Negative Pressure for Securing Skin Grafts for Treating Ulcers due to Deep Dissecting Hematomas or Necrotizing Fasciitis

array:23 ["pii" => "S0001731022002873" "issn" => "00017310" "doi" => "10.1016/j.ad.2020.11.038" "estado" => "S300" "fechaPublicacion" => "2022-05-01" "aid" => "3001" "copyrightAnyo" => "2022" "documento" => "simple-article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "crp" "cita" => "Actas Dermosifiliogr. 2022;113:T540-T542" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "itemAnterior" => array:19 [ "pii" => "S0001731021004269" "issn" => "00017310" "doi" => "10.1016/j.ad.2020.11.030" "estado" => "S300" "fechaPublicacion" => "2022-05-01" "aid" => "2816" "copyright" => "AEDV" "documento" => "simple-article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "crp" "cita" => "Actas Dermosifiliogr. 2022;113:540-2" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "es" => array:11 [ "idiomaDefecto" => true "cabecera" => "CARTA CIENTÍFICO-CLÍNICA" "titulo" => "Uso de la terapia de presión negativa para fijar injertos cutáneos en úlceras secundarias a hematoma profundo disecante o a fascitis necrosante" "tienePdf" => "es" "tieneTextoCompleto" => "es" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "540" "paginaFinal" => "542" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Negative Pressure for Securing Skin Grafts for Treating Ulcers due to Deep Dissecting Hematomas or Necrotizing Fasciitis" ] ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figura 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 604 "Ancho" => 1250 "Tamanyo" => 146875 ] ] "descripcion" => array:1 [ "es" => "A) Defecto inicial tras refrescar los bordes. B) Extracción del injerto laminar con un dermatomo. C) Colocación del injerto en el lecho, se realizan cortes para asegurar la aspiración de exudados. D) Sistema de presión negativa sobre el injerto, asegurando el contacto con el lecho." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J. Martín-Alcalde, C. Sarró-Fuente, R. Miñano-Medrano, J.L. López-Estebaranz" "autores" => array:4 [ 0 => array:2 [ "nombre" => "J." "apellidos" => "Martín-Alcalde" ] 1 => array:2 [ "nombre" => "C." "apellidos" => "Sarró-Fuente" ] 2 => array:2 [ "nombre" => "R." "apellidos" => "Miñano-Medrano" ] 3 => array:2 [ "nombre" => "J.L." "apellidos" => "López-Estebaranz" ] ] ] ] ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0001731021004269?idApp=UINPBA000044" "url" => "/00017310/0000011300000005/v1_202206110542/S0001731021004269/v1_202206110542/es/main.assets" ] "asociados" => array:1 [ 0 => array:19 [ "pii" => "S0001731021004269" "issn" => "00017310" "doi" => "10.1016/j.ad.2020.11.030" "estado" => "S300" "fechaPublicacion" => "2022-05-01" "aid" => "2816" "copyright" => "AEDV" "documento" => "simple-article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "crp" "cita" => "Actas Dermosifiliogr. 2022;113:540-2" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "es" => array:11 [ "idiomaDefecto" => true "cabecera" => "CARTA CIENTÍFICO-CLÍNICA" "titulo" => "Uso de la terapia de presión negativa para fijar injertos cutáneos en úlceras secundarias a hematoma profundo disecante o a fascitis necrosante" "tienePdf" => "es" "tieneTextoCompleto" => "es" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "540" "paginaFinal" => "542" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Negative Pressure for Securing Skin Grafts for Treating Ulcers due to Deep Dissecting Hematomas or Necrotizing Fasciitis" ] ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figura 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 604 "Ancho" => 1250 "Tamanyo" => 146875 ] ] "descripcion" => array:1 [ "es" => "A) Defecto inicial tras refrescar los bordes. B) Extracción del injerto laminar con un dermatomo. C) Colocación del injerto en el lecho, se realizan cortes para asegurar la aspiración de exudados. D) Sistema de presión negativa sobre el injerto, asegurando el contacto con el lecho." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J. Martín-Alcalde, C. Sarró-Fuente, R. Miñano-Medrano, J.L. López-Estebaranz" "autores" => array:4 [ 0 => array:2 [ "nombre" => "J." "apellidos" => "Martín-Alcalde" ] 1 => array:2 [ "nombre" => "C." "apellidos" => "Sarró-Fuente" ] 2 => array:2 [ "nombre" => "R." "apellidos" => "Miñano-Medrano" ] 3 => array:2 [ "nombre" => "J.L." "apellidos" => "López-Estebaranz" ] ] ] ] ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0001731021004269?idApp=UINPBA000044" "url" => "/00017310/0000011300000005/v1_202206110542/S0001731021004269/v1_202206110542/es/main.assets" ] ] "en" => array:14 [ "idiomaDefecto" => true "cabecera" => "Case and Research Letter" "titulo" => " Negative Pressure for Securing Skin Grafts for Treating Ulcers due to Deep Dissecting Hematomas or Necrotizing Fasciitis" "tieneTextoCompleto" => true "saludo" => "To the Editor:" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "T540" "paginaFinal" => "T542" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "J. Martín-Alcalde, C. Sarró-Fuente, R. Miñano-Medrano, J.L. López-Estebaranz" "autores" => array:4 [ 0 => array:4 [ "nombre" => "J." "apellidos" => "Martín-Alcalde" "email" => array:2 [ 0 => "javimartinalcalde@gmail.com" 1 => "jmartina@fhalcorcon.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "C." "apellidos" => "Sarró-Fuente" ] 2 => array:2 [ "nombre" => "R." "apellidos" => "Miñano-Medrano" ] 3 => array:2 [ "nombre" => "J.L." "apellidos" => "López-Estebaranz" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Dermatología, Hospital Universitario Fundación Alcorcón, Alcorcón (Madrid), Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Uso de la terapia de presión negativa para fijar injertos cutáneos en úlceras secundarias a hematoma profundo disecante o a fascitis necrosante" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 998 "Ancho" => 2081 "Tamanyo" => 291501 ] ] "descripcion" => array:1 [ "en" => "A, Initial defect after debriding of the wound margin. B, Removal of the lamellar graft with a dermatome. C, Placement of the graft on the wound bed: cuts are made to allow drainage of exudate. D, Negative pressure system on the graft, ensuring contact with the wound bed." ] ] ] "textoCompleto" => "Deep dissecting hematomas and necrotizing fasciitis require early debridement, often leading to large skin defects.<a class="elsevierStyleCrossRefs" href="#bib0055">1,2</a> Closure of these ulcers by secondary intention usually entails painful dressing changes and delays complete resolution. Topical negative pressure (TNP) therapy has been classically used to promote the formation of granulation tissue and improve the ulcer bed, but is also useful to secure skin grafts.<a class="elsevierStyleCrossRef" href="#bib0065">3</a> Application of negative pressure to the graft can increase adhesion, remove exudate, and reduce maceration.<a class="elsevierStyleCrossRef" href="#bib0070">4</a> We present 4 cases of patients with ulcers on the legs who underwent this technique after debridement of a deep dissecting hematoma or necrotizing fasciitis.The characteristics of the patients, their ulcers, and the type of graft are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. All patients had ulcers on the legs that ranged in size from 65cm2 to 210cm2 (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 1</a>A, B). The type of graft was selected according to the size of the ulcer and the experience of the dermatologist. A lamellar graft was used in 3 of the 4 cases. A nonadhesive dressing (Atrauman) was applied and the entire area was sealed with a TNP system (VAC [vacuum assisted closure]; <a class="elsevierStyleCrossRef" href="#fig0015">Fig. 2</a>). The TNP system was programmed at a continuous pressure of −75mmHg. All patients were hospitalized for 5 days, without requiring any additional cure. On the fifth postoperative day, the TNP system was removed and the patients were switched to an alternate-day outpatient schedule using conventional dressings and compression, depending on the appearance of the graft. In all patients, the graft took on the fifth day (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>, <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 1</a>C and D) and complete resolution of the ulcer was achieved by postoperative day 30 (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 1</a>E and F). Complications occurred in 3 of the 4 patients, and were minor in 2 cases, as summarized in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. In Patient 2 the donor site became infected with Pseudomonas aeruginosa, which was treated with silver dressings and oral ciprofloxacin and had no impact on the final outcome of the intervention.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia>Surgical debridement of deep dissecting hematoma and necrotizing fasciitis results in large, usually full-thickness skin defects. Repair of the lost tissue is initiated by granulation tissue, which permits subsequent epithelial covering.<a class="elsevierStyleCrossRef" href="#bib0075">5</a> TNP can be used to stimulate the formation of granulation tissue,<a class="elsevierStyleCrossRef" href="#bib0080">6</a> while skin grafts replace the epithelial lining and accelerate the healing process.<a class="elsevierStyleCrossRef" href="#bib0085">7</a> It is therefore essential to know how to maximize graft viability while minimizing surgical complications. The pressure and duration of TNP on the graft are the main variables in this technique. Data indicate that a continuous negative pressure of −75mmHg on skin grafts causes less inflammation and increases fibrinogen production compared with higher pressures or no pressure at all.<a class="elsevierStyleCrossRef" href="#bib0090">8</a> However, there are no data to indicate the optimal duration of TNP on the graft. In the majority of cases, TNP is removed between 4 and 7 days after the intervention.<a class="elsevierStyleCrossRef" href="#bib0085">7</a>The increase in cost with respect to a conventional graft without TNP is around $400 (€338.72).<a class="elsevierStyleCrossRef" href="#bib0095">9</a> The value of this approach is that is allows for reductions in other costs (e.g. those associated with increased admission time and repeated surgical interventions). A recent meta-analysis showed that TNP increases the likelihood of graft viability and reduces the rate of reoperation.<a class="elsevierStyleCrossRef" href="#bib0100">10</a> However, these results should be interpreted with caution given the heterogeneity of the studies included in this meta-analysis, and in particular the variability in ulcer etiology across studies.The main limitations of our study are the small patient population and the absence of a control group.In summary, we present 4 cases in which a skin graft was fixed with TNP in patients with ulcers secondary to deep dissecting hematoma or necrotizing fasciitis. This is a simple procedure based on techniques that are familiar to dermatologists, and constitutes an alternative to the traditional technique. However, more studies are required to confirm its efficacy and efficiency in this type of ulcer." "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 998 "Ancho" => 2081 "Tamanyo" => 291501 ] ] "descripcion" => array:1 [ "en" => "A, Initial defect after debriding of the wound margin. B, Removal of the lamellar graft with a dermatome. C, Placement of the graft on the wound bed: cuts are made to allow drainage of exudate. D, Negative pressure system on the graft, ensuring contact with the wound bed." ] ] 1 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1167 "Ancho" => 1584 "Tamanyo" => 277380 ] ] "descripcion" => array:1 [ "en" => "A, Initial defect in Patient 2, after improving the condition of the wound bed with negative pressure therapy prior to surgery. B, Initial defect in Patient 3. C and D, Appearance on day 5 after the intervention. E and F, Appearance on day 30 after the intervention." ] ] 2 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Abbreviations: AHT, arterial hypertension; CKD, chronic kidney disease; CVI, chronic venous insufficiency; DL, dyslipidemia; DM, diabetes mellitus; F, female; M, male; OAC, oral anticoagulants; PAD, peripheral arterial disease; TNP, topical negative pressure." "tablatextoimagen" => array:1 [ 0 => array:1 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Patient \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Sex \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Age \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Cause of defect \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">OAC \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Other \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Size/area \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Previous TNP \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Graft type \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Viable graft \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Complications \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">91 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Deep dissecting hematoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">AHTDL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12×10cm/120cm2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Lamellar \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Maceration of the margins \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">79 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Necrotizing fasciitis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">AHTCVI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15×14cm/210cm2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Lamellar \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Infection of donor site with P. aeruginosa \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">85 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Deep dissecting hematoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">AHTDMCKDPAD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13×5cm/65cm2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">None \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Full thickness \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Donor-site hematoma \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">57 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Necrotizing fasciitis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">AHTCVI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12.5×7cm/87.5cm2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Lamellar \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">None \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] ] "descripcion" => array:1 [ "en" => "Patient Characteristics, Type of Ulcer, and Complications." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Necrotizing fasciitis: treatment concepts and clinical results" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "M. 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Case and Research Letter

Negative Pressure for Securing Skin Grafts for Treating Ulcers due to Deep Dissecting Hematomas or Necrotizing Fasciitis

Uso de la terapia de presión negativa para fijar injertos cutáneos en úlceras secundarias a hematoma profundo disecante o a fascitis necrosante

J. Martín-Alcalde

Corresponding author

javimartinalcalde@gmail.com
jmartina@fhalcorcon.es

Corresponding author.

, C. Sarró-Fuente, R. Miñano-Medrano, J.L. López-Estebaranz

Servicio de Dermatología, Hospital Universitario Fundación Alcorcón, Alcorcón (Madrid), Spain

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    "titulo" => " Negative Pressure for Securing Skin Grafts for Treating Ulcers due to Deep Dissecting Hematomas or Necrotizing Fasciitis"
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A&#44; Initial defect after debriding of the wound margin&#46; B&#44; Removal of the lamellar graft with a dermatome&#46; C&#44; Placement of the graft on the wound bed&#58; cuts are made to allow drainage of exudate&#46; D&#44; Negative pressure system on the graft&#44; ensuring contact with the wound bed&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0010" class="elsevierStylePara elsevierViewall">Deep dissecting hematomas and necrotizing fasciitis require early debridement&#44; often leading to large skin defects&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#44;2</span></a> Closure of these ulcers by secondary intention usually entails painful dressing changes and delays complete resolution&#46; Topical negative pressure &#40;TNP&#41; therapy has been classically used to promote the formation of granulation tissue and improve the ulcer bed&#44; but is also useful to secure skin grafts&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> Application of negative pressure to the graft can increase adhesion&#44; remove exudate&#44; and reduce maceration&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> We present 4 cases of patients with ulcers on the legs who underwent this technique after debridement of a deep dissecting hematoma or necrotizing fasciitis&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The characteristics of the patients&#44; their ulcers&#44; and the type of graft are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; All patients had ulcers on the legs that ranged in size from 65<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">2</span> to 210<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">2</span> &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 1</a>A&#44; B&#41;&#46; The type of graft was selected according to the size of the ulcer and the experience of the dermatologist&#46; A lamellar graft was used in 3 of the 4 cases&#46; A nonadhesive dressing &#40;Atrauman&#41; was applied and the entire area was sealed with a TNP system &#40;VAC &#91;vacuum assisted closure&#93;&#59; <a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 2</a>&#41;&#46; The TNP system was programmed at a continuous pressure of &#8722;75<span class="elsevierStyleHsp" style=""></span>mmHg&#46; All patients were hospitalized for 5 days&#44; without requiring any additional cure&#46; On the fifth postoperative day&#44; the TNP system was removed and the patients were switched to an alternate-day outpatient schedule using conventional dressings and compression&#44; depending on the appearance of the graft&#46; In all patients&#44; the graft took on the fifth day &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#44; <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 1</a>C and D&#41; and complete resolution of the ulcer was achieved by postoperative day 30 &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 1</a>E and F&#41;&#46; Complications occurred in 3 of the 4 patients&#44; and were minor in 2 cases&#44; as summarized in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; In Patient 2 the donor site became infected with <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span>&#44; which was treated with silver dressings and oral ciprofloxacin and had no impact on the final outcome of the intervention&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Surgical debridement of deep dissecting hematoma and necrotizing fasciitis results in large&#44; usually full-thickness skin defects&#46; Repair of the lost tissue is initiated by granulation tissue&#44; which permits subsequent epithelial covering&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> TNP can be used to stimulate the formation of granulation tissue&#44;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> while skin grafts replace the epithelial lining and accelerate the healing process&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> It is therefore essential to know how to maximize graft viability while minimizing surgical complications&#46; The pressure and duration of TNP on the graft are the main variables in this technique&#46; Data indicate that a continuous negative pressure of &#8722;75<span class="elsevierStyleHsp" style=""></span>mmHg on skin grafts causes less inflammation and increases fibrinogen production compared with higher pressures or no pressure at all&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> However&#44; there are no data to indicate the optimal duration of TNP on the graft&#46; In the majority of cases&#44; TNP is removed between 4 and 7 days after the intervention&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The increase in cost with respect to a conventional graft without TNP is around &#36;400 &#40;&#8364;338&#46;72&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> The value of this approach is that is allows for reductions in other costs &#40;e&#46;g&#46; those associated with increased admission time and repeated surgical interventions&#41;&#46; A recent meta-analysis showed that TNP increases the likelihood of graft viability and reduces the rate of reoperation&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> However&#44; these results should be interpreted with caution given the heterogeneity of the studies included in this meta-analysis&#44; and in particular the variability in ulcer etiology across studies&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The main limitations of our study are the small patient population and the absence of a control group&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">In summary&#44; we present 4 cases in which a skin graft was fixed with TNP in patients with ulcers secondary to deep dissecting hematoma or necrotizing fasciitis&#46; This is a simple procedure based on techniques that are familiar to dermatologists&#44; and constitutes an alternative to the traditional technique&#46; However&#44; more studies are required to confirm its efficacy and efficiency in this type of ulcer&#46;</p></span>"
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          "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#58; AHT&#44; arterial hypertension&#59; CKD&#44; chronic kidney disease&#59; CVI&#44; chronic venous insufficiency&#59; DL&#44; dyslipidemia&#59; DM&#44; diabetes mellitus&#59; F&#44; female&#59; M&#44; male&#59; OAC&#44; oral anticoagulants&#59; PAD&#44; peripheral arterial disease&#59; TNP&#44; topical negative pressure&#46;</p>"
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Deep dissecting hematoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">AHTDL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleHsp" style=""></span>cm&#47;120<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Lamellar&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Maceration of the margins&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">79&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Necrotizing fasciitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">AHTCVI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>14<span class="elsevierStyleHsp" style=""></span>cm&#47;210<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Lamellar&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Infection of donor site with <span class="elsevierStyleItalic">P&#46; aeruginosa</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">85&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Deep dissecting hematoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">AHTDMCKDPAD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>cm&#47;65<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Full thickness&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Donor-site hematoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">57&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Necrotizing fasciitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">AHTCVI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&#46;5<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>7<span class="elsevierStyleHsp" style=""></span>cm&#47;87&#46;5<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Lamellar&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Patient Characteristics&#44; Type of Ulcer&#44; and Complications&#46;</p>"
        ]
      ]
    ]
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      "titulo" => "References"
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        0 => array:2 [
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                            1 => "I&#46; Marzi"
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                            1 => "C&#46; Higham"
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                  "contribucion" => array:1 [
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                      "titulo" => "Effectiveness of negative pressure closure in the integration of split thickness skin grafts&#58; a randomized&#44; double-masked&#44; controlled trial"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "S&#46; Llanos"
                            1 => "S&#46; Danilla"
                            2 => "C&#46; Barraza"
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            4 => array:3 [
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                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
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                            2 => "S&#46; Hager"
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                      "doi" => "10.1159/000454919"
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                  "contribucion" => array:1 [
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                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "J&#46; Webster"
                            1 => "Z&#46; Liu"
                            2 => "G&#46; Norman"
                            3 => "J&#46;C&#46; Dumville"
                            4 => "L&#46; Chiverton"
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                      ]
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                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1002/14651858.CD009261.pub4"
                      "Revista" => array:4 [
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            6 => array:3 [
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Skin grafting for the treatment of chronic leg ulcers &#8211; a systematic review in evidence-based medicine"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "R&#46; Serra"
                            1 => "A&#46; Rizzuto"
                            2 => "A&#46; Rossi"
                            3 => "P&#46; Perri"
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                  ]
                  "host" => array:1 [
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                      "doi" => "10.1111/iwj.12575"
                      "Revista" => array:6 [
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                        "fecha" => "2017"
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            7 => array:3 [
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Varying negative pressure wound therapy acute effects on human split-thickness autografts"
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Article information

ISSN: 00017310
Original language: English

DOI:10.1016/j.ad.2020.11.038

The statistics are updated each day

Year/Month	Html	Pdf	Total

2024 November	16	13	29
2024 October	121	62	183
2024 September	122	34	156
2024 August	132	60	192
2024 July	75	44	119
2024 June	110	59	169
2024 May	82	39	121
2024 April	78	35	113
2024 March	95	40	135
2024 February	77	27	104
2024 January	68	25	93
2023 December	77	20	97
2023 November	117	39	156
2023 October	80	30	110
2023 September	67	35	102
2023 August	69	17	86
2023 July	92	31	123
2023 June	64	22	86
2023 May	80	23	103
2023 April	41	21	62
2023 March	65	26	91
2023 February	59	21	80
2023 January	55	41	96
2022 December	83	43	126
2022 November	55	36	91
2022 October	57	39	96
2022 September	44	45	89
2022 August	52	46	98
2022 July	48	37	85
2022 June	88	49	137
2022 May	57	39	96
2022 April	22	23	45

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