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The Meek Technique

In 1958 a remarkable technique for expanding autografts was described by mr. Cicero Parker Meek from the University of South Carolina Aiken (USCA), USA. With a MEEK-WALL dermatome postage stamp autografts were obtained and expanded using double pleated gauzes. In this way a regular distribution of autograft islands was achieved with a nine fold expansion. This technique however required too much skill and it became eclipsed by the introduction of mesh skin grafts (Tanner et al., 1964). Eventually production of the MEEK-WALL dermatome and gauzes was discontinued.

In cooperation with surgeons of the burn centre of the Red Cross Hospital Beverwijk, The Netherlands, Humeca re-designed and modernized the MEEK technique. Imperfections of the original method were overcome and the prefolded gauzes are now manufactured with expansion ratios 1:3, 1:4, 1:6 and 1:9.

Humeca Meek GauzeHumeca Meek MachineHumeca cut graft

The clinical results with this modified MEEK technique are excellent: graft take is reported to be superior to other grafting methods, even in problematic zones and even in case of qualitatively inferior wound beds. Only very small donorsites are required. Any small piece of patients skin can be used. The graft islands are close together in a regular pattern, resulting in fast epithelialization. As the autograft islands are not mutually connected, failure of a few islands does not necessarily affect the overall graft take.
The method appears to be a simple technique to achieve a regular distribution of postage stamp grafts, correctly orientated to the wound surface.

Meek Features

Most important features of the MEEK technique for skin grafting:

• Very small donorsites
• Large expansion ratios (up to 1:9) possible
• Any small skin fragments can be used; no long strips required
• Graft islands are close together in a regular pattern, resulting in fast and uniform epithelialization
• All graft islands are correctly orientated (dermal side down) on the wound bed, resulting in excellent graft take
• Failure of a few islands does not affect the overall graft take • Actual expansion ratio equals theoretical expansion ratio
• Cosmetic results are comparable with meshgrafts of a lower expansion
• Grafts adhere to a fabric and are therefore very easy to manipulate when applying them to the wound

Meek Surgery

At operation wounds to be grafted are excised down to the underlying fascia and haemostasis is secured. A square piece of cork measuring 42 x 42 mm with thickness 2 mm is covered with a split skin autograft, dermal side down. Smaller graft remnants are also suitable by placing them on the cork plate like a “puzzle”. The cork, covered with graft, is then placed in a cutting machine.

The machine contains 13 parallel circular blades. The cork plate with the graft on it, is passed through the dermatome, where the blades cut through the graft, but not through the cork. Thus the graft is cut into 14 stripes 3 mm wide. After the first pass, the cork is rotated 90° and passed through the dermatome for the second time, thus cutting the graft into 14×14 pieces measuring 3×3 mm. Then the cork plate, with the cut graft in place, is removed from the machine.

The upper (epidermal) surface of the graft is sprayed with an adhesive dressing spray and allowed to dry and become tacky. The cork plate, covered with graft and adhesive is then pressed onto a prefolded gauze. This gauze is folded on a backing into 14×14 square pleats that correspond to the cuts in the autograft. Then the cork is gently removed, leaving the graft islands adhering to the gauze. The gauze is pulled out by firm traction on all four sides, until the pleats become completely unfolded. Finally the backing is peeled off, to leave the expanded gauze with the separated adherent autograft islands ready for transplantation.

Humeca Meek corkplate-on-plissee Humeca Meek expanded-plissee-1 Humeca Meek expanded-plissee-2
Cork plate pressed to the Plissee        Plissee extracted in the first direction                         Plissee unfolded

After trimming the margins, the gauze is applied, graft side down, to the wound bed and secured with surgical staples. After about 6 days the grafts have grown sufficiently into the wound bed to allow removal of the gauze, leaving the autograft islands in situ on the wound. Daily dressings are continued until epithelialization is complete.

Humeca Meek gauzes-applied-2 Humeca Meek detail-gauzes-on-wound Humeca Meek Gauzes fremoved from the wound
Gauzes are applied to the wound          Details of gauzes on the wound        Gauzes removed from the wound

 

The Meek Cutting Machine

The cutting machine contains 13 circular blades that cut the graft into 196 square pieces, measuring 3×3 mm. The graft and cork plate are placed in a cutting block that moves under a bridge during cutting. Both the drive of the blades and the drive of the cutting block can be performed by pneumatic motor or by hand.

The motor drive of the blades is exchangeable with the hand drive and both can be supplied as separate sets. For pneumatic drive a pressure of 5-7 bars is required.

The blades are coated with a durable, wear resistant ceramic layer. The cutting axis can simply be replaced and is also available as an extra spare part. Individual blades can also be replaced.

The machine is supplied with a single, or a double cutting block. The double cutting block enables simultaneous cutting of two cork plates, thus saving time in the MEEK procedure. Single and double blocks are exchangeable, using the same machine.

The machine is entirely washed and steam sterilized before use, except for the motor.

Do’s & Dont’s

From the experiences of surgeons in the last 20 years, we listed the most important recommendations when doing surgery with the MEEK technique. Reading them carefully will prevent unnecessary failure.

Do’s and don’ts in MEEK Micrografting

  • Prior to the first use, please take close look at the instruction film supplied with the equipment.
  • Don’t put any oil or other fatty substance on the patients skin when harvesting the graft. This prevents the glue from sticking the graft to the gauze. Use sterile water or salt solution instead.
  • Don’t harvest a graft so thick that fatty tissue is visible at the dermal side. Such fatty tissue will cause the graft to slip on the cork plate at cutting. Normally the MEEK technique is used for split thickness grafts (thickness approx. 0.3 mm).
  • Never sterilize the motor!!
  • Check before use whether or not the screws of the bridge are fixed (by hand).
  • Use pressure air to drive the motor (pressure 4-7 bars).
  • When activating the motor with the foot pedal, always press the foot pedal completely. Don’t try to throttle the airflow by pressing it partly as this will cause air leakage.
  • Before use, shortly immerse the cork plate into sterile water or salt solution.
  • Place the graft on the cork plate dermal side down. Alternatively place the graft on a cutting board epidermal side down and subsequently place the cork plate on top of it. What ever you do: finally the dermal side of the graft should face the cork plate.
  • Don’t let the graft overlap the cork plate. The size of the graft should be the same as the size of cork plate (42×42 mm) or just a little bit smaller. You can use the cutting aid (“stamp”) to be sure the graft has the correct size (41×41 mm).
  • Moisten the underside of the cover (the grating) of the cutting block before closing it to prevent the graft from sticking to the cover at opening. However, if the graft sticks to the cover anyway, use the “cam” to press it back to the cork plate before opening the cover.
  • Always place the cutting block in the machine at the side of the hand wheel and then move it towards the other side, not the other way round. If you do, the graft will move on the cork plate and the separation of the islands when unfolding the gauze will be disturbed.
  • Don’t spray too much glue on the graft. After spraying the graft should appear glossy. No “pool” of glue should be seen. Spray from a distance of about 20 cm.
  • Allow the glue to dry for at least 8 minutes before pressing the cork plate with the graft to the pre-folded gauze. At shorter drying times the grafts will remain on the cork plate after pressing it to the pre-folded gauze. Longer drying times will not harm.
  • Remove the cork plate from the prefolded gauze only immediately before transplantation to prevent the graft from drying. If transplantation is delayed, keep the cork plate on the gauze or wrap the prefolded gauzes in moistened dressings. You can also unfold the gauzes and put them into sterile water or salt solution until the moment of transplantation.
  • At transplantation, fix the gauze with the graft islands well on the wound bed with staples. This is to prevent the gauze from moving during dressing changes. Also stretch the fabric (all pleats completely unfolded) before stapling it for good contact between grafts and wound bed.
  • Don’t place the cutting axis on a hard surface (table). You will damage the blades. After use you can take out the axis from the machine and clean the blades with a soft brush. Put the axis back in the machine for washing and sterilization.
  • During transport the cutting block should be under the bridge to prevent it from falling from the machine when turned upside down.

Meek Cases

MEEK case by Dr. A.W.F.P. Vloemans, Surgeon at the Burns Centre of Red Cross Hospital Beverwijk, The Netherlands.

MEEK case by Prof. Ognian Hadjiiski, MD, Pirogov Emergency Medical Institute, Sofia, Bulgaria.

Meek Literature

MEEK Technique requires half donor site are compared to meshing. A publication in Burns by R. Peeters and A. Hubens.

1 Meek CP, Successful microdermagrafting using the Meek-Wall microdermatome – Am. Surg. vol. 29, pp. 61 (1958)
2 Meek CP, Extensive severe burn treated with enzymatic debridement and microdermagrafting – American Surgeon, vol. 29, no. 1, pp. 61-64 (1963)

3 Kreis RW, Mackie DP, Vloemans AWFP, Hermans RP, Hoekstra MJ, Widely expanded postage stamp skin grafts using a modified Meek technique in combination with an allograft overlay
Burns, vol. 19 (2), pp. 142-145 (1993)

4 Kreis RW, Mackie DP, Hermans RP, Vloemans AWFP, Expansion techniques for skin grafts: comparison between mesh and Meek island (sandwich-)grafts – Burns, vol. 20 (1), pp. S39-S42 (1994)

5 Peeters R, Hubens A, The mesh skin graft – true expansion rate – Burns, vol. 14 (3), pp. 239-240 (1988)

6 Raff T, Hartmann B, Wagner H, Germann G, Experience with the modified MEEK technique – Acta Chirurgiae Plasticae, vol. 38 (4) pp. 142-146 (1996)

7 Zermani Rita, Zarabini Andrea, Trivisonno Angelo, Micrografting in the treatment of severely burned patients – Burns, vol. 23 (7/8), pp. 604-607 (1997)

8 Hermans RP, Kreis R, Micrografting – Revival of an old technique – Annals of Burns and Fire Disasters, vol. 10 (1) (1997)

9 Vloemans AFPM, Micrografts versus Meshgrafts – Casus

10 Hadjiiski O, Method of micrografting in treatment of large area full-thickness burns – Annals of Burns and Fire Disasters, vol. 13 (3), pp. 155-158 (2000)

11 Lari AR, Gang RK, Expansion technique for skin grafts (Meek technique) in the treatment of severely burned patients – Burns, vol. 27, pp. 61-66 (2001)

12 Grenier de Cardenal D, Bey E, Lambert F, Duhamel P, Chaine A, Giraud O, Cantaloube D, Le procédé Humeca chez le grand brûlé: Difficultés – Brûlures, vol. III (1), pp. 34-37 (2002)

13 Papp A, Härmä M, Case report: A collagen based dermal substitue and the modified Meek technique in extensive burns – Report of three cases – Burns 29, pp. 167-171 (2003)

14 Kopp J, Noah EM, Rübben A, Merk HF, Pallua N, Radical resection of giant congenital melanocytic nevus and reconstruction with Meek-graft covered Integra dermal template
Dermatologic Surgery vol. 29 (6) pp. 653-657 (2003)

15 Tempelman FRH, Meek Micrografting – abstract lecture

16 Tempelman FRH, Vloemans AFPM, Middelkoop E, Kreis RW., The Meek-Wall Micrograft Technique. In: Surgery in Wounds, Téot L, Banwell PE, Ziegler UE, eds. Springer-Verlag Berlin Heidelberg,
pp.427-434, (2004), (ISBN 3-540-22254-5, ed. 2005)

17 GE Sheng-de, History of the clinic work about MEEK – Chinese Journal of Injury Repair and Wound Healing, vol. 1 (1) pp. 10-11 (2006)

18 LIN Cai, CHEN Geng-xin, ZHANG Peng, et al., The MEEK technology of tiny flap graft using on extensively and deeply burning – Chinese Journal of Injury Repair and Wound Healing,
vol. 1 (1) pp. 24-26 (2006)

19 YANG Ding-wen, TAN Qian, WU Jie, et al., Comparison between the MEEK’s autograft and the stamp-like autograft in the clinical application – Chinese Journal of Injury Repair and Wound Healing, vol. 1 (1) pp. 30-33 (2006)

20 SUN Yong-hua, ZHANG Ming-liang, ZHOU Yi-ping, et al., Transplantation of microskin Autografts and skin pulp auto-epithelium and homeoderma in the treatment of extensive full-thickness burns
Chinese Journal of Injury Repair and Wound Healing, vol. 2 (1) pp. 10-13 (2007)

21 YE, Sheng-jie, PANG Shu-guang, AZHANG Wen-zhen, et al., Application experience of MEEK Skin-piece making technique on large area deep burning
Chinese Journal of Injury Repair and Wound Healing, vol. 2 (1) pp. 10-13 (2007)

22 SUN, Dong-yuan, ZHANG, Hua-bin, CHEN Ji-yang, et al., Repairing of the residual wounds in major burn patients with Meek skin grafting technique
Chinese Journal of Injury Repair and Wound Healing, vol. 2 (2) pp. 113-114 (2007)

23 Chun-Sheng Hsieh, Jen-Yu Schuong, W.S. Huang, Ted T. Huang, Five years’ experience of the modified Meek technique in the management of extensive burns – Burns, vol. 34, pp. 350-354 (2008)

24 A.A. Dorai, C.K. Lim, A. Cik Farcha, A.S. Halim, Cultured epidermal autografts in combination with MEEK Micrografting technique in the treatment of major burn injuries — The Medical Journal of Malaysia vol. 63, supplement A, (2008)

25 Lumenta DB, Kamolz LP, Frey M., Adult burn patients with more than 60% TBSA involved – MEEK and other techniques to overcome restricted skin harvest availability
The Viennese Concept – Journal of Burn Care & Research, March/April, pp. 231-242 (2009)

26 S.E. James, S. Booth, P.M. Gilbert et. Al., Sprayed cultured autologous keratinocytes used alone or in combination with meshed autografts to accelerate wound closure in difficult-to-heal burns patients
Burns vol. 36, pp e10-e20 (2010).

27 Seema Menon a, Zhe Li b, John G. Harvey a, Andrew J.A. Holland, The use of the Meek technique in conjunction with cultured epithelial autograft in the management of major paediatric burns — Burns vol. 39, pp 674-679 (2013).

28 Medina Abelardo, Riegel Timothy et al, Modified Meek Micrografting technique for wound coverage in extensive burn injuries — J Burn Care Res 2016: 37:305-313