A consecutive case series of defects reconstructed using NovoSorbⓇ Biodegradable Temporising Matrix: Initial experience and early results

NovoSorb® biodegradable temporising matrix (BTM) in the reconstruction of cutaneous malignancies in a major cancer centre: a case series

BACKGROUND

Non-graftable or composite defect reconstruction represents a major challenge to the reconstructive surgeon, with many wounds requiring local flap or free microvascular tissue transfer approaches. The recent advent of synthetic skin substitutes such as Biodegradable Temporizing Matrix (BTM) have revolutionized the management of complex defects including those caused by burns, trauma and infection, with low-morbidity and low-complexity surgery. However, limited data exist supporting their use in cancer reconstruction in Australia.

METHODS

We performed a prospective cohort study of patients undergoing cancer resection and reconstruction with BTM between February 2021 and February 2023 in our institution. Reported outcomes included matrix integration, infection, and return to theatre.

RESULTS

Twelve patients underwent reconstruction of primary or secondary defects following cancer resection during this period. Eight patients were male, four female, mean age at surgery was 70 years. Pathology resected included squamous cell carcinoma (SCC) and melanoma of the head and neck, sarcoma resection of the lower limb, and osteoradionecrosis (ORN) of the scalp. T-stage of primary tumours ranged from T2 to T4 and one in-transit metastasis of melanoma. Four patients were treated with radiotherapy, two of whom received postoperative radiotherapy (PORT) and two who received neoadjuvant radiotherapy, three additional patients had an intervention to a previously irradiated wound bed for recurrence or ORN. Overall matrix integration was 83% (10/12), with a 50% integration rate (2/4) observed in the post-radiotherapy group, requiring return to theatre for alternative reconstructive approaches.

CONCLUSION

We report our experience with a synthetic dermal matrix (BTM) in cancer reconstruction, the largest cohort of this type in the Australian literature. BTM represents an exciting reconstructive tool for the cancer reconstructive surgeon, with a high rate of success and low morbidity.

Outcomes of Biodegradable Temporizing Matrix for Soft Tissue Reconstruction of the Hand and Extremities

Background

NovoSorb biodegradable temporizing matrix (BTM) is a novel, bilayer, synthetic skin substitute made of biodegradable polyurethane foam covered with a sealing membrane. BTM has demonstrated excellent outcomes in burn literature; however, few studies have been published for hand and extremity soft tissue reconstruction.

Methods

All patients who underwent extremity reconstruction with BTM from 2018 to 2023 were reviewed. Demographics, presentations, and clinical outcomes were recorded.

Results

A total of 86 cases from 54 patients (53.7% pediatric; age range: 0-81 years) were included. Common indications included trauma (36%), infection (18.6%), and malignancy (11.6%). BTM was placed over exposed tendon (38.4%), bone (19%), joints (12.8%), nerves (8.1%), and/or blood vessels (7%). BTM served as temporary wound coverage in 26 cases. Complications included hematoma (8.1%), infection (4.7%), and spontaneous delamination (4.7%). Wound closure was successfully obtained without flap use in 93.3%. Poor BTM take was associated with peripheral vascular disease, hypertension, immunosuppression, and BTM hematoma and infection (<0.05).

Conclusion

This study contributes to the growing body of evidence favoring BTM use in challenging reconstructive cases. Although prospective comparative studies are forthcoming, BTM likely has broad applications in reconstructive surgery.

The use of biodegradable temporising matrix (BTM) for facial unit reconstruction with adjuvant radiotherapy-A case study

Synthetic Biodegradable Temporising Matrix (BTM, NovoSorb; PolyNovo Biomaterials Pty Ltd, Port Melbourne, Victoria, Australia) has proven useful in the resurfacing of large burns,1 necrotising infection debridement2 and tumour excision with exposed bone.3 We present a case report of a large BCC invading three aesthetic subunits of the face which was successfully reconstructed with BTM, split-thickness skin graft with subsequent adjuvant radiotherapy due to the high risk nature of the BCC. We present our series of images illustrating the timeline of BTM, and the ability to achieve a good skin colour match with minimal contour deformity, even in the event of post operative radiotherapy use.

Strategic Use of Biodegradable Temporizing Matrix (BTM) in Wound Healing: A Case Series in Asian Patients

Skin and soft tissue reconstruction has long been based on the reconstructive ladder. However, a skin substitute has become popular due to its predictable outcomes, without donor-site morbidity. The biodegradable temporizing matrix (BTM; NovoSorb, PolyNovo Ltd., Port Melbourne, Australia) is a synthetic skin substitute that has recently gained its clinical application. Compared with those of other dermal templates, the clinical efficacy and performance of the BTM are not well established, especially among the Asian population. This study aims to share our experience and strategy of using BTM in various wound conditions. The data of patients who underwent skin and soft tissue reconstruction with BTM at a single institution between January 2022 and December 2023 were reviewed. The patient demographics, wound characteristics, surgical details, secondary procedures, and complications were recorded and analyzed. Postoperative 6-month photographs were collected and independently evaluated by two plastic surgeons and two wound care center nurses using the Manchester Scar Scale (MSS). This study included 37 patients, consisting of 22 males and 15 females with a mean age of 51.8 years (range, 18-86 years old). The wound etiologies included trauma (67.6%), necrotizing soft tissue infection (16.2%), burns (10.8%), toe gangrene (2.7%), and scar excision (2.7%). The average wound area covered by BTM was 50.6 ± 47.6 cm2. Among the patients, eight received concomitant flap surgery and BTM implantation, 20 (54.1%) underwent subsequent split-thickness skin grafts (STSG), and 17 had small wounds (mean: 21.6 cm2) healed by secondary intention. Infection was the most common complication, affecting six patients (n = 6 [16.2%]), five of whom were treated conservatively, and only one required debridement. Thirty-three patients (89.2%) had good BTM take, and only four had BTM failure, requiring further reconstruction. At the last follow-up, 35 out of the 37 patients (94.6%) achieved successful wound closure, and the total MSS score was 10.44 ± 2.94, indicating a satisfactory scar condition. The patients who underwent BTM grafting without STSG had better scar scores than those who received STSG (8.71 ± 2.60 vs. 11.18 ± 2.84, p = 0.039). In conclusion, the BTM is effective and feasible in treating various wounds, with relatively low complication rates, and it can thus be considered as an alternative for skin and soft tissue reconstruction. When combined with adipofasical flap reconstruction, it achieves a more comprehensive anatomical restoration.

Comparative Analysis of Animal-Derived vs Fully Synthetic Acellular Dermal Matrices in Reconstructive Surgery: An Examination of Clinical, Aesthetic, and Economic Measures

INTRODUCTION

The fully synthetic skin substitute, NovoSorb Biodegradable Temporizing Matrix (BTM), may be a cost-effective alternative to the animal-derived Integra Dermal Regeneration Template (IDRT). However, the current literature insufficiently compares the two. Therefore, our study compared clinical, aesthetic, and economic outcomes in treating soft tissue wounds with IDRT, an animal-derived template, vs BTM, a fully synthetic template.

METHODS

Our single-center retrospective study compared outcomes of 26 patient cases treated with BTM (57.7%) or IDRT (42.3%) during 2011-2022.

RESULTS

The mean surgery time was significantly shorter in BTM cases (1.632 ± 0.571 hours) compared with IDRT cases (5.282 ± 5.102 hours, P = 0.011). Median postoperative hospital stay was notably shorter for BTM placement than IDRT placement (0.95 vs 6.60 days, P = 0.003). The median postoperative follow-up length approached a shorter duration in the BTM group (P = 0.054); however, median follow-up visits were significantly lower in the BTM group compared with the IDRT group (5 vs 14, P = 0.012). The median duration for complete wound closure was shorter for BTM (46.96 vs 118.91 days, P = 0.011). Biodegradable Temporizing Matrix demonstrated a notably lower infection rate (0.0%) compared with IDRT (36.4%, P = 0.022). Integra Dermal Regeneration Template exhibited higher wound hypertrophy rates (81.8%) than BTM (26.7%, P = 0.015). Revisionary surgeries were significantly more frequent in the BTM group (P < 0.001). Failed closure, defined as requiring one or more attempts, exhibited a significant difference, with a higher risk in the IDRT group (26.7%) compared with BTM (6.7%, P = 0.003). Biodegradable Temporizing Matrix showed a lower mean Vancouver Scar Scale adjusted fraction (0.279) compared with IDRT (0.639, P < 0.001). Biodegradable Temporizing Matrix incurred lower costs compared with IDRT but displayed a lower mean profit per square centimeter ($10.63 vs $22.53, P < 0.001).

CONCLUSION

Economically, although the net profit per square centimeter of dermal template may favor IDRT, the ancillary benefits associated with BTM in terms of reduced hospital stay, shorter surgery times, fewer follow-up visits, and lower revisionary surgery rates contribute substantially to overall cost-effectiveness. Biodegradable Temporizing Matrix use reflects more efficient resource use and potential cost savings, aligning with broader trends in healthcare emphasizing value-based and patient-centered care.

Application of Novosorb biodegradable temporising matrix in wounds of different aetiologies: a case series

DECLARATION OF INTEREST

The authors have no conflicts of interest to declare.

Use of 'stacked' dermal template: Biodegradable temporising matrix to close a large myelomeningocele defect in a newborn

Background

Myelomeningocele is a severe and complex congenital malformation of the central nervous system. Failure of neural tube closure at around four weeks of gestation results in an open communication between the neural placode and the external environment with varied functional impairment. Surgery is usually required.

Objectives

The primary goals of surgical management are to preserve neural function and minimise infection. Reconstruction is dependent upon the site and size of the defect as well as the quality of the surrounding soft tissues. Surgeons may employ a range of reconstructive techniques in order to achieve closure. Skin substitutes, also known as dermal regeneration templates, have also been utilised.

Discussion

In our unit, we use NovoSorb Biodegradable Temporising Matrix to reconstruct full-thickness skin and soft tissue defects. It is a synthetic, biodegradable, dermal regeneration template, composed of polyurethane foam bonded to a transparent sealing membrane and typically requires a two stage reconstruction. Integration and vascularisation take approximately three weeks. After this time, the recipient wound bed is suitable for split thickness skin grafting. A further benefit of dermal regeneration templates is the possibility of 'stacking' layers, which serves to increase the thickness of the final construct and to minimise overall contour defects. The authors present the case of a one-day-old full-term neonate with a large lumbosacral myelomeningocele that was successfully managed with staged, stacked NovoSorb Biodegradable Temporising Matrix and split thickness skin grafting. The authors believe this is the first case in which a 'stacked' dermal regeneration templates has been used to achieve healing of a primary myelomeningocele defect.

Lay Summary

Background: NovoSorb Biodegradable Temporising Matrix (BTM) is a dermal regeneration template (DRT) and is used to reconstruct wounds following full-thickness skin and soft tissue loss resulting from burn injury, trauma, infection or surgery. It is composed of 2-millimetre thick, synthetic, biodegradable polyurethane foam bonded to a transparent (non-biodegradable) sealing membrane. Like all DRTs, it acts as a scaffold for cellular integration and vascularisation to eventually form a 'neo-dermis'. This is usually apparent from around three weeks. A second stage procedure can then be performed, with removal of the outer sealing membrane and split thickness skin grafting of the vascularised layer.Objectives: Myelomeningocele is a severe and complex congenital malformation of the central nervous system and forms the group of anomalies commonly referred to as neural tube defects (NTDs). Neural tube closure usually occurs at around four weeks of gestation and failure to do so, results in an open communication between the neural placode and the external environment. The degree of functional impairment varies but can include: lower limb paralysis; sensory loss; bladder and bowel dysfunction. In order to preserve neural function and minimise the risk of infection, surgery is usually required to close the defect. Reconstruction is varied and is dependent upon the site and size of the defect as well as the quality of the surrounding soft tissues. The use of local flaps has the potential complication of skin necrosis. Muscle based flaps may be debilitating and limit future functionality and worsen postural development. We were presented with a one-day-old neonate with a large lumbosacral myelomeningocele. A DRT (NovoSorb BTM) was selected as the primary reconstruction. Firstly, selection provided relatively low risk, with minimal morbidity and preserved the full complement of flap based reconstructive options for a later stage should instrumentation be required. Secondly, NovoSorb BTM conferred a robust seal over the dural repair with no demonstrable cerebrospinal fluid leak. Thirdly, the ability to add layers ('stack') of NovoSorb BTM in stages, once integration and vascularisation of the previous layer is complete, allows reconstruction of deeper contour defects.Discussion: We have illustrated the successful use of NovoSorb BTM as a DRT to achieve closure of a large lumbosacral myelomeningocele without complication and with longstanding stability. We believe this technique provides reconstructive teams with an alternative option that is effective, safe and reproducible and which spares local tissues for future elective reconstructive procedures, should they be required.

Upper Extremity Wounds Treated with Biodegradable Temporizing Matrix versus Collagen-Chondroitin Silicone Bilayer

Objective  This study aims to compare outcomes between Novosorb Biodegradable Temporizing Matrix (BTM) and Integra collagen-chondroitin silicone for upper-extremity wound reconstruction. Methods  This retrospective study analyzed adult patients who underwent wound reconstruction with either BTM or Integra at our institution between 2015 and 2020. Results  Forty-eight patients were included: 31 (64.6%) BTM and 17 (35.4%) Integra. Mean age was 44.0 (range: 18-68) years. Age, race, sex, smoking, comorbidities, and defect size were similar between groups. Wound etiologies included 12 (25.0%) burn, 22 (45.8%) trauma, and others. Median template size was 133 cm 2 for BTM and 104 cm 2 for Integra ( p  = 0.526). Skin grafting was performed after 14 (45.2%) and 14 (82.4%) wounds treated with BTM and Integra, respectively ( p  = 0.028). Template complications of infection and dehiscence were comparable. Skin-graft complications occurred in five (35.7%) and three (21.4%) wounds in BTM and Integra, respectively ( p  = 0.031). Skin-graft failure rates were comparable ( p  = 0.121). Mean number of secondary procedures required after template placement was higher in the Integra group (BTM, 1.0; Integra, 1.9; p  = 0.090). Final healing was achieved in 17 (54.8%) BTM and 11 (64.7%) Integra wounds ( p  = 0.694). Median time to healing was 4.1 months after BTM and 2.6 months after Integra placement ( p  = 0.014). Conclusion  Compared with Integra, BTM achieved comparable wound healing and complication rates. Fewer secondary procedures and skin grafts were observed in BTM wounds, likely as a result of the coronavirus disease 2019 pandemic. At our institution, 100 cm 2 of product costs $850 for BTM and $3,150 for Integra, suggesting BTM as an economical alternative to fulfill the high functional and aesthetic requirements of upper-extremity wounds.

Clinical outcomes and resource utilisation in patients with major burns treated with NovoSorb® BTM

INTRODUCTION

Patients with major burns can undergo temporary coverage while skin graft donor sites heal, where dermal templates have an emerging role. The aim of this study was to evaluate the clinical outcomes and resource utilisation in patients with major burns treated with a bilayer biodegradable synthetic matrix (NovoSorb BTM).

METHOD

This retrospective cohort study included patients admitted to the Royal Brisbane and Women's Hospital Adult Burn Unit with burns to at least 40 % TBSA who survived their acute admission. Patients treated from July 2017 to June 2022 with BTM were compared with patients with similar injuries treated using cadaveric allograft as temporising full thickness wound coverage between January 2013 and June 2017. Outcomes measures included number of operations, total operative time, hospital and intensive care unit (ICU) length of stay (LOS), cadaveric allograft and BTM use, and blood product use. Unadjusted comparisons were made with Wilcoxon Rank-Sum tests and Fisher's exact tests. Multivariate linear regression was used to adjust for the effect of TBSA on each outcome.

RESULTS

Fifty-five patients were included (78 % male), 22 of whom were treated with BTM. We found no significant differences in age, sex, or TBSA between groups. One patient had half of the BTM removed due to infection and replaced with allograft. Patients treated with BTM had significantly less operative theatre time (median 1361.5 min [BTM] vs 1768 min [no BTM], P = 0.044). Number of operations, allograft use, hospital and ICU LOS, and blood product use were similar between groups. Adjusted models accounting for TBSA supported unadjusted models.

CONCLUSION

Resource utilisation and clinical outcomes were similar in patients with at least 40 % TBSA treated with BTM and those who were treated with allograft before the introduction of BTM. Patients treated with BTM had significantly less total operative time and no difference in number of operations, allograft use and ICU LOS.

The Use of Intact Fish Skin Grafts in the Treatment of Necrotizing Fasciitis of the Leg: Early Clinical Experience and Literature Review on Indications for Intact Fish Skin Grafts

BACKGROUND

Necrotizing fasciitis (NF) is a serious infectious disease that can initially place the patient's life in danger and, after successful surgical and antibiotic treatment, leaves extensive wounds with sometimes even exposed bones and tendons. Autologous skin grafts are not always possible or require adequate wound bed preparation. Novel intact fish skin grafts (iFSGs; Kerecis® Omega3 Wound, Kerecis hf, Isafjördur, Iceland) have already shown their potential to promote granulation in many other wound situations. Faster wound healing rates and better functional and cosmetic outcomes were observed due to their additionally postulated anti-inflammatory and analgesic properties. Therefore, iFSGs may also be essential in treating NF. We present our initial experience with iFSGs in treating leg wounds after NF and review the literature for the current spectrum of clinical use of iFSGs.

CASE PRESENTATIONS

We present two male patients (aged 60 and 69 years) with chronic or acute postsurgical extensive leg ulcers six weeks and six days after necrotizing fasciitis, respectively. Both suffered from diabetes mellitus without vascular pathologies of the lower limbs. A single application of one pre-meshed (Kerecis® Graftguide) and one self-meshed 300 cm2 iFSG (Kerecis® Surgiclose) was performed in our operation room after extensive surgical debridement and single circles of negative wound pressure therapy. Application and handling were easy. An excellent wound granulation was observed, even in uncovered tibia bone and tendons, accompanied by pain relief in both patients. Neither complications nor allergic reactions occurred. The patients received autologous skin grafting with excellent functional and cosmetic outcomes.

CONCLUSIONS

iFSGs have the potential to play a significant role in the future treatment of NF due to the fast promotion of wound granulation and pain relief. Our experience may encourage surgeons to use iFSGs in NF patients, although high-quality, large-sized studies are still required to confirm these results. The observed effects of iFSGs on wounds associated with NF may be transferred to other wound etiologies as well.

The use of NovoSorb biodegradable temporising matrix in wound management: a literature review and case series

OBJECTIVE

NovoSorb (Poly-Novo Ltd, Australia) biodegradable temporising matrix (BTM) is a novel artificial dermal matrix. Previous literature is weighted towards its use in burns reconstruction; however, this paper describes its use within a range of wound aetiologies. The authors present one of the largest and most diverse case series to date, and aim to provide an independent benchmark of clinical practice.

METHOD

A retrospective observational study was performed. Patient demographics and clinical data (wound aetiology, site, total body surface area (TBSA), wound bed, number of debridements, time to BTM integration, time to skin grafting) were collected and subgroup analysis preformed.

RESULTS

The cohort consisted of 37 patients (acute trauma wounds, n=19; hard-to-heal wounds, n=9; acute infections, n=6; cancer, n=3). Successful BTM integration, allowing subsequent split-thickness skin grafting (STSG), occurred in 70% of cases, despite an overall complication rate of 51%. Mean time from BTM application to STSG was 53 days. There was no difference in STSG outcomes when grafting was performed either before or after the six-week BTM application period. There was no difference when various wound beds (fascia, tendon, periosteum) were compared. Patients >65 years of age were more likely to experience complications; however, this did not affect the speed of integration. The relation of diabetes and smoking to overall integration had no statistical significance.

CONCLUSION

In comorbid patients in particular, the time between BTM application and STSG may be longer than the manufacturer's recommendation. Furthermore, data suggest greater wound bed optimisation and closer interval monitoring in hard-to-heal/malignant wounds, and in older patients and patients with comorbidities. However, BTM appears robust (even in infection) and is showing promise as a useful reconstructive tool.

Surgical Reconstruction of Stage 3 and 4 Pressure Injuries: A Literature Review and Proposed Algorithm from an Interprofessional Working Group

OBJECTIVE

Stage 3 and 4 pressure injuries (PIs) present an enormous societal burden with no clearly defined interventions for surgical reconstruction. The authors sought to assess, via literature review and a reflection/evaluation of their own clinical practice experience (where applicable), the current limitations to the surgical intervention of stage 3 or 4 PIs and propose an algorithm for surgical reconstruction.

METHODS

An interprofessional working group convened to review and assess the scientific literature and propose an algorithm for clinical practice. Data compiled from the literature and a comparison of institutional management were used to develop an algorithm for the surgical reconstruction of stage 3 and 4 PIs with adjunctive use of negative-pressure wound therapy and bioscaffolds.

RESULTS

Surgical reconstruction of PI has relatively high complication rates. The use of negative-pressure wound therapy as adjunctive therapy is beneficial and widespread, leading to reduced dressing change frequency. The evidence for the use of bioscaffolds both in standard wound care and as an adjunct to surgical reconstruction of PI is limited. The proposed algorithm aims to reduce complications typically seen with this patient cohort and improve patient outcomes from surgical intervention.

CONCLUSIONS

The working group has proposed a surgical algorithm for stage 3 and 4 PI reconstruction. The algorithm will be validated and refined through additional clinical research.

NovoSorb Biodegradable Temporizing Matrix for Reconstruction of Multiplanar Degloving Injury of the Upper Limb

Originally described as “wringer injuries” by MacCollum in 1938,¹ traumatic multiplanar degloving injuries that occur as the result of the hand, forearm or arm being drawn between the rollers of a machine are functionally devastating and present a significant reconstructive challenge. Revascularization and comprehensive excision of devitalized bone and soft tissue, followed by appropriate skeletal fixation and vascularized soft tissue cover are the mainstays of management. To date, published case series have described local flaps and free tissue transfer for coverage of wounds that involve exposed vital structures such as nerves, vessels, and tendons.² NovoSorb biodegradable temporizing matrix (BTM; PolyNovo Biomaterials Pty Ltd, Melbourne, Australia) is a bilayer bioabsorbable synthetic polymer dermal substitute, which has the ability to integrate into large wound beds and is resistant to infection.³ BTM comprises a bioabsorbable, polyurethane matrix that allows for cellular infiltration and a temporary nonbiodegradable, nonporous polyurethane layer, which limits moisture loss and provides a barrier to bacteria. Here we describe the successful use of BTM in the staged reconstruction of a high-energy industrial roller injury in an adolescent patient.

Dermal Regenerative Templates in Orthopaedic Surgery

Management of soft-tissue injuries is a critical principle in the treatment of orthopaedic trauma. Understanding the options for soft-tissue reconstruction is vital for successful patient outcomes. Application of dermal regenerative templates (DRTs) in traumatic wounds has created a new rung in the reconstructive ladder bridging the gap between skin graft and flap coverage. There are multiple DRT products with specific clinical indications and mechanisms of action. This review outlines the up-to-date specifications and uses of DRT in commonly seen orthopaedic injuries.

Treatment of Complex Wounds with NovoSorb® Biodegradable Temporising Matrix (BTM)-A Retrospective Analysis of Clinical Outcomes

Complex and chronic wounds represent a highly prevalent condition worldwide that requires a multimodal and interdisciplinary treatment approach to achieve good functional and aesthetic outcomes. Due to increasing costs of health care, an aging population and an increase in difficult-to-treat microbial colonization of wounds, complex wounds will become a substantial clinical, social and economic challenge in the upcoming years. In plastic reconstructive surgery, a variety of dermal skin substitutes have been established for clinical use. Since its approval as a dermal skin substitute in Germany, NovoSorb^® Biodegradable Temporising Matrix (BTM) has become a valuable therapeutic option for the treatment of full-thickness wound defects. The clinical data published to date are limited to case reports and small-scale case series with the main focus on single wounds. The aim of this single-center study was a retrospective analysis of our own patient collective that has received treatment with BTM for complex wounds. Overall, BTM showed to be a reliable and versatile reconstructive option, especially for patients with multiple co-morbidities and microbiologically colonized wounds. Although the preliminary findings have produced promising results, further investigation and research are warranted regarding long-term outcomes and additional clinical applications.

Double-layer biodegradable temporising matrix reconstruction for abdominal skin and soft-tissue reconstruction

Dermatofibrosarcoma protuberans (DFSP) is a rare, locally invasive dermal sarcoma. The management is generally surgical, with wide local excision (WLE) forming the mainstay of treatment. Large abdominal wall defects are most aesthetically reconstructed using pedicled or free flaps; however, these require tumour-free surgical margins, and are off-set by donor site morbidity. We describe an alternative, aesthetic and low-morbidity technique for reconstruction of a subfascial defect following WLE of DFSP in a young woman in her early 20s, using two layers of a novel synthetic dermal matrix (NovoSorbBTM). To our knowledge, a double-layer reconstruction using an artificial dermal matrix has never been described for trunk reconstruction. We found that double-layer biodegradable temporising matrix can restore the inherent thickness and pliability of skin in a partial-thickness abdominal wall defect and offers improved durability and cosmesis compared with skin grafting or indeed single layer skin substitutes alone.

Synergistic Use of Novel Technological Advances in Burn Care Significantly Reduces Hospital Length of Stay Below Predicted: A Case Series

Length of stay is an important metric in healthcare systems, primarily because it reflects the cost of care provided. In the US, as in many countries, inpatient hospital stays are significantly more expensive than outpatient care across all healthcare conditions [1], so earlier discharge and transition to outpatient care is crucial to help control the ever-increasing cost of healthcare. In burn patients, length of stay has traditionally been estimated at 1 day per 1% total body surface area of burn. This estimation was first described in a round table discussion in 1986.[2] However, since that time there has been significant evolution in the quality of care available to burn patients, in both the operating room and ICU. The use of new harvesting techniques, synthetic dermal substitution, and autologous epidermal skin cell suspension are allowing large, deep burns to be excised and covered in much quicker time frames than historically were possible. Examples include the skin harvesting and wound debridement device for grafting and excision, biodegradable temporizing matrix as a fully synthetic dermal template, and regenerative epidermal suspension concerning cell harvesting. Although these modalities can all be used separately, we believe that using them in conjunction has allowed us to shorten the length of stay in patients with severe partial and full-thickness burns. We present an initial case series of 3 patients with anticipated hospital lengths of stay of 54.5, 55, and 51 days, who were ready for discharge in 37, 35, and 43 days, respectively.

Use of a bilayer biodegradable synthetic dermal matrix for the management of defects arising from necrotising fasciitis

The aim of this article is to provide a brief overview of necrotising fasciitis, including causative factors, incidence, diagnosis and clinical outcomes. Various surgical treatment options are outlined, including methods of soft tissue reconstruction after wide excision of infected and necrotic tissues. The role of dermal matrices, including a synthetic biodegradable temporising matrix made of polyurethane, are described in terms of wound bed preparation, surgical application and clinical outcomes.

Use of a synthetic biodegradable temporising matrix after necrotising fasciitis infection of the thigh

Biodegradable temporising matrix (BTM NovoSorb; PolyNovo, Melbourne, Australia) is a novel synthetic polyurethane dermal substitute. Licensed in Europe in 2020, it was developed primarily for reconstruction of infected wounds. We present a case of a healthy man in his 60s with necrotising fasciitis of his left thigh. His medical history was significant for recurrent left thigh liposarcoma that was treated years earlier with surgical excision and adjuvant radiotherapy. The affected area was within the previously irradiated tissue, debrided down to fascia and dressed with a vacuum-assisted closure to help regenerate the wound bed. Reconstruction options were limited by having a circumferential thigh defect that was infected. Following the use of NovoSorb BTM, the area was dressed with Acticoat Flex 7 antimicrobial barrier dressing for 5 weeks. Patient mobilisation was permitted. The material integrated very well and formed a soft, pliable healthy dermal layer that was autografted with split thickness skin grafts. This resulted in durable cover of the thigh with good aesthetic contour and minimal contracture.

A novel use for the biodegradable temporizing matrix

Biodegradable Temporising Matrix (BTM), a skin substitute, has been recently developed as a novel adjunct to the plastic surgeon’s reconstructive repertoire. Its use has been described in literature in a variety of settings and complex wounds, including those that previously would have been described as “non-graftable”, with favourable outcomes. We present the case of a patient with a wound to the right foot and ankle following extravasation injury. Following surgical debridement, this injury was managed with BTM, which allowed granulation and production of a “neo-dermis”. A split-thickness skin graft was subsequently applied. The characteristics of the BTM allowed the resulting skin graft and scar to be pliable, avoiding tendon tethering and joint contracture. To the authors’ knowledge, this skin substitute has not been reported in a wound of this aetiology before. It is our hope that this report will provide evidence to colleagues that this is a valuable adjunct that may be used in complex wounds.

Level of evidence: Level V, therapeutic study.

Biodegradable polyurethane scaffolds in regenerative medicine: Clinical translation review

Early explorations of tissue engineering and regenerative medicine concepts commonly utilized simple polyesters such as polyglycolide, polylactide, and their copolymers as scaffolds. These biomaterials were deemed clinically acceptable, readily accessible, and provided processability and a generally known biological response. With experience and refinement of approaches, greater control of material properties and integrated bioactivity has received emphasis and a broadened palette of synthetic biomaterials has been employed. Biodegradable polyurethanes (PUs) have emerged as an attractive option for synthetic scaffolds in a variety of tissue applications because of their flexibility in molecular design and ability to fulfill mechanical property objectives, particularly in soft tissue applications. Biodegradable PUs are highly customizable based on their composition and processability to impart tailored mechanical and degradation behavior. Additionally, bioactive agents can be readily incorporated into these scaffolds to drive a desired biological response. Enthusiasm for biodegradable PU scaffolds has soared in recent years, leading to rapid growth in the literature documenting novel PU chemistries, scaffold designs, mechanical properties, and aspects of biocompatibility. Despite the enthusiasm in the field, there are still few examples of biodegradable PU scaffolds that have achieved regulatory approval and routine clinical use. However, there is a growing literature where biodegradable PU scaffolds are being specifically developed for a wide range of pathologies and where relevant pre-clinical models are being employed. The purpose of this review is first to highlight examples of clinically used biodegradable PU scaffolds, and then to summarize the growing body of reports on pre-clinical applications of biodegradable PU scaffolds.

Biodegradeable temporising matrix use in a traumatic chest wound

The Welsh Centre for Burns and Plastic Surgery is responsible for a population of 10 million people in Wales and England. We describe the use of biodegradable temporising matrix (BTM) in a large traumatic chest wound in a 23-year-old woman. BTM is a synthetic dermal substitute and has been utilised to achieve soft tissue coverage in complex wounds. This wound was sustained after the patient fell from a tractor into a large silage rake, resulting in injuries to her chest and limbs. Following meticulous debridement, her resulting full thickness skin defect measured 30 × 30 cm extending from the sternal notch to the upper abdomen, with bone, muscle and breast tissue exposure. The central chest area is complex to reconstruct due to the contours of the breasts and tendency to contracture following skin graft reconstruction. We demonstrate the first reported use of BTM for breast reconstruction, as far as we are aware.

Non-Invasive and Surgical Modalities for Scar Management: A Clinical Algorithm

Scars can lead to aesthetic and functional impairments. The treatment of scars requires meticulous planning and an individually adapted therapeutic strategy. A conceptual algorithm for scar treatment makes everyday clinical work easier for the practitioner and offers more safety for the patient. Based on a retrospective analysis of 1427 patients who presented for treatment of a variety of scars, we developed an algorithm for scar management and treatment. The treatments are presented using case descriptions. Additionally, an electronic search of MEDLINE, EMBASE, and ClinicalTrials.gov databases was performed utilizing combinations of relevant medical subject headings for "scar treatment", "hypertrophic scar treatment" and "keloid treatment". Reference lists of relevant articles and reviews were hand-searched for additional reports. Observed outcomes included: conservative scar therapy, minimally invasive scar therapy, and surgical scar therapy using local, regional and free flaps. With this work, we provide an algorithm for safe scar treatment. For better understanding, we have described a clinical case for each algorithm modality.

The Current Challenges on Spray-Based Cell Delivery to the Skin Wounds

Cell delivery through spray instruments is a promising and effective method in tissue engineering and regenerative medicine. It is used for treating different acute and chronic wounds, including burns with different etiologies, chronic diabetic or venous wounds, postcancer surgery, and hypopigmentation disorders. Cell spray can decrease the needed donor site area compared with conventional autologous skin grafting. Keratinocytes, fibroblasts, melanocytes, and mesenchymal stem cells are promising cell sources for cell spray procedures. Different spray instruments are designed and utilized to deliver the cells to the intended skin area. In an efficient spray instrument, cell viability and wound coverage are two determining parameters influenced by various physical and biological factors such as air pressure, spraying distance, viscosity of suspension, stiffness of the wound surface, and velocity of impact. Besides, to improve cell delivery by spray instruments, some matrices and growth factors can be added to cell suspensions. This review focuses on the different types of cells and spray instruments used in cell delivery procedures. It also discusses physical and biological parameters associated with cell viability and wound coverage in spray instruments. Moreover, the recent advances in codelivery of cells with biological glues and growth factors, as well as clinical translation of cell spraying, have been reviewed. Impact statement Skin wounds are a group of prevalent injuries that can lead to life-threatening complexities. As a focus of interest, stem cell therapy and spray-based cell delivery have effectively decreased associated morbidity and mortality. This review summarizes a broad scope of recent evidence related to spray-based cell therapy, instruments, and approaches adopted to make the process more efficient in treating skin wounds. An overview including utilized cell types, clinical cases, and current challenges is also provided.

Advances in Skin Tissue Bioengineering and the Challenges of Clinical Translation

Skin tissue bioengineering is an emerging field that brings together interdisciplinary teams to promote successful translation to clinical care. Extensive deep tissue injuries, such as large burns and other major skin loss conditions, are medical indications where bioengineered skin substitutes (that restore both dermal and epidermal tissues) are being studied as alternatives. These may not only reduce mortality but also lessen morbidity to improve quality of life and functional outcome compared with the current standards of care. A common objective of dermal-epidermal therapies is to reduce the time required to accomplish stable closure of wounds with minimal scar in patients with insufficient donor sites for autologous split-thickness skin grafts. However, no commercially-available product has yet fully satisfied this objective. Tissue engineered skin may include cells, biopolymer scaffolds and drugs, and requires regulatory review to demonstrate safety and efficacy. They must be scalable for manufacturing and distribution. The advancement of technology and the introduction of bioreactors and bio-printing for skin tissue engineering may facilitate clinical products' availability. This mini-review elucidates the reasons for the few available commercial skin substitutes. In addition, it provides insights into the challenges faced by surgeons and scientists to develop new therapies and deliver the results of translational research to improve patient care.

Reconstruction of Chronic Wounds Secondary to Injectable Drug Use with a Biodegradable Temporizing Matrix

Injectable drug use in the upper extremity often leads to chronic wounds complicated by osteomyelitis. Conventional reconstructive options are often not feasible and/or are contraindicated in this patient population. We have started using a synthetic, biodegradable temporizing matrix (BTM) for the treatment of these patients. We hypothesize that BTM is a safe, low-risk, and low-morbidity alternative reconstructive option. We report outcomes after staged debridement and BTM application followed by split-thickness skin grafting for two patients with large, chronic bilateral forearm wounds with concomitant osteomyelitis confirmed by MRI and biopsy. No acute surgical complications were encountered and at a mean follow-up of 13 months, both patients had maintained stable soft-tissue coverage. Reconstruction using BTM is a novel treatment option that can simplify the reconstruction, reduce donor-site morbidity, and optimize success for patients with chronic wounds resulting from injectable drug use. Initial outcomes are promising; however, further comparative studies are needed to better evaluate long-term outcomes of this technique.

An Alternative Dermal Template for Reconstruction of Complex Upper Extremity Wounds

The management of upper extremity soft-tissue defects with full-thickness skin loss and denuded tendon and/or bone traditionally requires vascularized tissue reconstruction. Herein, we present patient outcomes utilizing Novosorb Bio-degradable Temporizing Matrix (PolyNovo, Wilmington, Del.), a novel bilaminar dermal regenerative template, followed by skin grafting, for reconstruction of complex upper extremity injuries with exposed tendon and/or bone. We retrospectively reviewed all patients treated at our Level I trauma center with upper extremity trauma and exposed tendon and/or bone who had application of Novosorb Bio-degradable Temporizing Matrix over a 1-year period. At the time of surgery, all nonviable tissue was debrided, and the product was applied according to the manufacturer’s instructions. If required, split thickness skin grafting was performed once neodermis appeared perfused, or after the sealing layer delaminated spontaneously. Six patients (four men, two women) with an average age of 49.8 (35–60) years were included in the study. Average defect size measured 97 cm² (10–440). Average time to complete healing was 45 days (27–57). Three patients reepithelialized spontaneously and did not require grafting; average defect size in these patients was 26 cm² (10–42). There were no infections and no loss of the dermal matrix or skin graft, when performed. All patients healed without complication after grafting and did not require further surgical treatment. Therefore, we contend that Novosorb BTM is a dermal regenerative template that shows potential as an alternative option to flap reconstruction in select patients after upper extremity trauma and soft-tissue defects with exposed tendon and/or bone. Further studies will be required to refine indications and evaluate outcomes.

Biodegradable Temporizing Matrix Reconstruction of Complex Perineal Burn Wound: A Case Report

This case report details our experience using a two-stage Biodegradable Temporizing Matrix (NovoSorb® PolyNovo Ltd) and autograft for acute reconstruction of a complex perineal burn wound in an elderly comorbid patient. A 77-year-old man sustained 42% full-thickness burns extending circumferentially from bilateral thighs and buttocks, across the entire perineal and genital regions up to his mid-trunk, following self-immolation using an accelerant. Early total burn wound excision was carried out with acute application of Biodegradable Temporizing Matrix to all affected sites. Excellent integration and vascularization of Biodegradable Temporizing Matrix took place despite the challenge of intermittent fecal contamination affecting the perineal and buttock burn sites and matrix colonization with multidrug-resistant organisms. Delamination and serial split-thickness skin autografting were carried out 42 days after the first matrix application with complete and robust graft take. Perineal burns present a reconstructive challenge due to the proximity of specialized structures such as the genitalia, urethral, and anal orifices. Restoration of complex anatomy and function may be required after debridement with increased risks of infection, contracture formation, and mortality compared with burns affecting other anatomical sites. Two-stage Biodegradable Temporizing Matrix represents a reliable reconstruction option for complex extensive perineal wounds in frail elderly patients, despite an unfavorable local microbial environment.