| Abstract | Uvod: Lokalni nasumični kožni režnjevi te autotransplantati pune debljine kože (engl. full
thickness skin graft, FTSG) i djelomične debljine kože (engl. split thickness skin graft, STSG)
svakodnevne su kirurške tehnike koje se koriste za rekonstrukciju kožnih defekata. Posebno su
potrebni i korišteni u rekonstrukciji lica zbog svoje svestranosti. Iako su njihove kliničke prednosti
i nedostaci dobro poznati, još uvijek postoje neizvjesnosti u pogledu njihovih dugoročnih rezultata,
osobito nakon faze remodeliranja u procesu cijeljenja rane. Nadalje, većina prethodnih studija
koristila je samo subjektivne alate za procjenu kože, dok se nedavno za procjenu kože primjenjuju
kvantitativni objektivni alati.
Cilj: Glavni cilj ove studije bio je usporediti, nakon faze remodeliranja kože, razinu melanina,
eritema, sebuma, hidracije, frikcije i transepidermalnog gubitka vode (engl. Transepidermal water
loss, TEWL) između skupine čiji su defekti lica rekonstruirani nasumičnim lokalnim režnjevima
kože, skupina čiji su defekti lica rekonstruirani autotransplantatom kože pune debljine i skupina
čiji su defekti lica rekonstruirani autotransplantatom kože djelomične debljine. Nadalje,
sekundarni cilj bio je procijeniti subjektivnu kvalitetu kože nakon faze remodeliranja korištenjem
validiranih instrumenata upitnika nakon rekonstrukcije s nasumičnim lokalnim režnjevima kože,
FTSG-ovima i STSG-ovima. Na kraju, cilj nam je bio usporediti razine melanina, eritema, sebuma,
hidratacije, frikcije i transepidermalnog gubitka vode nakon remodeliranja između rekonstruiranog
mjesta lica s nasumičnim lokalnim režnjem kože, FTSG-om i STSG-om u usporedbi sa zdravom
kontralateralnom stranom lica.
Metode: Studija je obuhvatila 31 facijalni defekt rekonstruiran lokalnim nasumičnim režnjem, 30
facijalnih defekata rekonstruiranih STSG-ovima i 30 facijalnih defekata rekonstruiranih FTSGovima.
Sudionici su uključeni u studiju tijekom kontrolnih pregleda. Svi uključeni sudionici bili
su operirani zbog karcinoma bazalnih stanica (BCC) ili karcinoma skvamoznih stanica (SCC).
Nadalje, sva tri rekonstrukcijska zahvata provedena su u Zavodu za maksilofacijalnu kirurgiju
KBC-a Split, prema standardnim kirurškim protokolima i smjernicama. Kvalitetu kože objektivno
je procijenio isti iskusni istraživač pomoću MP6 instrumenta za procjenu kvalitete kože (Courage
+ Khazaka GmbH, Köln, Njemačka). Instrument procjenjuje TEWL, melanin, eritem, sebum,
frikciju i hidraciju pomoću neinvazivnih sondi. Subjektivna procjena provedena je korištenjem
Manchesterske skale ožiljka (engl. Manchester scar scale, MSS), Vankuverske skale ožiljka (engl. Vancouver scar scale, VSS) i Skale za procjenu ožiljka pacijenta i promatrača (engl. Patient and
observer scar assessment scale, POSAS).
Rezultati: Nije bilo značajnih razlika u pogledu objektivnih parametara kože između nasumičnih
lokalnih režnjeva i zdrave kontralateralne strane za sve testirane parametre. Međutim, FTSG i
STSG pokazali su značajno više razine eritema i TEWL, a obje su skupine pokazale značajno niže
razine hidracije, sebuma i frikcije u usporedbi sa zdravom kontralateralnom stranom. Međutim,
samo su bolesnici sa STSG imali značajno veću količinu melanina (p < 0,001). Nadalje, nakon
procjene Δ između zdrave kontralateralne strane i rekonstruiranog mjesta, postojala je statistički
značajna razlika melanina (H = 69,498; p < 0,001), eritema (H = 44,244; p < 0,001), hidracije (H
= 53,589; p < 0,001), sebum (H = 56,315; p < 0,001), frikcije (H = 14,017; p < 0,001) i TEWL (H
= 42,965; p < 0,001). Postojala je statistički značajna razlika između sve tri skupine u subjektivnim
procjenama pomoću VSS (H=65,12 ; p < 0,001), MSS (H=62,88 ; p < 0,001) te POSAS-a prema
i pacijentu (H=62,61 ; p < 0,001) i promatraču (H=59,25; p < 0,001).
Zaključak: Rezultati ove studije pokazali su da nije bilo značajnih razlika u količini melanina,
eritema, hidracije, razine sebuma, frikcije i TEWL između mjesta rekonstruiranog nasumičnim
lokalnim režnjevima i istog mjesta na zdravoj kontralateralnoj strani lica. Međutim, FTSG i STSG
imali su značajno više razine TEWL i eritema, dok su razine hidracije, sebuma i frikcije bile
značajno niže u usporedbi sa zdravom kontralateralnom stranom. STSG su također imale veću
količinu melanina u usporedbi sa zdravom kontralateralnom stranom. S obzirom na razlike (Δ)
između zdravog i rekonstruiranog mjesta, rezultati su pokazali značajnu razliku između tri metode
rekonstrukcije u svim parametrima. Štoviše, skupina nasumičnih lokalnih režnjeva imala najniži
Δ, dok je STSG skupina imala najviši Δ s obzirom na sve procijenjene parametre kvalitete kože.
Nadalje, kada se uspoređuju subjektivne ljestvice za kvalitetu kože i ožiljak, rezultati su pokazali
da lokalni nasumični režnjevi kože imaju najniže i najbolje rezultate u VSS, MSS i POSAS. S
druge strane, FTSG su imali statistički značajno bolje rezultate, dok su STSG imali statistički
značajno najviše ili najlošije rezultate. |
| Abstract (english) | Background: Local random skin flaps and both full-thickness skin grafts (FTSG) and splitthickness
skin grafts (STSG) are everyday surgical techniques used to reconstruct skin defects.
They are especially needed and use in facial reconstruction due to their versatility Even though
their clinical advantages and disadvantages are well known, there are still uncertainties with
respect to their long-term results, especially after the remodeling phase of the wound healing
process. Furthermore, most of the previous studies used only subjective skin evaluation tools while
recently quantitative objective tools are implemented for skin assessment.
Aims of the study: The main objective of this study was to compare, after the remodeling phase
of wound healing process, the level of melanin, erythema, sebum, hydration, friction and
transepidermal water loss (TEWL) between the group whose facial defects were reconstructed
with random local skin flaps, the group whose facial defects were reconstructed with full-thickness
autograft skin, and the group whose facial defects were reconstructed partial thickness skin
autograft. Furthermore, the secondary goal was to assess subjective skin quality after the
remodeling phase using validated instruments after reconstruction with random local skin flaps,
FTSGs, and STSGs. Lastly, we aimed to compare post-remodeling levels of melanin, erythema,
sebum, hydration, friction and transepidermal water loss between the reconstructed facial site with
a random local skin flap, FTSG and STSG compared to the healthy contralateral side of the face.
Participants and Methods: The study included 31 facial defects reconstructed with local random
flap, 30 facial defects reconstructed with STSGs and 30 facial defects reconstructed with FTSGs.
Participants were recruited to the study during control check-ups. All included participants
underwent an operation due to basal cell carcinoma (BCC) or squamous cell carcinoma (SCC).
Furthermore, all three reconstructive procedures were conducted at the Department of
Maxillofacial Surgery, University Hospital of Split, according to the standard surgical protocols
and guidelines. Skin quality was objectively evaluated by the same experienced investigator using
an MP6 skin quality assessment instrument (Courage + Khazaka GmbH, Cologne, Germany). The
instrument assesses TEWL, melanin, erythema, sebum, friction and hydration using noninvasive
probes. Subjective assessment was conducted using the Manchester scar scale (MSS), Vancouver
scar scale (VSS), Patient and observer scar assessment scale.
Results: There were no significant differences regarding objective skin parameters between the
random local flaps and the healthy contralateral side for all parameters tested. However, FTSGs
and STSGs showed significantly higher levels of erythema and TEWL, and both groups showed
significantly lower levels of hydration, sebum, and friction compared to the healthy contralateral
side. However, only STSG patients had a significantly higher amount of melanin (p < 0.001).
Furthermore, after estimating the Δ between the healthy contralateral side and the reconstructed
site, there was a statistically significant difference of the melanin (H = 69.498; p < 0.001), erythem
(H = 44.244; p < 0.001), hydration (H = 53.589; p < 0.001), sebum (H = 56.315; p < 0.001), friction
(H = 14.017; p < 0.001) and TEWL (H = 42.965; p < 0.001). There was a statistically significant
difference between all three groups in subjective assessments using VSS (H=65.12; p < 0.001),
MSS (H=62.88 ; p < 0.001) and both patient (H=62.61 ; p < 0.001) and observer (H=59.25 ; p <
0.001) reported POSAS.
Conclusions: The results of this study showed that there were no significant differences in the
amount of melanin, erythema, hydration, sebum level, friction and TEWL between the site
reconstructed with random local flaps and the same site on the healthy contralateral side of the
face. However, FTSGs and STSGs had significantly higher TEWL and erythema levels, while
hydration, sebum and friction levels were significantly lower compared to the healthy contralateral
side. STSGs also had a higher amount of melanin compared to the healthy contralateral side.
Considering the differences (Δ) between the healthy and the reconstructed site, the results showed
a significant difference between the three methods of reconstruction in all parameters. Moreover,
the random local flap group had the lowest Δ, while the STSG group had the highest Δ with respect
to all assessed skin quality parameters. Furthermore, when comparing subjective scales for skin
quality and scar, the results showed that local random skin flaps had the lowest and best results in
VSS, MSS and POSAS. On the other hand, FTSGs had statistically significantly higher results,
while STSGs had statistically significantly the highest results or the worst results. |
