Volume 139, Number 1 Letters
Our current article only described the expan- Early versus Delayed Excision and Grafting of
sion effect alone on irradiated tissue, but we also have
recently completed a study of the combined effects of
external volume expansion and fat grafting in a simi-
lar irradiated murine model. We believe that these new
results further reinforce the synergistic role between
fat grafting and volume expansion in the treatment of
irradiated skin, and this will be the subject of a soon-to-
be-submitted manuscript.
DOI: 10.1097/PRS.0000000000002872
Michael S. Chin, M.D.
Department of Radiation Oncology
Jorge Lujan-Hernandez, M.D.
Oksana Babchenko, M.D.
Division of Plastic Surgery
Elizabeth Bannon, M.S.
Department of Radiation Oncology
Dylan J. Perry, B.A.
Ava G. Chappell, B.A.
Division of Plastic Surgery
Yuan-Chyuan Lo, Ph.D.
Thomas J. Fitzgerald, M.D.
Department of Radiation Oncology
Janice F. Lalikos, M.D.
Division of Plastic Surgery
University of Massachusetts Medical School
Worcester, Mass.
Correspondence to Dr. Chin
Department of Radiation Oncology
University of Massachusetts Medical School
55 Lake Avenue North
Worcester, Mass. 01655
mchin.md@gmail.com
disclosure
The authors have no financial interest to declare in
relation to the content of this communication.
references
1. Chin MS, Lujan-Hernandez J, Babchenko O, et al. External
volume expansion in irradiated tissue: Effects on the recipi-
ent site. Plast Reconstr Surg. 2016;137:799e807e.
2. Caviggioli F, Maione L, Klinger F, Lisa A, Klinger M. Autolo-
gous fat grafting reduces pain in irradiated breast: A review
of our experience. Stem Cells Int. 2016;2016:2527349.
3. Maione L, Vinci V, Caviggioli F, et al. Autologous fat graft in
postmastectomy pain syndrome following breast conservative
surgery and radiotherapy. Aesthetic Plast Surg. 2014;38:528532.
4. Chin MS, Lancerotto L, Helm DL, et al. Analysis of neuropep-
tides in stretched skin. Plast Reconstr Surg. 2009;124:102413.
5. Chin MS, Ogawa R, Lancerotto L, et al. In vivo acceleration
of skin growth using a servo-controlled stretching device. Tis-
sue Eng Part C Methods 2010;16:397405.
Copyright 2016 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Full-Thickness Burns in a Porcine Model: A
Randomized Study
Sir:
W
e read with respect the latest article entitled Early
versus Delayed Excision and Grafting of Full-Thick-
ness Burns in a Porcine Model: A Randomized Study by
Singer and colleagues.1 The authors did excellent work to
establish a novel porcine full-thickness burn model that
can be adopted in future burn studies. In addition, they
concluded that burn excision and grafting would facili-
tate epithelialization and reduce scarring, and doing so
earlier than later may reduce scarring to a greater extent.
This study is valuable in terms of reflections on clinical
practice, yet from an experimental research perspective,
it could have been more persuasive.
First, through comparing epithelialization at day
16, the authors proved the superiority of the early-
excision group over the control group. However, epi-
thelialization of the late-excision group was measured
only at day 21, when the wounds of all groups were
completely epithelialized. There was very little mean-
ingful comparison of epithelialization between the late-
excision group and the other two groups. Moreover,
as the authors mentioned in the beginning of their
article, full-thickness burns themselves can heal in 21
days without other intervention. Therefore, complete
epithelialization at day 21 did not reveal any advantage
of late burn excision compared with the control group.
Instead, comparison of data revealing dynamic change
of epithelialization could be more convincing, and this
could be realized by date adjustment for biopsy.
Other than epithelialization, scar thickness and
scar contraction were two significant parameters for
evaluating the effects of different treatments. At day 28,
both scar thickness and scar contraction were greater in
the late-excision group than in the early-excision group.
However, at day 42, scar contraction in all groups was
obviously alleviated and there was no significant dif-
ference between the early- and late-excision groups.
Was the alleviation of scar contraction statistically sig-
nificant? Was it attributable to scar remodeling? If so,
would the scar thickness, especially that of the late-exci-
sion group, gradually reduce? In addition, scar contrac-
tion in this study conspicuously improved before day
42. If it was attributable to scar remodeling, it did not
accord with the well-known finding that scar remodels
from the third month until the sixth month.2 If it was
not, then what could explain the improvement of scar
contraction? All these queries need further study.
DOI: 10.1097/PRS.0000000000002919
Panxi Yu, M.D.
Xiaonan Yang, M.D., Ph.D.
Zuoliang Qi, M.D., Ph.D.
Plastic Surgery Hospital
Chinese Academy of Medical Sciences and Peking Union
Medical College
Beijing, Peoples Republic of China
315e
 Plastic and Reconstructive Surgery January 2017
Correspondence to Dr. Qi
Plastic Surgery Hospital
Chinese Academy of Medical Sciences
and Peking Union Medical College
33 Badachu Road
Shijingshan District
Beijing 100144, Peoples Republic of China
qizuoliangls@163.com
disclosure
The authors have no financial interest to declare in
relation to the content of this communication.
references
1. Singer AJ, Toussaint J, Chung WT, McClain SA, Raut V,
Rosenberg L. Early versus delayed excision and grafting of
full-thickness burns in a porcine model: A randomized study.
Plast Reconstr Surg. 2016;137:972e979e.
2. Hur GY, Seo DK, Lee JW. Contracture of skin graft in human
burns: Effect of artificial dermis. Burns 2014;40:1497
1503.
Reply: Early versus Delayed Excision and
Grafting of Full-Thickness Burns in a Porcine
Model: A Randomized Study
Sir:
We greatly appreciate the comments of Xu et al.
and the opportunity to respond. Our study was a small
study aimed at developing a standardized and repro-
ducible porcine model of excised and grafted full-thick-
ness burns.1 Animal models in general have limitations
and usually can represent only a specific phase of the
investigated biological process. In general, the wound
healing process in pigs is much faster than in humans
because of several overlapping reasons:
1. Pigs are less susceptible to wound infections
even in the presence of necrotic tissue, where
a very limited (just to the interface between the
eschar and viable bed) inflammatory/infectious
process separates the eschar in just a little over
2 weeks.
2. In full-thickness defects, this inflammatory pro-
cess ends in a thin layer of granulation tissue that
starts to scar but also serves as a viable bed for
rapid epithelialization from the edges.
3. The combination of these two processes results
in a much more rapid wound closure than in
humans (<3 weeks), and the thin granulation
layer does not cause excessive scarring such as
seen in humans.
4. As a result of the above-mentioned features, scar
formation is limited and remodeling begins prac-
tically immediately. In pigs, and even more so in
loose-skinned animals (e.g., rodents), scar contrac-
tion starts immediately and thus they do not have
the time to form thick, hypertrophic scars, not to
mention that they do not form keloids at all.
316e
Copyright 2016 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
As early as the 1960s, studies reported earlier heal-
ing of similar depth wounds in pigs versus humans.2,3
Thus, most porcine studies should focus mostly on the
initial wound healing phase just to the point where
the accelerated reepithelialization and acute phase
of scarring end. The benefits of early excision and
grafting in humans are apparent, where healing pro-
cesses are much longer, the inflammatory/infectious
process is more violent and less limited, granulation
is more exuberant, and scarring is likely to be greater
than for pigs. Indeed, full-thickness burns in humans
are unlikely to heal within 21 days, which is the case
in pigs. This is represented very nicely in Figure 5 of
our article, where the nonexcised burns healed rapidly
by secondary intention with much less florid granu-
lation than typically seen in such wounds in humans
(hypergranulation).
As noted above, pigs have a tremendous capacity
to heal after cutaneous wounds. This is also reflected
by the fact that excessive scarring is hard to produce
in pigs. Even with Red Duroc pigs, hypertrophic scars
are less elevated and erythematous than in humans
and can be seen only early after healing when they
undergo complete modulation.4 Thus, although very
useful as an animal model, the healing of porcine
burns does not completely reflect healing in humans.
As a result, it is not surprising that by day 42, there
were little if any differences in scar depth and con-
traction between burns that were excised and grafted
after 2 or 14 days. However, we believe that our results
in the pig model do not diminish in any way the
importance of early removal of the necrotic eschar in
humans with burns.
We also used this model to determine whether
early excision accelerated reepithelialization and
reduced scarring compared with later or no excision
and grafting. Although the sample size was small, the
differences in reepithelialization at day 16 between
early excision followed by grafting and no excision
or grafting were statistically significant. Because at
day 16 the late excised and grafted burns had been
grafted only 2 days earlier, we thought that the grafts
would be too fragile and not yet vascularized to allow
obtaining a full-thickness biopsy specimen without
disrupting the graft. It is possible that biopsy speci-
mens taken between days 16 and 21 would have
shown more convincing evidence that early excised
and grafted burns heal faster than later excised and
grafted wounds, but this would be less representative
of humans. However, because of the limited number
and size of the burns, the number of tissue biopsy
specimens in our study was limited. Future, larger
studies including more frequent biopsy specimen
might give more descriptive results but, beyond day
16, they will be less and less representative of humans.
Regardless, because all wounds were reepithelial-
ized by day 21, the clinical benefits of early excision
and grafting on wound reepithelialization in the pig
model are limited.
DOI: 10.1097/PRS.0000000000002918