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SHAVE THERAPY
SHAVE THERAPY
Introduction
Patients with long-standing venous insufficiency often develop significant complications, including lipodermatosclerosis (LDS). A spectrum of disease exists in LDS, characterized by hyperpigmentation, induration, and inflammation of the skin on the legs of patients with venous insufficiency.97โ99 Acute LDS may be confused with cellulitis or various panniculitides, as it is characterized by intense pain, induration, warmth, and red or purple scaling plaques usually noted just above the medial malleolus.98 Chronic LDS, the stage that is thought to precede ulceration, leads to fibrosis and sclerosis of the lower leg.97,98 This results in a hard, woody texture of the involved skin, with hyperpigmentation and the pathognomonic inverted champagne bottle appearance.97 It is thought that degree of induration of LDS corresponds with the delayed healing of an associated VLU.39 Though its exact pathogenesis is unclear, LDS is likely linked to fibrinolytic abnormalities, and is thus seen on the legs of patients with venous insufficiency.99 Compression is the mainstay treatment of VLUs, and various fibrinolytic therapies may be used as adjuncts in patients with LDS, including stanozolol, oxandrolone, and danazol.100 However, VLUs may fail conservative management, with the postthrombotic etiology being most resistant to treatment.101
Shave therapy is a surgical technique developed for the treatment of refractory VLUs with accompanying LDS. It was first introduced in 1987 by Quaba et al. as a rapid method to shave and remove LDS in layers with subsequent autograft placement.102 In a study by Schmeller et al., 80 patients with persistent or recurrent VLUs were treated with shave therapy and evaluated for the short- and long-term effects of treatment. The ulcers of the patients were removed together with the surrounding LDS and then covered
with a meshed split-skin graft. The short-term healing rate 3 months postsurgery was 79% in 59 patients, while the long-term healing rate was 88% in 18 patients.101
Indications Shave therapy followed by STSG is indicated for recalcitrant VLUs with LDS. Without LDS, shave therapy is generally not necessary. It has been used in patients who failed conventional STSG, with circumferential legs ulcers, and with ulcers associated with primary venous insufficiency, postthrombotic syndrome, or mixed ulcers.103 It may be combined with other procedures, such as excision of insufficient veins for the reduction of pathological reflux.101,103
Contraindications Surgery should not be initiated in the case of infection. Patients presenting with erythema, edema, and pain within the ulcer should be treated with antibiotics, and the surgery should be postponed until the infection resolves. Concomitant peripheral arterial disease may restrict the use of compression bandages or stockings following surgery.103
Procedural technique Shave therapy usually requires general or spinal anesthesia, unless the ulcer is small or the LDS does not extend to involve the fascia and subcutaneous tissue, in which case local or tumescent anesthesia may be used. Before beginning, the size of the transplant must be measured, keeping in mind that it must be larger than the initial ulcer size. The area of LDS should be marked with a felt-tip marker. Usually the lateral or medial thigh will serve as the donor site, though if larger grafts are necessary, the buttocks or abdomen may be used. At least 4 months must pass before a prior donor site may be reused.103
The STSG is harvested using a dermatome, which can adjust the thickness of the transplant. A 0.3-mm thickness has been noted to be adequate for successful healing, though Schmeller et al. used 0.4- to 0.6-mm thick transplants.103,104 Various instruments may be used to remove the LDS, depending of the surgeonโs experience.103 The use of the Schink Dermatome (Aesculap, Tuttlingen, Germany) has been described in numerous studies.103,104
The entire area of LDS is tangentially removed, layer-by-layer, using the Schink Dermatome, exposing the sclerotic area beneath. The perforating veins are often revealed during the surgery, and bleeding is controlled either by compression and elevation of the leg or by suturing the vessel if bleeding is extensive to minimize the need for cauterization. The ablation process is terminated once the surrounding tissue is soft and less indurated to palpation, indicating removal of LDS. The sclerotic process
may extend down to the fascia of the lower leg, though it may be difficult to differentiate from the fascia. In these cases, a thin layer of sclerosis is left overlying the fascia.103
Closure is achieved most commonly by STSG from the thigh. Schmeller et al. recommended the use of tissue glue to secure the graft to eliminate the need for suture or staple removal.101
Complications and limitations There is a risk of blood loss due to vascular manipulation during the procedure, which may require transfusion in severe cases. Damage to underlying and adjacent structures, such as vessels, bony structures, tendons, and muscle, are possible complications. In the case of penetration by the dermatome to the muscle or periosteum, these should be repaired with absorbable sutures immediately.103 STSG complications are similar to those described above.
Follow-up care In a later study by Schmeller et al., the long-term sequelae of shave therapy were evaluated in patients with nonhealing VLUs secondary to primary venous insufficiency or postthrombotic syndrome. Thirty-eight percent of their patients had hypoesthesia of the transplanted areas. The healing of patients with primary venous insufficiency was favorable compared to those with postthrombotic syndrome, with healing rates of 76% and 58%, respectively. Recurrence occurred in 33% of cases, though these ulcers were reduced by 80% to 90% of their original size. In some patients, there was a direct correlation between use of compression and avoidance of recurrence, as shave therapy does not address the underlying venous insufficiency. Thus, they stress the importance of patient compliance with compression therapy for optimal long-term results.104