled study in a homogeneous patient group.
© 2017 Deutsche Dermatologische Gesellschaft (DDG). Published by John Wiley & Sons Ltd. | JDDG | 1610-0379/2017
ddg13337_eng.indd 1
1
12/09/17 8:35 PM
Original Article Occipital donor site of split-thickness skin grafts
Patients and Methods Study protocol Over a period of twelve months (01/2014–01/2015), all patients of the Department of Dermatology at Darmstadt Medical Center scheduled for split-thickness skin grafting following micrographically controlled surgery were asked to participate in this monocenter study. The study protocol was based on the principles of evidence-based medicine; it was reviewed and approved by the ethics committee of the Hessen Regional Medical Council according to the standards of the Declaration of Helsinki (FF 132/2013). The study was registered in the German register for Clinical Trials (deutsches Register für klinische Studien, DRKS) (trial number 00006775). Patients were informed about the details of the study, possible risks, and therapeutic alternatives; inclusion and exclusion criteria were evaluated. Following written consent, patients were randomized into two groups: occipital versus femoral donor site. Included were adult patients capable of giving consent who required defect closure after micrographically controlled surgery. Exclusion criteria were immunosuppressive therapy, pregnancy, and alopecia at a potential occipital donor site. After harvesting the split-thickness skin graft under tumescent local anesthesia, follow-up exams were performed on days 3, 5, 7, 14, 30, and 90. The documentation included: graft take, re-epithelialization rate of the donor site, pain, cosmetic outcome, patient satisfaction as well as complications during the healing process such as alopecia, bleeding, pruritus, or dysesthesia. The quality of the scar at the donor and acceptor site were assessed on the basis of the validated Vancouver Scar Scale (VSS), which compares pigmentation, height, pliability, and vascularity of the scar with the surrounding skin, resulting in a total score [12, 13]. Graft take and healing rates were postoperatively assessed on days 3, 5, 7, 14, 30, and 90. The former was defined as vital graft with a rosy color, and given as percentage of the total size. The latter was defined as the rate of re-epithelialization, and given as percentage of the total size. Possible alopecia was documented using a 4-point nominal scale from 0 = no alopecia to maximum 3 = complete alopecia; said assessment was carried out on days 7, 30, and 90 post surgery. The donor site of the graft was examined for bleeding, dysesthesia, and pruritus on days 3, 5, 7, 14, 30, and 90. The overall cosmetic outcome of both donor site and graft was assessed using a 4-point nominal scale, which ranged from 4 = sufficient, 3 = satisfactory, 2 = good, to 1 = very good; the assessment was done on days 7, 30, and 90 post surgery.
2
To evaluate patient satisfaction, patients were asked on day 90 whether they would, in the same situation, again opt for this procedure or whether they would prefer secondary intention healing. In addition, patients were asked whether they would recommend this procedure to others with the same diagnosis and under the same circumstances. All data were obtained and evaluated by a principal investigator; for this purpose, patients presented at the hospital on the indicated dates.
Surgical procedure After shaving the occipital – respectively the femoral – region and marking the donor site, patients underwent local and tumescent local anesthesia (1,000 ml normal saline, 50 ml prilocaine 1 %, 1 ml epinephrine 0.1 %, 8 ml NaHCO3). Factors facilitating the harvesting of the split-thickness graft include the resultant hydrodissection to separate tissue planes as well as the application of a silicone spray (Asid Bonz GmbH, Germany), which acts as a lubricant, to the dermatome blade and donor site. In the next step, the free graft was harvested with an electrical hand-held dermatome (Acculan 3Ti, Aesculap, Tuttlingen, Germany). As standard, the depth of the donor site was 0.3 mm. The graft was attached to the wound margins with non-absorbable sutures (prolene; depending on the location: head 5/0, trunk 4/0, Ethicon, Germany). Wound management involved the use of non-adhesive wound dressings (Mepitel, Mölnlycke Health Care, Sweden) and pressure dressings, which were checked on a daily basis. In addition, polyvidone iodine ointment (PVP-iodine ointment, ratiopharm, Germany) was applied to the donor site. The first dressing change at the acceptor site was carried out on the third postoperative day. Dressing changes at the donor site were done on a daily basis starting from the second postoperative day; here, dexpanthenol-containing topical agents (panthenol ointment, ratiopharm, Germany) and non-adhesive wound dressings (Mepitel, Mölnlycke Health Care, Sweden) were used. During each dressing change, the wound was documented by photography (FotoFinder, Dermoscope, Germany, Figure 1).
Statistical analysis For both treatment groups, descriptive statistics were used to describe the quantitative parameters assessed during the various follow-up visits, including mean values and standard deviation, minimum and maximum values as well as quartiles; the parameters were analyzed for normal distribution by the Kolmogorov-Smirnov test. Given the significant deviations from a normal distribution, the U test was employed to analyze both treatment groups (occipital and femoral) as
© 2017 Deutsche Dermatologische Gesellschaft (DDG). Published by John Wiley & Sons Ltd. | JDDG | 1610-0379/2017
ddg13337_eng.indd 2
12/09/17 8:35 PM
Original Article Occipital donor site of split-thickness skin grafts
Figure 1 Healing of the donor site on postoperative days 3, 5, 7, 14, 30.
independent samples for significant differences with respect to the analyzed scales. Spearman's rank correlation was used to examine whether the size of the donor site had any effect on its healing rate and graft take. Description of ordinal and nominal data was done by stating absolute and percentage frequencies. Based on these parameters, contingency tables were used to compare both treatment groups. Employing the chi-squared test, it was thus possible to examine whether there were any differences in the respective frequency distributions. Alternatively, if the expected frequencies were too low, Fisher‘s exact test was used, and the chi-squared test for linear trend was carried out for ordinal parameters. We performed two-sided tests; a P value
DOI: 10.1111/ddg.13337
Superiority of occipital donor sites for split-thickness skin grafting in dermatosurgery: Results of a prospective randomized controlled study
Maximilian Kovacs1,*, Syrus Karsai1, 2,*, Maurizio Podda1, 3 (1) Hautklinik, Klinikum Darmstadt GmbH Heidelberger Landstra.e 379 D-64297 Darmstadt (2) Klinik und Poliklinik für Hautkrankheiten Universitätsmedizin Greifswald Ferdinand Sauerbruchstraße D-17475 Greifswald (3) Klinik für Dermatologie Venerologie und Allergologie Universitätsklinik Frankfurt am Main Theodor-Stern-Kai 1 D- 60596 Frankfurt am Main *Both authors contributed equally to this manuscript.
Summary Background: Split-thickness skin grafts are commonly used in dermatosurgery. For occipital donor sites, retrospective studies have shown good results with respect to graft take and healing rates. Nevertheless, the majority of grafts in dermatosurgery are harvested from the thigh. To date, there has been no prospective randomized controlled study comparing occipital versus femoral donor sites. Patients and methods: Following micrographically controlled R0 tumor resection, 108 patients were randomized prior to undergoing split-thickness skin grafting (donor site: occiput vs. thigh). Follow-up examinations were carried out on day 3, 5, 7, and 14, as well as one month and three months after surgery. Documented data included graft take rates, re-epithelialization rates at the donor site, pain, cosmetic outcome, Vancouver Scar Scale (VSS), and complications. Results: Occipital donor sites showed significantly faster reepithelization, less pain, fewer complications, a better cosmetic outcome, and better results on the VSS. With regard to graft take rates, grafts harvested from the occiput were significantly superior on days 3 and 5. Conclusions: This is the first randomized controlled trial showing a significant superiority of occipital compared to femoral donor sites regarding re-epithelialization, pain, cosmetic outcome and the Vancouver Scar Scale.
Introduction As early as 3,000 years ago, the first successful skin grafts were described in the “Sushrata Samhita” texts in India. In modern times, the Marburg-based anatomist and surgeon Christian Heinrich Bünger was the first to describe a successful surgery involving skin grafting in humans: In 1817, he performed nasal reconstruction in a 33-year-old woman using an autologous skin graft from the inner thigh [1]. Given the easy harvesting technique and the low risk of infection, the extensor aspect of the thigh and the buttocks have been predominantly used as donor sites despite the fact that, since the 1960s, case series as well as retrospective studies on the use of occipital donor sites for split-thickness skin grafts have demonstrated good outcomes with regard to graft
take and complication rates as well as patient satisfaction [2–9]. To date, occipital donor sites have become established in the management of children and burn patients [3–5, 9]. In addition, they are used for combined defect closure [10, 11]. When using free skin grafts, rapid, complication-free re-epithelialization of the donor site and prompt graft take at the acceptor site are desirable. A donor site that combines these positive features would thus be preferable. Published data and the few non-controlled clinical observations suggest that split-thickness skin grafts harvested from the occiput are associated with faster healing rates, less pain, and a lower risk of scarring [2–10]. Given that there are still no controlled studies on donor site selection, we set out to conduct a prospective randomized controlled study in a homogeneous patient group.
© 2017 Deutsche Dermatologische Gesellschaft (DDG). Published by John Wiley & Sons Ltd. | JDDG | 1610-0379/2017
ddg13337_eng.indd 1
1
12/09/17 8:35 PM
Original Article Occipital donor site of split-thickness skin grafts
Patients and Methods Study protocol Over a period of twelve months (01/2014–01/2015), all patients of the Department of Dermatology at Darmstadt Medical Center scheduled for split-thickness skin grafting following micrographically controlled surgery were asked to participate in this monocenter study. The study protocol was based on the principles of evidence-based medicine; it was reviewed and approved by the ethics committee of the Hessen Regional Medical Council according to the standards of the Declaration of Helsinki (FF 132/2013). The study was registered in the German register for Clinical Trials (deutsches Register für klinische Studien, DRKS) (trial number 00006775). Patients were informed about the details of the study, possible risks, and therapeutic alternatives; inclusion and exclusion criteria were evaluated. Following written consent, patients were randomized into two groups: occipital versus femoral donor site. Included were adult patients capable of giving consent who required defect closure after micrographically controlled surgery. Exclusion criteria were immunosuppressive therapy, pregnancy, and alopecia at a potential occipital donor site. After harvesting the split-thickness skin graft under tumescent local anesthesia, follow-up exams were performed on days 3, 5, 7, 14, 30, and 90. The documentation included: graft take, re-epithelialization rate of the donor site, pain, cosmetic outcome, patient satisfaction as well as complications during the healing process such as alopecia, bleeding, pruritus, or dysesthesia. The quality of the scar at the donor and acceptor site were assessed on the basis of the validated Vancouver Scar Scale (VSS), which compares pigmentation, height, pliability, and vascularity of the scar with the surrounding skin, resulting in a total score [12, 13]. Graft take and healing rates were postoperatively assessed on days 3, 5, 7, 14, 30, and 90. The former was defined as vital graft with a rosy color, and given as percentage of the total size. The latter was defined as the rate of re-epithelialization, and given as percentage of the total size. Possible alopecia was documented using a 4-point nominal scale from 0 = no alopecia to maximum 3 = complete alopecia; said assessment was carried out on days 7, 30, and 90 post surgery. The donor site of the graft was examined for bleeding, dysesthesia, and pruritus on days 3, 5, 7, 14, 30, and 90. The overall cosmetic outcome of both donor site and graft was assessed using a 4-point nominal scale, which ranged from 4 = sufficient, 3 = satisfactory, 2 = good, to 1 = very good; the assessment was done on days 7, 30, and 90 post surgery.
2
To evaluate patient satisfaction, patients were asked on day 90 whether they would, in the same situation, again opt for this procedure or whether they would prefer secondary intention healing. In addition, patients were asked whether they would recommend this procedure to others with the same diagnosis and under the same circumstances. All data were obtained and evaluated by a principal investigator; for this purpose, patients presented at the hospital on the indicated dates.
Surgical procedure After shaving the occipital – respectively the femoral – region and marking the donor site, patients underwent local and tumescent local anesthesia (1,000 ml normal saline, 50 ml prilocaine 1 %, 1 ml epinephrine 0.1 %, 8 ml NaHCO3). Factors facilitating the harvesting of the split-thickness graft include the resultant hydrodissection to separate tissue planes as well as the application of a silicone spray (Asid Bonz GmbH, Germany), which acts as a lubricant, to the dermatome blade and donor site. In the next step, the free graft was harvested with an electrical hand-held dermatome (Acculan 3Ti, Aesculap, Tuttlingen, Germany). As standard, the depth of the donor site was 0.3 mm. The graft was attached to the wound margins with non-absorbable sutures (prolene; depending on the location: head 5/0, trunk 4/0, Ethicon, Germany). Wound management involved the use of non-adhesive wound dressings (Mepitel, Mölnlycke Health Care, Sweden) and pressure dressings, which were checked on a daily basis. In addition, polyvidone iodine ointment (PVP-iodine ointment, ratiopharm, Germany) was applied to the donor site. The first dressing change at the acceptor site was carried out on the third postoperative day. Dressing changes at the donor site were done on a daily basis starting from the second postoperative day; here, dexpanthenol-containing topical agents (panthenol ointment, ratiopharm, Germany) and non-adhesive wound dressings (Mepitel, Mölnlycke Health Care, Sweden) were used. During each dressing change, the wound was documented by photography (FotoFinder, Dermoscope, Germany, Figure 1).
Statistical analysis For both treatment groups, descriptive statistics were used to describe the quantitative parameters assessed during the various follow-up visits, including mean values and standard deviation, minimum and maximum values as well as quartiles; the parameters were analyzed for normal distribution by the Kolmogorov-Smirnov test. Given the significant deviations from a normal distribution, the U test was employed to analyze both treatment groups (occipital and femoral) as
© 2017 Deutsche Dermatologische Gesellschaft (DDG). Published by John Wiley & Sons Ltd. | JDDG | 1610-0379/2017
ddg13337_eng.indd 2
12/09/17 8:35 PM
Original Article Occipital donor site of split-thickness skin grafts
Figure 1 Healing of the donor site on postoperative days 3, 5, 7, 14, 30.
independent samples for significant differences with respect to the analyzed scales. Spearman's rank correlation was used to examine whether the size of the donor site had any effect on its healing rate and graft take. Description of ordinal and nominal data was done by stating absolute and percentage frequencies. Based on these parameters, contingency tables were used to compare both treatment groups. Employing the chi-squared test, it was thus possible to examine whether there were any differences in the respective frequency distributions. Alternatively, if the expected frequencies were too low, Fisher‘s exact test was used, and the chi-squared test for linear trend was carried out for ordinal parameters. We performed two-sided tests; a P value
