Background:
Split-thickness skin grafts (STSG) are an effective modality for lower extremity wound coverage. Many patients in the highly comorbid chronic wound population present with cardiovascular disease requiring chronic antiplatelet or anticoagulant therapy, theoretically increasing risk for bleeding complications, donor site morbidity, and poor graft take. Some surgeons advocate temporary cessation of antithrombotic therapy, which may increase cardiovascular risk. The objective of this study was to examine the effects of anticoagulation use on STSG outcomes.
Methods:
All patients receiving STSGs for lower extremity wounds from 2014 to 2016 at a single institution were retrospectively reviewed. Successful grafts were defined as greater than 99.5% wound coverage. Patients were divided into two groups: anticoagulation/antiplatelet or no anticoagulation/antiplatelet. Continuous variables were described by means and SDs and analyzed using student’s t-test. Categorical variables were described by frequencies and percentages and analyzed using Chi-square or Fisher exact tests as appropriate.
Results:
In total, 231 wounds were identified among 189 patients; 124 patients were receiving at least one antiplatelet/anticoagulant at time of grafting. Three hematomas were reported during 30 days of follow-up; there was no significant difference between groups (P > 0.05). Anticoagulation/antiplatelet therapy in the perioperative period had no significant impact on STSG take and overall healing.
Conclusions:
The findings from this study demonstrate that administration of anticoagulant/antiplatelet agents in the perioperative period does not increase the risk of skin graft failure. Based on these findings, STSG can be performed without cessation of anticoagulation or antiplatelet therapy.
Takeaways
Question: Does antiplatelet or anticoagulant use at time of split-thickness skin graft placement affect graft outcomes?
Findings: A single institution retrospective review of 231 patients undergoing STSGs for lower extremity wounds found no significant differences in STSG take or overall healing between antiplatelet/anticoagulant and no antiplatelet/anticoagulant groups.
Meaning: Continuation of antiplatelet/anticoagulant agents at time of STSG placement does not increase risk of skin graft failure and can therefore be pursued to mitigate risk of cardiovascular events.
INTRODUCTION
Patients with vascular comorbidities often present with chronic lower extremity wounds. Management is individualized on a case-by-case basis, to maximize the chance of functional and definitive wound closure, and includes debridement and infection control, mechanical off-loading, revascularization, foot care education, lifestyle modifications, and optimization of underlying comorbidities such as hyperlipidemia, hypertension, and diabetes.1–4 Patients with underlying cardiovascular comorbidities are often on one or several antiplatelet or anticoagulation agents, which may theoretically compromise surgical wound healing efforts by increasing bleeding risk in the perioperative period. A growing body of literature suggests that optimal treatment of chronic wounds entails frequent excisional debridement and early operative coverage/closure1,4–6; therefore, it is crucial for surgeons to weigh the risks and benefits of antiplatelet and/or anticoagulation agents in the setting of surgical wound management in these patients.
Placement of split-thickness skin grafts (STSG) can provide durable coverage and accelerate wound closure. In some situations, repeat procedures may be necessary.7 When treating patients on anticoagulation or antiplatelet therapy, surgeons may be hesitant to operate frequently or repeatedly due to the theoretical risk of increased bleeding complications and reduced graft take secondary to these medications. As a result, surgeons may advocate for perioperative cessation of antiplatelet therapy. Several consensus articles, however, have expressed concern about early suspension or cessation of antiplatelet therapy, citing significant risk for cardiovascular morbidity and mortality.8,9 The aim of this study was to assess the impact of perioperative anticoagulation/antiplatelet medications on graft success rates and wound healing outcomes.
METHODS
All patients who received STSGs for lower extremity wounds between 2014 and 2016 were retrospectively reviewed. Patient characteristics (including age, gender, tobacco use, comorbidities, coagulation laboratories on the day of STSG, and antiplatelet or anticoagulant use) were collected. Wound characteristics such as etiology, location, and outcomes were also collected. Wound etiology categories included diabetic foot ulcers, peripheral arterial disease, venous stasis ulcers, surgical wounds, cancer, trauma, mixed, and other.
Surgical Methods: STSG Harvest and Placement
The donor and recipient sites were prepared and draped in a standard surgical fashion. Wounds were excisionally debrided to remove infected and devitalized tissue and then irrigated with 3 L of normal saline. Gloves, instruments, and drapes were then changed for a clean field. The STSG was then harvested using a Zimmer dermatome (Zimmer Biomet, Warsaw, Ind.) set to the 0.0010 inch to 0.0015 inch thickness. The STSG was transferred to the wound bed and secured with tie-over sponge bolster or negative pressure wound therapy as appropriate, depending on wound location and surgeon preference. Sterile dressings were applied. Percentage of overall graft take was measured 30 days after STSG placement. A threshold of 99.5% was used to define STSG success. All graft takes less than 99.5% take were defined as STSG failure.
Statistical Analysis
Patients were divided into two groups: anticoagulation/antiplatelet or no anticoagulation/antiplatelet. The anticoagulation/antiplatelet group was defined as use of an anticoagulation or antiplatelet medication at time of STSG placement. Patients who did not have anticoagulation/antiplatelet agents were discontinued before surgery specifically for the purpose of this study. The primary outcomes of interest included STSG percentage take and success at 30 days and at final follow-up. Rate of hematoma formation within the first 30 days was also assessed. Continuous variables were described by means and SDs and analyzed using Student t test. Categorical variables, including STSG success/failure, were described by frequencies and percentages and analyzed using chi-square or Fisher exact tests as appropriate. Significance was defined as a P value less than 0.05. Statistical analyses were performed using SAS/STAT software, version 9.4 of the SAS System for Microsoft (SAS Institute Inc.).
RESULTS
Summary statistics are outlined in Table 1. A total of 189 patients received an STSG for lower extremity wounds during the study period. In total, 122 patients were taking an anticoagulation or antiplatelet medication at the time of surgery; 67 patients were not taking an agent from either class. Of the 122 patients, 34 (27.9%) patients were taking at least one anticoagulation agent (warfarin, enoxaparin, Xa-inhibitor). Patients in the no anticoagulation/antiplatelet group were significantly older (62.6 years versus 54.9 years, P = 0.0004). There were no significant differences between groups with respect to gender or history of tobacco use. There were no significant differences in body mass index (P = 0.289) or hemoglobin A1C (HbA1c) levels (P = 0.693) between the two groups. Of the 11 comorbidities that were compared between the two groups, five comorbidities were significantly more prevalent in the anticoagulation/antiplatelet therapy group: diabetes mellitus (73.0% versus 50.8%), hypertension (88.5% versus 73.1%), hyperlipidemia (68.9% versus 35.8%), congestive heart failure (26.2% versus 9.0%), and CKD (50.8% versus 28.4%). Day of surgery coagulation laboratory values (PT, PTT, INR) did not differ significantly between groups (Table 1).
Table 1.
Patient Characteristics
| Characteristics | All Patients | No Anticoagulation (n = 67) |
Anticoagulation or Antiplatelet (n = 122) |
P |
|---|---|---|---|---|
| Age | 59.9 ± 14.4 | 62.6 ± 13.3 | 54.9 ± 15.1 | 0.0004 |
| Gender | 0.565 | |||
| Women | 71 (37.6) | 27 (40.3) | 44 (36.1) | |
| Men | 118 (62.4) | 40 (59.7) | 78 (63.9) | |
| Tobacco | 0.395 | |||
| No | 98 (51.9) | 35 (52.2) | 63 (51.6) | |
| Past | 70 (37.0) | 22 (32.8) | 48 (39.3) | |
| Active | 21 (11.1) | 10 (14.9) | 11 (9.0) | |
| Comorbidities | ||||
| DM | 123 (65.1) | 34 (50.8) | 89 (73.0) | 0.002 |
| HTN | 157 (83.1) | 49 (73.1) | 108 (88.5) | 0.007 |
| HLD | 108 (57.1) | 24 (35.8) | 84 (68.9) | <0.0001 |
| CHF | 38 (20.1) | 6 (9.0) | 32 (26.2) | 0.005 |
| Renal failure | 63 (33.3) | 17 (25.4) | 46 (37.7) | 0.085 |
| CKD | 81 (42.9) | 19 (28.4) | 62 (50.8) | 0.003 |
| PAD | 38 (20.1) | 14 (20.9) | 24 (19.7) | 0.841 |
| Transplant | 7 (3.7) | 3 (4.5) | 4 (3.3) | 0.700 |
| HCV | 14 (7.4) | 7 (10.5) | 7 (5.7) | 0.237 |
| HIV | 7 (3.7) | 4 (6.0) | 3 (2.5) | 0.247 |
| RA | 10 (5.3) | 2 (2.99) | 8 (6.6) | 0.499 |
| BMI | 31.5 ± 8.4 | 32.0 ± 8.4 | 30.6 ± 8.3 | 0.289 |
| A1c | 6.8 ± 1.9 | 6.9 ± 1.8 | 6.8 ± 1.9 | 0.693 |
| Coagulation Laboratories | ||||
| PT | 14.4 ± 2.3 | 14.4 ± 2.8 | 14.5 ± 2.2 | 0.378 |
| PTT | 32.5 ± 7.6 | 34.5 ± 8.7 | 31.8 ± 7.2 | 0.854 |
| INR | 1.4 ± 2.7 | 1.2 ± 0.3 | 1.6 ± 3.2 | 0.315 |
Age, BMI, A1c, PT, PTT, and INR are reported as the mean ± SD. All other variables are reported as n (percent). PT and INR data available for 90 patients. INR data available for 57 patients.
Significant P values (<0.05) are in bold.
DM = diabetes mellitus; HTN = hypertension; HLD = hyperlipidemia; CHF = congestive heart failure; CKD = chronic kidney disease; HCV = hepatitis C virus; HIV = human immunodeficiency virus; RA = rheumatoid arthritis; A1c = hemoglobin A1c; PT = prothrombin time; PTT = partial thromboplastin time; INR = international normalized ratio.
Wound Characteristics
The anticoagulation/antiplatelet group had significantly more wounds of mixed etiology (7.4% versus 0%, P = 0.028) and significantly less wounds of “other” etiology (11.5% versus 25.4%, P = 0.014). Otherwise, there were no other statistically significant differences in wound etiology between the two groups (Table 2), The mean initial wound size was not significantly different between groups (anticoagulation/antiplatelet: 47.0 ± 59.3 cm2; no anticoagulation/antiplatelet: 58.5 cm2 ± 63.1 cm2; P = 0.220) (Table 3). The average number of days of follow-up was higher for patients on anticoagulation/antiplatelet therapy (458.4 days ± 343) than for those not on anticoagulation/antiplatelet therapy (369.5 days ± 352.5), but this finding did not reach significance (P = 0.095). Patients in both groups underwent a similar number of debridements (P = 0.401). A total of 143 patients underwent dermal matrix placement before STSG; rates were similar between groups (P = 0.643). All dermal matrices were placed in a two-stage fashion except for in two patients, who received a dermal matrix at the time of STSG.
Table 2.
Wound Etiology
| Characteristics | No Anticoagulation (n = 67) | Anticoagulation or Antiplatelet (n = 122) | P |
|---|---|---|---|
| DFU | 27 (40.3) | 47 (38.5) | 0.811 |
| PAD | 3 (4.5) | 9 (7.4) | 0.544 |
| VSU | 11 (16.4) | 11 (9.0) | 0.129 |
| Surgical | 4 (6.0) | 14 (11.5) | 0.302 |
| Cancer | 1 (1.5) | 6 (4.9) | 0.425 |
| Trauma | 4 (6.0) | 12 (9.8) | 0.425 |
| Mixed | 0 (0.0) | 9 (7.4) | 0.028 |
| Other | 17 (25.4) | 14 (11.5) | 0.014 |
Significant P values (<0.05) are in bold.
DFU = diabetic foot ulcer; VSU = venous stasis ulcer.
Table 3.
Wound Characteristics and Outcomes
| Characteristic | No Anticoagulation or Antiplatelet Therapy (n = 67) |
Anticoagulation or Antiplatelet Therapy (n = 122) |
P |
|---|---|---|---|
| Mean initial wound size (cm2) | 58.5 ± 63.1 | 47.0 ± 59.3 | 0.220 |
| Mean no. previous debridements | 3.6 ± 2.1 | 3.9 ± 2.3 | 0.401 |
| Mean days of follow-up | 369.5 ± 352.5 | 458.4 ± 343 | 0.095 |
| Use of dermal matrix | 52 (77.6%) | 91 (74.6%) | 0.643 |
| 30 d outcomes | |||
| Mean size at 30 d (cm2) | 11.5 ± 19.0 | 9.1 ± 17.3 | 0.412 |
| Mean % take at 30 d | 75.3 ± 28.3 | 70.6 ± 41.4 | 0.376 |
| Success at 30 d | 18 (26.9%) | 30 (24.6%) | 0.731 |
| No follow-up at 30 d | 3 (4.5%) | 11 (9.0%) | 0.254 |
| Final outcomes | |||
| Weeks to complete healing | 19.9 ± 21.8 | 22.7 ± 28.3 | 0.600 |
| Complete healing at final follow-up | 46 (68.7%) | 92 (75.4%) | 0.317 |
| Lost to follow-up | 10 (14.9%) | 8 (6.6%) | 0.061 |
Wound characteristics and outcomes of STSG patients with lower extremity wounds were documented throughout follow-up. Data are reported as mean ± SD or n (percent).
Hematoma Formation
Three hematomas were reported during 30 days of follow-up: one patient was receiving no antiplatelet or anticoagulant therapy, and two patients were on at least one anticoagulation/antiplatelet agent. There was no significant difference in hematoma incidence between groups (P > 0.05).
STSG Outcomes
Outcomes at 30 days post-STSG are summarized in Table 3. Of the 122 patients on anticoagulation/antiplatelet therapy, 81 (66.4%) remained unhealed, 30 (24.6%) achieved complete healing, and 11 (9.0%) were lost to follow-up. Of the 67 patients not on anticoagulation/antiplatelet therapy, 46 (68.6%) remained unhealed, 18 (26.9%) achieved healing, and three (4.5%) did not have follow-up. Rates of complete healing at 30 days were similar between the two groups (P = 0.731). There were no significant differences between groups with respect to mean percent STSG take (P = 0.376) and mean wound size (P = 0.412) at 30 days.
Outcomes at final follow-up were also analyzed and are summarized in Table 3. Of the 122 patients on anticoagulation/antiplatelet therapy, 22 (18.0%) remained unhealed, 92 (75.4%) achieved complete healing, and eight (4.5%) were lost to follow-up. Of the 67 patients not on anticoagulation/antiplatelet therapy, 11 (16.4%) remained unhealed, 46 (68.7%) achieved complete healing, and 10 (14.9%) were lost to follow-up. Rates of complete healing at final follow-up were similar between the two groups (P = 0.317). Time to complete healing was 22.7 (SD 28.3) weeks for patients on anticoagulation/antiplatelet therapy versus 19.9 (SD 21.8) weeks for those not on anticoagulation/antiplatelet therapy (P = 0.600).
STSG Outcomes by Individual Anticoagulation/Antiplatelet Agents
Chi-square or Fisher exact tests were performed to determine the effect of individual agents on STSG outcomes (Table 4). Statistical analysis revealed that there was no significant difference in STSG success between patients receiving aspirin therapy (n = 92) and those not on aspirin therapy (n = 121) (aspirin: 41.8% success, 43.7% fail; no aspirin: 58.2% success, 56.3% fail; P = 0.8112). Rates of success and failure were also not statistically different with respect to clopidogrel, warfarin, factor Xa-inhibitors, enoxaparin, and dual antiplatelet therapy (DAPT; aspirin and clopidogrel).
Table 4.
STSG Success at 30 Days by Specific Anticoagulation/Antiplatelet Therapy
| Treatment | Aspirin | Clopidogrel | ||
|---|---|---|---|---|
| Status | Failure | Success | Failure | Success |
| + | 69 (43.67%) | 23 (41.82%) | 29 (18.35%) | 10 (18.18%) |
| - | 89 (56.33%) | 32 (58.18%) | 129 (81.65%) | 45 (81.82%) |
| χ2 = 0.057; df = 1; P = 0.811 | χ2 = 0.001; df = 1; P = 0.977 | |||
| Treatment | Warfarin | Xa-inhibitor | ||
| Status | Failure | Success | Failure | Success |
| + | 15 (9.49%) | 7 (12.73%) | 13 (8.23%) | 5 (9.09%) |
| - | 143 (90.51%) | 48 (87.27%) | 145 (91.77%) | 50 (90.91%) |
| χ2 = 0.461; df = 1; P = 0.4973 | χ2 = 0.039; df = 1; P = 0.8429 | |||
| Treatment | Enoxaparin | ASA/Clopidogrel (DAPT) | ||
| Status | Failure | Success | Failure | Success |
| + | 10 (6.33%) | 3 (5.45%) | 62 (88.57%) | 22 (95.65%) |
| - | 148 (93.67%) | 52 (94.55%) | 8 (11.43%) | 1 (4.35%) |
| Fisher; P = 1 | Fisher; P = 0.443 | |||
χ2(0.05) (df) = 3.841
Results of chi-square/Fisher exact test and descriptive statistics for STSG success at 30 days. Data are reported as n (column percentages).
Df = degrees of freedom, DAPT = dual antiplatelet therapy.
DISCUSSION
Anticoagulant and antiplatelet agent use is common among patients with lower extremity wounds. However, data on the effects of these medications on wound healing are limited. Significant evidence exists suggesting that perioperative suspension of antithrombotic agents in susceptible individuals can lead to dangerous thrombotic events.9,10 In instances where continuation of antiplatelet/anticoagulation medications may be beneficial for reducing perioperative cardiovascular events, surgeons must consider whether these benefits outweigh the possible bleeding risk posed by these agents. The findings from this study show no significant differences in graft healing, graft success, or hematoma formation in patients receiving anticoagulation or antiplatelet therapy at the time of STSG placement compared with patients who were not, suggesting risk of bleeding and subsequent graft failure attributable to these agents is insignificant.
The prevailing concern of continuing antiplatelet or anticoagulation therapy in the perioperative period includes uncontrolled bleeding, hematoma formation, and in the case of STSG, decreased graft take.10 A meta-analysis by Lewis and Dufresne in 2008 analyzed the risk of postoperative complications from 6 studies, including 1373 patients undergoing cutaneous surgery, and found that bleeding complications may be higher in patients taking warfarin (OR 6.69; 95% CI, 3.03–14.7; P < 0.001) or aspirin (OR 2.0; 95% CI, 0.97–4.13; P = 0.06) compared with control populations.11 Of note, however, this same study concluded that the risk of death from blood loss is low compared with all-cause mortality.11,12 Thus, in patients with underlying cardiovascular comorbidities necessitating maintenance antiplatelet or anticoagulant use, surgeons have traditionally been pressed to weigh the risks and benefits of stopping versus continuing these medications in the perioperative period.
Several studies have explored surgical procedures that can be safely performed in the anticoagulated patient. Early experiments in animal models theorized that graft failure secondary to thrombosis could be avoided with anticoagulants.13 Later trials expanded on these conclusions. Billingsley and Maloney concluded that there is no need to stop aspirin, warfarin, or NSAIDs in patients undergoing cutaneous procedures such as Mohs, excisions, and repairs due to insignificant differences in duration of intraoperative bleeding between treatment and control groups.12 Bartlett prospectively analyzed patients taking aspirin and investigated bleeding complications during minor dermatological plastic surgery procedures, including excisions of non-melanoma skin cancers, melanomas, benign tumors, keratoses, cysts, and nevi. The study demonstrated no difference in complication rates between regular aspirin users and those not taking aspirin.14 Alam et al conducted a multicenter prospective cohort study of 20,821 patients undergoing Mohs micrographic surgery (MMS).15 While most bleeding and wound healing complications occurred in patients who were taking anticoagulation therapy, only four patients in the overall cohort experienced major adverse events requiring hospitalization and none of these events were associated with bleeding or wound healing complications. Otley et al performed a retrospective analysis of 653 patients undergoing MMS and determined that only 1.6% of regular warfarin or platelet inhibitor users developed intraoperative or postoperative complications such as hemorrhage, bleeding, hematoma formation, necrosis, or dehiscence.16 Nelms et al investigated the effects of warfarin on outcomes in patients undergoing minor plastic surgery procedures. Although not measured objectively, the authors stated no subjective difference in intraoperative or postoperatitve bleeding compared with those not taking warfarin. Thus, they suggest that warfarin can be safely continued for superficial soft tissue procedures.17 A recent systematic review of over 14,000 patients found no increased rate of graft failure in anticoagulant or antiplatelet users. There were no differences in hemorrhagic complications in aspirin users; however; data were conflicting in patients receiving warfarin or clopidogrel monotherapy and undergoing minor cutaneous surgery. Unlike the present study which primarily focused on lower extremity wounds, this systematic review focused on STSG placement that was limited to the head and neck or undisclosed locations.18 Our data expand on these prior studies as the first to examine outcomes of split-thickness skin grafting in lower extremity wound patients. We have shown comparable results establishing STSG as a safe cutaneous procedure in the actively anticoagulated patient.
Although, there are multiple studies justifying the use of antithrombotic drugs in minor surgery, some patient populations warrant special considerations when considering the discontinuation of these agents in the perioperative period. Grines et al stress the importance of continuing DAPT and postponing elective surgery for 1 year after placement of drug-eluting stents to prevent cardiac events. If a procedure cannot be deferred, aspirin should be continued perioperatively in these patients.8 Our data showed no difference in STSG outcomes between patients on DAPT and those not on DAPT. These results suggest that patients who are taking a combination of aspirin and clopidogrel need not suspend antiplatelet therapy in anticipation of graft failure when procedures are emergent or cannot be deferred. Cardiovascular events inherently carry much more detrimental consequences compared with STSG failure. Alam and Goldberg presented two patients whose antithrombotics were withheld for MMS and subsequently developed serious adverse cardiovascular events postoperatively, highlighting the consequential, albeit low, risk of stopping these medications.19 These results, in combination with the findings of previous studies, suggest that cessation of antithrombotics to minimize bleeding and healing complications after minor cutaneous surgery is unwarranted.
Contrarily, there is a growing body of evidence suggesting that heparins may even be beneficial for wound healing. Serra et al performed a prospective trial of 120 patients undergoing excision and mesh grafting of chronic leg ulcers and demonstrated that low-molecular-weight heparin improved healing outcomes.20 Solak indicated that in addition to their primary action as an anticoagulant, low-molecular-weight heparins also may have some effect on cell proliferation and inflammatory modulation.21 Kalani et al performed a prospective, randomized, double-blind, placebo-controlled trial and determined that dalteparin improves wound outcomes in diabetic patients with peripheral arterial occlusive disease.22 The applications of antithrombotic agents for wound healing augmentation requires extensive investigation, considering the risk of bleeding and adverse events.
LIMITATIONS
There are many options for systemic anticoagulation or antiplatelet therapy. A wide-encompassing and comprehensive evaluation of the effects of these medications on STSG healing and complications is beyond the scope of this analysis. Systemic heparin therapy was not included in this analysis, as there were too few patients within the studied population on this medication. Patients on Xa-inhibitors also required pooling due to low numbers on individual formulations. The primary outcomes of interest of this study centered on wound and STSG outcomes and thus, risk of cardiovascular events was not assessed. Furthermore, patients in the no anticoagulation/antiplatelet group largely were not on these agents because they lacked the medical indications, thereby introducing a selection bias if cardiovascular events were to be assessed. Therefore, this study does not assess the risk profile of cardiovascular events in the use or discontinuation of antithrombotic agents for STSG procedures.
Furthermore, the retrospective nature of this analysis presents additional inherent biases. To our knowledge, this is the first study to evaluate the effect of concurrent antiplatelet or anticoagulant therapy on STSG healing and success for lower extremity chronic wound patients. Additional studies are needed to elucidate the effects of novel antithrombotics. As these medications become more prevalent and the use of STSG expands for coverage of chronic wounds, these studies will likely become not only possible but also necessary to maintain patient safety and improve wound healing outcomes.
CONCLUSIONS
The use of anticoagulant and antithrombotic medication is common among patients with lower extremity wounds. The findings from this study suggest that there is no need to suspend these medications for STSG coverage of chronic lower extremity wounds. With careful consideration of the patient’s medical history and attention to intraoperative hemostasis, safe and acceptable STSG outcomes are possible in patients on concomitant anticoagulant or antiplatelet therapy.
ACKNOWLEDGMENTS
We thank Ms. Sayyed for her contributions to data procurement and analysis. We also thank Ms. Haffner for her contributions to data procurement and analysis.
Footnotes
Published online 16 December 2022.
Disclosure: Dr. Christopher E. Attinger receives consulting fees from Acelity (eg, advisory boards) and Integra (eg, advisory boards). Dr. Paul J. Kim receives consulting fees from Acelity (eg, advisory boards) and Integra (eg, advisory boards). Dr. John S. Steinberg receives consulting fees from Acelity (eg, advisory boards) and Integra (eg, advisory boards). All other authors have no financial or other conflicts of interest to disclose. No funding was received for this article.
This study was approved by the institutional review board of the MedStar Georgetown University Hospital.
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