Decellularized dermal grafting in cleft palate repair

Acellular dermal matrices in reconstructive surgery; history, current implications and future perspectives for surgeons

Large-scale defects of body in the reconstructive surgical practice, and the helplessness of their repair with autologous tissues, have been an important factor in the development of artificial biological products for the temporary, definitive, or staged repair of these defects. A major advance in the field of plastic and other reconstructive surgery in this regard has been the introduction and successful use of acellular dermal matrices (ADMs). In recent years, not only the type of tissue from which ADMs are produced, product range, diversity and areas of use have increased, but their use in reconstructive fields, especially in post oncologic breast surgery, has become highly regarded and this has favored ADMs to be a potential cornerstone in specific and well-defined surgical fields in future. It is essential that reconstructive surgeons become familiar with some of the ADM’s as well as the advantages and limitations to their use. This review not only provides basic science and clinical evidence of the current use of ADMs in wide range of surgical fields but also targets to keep them as an important backdrop in the armamentarium of reconstructive surgeons. Brief considerations of possible future directions for ADMs are also conducted in the end.

Effect of Acellular Dermal Matrix on Long-Term Speech Outcomes in Primary Palatoplasty with Radical Intravelar Veloplasty

OBJECTIVE

This study investigates whether the use of acellular dermal matrix (ADM) affects the long-term speech outcomes in patients undergoing primary palatoplasty with radical intravelar veloplasty.

DESIGN

Retrospective cohort study.

SETTING

Tertiary university-affiliated hospital.

PARTICIPANTS

A consecutive cohort of 112 patients who underwent primary palatoplasty with radical intravelar veloplasty from August 2014 to March 2018 were included.

MAIN OUTCOME MEASURES

A 2 × 2 cm-sized ADM was incorporated as an interpositional graft between the oral and nasal lining at the soft-hard palate junction. The perceptual analysis of hypernasality and articulation was performed when the age of the patient reached at least 36 months. Cleft-related characteristics and surgical factors affecting the speech outcomes were investigated.

RESULTS

The ADM was applied in 57 patients with a mean follow-up of45.76 months (SD, 10.69), while no ADM was used in 55 patients with a mean follow-up of 48.43 months (SD, 14.98). Regarding the hypernasality outcome, 33.3% (19 of 57 patients) of the ADM group and 27.3% (15 of 55 patients) of the control group showed a greater than mild-to-moderate degree. The distribution of hypernasality and articulation grade showed no significant difference between the two groups. After controlling for potential risk factors that may affect the speech outcomes, the use of ADM showed no significant relationship with velopharyngeal insufficiency.

CONCLUSION

The use of ADM use in primary palatoplasty with radical intravelar veloplasty is not associated with the alteration of speech function in early childhood.

Outcome of Nasal Layer Reinforcement With Autologous Dermis in Cleft Palate Repair on Postoperative Fistula Formation

Palatal fistulae are challenging complications following cleft palate repair. The addition of acellular dermal matrix (ADM) to cleft palate repair has been shown to reduce fistula formation in previous studies. The use of autologous dermal graft has all the structural advantages of ADM, has less rejection and immunogenic potential, and is cost effective.

A prospective study.

Patients with Group II and III cleft palate (Nagpur Classification) without prior intervention for palatal repair in the Department of Plastic Surgery at PGIMER from January 2020 till June 2021.

The addition of autologous dermal graft for palatoplasty.

Outcome of the study was fistula development or exposure of dermal graft.

Autologous dermal graft was harvested of average dimension of 8.73 cm2 (range 5.25-18 cm2) from groin region. Sixteen patients were included in the study. Among them, 2 patients (12.5%) developed postoperative fistula (Type III &V Pittsburgh Classification).

Our study showed that the rates of postoperative fistula formation are comparable with prior literature using artificial dermal matrices.

Interposition grafting of collagen-gelatin sponge impregnated with basic fibroblast growth factor in primary palatoplasty

INTRODUCTION

An oronasal fistula is a challenging post-operative complication of palatoplasty due to impaired velopharyngeal function or its high recurrence rate. Muscle repositioning, a key procedure in palatoplasty, causes dead space at the junction between the hard and soft palates. Consequently, thin oral and nasal mucosae are prone to break down and form fistulas. In this study, we used basic fibroblast growth factor-impregnated collagen gelatin sponge (bFGF-CGS) in primary palatoplasty to reduce fistula formation.

METHODS

This retrospective study assessed the complications and efficacy of bFGF-CGS to reduce fistula formation. Patients who underwent primary palatoplasty with bFGF-CGS were included. The same number of patients who underwent primary palatoplasty without bFGF-CGS was included as a control group. The outcomes included post-operative oronasal fistula formation, delayed healing, bleeding, and infection.

RESULTS

Both groups included 44 patients. Except for age at palatoplasty, there were no statistically significant demographic differences between the two groups; however, the rates of fistula formation in the study and control group were 2.3% and 13.6%, respectively. There were no infections among the patients.

CONCLUSIONS

The grafting of bFGF-CGS in primary palatoplasty was safe and probably effective in reducing post-operative oronasal fistula formation.

Tissue adjuncts in primary cleft palate reconstruction: A systematic review

BACKGROUND

Tissue adjunct is non-palatal tissue used to manage tension at the defect site by providing additional coverage. This review aimed to compare outcomes of various adjuncts employed in primary palatoplasty.

METHODS

A literature search was conducted of MEDLINE, EMBASE, and Cochrane Library with keywords cleft palate, palatoplasty, surgical flaps, and allografts. Data extracted included demographics, cleft severity, primary/adjunctive techniques, outcomes, and follow-up periods. Logistic regression analyses and chi-squared tests were performed to investigate associations among variables.

RESULTS

A total of 1332 patients (aged 3 months-5 years) with follow-up of 1 month to 21 years were included. Cleft severity included submucous cleft (1.7%), Veau I/II (33.3%), Veau III (46.3%), and Veau IV (15.1%). Most reported techniques were Furlow (52%) and intravelar veloplasty (14.3%) for soft palate, Bardach (27.2%), and V-Y Pushback (11.1%) for hard palate. Buccal myomucosal flap (BMMF) was performed in 45.4% of cases, followed by buccal fat pad flap/graft (BFP) in 40.8% and acellular dermal matrix (ADM) in 14%. Severe clefts (Veau III/IV) were repaired more frequently with BMMF compared with ADM (p = 0.003) and BFP (p = 0.01). Oronasal fistula occurred in 3.1% of patients, and velopharyngeal insufficiency (VPI) in 4%, both associated with Veau IV (fistula: p = 0.002, VPI: p = 0.0002). No significant differences were found in fistula (p = 0.79) or VPI (p = 0.14) rates between adjuncts. In severe clefts (Veau III/IV), ADM was associated with fistula formation (p = 0.03).

CONCLUSIONS

Adjuncts in primary palatoplasty may mitigate unfavorable outcomes associated with severe clefts. BMMF is superior, given its inherent tissue properties, whereas BFP is effective in reducing fistula formation.

Human Acellular Dermal Matrix in Reconstructive Surgery-A Review

Reconstructive surgery often confronts large tissue defects. This creates a need to look for materials that are immunogenic but offer the possibility of tissue filling. ADM-acellular dermal matrix-is a biological collagen matrix without immunogenicity, which is more commonly used in surgical treatment. Reconstructive surgery is still searching for various biocompatible materials that can be widely used in surgery. The available materials have their advantages and disadvantages. This paper is a literature review on the use of human acellular dermal matrix (ADM) in reconstructive surgery (surgical oncology, plastic and reconstructive surgery, and gynecologic reconstructive surgery). ADM appears to be a material of increasing use in various fields of surgery, and thus, further research in this area is required.

Biologics and acellular dermal matrices in head and neck reconstruction: A comprehensive review

Acellular dermal matrices (ADMs) have been studied extensively in the literature and have gained popularity for various reconstructive and aesthetic purposes. ADMs are composed of a basement membrane and acellular dermal layer of collagen and provide a platform for mucosal epithelization and neovascularization. Combining dermal collagen and essential growth factors allows ADMs to support adequate wound healing and bolster soft-tissue repairs. These dermal matrices can be derived from human cadaveric donor skin (allogenic) or mammalian donor sources (xenogeneic). These dermal substitutes provide the benefit of reducing or eliminating the need for autologous tissue grafts and subsequently minimize donor site morbidity. Many ADMs are currently available in the market, each with variations in processing, manufacturing, storage, preparation, and use. The literature validating ADMs in the head and neck for both cosmetic and reconstructive purposes is evolving rapidly. This review aims to provide an up-to-date and comprehensive overview of the principles of acellular dermal matrices (ADMs), the different types of ADMs, and evaluate common indications, techniques, and outcomes pertaining to select anatomic sites in the head and neck reconstruction.

Use of dCELL (Decellularized Human Dermis) in Repair of Urethrocutaneous Fistulas or Glans Dehiscence

Background

In hypospadias repairs, there is some evidence to suggest that a "waterproofing" layer can be helpful in reducing the risk of urethrocutaneous fistula formation. The most likely role of this layer is to prevent the creation of overlapping suture lines. Many hypospadias surgeons use a dartos fascia interposition flap for this purpose. However, raising a dartos fascia flap adds time to the procedure, can result in devascularization of the overlying skin, and can create unsightly torsion of the penis, which may be hard to correct. To avoid these problems, the senior author has started to use dCELL (decellularized human dermis) as an alternative to dartos fascia to separate the suture lines.

Methods

Between March and July 2018, a pilot study was performed in 8 patients undergoing closure of a urethrocutaneous fistula or glans dehiscence combined with dCELL. Data on infections, wound breakdown, length of stay and catheterization, surgical time, and hospital stay were collected.

Results

All patients had a successful reconstruction. One patient developed a urinary tract infection, possibly related to prolonged catheterization following his repair.

Conclusion

Our results suggest that dCELL may be useful in the repair of urethrocutaneous fistulas and glans dehiscence after hypospadias surgery.

Single-institution Outcome Experience Using AlloDerm® as Temporary Coverage or Definitive Reconstruction for Cutaneous and Soft Tissue Malignancy Defects

Definitive reconstruction after excision of cutaneous and soft tissue malignancies is sometimes limited as a result of lack of native tissue coverage options, patient comorbidities, or pending permanent margin analysis. Acellular dermis (AlloDerm®) reconstruction offers an excellent coverage alternative in these situations. We describe our experience using AlloDerm for coverage of skin and soft tissue defects. An Institutional Review Board approved review of patients undergoing skin/soft tissue coverage with AlloDerm from 2006 to 2012 was performed. Clinicopathologic variables, early postoperative findings, and subjective final cosmetic outcome were analyzed. Sixty-seven patients underwent AlloDerm reconstruction. Melanoma (67%) was the most frequent diagnosis. The median defect size was 42 cm2 (range, 2 to 340 cm2), involving predominantly the lower extremity (45%) or head and neck (32%). AlloDerm was intended for use as a temporary dressing in 64 per cent (43 of 67) and permanent coverage in 24 (36%). Ten patients required reexcision for positive margins. Twenty-five (37%) underwent split-thickness skin graft or flap coverage after AlloDerm placement. Radiation was administered to 16 patients (24%) after AlloDerm reconstruction within a median of 53 days after surgery (range, 18 to 118 days). At first postoperative examination (median, 11 days after surgery), 85 per cent had evidence of healthy AlloDerm incorporation. Cellulitis was the most frequent complication (13%), all resolving with oral antibiotics. AlloDerm reconstruction after skin and soft tissue resection offers a suitable coverage alternative and may serve as a bridge to permanent reconstruction or as a permanent biologic dressing of complex surgical defects. In situations in which adjuvant radiation is needed, AlloDerm can be used without major complications.

Soft-Tissue Grafting Solutions

Many soft-tissue grafting solutions are available for reconstruction and restoration of volume and esthetics of keratinized attached mucosa at compromised periodontal and peri-implant interfaces. Presence of healthy soft tissues is crucial for functional and esthetic implant success as well as longevity of natural dentition. The options available each provide unique characteristics with different indications. This article is intended to provide an efficient and comprehensive overview of this topic, covering the essentials of periodontal anatomy and physiology, indications for soft-tissue grafting, and keys in recipient and donor-site preparation, and exploring the available procedural arsenal in soft-tissue grafting.

Decellularized human bone as a 3D model to study skeletal progenitor cells in a natural environment

There has been an increasing interest in exploring naturally derived extracellular matrices as an material mimicking the complexity of the cell microenvironment in vivo. Bone tissue-derived decellularized constructs are able to preserve native structural, biochemical, and biomechanical cues of the tissue, therefore providing a suitable environment to study skeletal progenitor cells. Particularly for bone decellularization, different methods have been reported in the literature. However, the used methods critically affect the final ultrastructure and surface chemistry as well as the decellularization efficiency, consequently causing complications to draw conclusions and compare results in between studies. In this chapter, an optimized protocol for the preparation of human bone derived scaffolds is described, including processing techniques and further characterization methods, which allow the final construct to be recognized as a major platform for bone therapeutic and/or diagnostic applications.

Acellular Dermal Matrices: Applications in Plastic Surgery

Modern advances in tissue engineering have transformed the plastic surgeon's management strategies across a wide variety of applications. Comprehension of the fundamentals of biologic constructs is critical to navigating the available armamentarium. It is essential that plastic surgeons become familiar with some of the existing methods for utilizing biologics as well as the advantages and limitations to their use. In this article, the authors describe the basic science of biologics with a focus on acellular dermal matrices (ADMs), and review the recent evidence behind their use for a variety of reconstructive and aesthetic purposes. The review is organized by system and examines the common indications, techniques, and outcomes pertaining to the application of ADMs in select anatomic areas. The final section briefly considers possible future directions for using biologics in plastic and reconstructive surgery.

The Use of Acellular Dermal Matrix in Combination With Pedicled Buccal Fat Pad in Wide Cleft Palate Repair: A Case Report and Literature Review

We describe a case of the combined use of acellular dermal matrix and pedicled buccal fat pad (BFP) in a wide U-shaped cleft palate repair. Acellular dermal matrix was used as a "patch" repair for the nasal mucosa defect as opposed to the conventional inlay graft. The advantages include reduced cost and a smaller avascular graft load. Lateral relaxing incisions were made to ensure tension-free closure of oromucosa at midline. Lateral oromucosa defect closure with well-vascularized pedicled BFP ensures enhanced healing, less palatal contracture and shortening, and reduced infection. The palate healed with mucosalization at 2 weeks, and no complications were noted at 6 months follow-up.

[Clinical analysis of acellular dermal matrix and acellular bone matrix in oro-antral fistula repair]

OBJECTIVE

This study aimed to investigate the application of acellular dermal matrix and acellular bone matrix in the management of oro-antral fistula.

METHODS

Nine patients with oro-antral fistula (with defect greater than 5 mm×5 mm) after maxillary cyst resection or maxillary molar extraction were selected. The defects were repaired by the simultaneous implantation of acellular dermal matrix and acellular bone matrix.

RESULTS

The incisions of nine patients were all primary healing. After 6 months of follow-up, the oro-antral communication healed well, and no symptom such as nasal congestion or runny nose was observed. The clinical and CT examinations confirmed wound healing.

CONCLUSIONS

The usage of acellular dermal matrix and acellular bone matrix is a reliable repairing method for ora-antral fistula.

A Prospective Study Investigating Fistula Rate Following Primary Palatoplasty Using Acellular Dermal Matrix

Supplemental Digital Content is available in the text.

Background:

Acellular dermal matrix (ADM) has been described as an adjunct in primary cleft palate repair to reduce the fistula rate in several retrospective studies (level III or lower); however, current data are insufficient to definitively conclude its efficacy for this purpose. The goal of the present study was to provide prospective, higher level of evidence data investigating the effect of ADM on fistula rate following primary palatoplasty.

Methods:

A prospective clinical trial was conducted in which ADM was used uniformly in all primary cleft palate repairs that met inclusion criteria. For comparison, a matched control group was identified (retrospectively) from the same center/surgeon’s database. Primary outcome was the rate of palatal fistula formation. Secondary outcomes included bleeding, infection, and delayed healing.

Results:

A total of 130 patients were included in the analysis consisting of 65 in both the study and control groups. There were no statistically significant differences in patient demographics or cleft /surgical characteristics. The results demonstrated a fistula rate of 1.5% in the study group versus 12.3% in the control group (P = 0.03). The other complications (infection, bleeding, delayed healing) were similar between the groups.

Conclusion:

The study provides the highest level of evidence currently available (level II, prospective data) investigating the effect of ADM on fistula rate following primary palatoplasty. The results demonstrate a low overall fistula rate (1.5%) and suggest there may be a clinically significant reduction in fistula formation associated with the routine use of ADM in all primary palate repairs.

Repair of Primary Cleft Palate and Oronasal Fistula With Acellular Dermal Matrix: A Systematic Review and Surgeon Survey

OBJECTIVE

The current review and survey aim to assess the effectiveness of acellular dermal matrix (ADM) in the repair of cleft palate and oronasal fistula and to evaluate the current trends of ADM use in palate surgery.

DESIGN

A systematic review of English articles was conducted using MEDLINE (1960 to July 1, 2016), the Cochrane Controlled Trials Register (1960 to July 1, 2016), and EMBASE (1991 to July 1, 2016). Additional studies were identified through a review of references cited in initially identified articles. Search terms included "cleft palate," "palatal," "oronasal fistula," "acellular dermal matrix," and "Alloderm®." An online survey was disseminated to members of the American Cleft Palate-Craniofacial Association to assess current trends in ADM use in palate surgery.

STUDY SELECTION

All studies evaluating the outcome of primary palate repair or repair of oronasal fistula with the use of aceullar dermal matrix products were included in the review.

RESULTS

Twelve studies met inclusion criteria for review. Studies were generally of low quality, as indicated by methodological index for non-randomized studies (MINORS) scores ranging from 7 to 14. The pooled estimate for fistula formation after primary palatoplasty following ADM use was 7.1%. The pooled estimate for recurrence of fistula after attempted repair using ADM was 11%. Thirty-six cleft surgeons responded to the online survey study. Of these, 45% used ADM in primary cleft palate repair, while 67% used ADM for repair of oronasal fistulae.

CONCLUSION

Use of ADM products is commonplace in palate surgery. Despite this, there is a paucity of high-quality data demonstrating benefit. Further randomized controlled trials examining ADM in palate surgery are required to help develop structured guidelines and improve care.

The Role of Human Acellular Dermis in Preventing Fistulas After Bladder Neck Transection in the Exstrophy-epispadias Complex

OBJECTIVE

To evaluate human acellular dermis (HAD) as an adjunct during bladder neck transection (BNT) by comparing surgical outcomes with other types of tissue interposition.

METHODS

A prospectively maintained institutional database of exstrophy-epispadias complex (EEC) patients was reviewed for those who underwent a BNT with at least 6 months follow-up. The primary outcome was the occurrence of BNT-related fistulas.

RESULTS

In total, 147 EEC patients underwent a BNT with a mean follow-up time of 6.9 years (range 0.52-23.35 years). There were 124 (84.4%) classic exstrophy patients, 22 (15.0%) cloacal exstrophy patients, and 1 (0.7%) penopubic epispadias patient. A total of 12 (8.2%) BNTs resulted in fistulization, including 4 vesicoperineal fistulas, 7 vesicourethral fistulas, and 1 vesicovaginal fistula. There were 5 (22.7%) fistulas in the cloacal exstrophy cohort and 7 (5.6%) fistulas in the classic bladder exstrophy cohort (P = .019). Using either HAD or native tissue flaps resulted in a lower fistulization rate than using no interposed layers (5.8% vs 20.8%; P = .039). Of those with HAD, the use of a fibrin sealant did not decrease fistulization rates when compared to HAD alone (6.5% vs 8.8%, P = .695). There was no statistical difference in surgical complications between the use of HAD and native flaps (8.6% vs 5%, P = .716).

CONCLUSION

Use of soft tissue flaps and HAD is associated with decreased fistulization rates after BNT. HAD is a simple option and an effective adjunct that does not require harvesting of tissues in patients where a native flap is not feasible.

Bridging the Gap: Engineered Porcine-derived Urinary Bladder Matrix Conduits as a Novel Scaffold for Peripheral Nerve Regeneration

PURPOSE

This study aims to compare engineered nerve conduits constructed from porcine-derived urinary bladder matrix (UBM) with the criterion-standard nerve autografts, for segmental loss peripheral nerve repairs.

METHODS

Forty-eight Sprague-Dawley rats were divided into 2 groups. All underwent a 10-mm sciatic nerve gap injury. This was repaired using either (1) reverse autograft-the 10-mm cut segment was oriented 180 degrees and used to coapt the proximal and distal stumps or (2) UBM conduit-the 10-mm nerve gap was bridged with UBM conduit. Behavior assessments such as sciatic function index and foot fault asymmetry scores were performed weekly. At 3- or 6-week time endpoints, the repaired nerves and bilateral gastrocnemius/soleus muscles were harvested from each animal. Nerves were evaluated using immunohistochemistry for motor and sensory axon staining and with diffusion tensor imaging. The net wet muscle weights were calculated to assess the degree of muscle atrophy.

RESULTS

The UBM group demonstrated significantly improved foot fault asymmetry scores at 2 and 4 weeks, whereas there was no difference in sciatic function index. The net muscle weights were similar between both groups. Motor axon counts proximal/inside/distal to the conduit/graft were similar between UBM conduits and reverse autografts, whereas sensory axon counts within and distal to the conduit were significantly higher than those of the autograft at 6 weeks. Sensory axonal regeneration seemed to be adherent to the inner surface of the UBM conduit, whereas it had a scattered appearance in autografts. Diffusion tensor imaging parameters between groups were similar.

CONCLUSIONS

Urinary bladder matrix conduits prove to be at least similar to nerve autografts for the repair of peripheral nerve injuries with a short gap. The matrix perhaps serves as a scaffold to augment sensory nerve growth.

CLINICAL RELEVANCE

In a clinical setting, UBM may eliminate the donor site morbidity and increased operative time associated with nerve autografting.

Cleft Palate Fistula Closure Utilizing Acellular Dermal Matrix

Fistulas represent failure of cleft palate repair. Secondary and tertiary fistula repair is challenging, with high recurrence rates. In the present retrospective study, we review the efficacy of using acellular dermal matrix as an interposition layer for cleft palate fistula closure in 20 consecutive patients between 2013 and 2016. Complete fistula closure was obtained in 16 patients; 1 patient had asymptomatic recurrent fistula; 2 patients had partial closure with reduction of fistula size and minimal nasal regurgitation; 1 patient developed a recurrent fistula without changes in symptoms (success rate of 85%). We conclude that utilizing acellular dermal matrix for cleft palate fistula repair is safe and simple with a high success rate.

Custom-Made Palatal Shield Use in Cleft Palate and Fistula Repair: A Potential Benefit for Fast Postoperative Recovery

OBJECTIVE

To review our experience with a polymethylmethacrylate (PMMA) protective shield used as an adjunct to protect the newly restored palate in wide bilateral cleft and complex fistula closure without diet restrictions.

DESIGN

Clinical cohort study.

SETTING

Division of Plastic Surgery and Maxillary Surgery.

PATIENTS

A selection of 22 cleft palate children undergoing (tertiary) palatal fistula repair (n = 16) or closure of a complex wide primary palatal defect (n = 6).

INTERVENTIONS

One month prior to surgery, a plaster model of the palate was made adding a 5- to 8-mm-thick layer of dental putty to the level of the dental arch. On top of the putty, a 1.5-mm-thick PMMA shield was created to cover the postoperative elevated and restored palate.

MAIN OUTCOME MEASURES

Fistula recurrence rate, postoperative complications, days of hospitalization.

RESULTS

All patients maintained durable and safe palatal closure without fistula recurrence within the follow-up period, varying from 1 until 4 years. Recovery was fast, with a mean duration of hospitalization of 1.5 days. All patients could directly resume their normal diet.

CONCLUSIONS

A PMMA shield has been shown to be a safe and helpful adjunct in complex fistula repair and late anterior palate repair.

A Microbiological and Ultrastructural Comparison of Aseptic versus Sterile Acellular Dermal Matrix as a Reconstructive Material and a Scaffold for Stem Cell Ingrowth

BACKGROUND

Recent data suggest an increased risk for infection when acellular dermal matrix is used in breast reconstruction. This may be because some acellular dermal matrices are actually not terminally sterilized but are instead "aseptically processed." This study evaluates aseptic and sterile matrices for evidence of bacterial contamination and whether or not terminal sterilization affects matrix collagen architecture and stem cell ingrowth.

METHODS

Five separate samples of 14 different matrices were analyzed by fluorescent in situ hybridization using a bacterial DNA probe to detect bacterial DNA on the matrices. Separate samples were incubated for bacteria, acid-fast bacilli, and fungi for 2 to 6 weeks to detect living organisms. The impact of terminal sterilization on the collagen network and stem cell ingrowth on the matrices was then assessed.

RESULTS

Traces of bacterial DNA were encountered on all matrices, with more bacteria in the aseptic group compared with the sterile group (3.4 versus 1.6; p = 0.003). The number of positive cultures was the same between groups (3.8 percent). Electron microscopy demonstrated decreased collagen organization in the sterile group. Stem cell seeding on the matrices displayed a wide variation of cellular ingrowth between matrices, with no difference between aseptic and sterile groups (p = 0.2).

CONCLUSIONS

Although there was more evidence of prior bacterial contamination on aseptically processed matrices compared with sterile matrices; clinical cultures did not differ between groups. Terminal sterilization does not appear to affect stem cell ingrowth but may come at the cost of damaging the collagen network.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, V.

Biomimetic tendon extracellular matrix composite gradient scaffold enhances ligament-to-bone junction reconstruction

Management of ligament/tendon-to-bone-junction healing remains a formidable challenge in the field of orthopedic medicine to date, due to deficient vascularity and multi-tissue transitional structure of the junction. Numerous strategies have been employed to improve ligament-bone junction healing, including delivery of stem cells, bioactive factors, and synthetic materials, but these methods are often inadequate at recapitulating the complex structure-function relationships at native tissue interfaces. Here, we developed an easily-fabricated and effective biomimetic composite to promote the regeneration of ligament-bone junction by physically modifying the tendon extracellular matrix (ECM) into a Random-Aligned-Random composite using ultrasound treatment. The differentiation potential of rabbit bone marrow stromal cells on the modified ECM were examined in vitro. The results demonstrated that the modified ECM enhanced expression of chondrogenesis and osteogenesis-associated epigenetic genes (Jmjd1c, Kdm6b), transcription factor genes (Sox9, Runx2) and extracellular matrix genes (Col2a1, Ocn), resulting in higher osteoinductivity than the untreated tendon ECM in vitro. In the rabbit anterior cruciate ligament (ACL) reconstruction model in vivo, micro-computed tomography (Micro-CT) and histological analysis showed that the modified Random-Aligned-Random composite scaffold enhanced bone and fibrocartilage formation at the interface, more efficaciously than the unmodified tendon ECM. Therefore, these results demonstrated that the biomimetic Random-Aligned-Random composite could be a promising scaffold for ligament/tendon-bone junction repair.

STATEMENT OF SIGNIFICANCE

The native transitional region consists of several distinct yet contiguous tissue regions, composed of soft tissue, non-calcified fibrocartilage, calcified fibrocartilage, and bone. A stratified graft whose phases are interconnected with each other is essential for supporting the formation of functionally continuous multi-tissue regions. Various techniques have been attempted to improve adherence of the ligament/tendon graft to bone, including utilization of stem cells, growth factors and biomaterials, but these methods are often inadequate at recapitulating the complex structure-function relationships at native tissue interfaces. Here, we developed an easily-fabricated and effective biomimetic composite to promote the regeneration of ligament-bone junction by physically modifying the tendon extracellular matrix (ECM) into a Random-Aligned-Random composite using ultrasound treatment. The modified ECM enhanced expression of chondrogenesis and osteogenesis-associated epigenetic genes expression in vitro. In the rabbit anterior crucial ligament reconstruction model in vivo, results showed that the modified Random-Aligned-Random composite enhances the bone and fibrocartilage formation in the interface, proving to be more efficient than the unmodified tendon ECM. Therefore, these results demonstrated that the biomimetic Random-Aligned-Random composite could be a promising scaffold for ligament/tendon-bone junction repair.

Oro-Nasal Communication

INTRODUCTION

Breach in the palatal vault leading to an abnormal communication between oral and nasal cavity is known as oro-nasal communication. It is an uncommon presentation in day-to-day clinical practice except in some patients of cleft lip and palate.Etiology may be congenital or acquired. Alveolar and palatal cleft defects are the most common etiological factor. The acquired causes may be trauma, periapical pathology, infections, neoplasms, postsurgical complications, and radio and chemo necrosis.Clinical features like nasal regurgitation of food, defective speech, fetid odor, bad taste, and upper respiratory tract and ear infection are associated with oro-nasal communication.Management depends upon the size and site of defect, age of patient, and associated comorbidity. The definitive management is always surgical. Two layered closure provides greater support and stability and reduces the risk of failure. Palatal rotational flaps are suitable for smaller defects. The other local flaps are buccal mucosal flap, tongue flap, and facial artery myomucosal flap. Temporoparietal galeal flap, turbinate flap, free radial forearm flap, and scapular flap have also been successfully used for closure of oronasal communication. Newer procedures like the use of bone morphogenic protein, acellular dermal matrices, human amniotic membrane, and distraction osteogenesis have been tried successfully. The rate of recurrence is high.Unsuccessful surgical attempts and larger defects associated with compromised medical conditions are better managed nonsurgically with obturator incorporating the missing teeth.

Histological Comparison of Implanted Cadaveric and Porcine Dermal Matrix Grafts

OBJECTIVES: Histological comparison of human-based (AlloDerm) and porcine-based (ENDURAGen) dermal matrices regarding tissue incorporation and neovascularization as potential soft tissue augmentation materials.

STUDY DESIGN: In vivo, rat model.

METHODS: Subcutaneous implantation of 1-mm thick, 1 cm X 1 cm pieces of AlloDerm, ENDURAGen, and meshed ENDURAGen was performed in 24 Sprague Dawley rats. Implant materials were harvested at 4 (n = 12) and 8 weeks (n = 12). Histological quantification of soft tissue ingrowth and microvascular density was performed following hematoxylin-eosin staining and CD34 immunohistochemistry, respectively.

RESULTS: AlloDerm showed significantly greater soft tissue in-growth and microvascular density compared with both ENDURAGen and meshed ENDURAGen at 4 and 8 weeks ( P < 0.001).

CONCLUSIONS: Although these results may differ in human host tissues, AlloDerm seems to be a more suitable dermal matrix implant than ENDURAGen for cases in which tissue incorporation and neovascularization are sought for the optimal outcome based on this animal model.

Total tympanic membrane reconstruction: AlloDerm versus temporalis fascia

BACKGROUND AND OBJECTIVE: Patients who require surgery for chronic otitis media with perforation and cholesteatoma frequently provide no residual tympanic membrane that is usable in grafting procedures. A novel technique of total tympanic membrane reconstruction (TTMR) is described that maximizes perforation closure rate in these situations while minimizing mucosalization, incomplete healing, and anterior blunting. The specific aim of this report is to assess the safety and efficacy of TTMR and to compare the results obtained with AlloDerm compared with temporalis fascia as a grafting material.

METHODS: The records of 50 patients operated within the years 1999 and the 2004 were reviewed. TTMR with intact canal wall was performed in all cases. Both clinical and audiometric data were analyzed.

RESULTS: Overall perforation closure rate was 92%. There was no statistical significance in closure rate when grafting with AlloDerm versus temporalis fascia. A statistically significant shortened healing time was observed with AlloDerm grafting.

CONCLUSIONS: TTMR is a highly effective and safe technique.

Use of regenerative tissue matrix as an oral layer for the closure of recalcitrant anterior palatal fistulae: a pilot study

OBJECTIVES

To evaluate the effectiveness of regenerative tissue matrix (Alloderm) as an oral layer for difficult anterior palatal fistula closure.

MATERIALS AND METHODS

The authors have tested the feasibility of a novel surgical technique of adding a regenerative tissue matrix (Alloderm) as an oral layer for closure of recalcitrant large anterior palatal fistulae and report the outcome of the first 12 patients in this pilot study. Patients with recurrent large fistula who otherwise would require either a local pedicled flap, free flap, or an obturator were treated with this technique and followed up for at least 6 months to monitor the progress of healing.

RESULTS

Of the 12 patients, 8 patients (66.7%) had complete closure of the fistula, and 2 patients (16.7%) showed reduction in size of the fistula to the extent that symptoms were eliminated, for an overall success rate of 83.3% (10/12 patients). Premature graft loss and recurrence of the fistula were noted in 2 patients (16.7%).

CONCLUSION

Alloderm provided an adequate barrier allowing healing to occur unimpeded and allowed closure of the palatal fistula. In our experience, this new technique using regenerative tissue matrix as an adjunct to the oral layer in large anterior palatal fistula has an advantage compared to other more invasive complex procedures and has been shown to provide satisfactory results.

Dental materials for cleft palate repair

Numerous bone and soft tissue grafting techniques are followed to repair cleft of lip and palate (CLP) defects. In addition to the gold standard surgical interventions involving the use of autogenous grafts, various allogenic and xenogenic graft materials are available for bone regeneration. In an attempt to discover minimally invasive and cost effective treatments for cleft repair, an exceptional growth in synthetic biomedical graft materials have occurred. This study gives an overview of the use of dental materials to repair cleft of lip and palate (CLP). The eligibility criteria for this review were case studies, clinical trials and retrospective studies on the use of various types of dental materials in surgical repair of cleft palate defects. Any data available on the surgical interventions to repair alveolar or palatal cleft, with natural or synthetic graft materials was included in this review. Those datasets with long term clinical follow-up results were referred to as particularly relevant. The results provide encouraging evidence in favor of dental and other related biomedical materials to fill the gaps in clefts of lip and palate. The review presents the various bones and soft tissue replacement strategies currently used, tested or explored for the repair of cleft defects. There was little available data on the use of synthetic materials in cleft repair which was a limitation of this study. In conclusion although clinical trials on the use of synthetic materials are currently underway the uses of autologous implants are the preferred treatment methods to date.

Acellular dermal matrix allograft: An effective adjunct to oronasal fistula repair in patients with cleft palate

Context:

Oronasal fistula (ONF) following cleft palate (CP) repair are a challenging problem associated with high recurrent rates. Acellular dermal matrix allograft is an available tissue substitute.

Aims:

The aim of this study was to evaluate the effectiveness of acellular dermal matrix in the repair of ONF associated with CP that is recurrent or larger than 15 mm in any dimension.

Settings and Design:

This is a prospective study where 12 patients with repaired CP suffering from ONF of the hard palate >15 mm in diameter were included.

Materials and Methods:

Age ranged from 12 to 25 years. Acellular dermal matrix was firmly secured between repaired oral and nasal mucosal layers. Patients were clinically followed-up for 6 months postoperatively to assess total time for complete healing, dehiscence and/or refistulaization.

Statistical Analysis Used:

Fisher's exact test.

Results:

Acellular dermal matrix was integrated with successful fistula closure in all except 1 patient where failure of graft integration was noticed early postoperatively. In 6 patients, the oral mucosal layer showed dehiscence, through which the graft was exposed. Graft integration extended from 4 to 12 weeks postoperatively during which patients were instructed to follow a soft diet and meticulous oral hygiene measures.

Conclusions:

Acellular dermal matrix allografts are safe and effective adjuncts for use in closure of ONF in the hard palate that is recurrent or larger than 15 mm in any dimension.

The Rate of Oronasal Fistula Following Primary Cleft Palate Surgery: A Meta-Analysis

BACKGROUND

Despite decades of craniofacial surgeons repairing cleft palates, there is no consensus for the rate of fistula formation following surgery. The authors present a meta-analysis of studies that reported on primary cleft palate to determine the rate of oronasal fistula and to identify risk factors for their development.

METHODS

A literature search for the period between 2000 and 2012 was performed. Articles were queried and strict inclusion and exclusion criteria were applied to focus on primary cleft palate repair. A meta-analysis of these data was conducted.

RESULTS

The meta-analysis included 11 studies, comprising 2505 children. The rate of oronasal fistula development was 4.9% (95% confidence interval, 3.8% to 6.1%). When analyzing a larger cohort, there was a significant relationship between Veau classification and the occurrence of a fistula (P < .001), with fistulae most prevalent in patients with a Veau IV cleft. The most common location for a fistula was at the soft palate-hard palate junction. One study used decellularized dermis in cleft repair with a fistula rate of 3.2%.

CONCLUSIONS

Using 11 studies comprising 2505 children, we find the rate of reported fistula occurrence to be 4.9%. Furthermore, patients with a Veau IV cleft are significantly more likely to develop an oronasal fistula. When fistulae do occur, they do so most often at the soft palate-hard palate junction. A deeper understanding of fistula formation will help cleft palate surgeons improve their outcomes in the operating room and will allow them to effectively communicate expectations with patients' families in the clinic.

A glance at methods for cleft palate repair

Context:

Cleft palate is the second most common birth defect and is considered as a challenge for pediatric plastic surgeons. There is still a general lack of a standard protocol and patients often require multiple surgical interventions during their lifetime along with disappointing results.

Evidence Acquisition:

PubMed search was undertaken using search terms including 'cleft palate repair', 'palatal cleft closure', 'cleft palate + stem cells', 'cleft palate + plasma rich platelet', 'cleft palate + scaffold', 'palatal tissue engineering', and 'bone tissue engineering'. The found articles were included if they defined a therapeutic strategy and/or assessed a new technique.

Results:

We reported a summary of the key-points concerning cleft palate development, the genes involving this defect, current therapeutic strategies, recently novel aspects, and future advances in treatments for easy and fast understanding of the concepts, rather than a systematic review. In addition, the results were integrated with our recent experience.

Conclusions:

Tissue engineering may open a new window in cleft palate reconstruction. Stem cells and growth factors play key roles in this field.

Autologous bone grafting with adjunctive use of acellular dermal matrix for alveolar cleft defects: early outcomes

BACKGROUND AND PURPOSE

Alveolar bone grafting remains the standard for alveolar cleft repair. Compromised oral and/or nasal closure may impede healing and result in graft failure or persistent fistulae. Incorporating acellular dermal matrix into these repairs may protect the bone graft during mucosal healing by providing an additional layer of soft tissue coverage.

METHODS

A retrospective review of alveolar bone grafts undertaken at our cleft-craniofacial center from 2005 to 2007 was performed. The use of acellular dermal matrix for nasal and/or oral lining augmentation was determined. A minimum 3 months' follow-up was required for inclusion. Outcomes included (1) mucosal disruption, (2) time to complete mucosal healing, (3) bone graft exposure, (4) postoperative bone graft incorporation using the Chelsea scale, and (5) canine eruption through the graft site.

RESULTS

In total, 35 patients were included. Of those, 15 patients (four girls, 11 boys; seven Veau III, eight Veau IV) received acellular dermal matrix for mucosal augmentation (five nasal, one oral, nine nasal and oral lining). Average age at surgery was 10 years (range, 9 to 16 years). Average follow-up was 23 months (range, 3 to 35 months). Mucosal disruption occurred in 20% of the acellular group and in 30% of the control group (p=nonsignificant). Complete mucosal healing was achieved at an average of 4 weeks (range, 1 to 14 weeks) in the acellular dermal matrix group versus 4 weeks (range, 2 to 11 weeks) in the control group (p=nonsignificant). Exposure of bone graft occurred in 0% of the acellular dermal matrix group and in 30% of the control group (p=.016). The Chelsea scale demonstrated no significant radiographic difference in postoperative bone graft incorporation between the acellular dermal matrix and control groups. Canine eruption through the graft site was similar for both groups.

CONCLUSIONS

These data support the conclusions that using acellular dermal matrix to augment nasal/oral mucosal lining in alveolar bone grafts (1) does not increase mucosal disruption or time to complete healing, (2) prevents postoperative bone graft exposure, and (3) appears to have no negative effect on postoperative bone graft incorporation or canine eruption through the graft site.

Persistent oro-nasal fistula after primary cleft palate repair: minimizing the rate via a standardized protocol

OBJECTIVES

Multiple methods are described for cleft palate repair. Similarly, a wide range of postoperative oro-nasal fistula rates are described, depending on technique and series examined. We describe long-term outcomes and fistula rates for primary cleft palate repair for a single surgeon using a standardized protocol. Furlow palatoplasty was used for clefts limited to the soft palate, and two-flap palatoplasty was used for clefts involving both the hard and soft palate.

METHODS

Retrospective review of prospectively gathered data.

RESULTS

Eighty-two patients underwent cleft palate repair within the study period. Average age at time of repair was 1.69 years (range 0.47-12.1 years), 19 patients had cleft palate as a part of a known genetic syndrome, and male:female ratio was 1.05:1. Overall fistula rate requiring repair was 5.5%, and fistula development was not significantly associated with type of cleft repair or use of AlloDerm in the repair.

CONCLUSIONS

A very low rate of oro-nasal fistula and good postoperative outcomes were achieved utilizing this protocol for cleft palate repair. It is effective both in isolated cleft palate, as well as in more complicated syndromic patients. It is possible that significant associations between repair technique and fistula rate exist that were not elucidated in this study as a result of the small number of oro-nasal fistulas.

Calvarial periosteal graft for second-stage cleft palate surgery: a preliminary report

OBJECTIVE

The objectives of cleft palate surgery are to achieve optimal outcomes regarding speech development, hearing, maxillary arch development and facial skull growth. Early two-stage cleft palate repair has been the most recent protocol of choice to achieve good maxillary arch growth without compromising speech development. Hard palate closure occurs within one year of soft palate surgery. However, in some cases the residual hard palate cleft width is larger than 15 mm at the age of two. As previously reported, integrated speech development starts around that age and it is a challenge since we know that early mobilization of the mucoperiosteum interferes with normal facial growth on the long-term. In children with large residual hard palate clefts at the age 2, we report the use of calvarial periosteal grafts to close the cleft.

MATERIAL AND METHODS

With a retrospective 6-year study (2006-2012) we first analyzed the outcomes regarding impermeability of hard palate closure on 45 patients who at the age of two presented a residual cleft of the hard palate larger than 15 mm and benefited from a periosteal graft. We then studied the maxillary growth in these children. In order to compare long-term results, we included 14 patients (age range: 8-20) treated between 1994 & 2006. Two analyses were conducted, the first one on dental casts from birth to the age of 6 and the other one based on lateral cephalograms following Delaire's principles and TRIDIM software.

RESULTS

After the systematic cephalometric analysis of 14 patients, we found no evidence of retrognathia or Class 3 dental malocclusion. In the population of 45 children who benefited from calvarial periosteal grafts the rate of palate fistula was 17% vs. 10% in the overall series.

CONCLUSION

Despite major advances in understanding cleft defects, the issues of timing and choice of the surgical procedure remain widely debated. In second-stage surgery for hard palate closure, using a calvarial periosteal graft could be the solution for large residual clefts without compromising adequate speech development by encouraging proper maxillary arch growth.

Palatogenesis: engineering, pathways and pathologies

Cleft palate represents the second most common birth defect and carries substantial physiologic and social challenges for affected patients, as they often require multiple surgical interventions during their lifetime. A number of genes have been identified to be associated with the cleft palate phenotype, but etiology in the majority of cases remains elusive. In order to better understand cleft palate and both surgical and potential tissue engineering approaches for repair, we have performed an in-depth literature review into cleft palate development in humans and mice, as well as into molecular pathways underlying these pathologic developments. We summarize the multitude of pathways underlying cleft palate development, with the transforming growth factor beta superfamily being the most commonly studied. Furthermore, while the majority of cleft palate studies are performed using a mouse model, studies focusing on tissue engineering have also focused heavily on mouse models. A paucity of human randomized controlled studies exists for cleft palate repair, and so far, tissue engineering approaches are limited. In this review, we discuss the development of the palate, explain the basic science behind normal and pathologic palate development in humans as well as mouse models and elaborate on how these studies may lead to future advances in palatal tissue engineering and cleft palate treatments.

Acellular dermal matrix in palatoplasty

The primary goal of palatoplasty is to allow normal speech through the correction of velopharyngeal incompetence. Failure to accomplish a tension-free, watertight closure predisposes the palatoplasty patient to postoperative fistula formation. Fistulas may in turn contribute to velopharyngeal incompetence. Reported fistula rates vary widely, ranging from 0% to greater than 70%; recurrence rates after attempted repair approach 65% in some series. These lesions therefore represent a significant clinical burden. Acellular dermal matrix materials have been introduced into various phases of palatoplasty as a strategy to augment repairs and minimize postoperative fistula formation, as well as repair fistulas when they do occur. In this article, the authors review the existing literature regarding acellular dermal matrix in palatoplasty and describe their own algorithm and results for primary and secondary palatoplasty in which acellular dermal matrix plays a central role.

Acellular dermal matrix: general principles for the plastic surgeon

Acellular dermal matrix (ADM) is a recently-developed, biologically-derived product with many useful applications in plastic surgery, in both cosmetic and reconstructive procedures. While the use of ADM initially outpaced quality literature, within the past 10 years the literature on ADM has rapidly expanded. Some of these data show promising results in treating historically-challenging problems within our field; thus, an effort to clarify and summarize existing work with ADM is indicated. While subsequent articles in this supplement focus on specific applications, this article provides a general overview of the biology of, applications for, and existing literature on ADM.

The use of alloderm as an adjunct in the closure of the bladder - Cloacal exstrophy complex

OBJECTIVE

To decrease the incidence of vesicocutaneous fistulae (VCF), intra-pubic stitch erosion (IPE) and intrasymphyseal plate erosion (ISE) of bladder or cloacal exstrophy in patients undergoing reclosure, we sought additional bulking material to place between the posterior urethral/bladder neck and pubic closures.

MATERIAL AND METHODS

In 43 patients (2005-2009) undergoing exstrophy/cloacal exstrophy closure or reclosure, we placed human acellular dermis (HAD) between the posterior urethral/bladder neck and pubic closures. The thickest piece of HAD available was placed above the urethra and bladder neck, and attached to the pelvic floor with sutures of 4-0 Vicryl prior to pubic bone apposition.

RESULTS

Twenty-three were primary and 20 were reclosures. Of the 23 primary closures, 17 were classic exstrophy and six were cloacal exstrophy. Of the 20 reclosures, 17 were classic exstrophy and three were cloacal exstrophy. Thirty-four had an osteotomy and nine did not, at the time of closure. No patient experienced failure of closure, a VCF, an IPE or an ISE into the urethra after pubic apposition, or other complication related to the use of HAD. One patient had a superficial wound infection, and one had premature suprapubic tube dislodgement requiring replacement in the operating room.

CONCLUSION

From the success of this novel technique in failed closures, we have begun using HAD as an adjunct in all exstrophy closures.

Epithelial-mesenchymal interactions as a working concept for oral mucosa regeneration

Oral mucosa consists of two tissue layers, the superficial epithelium and the underlying lamina propria. Together, oral mucosa functions as a barrier against exogenous substances and pathogens. In development, interactions of stem/progenitor cells of the epithelium and mesenchyme are crucial to the morphogenesis of oral mucosa. Previous work in oral mucosa regeneration has yielded important clues for several meritorious proof-of-concept approaches. Tissue engineering offers a broad array of novel tools for oral mucosa regeneration with reduced donor site trauma and accelerated clinical translation. However, the developmental concept of epithelial-mesenchymal interactions (EMIs) is rarely considered in oral mucosa regeneration. EMIs in postnatal oral mucosa regeneration likely will not be a simple recapitulation of prenatal oral mucosa development. Biomaterial scaffolds play an indispensible role for oral mucosa regeneration and should provide a conducive environment for pivotal EMIs. Autocrine and paracrine factors, either exogenously delivered or innately produced, have rarely been and should be harnessed to promote oral mucosa regeneration. This review focuses on a working concept of epithelial and mesenchymal interactions in oral mucosa regeneration.

A successful algorithm for limiting postoperative fistulae following palatal procedures in the patient with orofacial clefting

BACKGROUND

Palatal procedures include (1) primary palatoplasty, (2) oronasal fistulas repair, and (3) secondary palatoplasty for velopharyngeal insufficiency. Any time a palatal procedure is performed, postoperative fistulas remain potential consequences. Presented here is a successful algorithm for performing palatal procedures and decreasing the rate of postoperative fistulas in a large, single-surgeon, consecutive series.

METHODS

A retrospective review of all consecutive palatal procedures performed between 2002 and 2006 including (1) primary palatoplasty, (2) oronasal fistulas repair, and (3) secondary palatoplasty for velopharyngeal insufficiency was performed. Cleft Veau type, surgical technique, and outcomes are reviewed. The algorithm included (1) relaxing incisions, (2) complete intravelar veloplasty, (3) total release of the tensor tendon, (4) dissection of the neurovascular bundle with optional osteotomy of the foramen, and (5) incorporation of acellular dermal matrix to achieve complete nasal lining reconstruction.

RESULTS

Two hundred sixty-eight palatal procedures were performed: (1) 132 primary Furlow palatoplasties yielding one symptomatic post-Furlow palatoplasty fistula (0.76 percent) (acellular dermal matrix was used in 39.4 percent of primary palatoplasties); (2) 55 oronasal fistula repairs yielding two symptomatic postoperative fistulas (3.6 percent) (acellular dermal matrix was used in 90.9 percent of fistula repairs); and (3) 81 secondary palatoplasties for velopharyngeal insufficiency resulting in no postoperative fistulas. Acellular dermal matrix was used in 14.8 percent of secondary palatoplasties for velopharyngeal insufficiency. No recommendations for speech surgery followed palatoplasty.

CONCLUSIONS

Using the proposed algorithm in this single-surgeon consecutive series of 268 cases, the authors achieved the lowest reported incidence of postoperative fistulas in all forms of palatal procedures, including the lowest incidence (0.76 percent) of symptomatic palatal fistulas following primary Furlow palatoplasty.

Autologous Bone Grafting with Adjunctive Use of Acellular Dermal Matrix for Alveolar Cleft Defects: Early Outcomes

Background and Purpose

Alveolar bone grafting remains the standard for alveolar cleft repair. Compromised oral and/or nasal closure may impede healing and result in graft failure or persistent fistulae. Incorporating acellular dermal matrix into these repairs may protect the bone graft during mucosal healing by providing an additional layer of soft tissue coverage.

Methods

A retrospective review of alveolar bone grafts undertaken at our cleft–craniofacial center from 2005 to 2007 was performed. The use of acellular dermal matrix for nasal and/or oral lining augmentation was determined. A minimum 3 months’ follow-up was required for inclusion. Outcomes included (1) mucosal disruption, (2) time to complete mucosal healing, (3) bone graft exposure, (4) postoperative bone graft incorporation using the Chelsea scale, and (5) canine eruption through the graft site.

Results

In total, 35 patients were included. Of those, 15 patients (four girls, 11 boys; seven Veau III, eight Veau IV) received acellular dermal matrix for mucosal augmentation (five nasal, one oral, nine nasal and oral lining). Average age at surgery was 10 years (range, 9 to 16 years). Average follow-up was 23 months (range, 3 to 35 months). Mucosal disruption occurred in 20% of the acellular group and in 30% of the control group ( p = nonsignificant). Complete mucosal healing was achieved at an average of 4 weeks (range, 1 to 14 weeks) in the acellular dermal matrix group versus 4 weeks (range, 2 to 11 weeks) in the control group ( p = nonsignificant). Exposure of bone graft occurred in 0% of the acellular dermal matrix group and in 30% of the control group ( p = .016). The Chelsea scale demonstrated no significant radiographic difference in postoperative bone graft incorporation between the acellular dermal matrix and control groups. Canine eruption through the graft site was similar for both groups.

Conclusions

These data support the conclusions that using acellular dermal matrix to augment nasal/oral mucosal lining in alveolar bone grafts (1) does not increase mucosal disruption or time to complete healing, (2) prevents postoperative bone graft exposure, and (3) appears to have no negative effect on postoperative bone graft incorporation or canine eruption through the graft site.