Eyelid reconstruction with acellular human dermal allograft after chemical and thermal burns

A Comparative Analysis of the Outcomes of Various Graft Types in Burn Reconstruction Over the Past 24 Years: A Systematic Review

Burn injuries, a major global health concern, result in an estimated 180,000 fatalities annually. Despite tremendous progress in treatment methods over the years, the morbidity and mortality associated with burns remain significant. Autologous skin grafting, particularly split-thickness skin grafting (STSG), has been a cornerstone in burn reconstruction, and it has facilitated survival and functional recovery for total body surface area (TBSA) significantly. However, the requirement for primary closure at the donor site due to the constraints of full-thickness donor harvesting continues to pose challenges. The introduction of dermal regenerative templates (DRT) in the late 1970s marked a substantial step forward in tissue engineering, addressing the inadequacy of dermal replacement with STSGs. This systematic review aimed to compare the outcomes of different graft types - bioengineered, autografts, allografts, and xenografts - in burn reconstruction over the last 24 years. The review focused on the pros and cons of each graft type, offering clinical insights grounded in experience and evidence. The approach involved a systematic review of studies published in English from January 2000 to January 2024, covering randomized controlled trials (RCTs), cohort studies, case-control studies, and case series. The participants comprised individuals of all ages who underwent burn reconstruction with skin grafts, specifically split-thickness grafts, full-thickness grafts, composite grafts, and epidermal grafts (autografts, allografts, and xenografts) and bioengineered grafts. The primary outcomes were functional and cosmetic results, patient satisfaction, graft survival, and complications. The risk of bias was evaluated using the Cochrane risk-of-bias tool for randomized trials version 2 (RoB 2), the Newcastle-Ottawa Scale (NOS) for non-randomized studies, and the Canada Institute for Health Economics (IHE) quality appraisal tool for case series. Our initial search yielded a total of 1,995 articles, out of which 10 studies were selected for final analysis. Among the four clinical trials assessed, 75% showed a high risk of bias. The studies reviewed involved various graft types, with six studies (60%) concentrating on allografts, three (30%) on autografts, and one (10%) on bioengineered skin grafts. The outcomes were varied, underlining the intricate nature of burn wound management. Our evaluation revealed promising results for autologous-engineered skin substitutes and allografts but also highlighted methodological disparities among the studies included. The dominance of observational studies and the diversity of outcome measures present obstacles to direct comparisons. Future research should address these limitations, employing well-structured RCTs, standardized outcome measures, and exploring long-term outcomes and patient-specific factors. The rapidly evolving field of regenerative medicine offers great potential for novel grafting methods. This systematic review provides valuable insights into the diverse outcomes of burn reconstruction using different graft types. Autologous-engineered skin substitutes and allografts seem to hold significant promise, suggesting a possible shift in grafting techniques. However, methodological inconsistencies and the lack of high-quality evidence underscore the necessity for further research to fine-tune burn care approaches.

Use of biomaterials in the reconstruction of posterior lamellar eyelid defects: a systematic review and meta-analysis

Eyelid defects can occur secondary to tumours, trauma, burns, and congenital factors. Among the most challenging aspects of eyelid reconstruction is the rebuilding of a tarsal substitute due to its delicate and multi-layered tissue composition. Attempts to use biomaterials for posterior lamellar reconstruction are intended to provide an alternative to traditional autograft reconstructions. In this review, we aimed to assess the types of biomaterials used for the reconstruction of the posterior lamella associated with eyelid defects and the associated clinical outcomes. A literature search was conducted on Pubmed, Prospero, Dynamed, DARE, EMBASE, and COCHRANE databases. A total of 15 articles fulfilled the inclusion criteria, and 129 patients with 142 eyelids reconstructed, using artificial grafts, were included in the review. Acellular dermis allograft (AlloDerm®, LifeCell) (n = 49) was the most common artificial graft used. A meta-analysis was performed, which demonstrated a pooled success rate of artificial grafts of 99% (95% CI 96-100, p = 0.05; I2 = 40%, total complications seen 39% (95% CI 96-100, p = 0.05; I2 = 40%) and re-operation rates of 5.6% (n = 8). The biomaterials used demonstrated an overall success rate of 99%, which is similar if not greater than that reported with the use of traditional autograft reconstruction techniques, with similar complications and fewer re-operations than autografts. This suggests that clinicians should consider the clinical use of artificial grafts for posterior lamellar reconstruction.

Comparison of Efficacy and Complications Among Various Spacer Grafts in the Treatment of Lower Eyelid Retraction: A Systematic Review

BACKGROUND

Lower eyelid retraction is a difficult problem to treat, but it is a prevalent condition and a common complication of blepharoplasty. The use of spacer grafts to increase eyelid height and improve symptoms has been described for a long time, but the optimal choice of spacer graft material is unknown.

OBJECTIVES

The authors reviewed the currently available evidence to determine the best available spacer graft material in terms of efficacy and complications.

METHODS

A systematic review of all available literature published between 1985 and the present was performed using the Pubmed, Ovid MEDLINE, and Cochrane library databases. Inclusion criteria were that the studies contain original content assessing the treatment of lower eyelid retraction in humans using a spacer graft and provide quantitative outcomes data.

RESULTS

One hundred and twelve articles were reviewed following an initial screen using titles, and 19 articles were chosen for inclusion in this systematic review. Analysis of these articles revealed no spacer graft material that is clearly superior to others.

CONCLUSIONS

Due to a lack of high quality evidence, this review did not reveal one spacer graft material that is clearly superior to others. However, a narrative summary of the available evidence reveals unique sets of advantages and disadvantages associated with the various materials currently available. Further research in the form of well-designed studies will be necessary to further clarify advantages of certain spacer graft materials over others.

LEVEL OF EVIDENCE

5.

Modern surgical methods of ectropion treatment

This review is considering methods of ectropion surgical treatment, which are based on modern understanding of etiology and pathogenic mechanisms of this eyelid condition. Attention is driven both to monosurgical methods for mild ectropion correction and to combined methods in complicated cases. Special aspects of surgical approach to severe cicatricial ectropion are described.

Reconstructive surgery of post-burn cicatricial ectropion of upper and lower eyelid

In the article, an outcome analysis of post-burn upper and lower eyelid ectropion repair in 27 patients (49 cases) is presented. The study group included 31 cases (15 males, 2 females, aged 16-67), the control group consisted of 18 cases (5 males, 5 females, aged 2-52). Patients from the control group underwent free skin grafting of upper and lower eyelids. Patients from the study group underwent combined surgery using two different types of Alloplant biomaterial: allogenous tendon fibres and transplant for eyelid plasty. The operation results were assessed by change in ectropion grade, lagophthalmos and interpalpebral width.

A primary study of poly(propylene fumarate)-2-hydroxyethyl methacrylate copolymer scaffolds for tarsal plate repair and reconstruction in rabbit eyelids

Eyelid reconstruction includes anterior lamella reconstruction and posterior lamella reconstruction. As an important skeletal component of the posterior lamella, tarsal plates repair is the key issue for eyelid reconstruction. Presently, neither traditional surgery nor autograft/allograft has achieved satisfactory repair effects. Poly(propylene fumarate)-co-2-hydroxyethyl methacrylate (PPF-HEMA) networks with mass ratios of 1 : 0.5, 1 : 1 and 1 : 2 were synthesized and used as the tarsal substitute in this study. Their chemical compositions, swelling ability, and mechanical properties were characterized. Porous scaffolds were fabricated by a gelatin particle leaching method. The in vitro studies of cytotoxicity on human dermal fibroblasts (HDFs) and degradation demonstrated that PPF-HEMA scaffolds did not have noticeable cell cytotoxicity and their degradation rates correlated with the ratio of PPF to HEMA. The PPF-HEMA networks, with mass ratios of 1 : 1 and 1 : 2, and an ADM control were implanted in rabbits with tarsal plate defects for in vivo biocompatibility and degradation behavior evaluation. PPF-HEMA scaffolds provided satisfactory repair results with mild tissue response and biocompatibility to fibroblast growth and fibrous capsulation compared to the ADM control. The tissue compatible and biodegradable PPF-HEMA networks with elastic mechanical properties were proven to be a suitable candidate for tarsal repair.

Burns: treatment and outcomes

Burns can cause extensive and devastating injuries of the head and neck. Prevention of the initial injury must always be a priority, but once an injury has occurred, then prevention of progression of the damage together with survival of the patient must be the immediate goals. The acute care will have a major influence on the subsequent scarring, reconstructive need, and long-term outcome. In the majority of cases, the reconstruction will involve restoration of form and function to the soft tissues, and the methods used will depend very much on the extent of scarring locally and elsewhere in the body. In nearly all cases, a significant improvement in functional and aesthetic outcomes can be achieved, which, in conjunction with intensive psychosocial rehabilitation, can lead to high-quality patient outcomes. With the prospect of facial transplantation being a clinical reality, the reconstructive spectrum has opened up even further, and, with appropriate reconstruction and support, no patient should be left economically deprived or socially isolated after a burn injury.

Acellular dermal matrix in the management of the burn patient

Although the principles of burn management are still primarily focused on survival, as advances are realized in resuscitation, nutrition, and wound management, the functional and aesthetic outcomes following burn injury have become increasingly important. Acellular dermal matrix materials, which allow surgeons to minimize skin graft donor site morbidity in the process of repairing injured areas, play a role in addressing these important issues. Many favorable reports have been published, but they are generally characterized by small sample sizes, limited objective testing, and retrospective analysis. There does appear to be some evidence for ADM application in patient populations in whom donor site availability (those with massive burns) or morbidity (children, the elderly) is a concern, but more studies are needed. In this article, the authors discuss the current applications for ADM in burn management, review the existing literature, and present opportunities for future research.

The use of AlloDerm in the reconstruction of full-thickness eyelid defects

PURPOSE

To demonstrate the potential for the use of AlloDerm as a posterior lamellar graft in the reconstruction of full-thickness lid defects.

METHOD

In our case series, we evaluated the surgical outcome of three consecutive patients, two with an upper eyelid defect and one with a lower eyelid defect who underwent lid reconstruction using AlloDerm grafts.

RESULTS

AlloDerm was readily taken up into the wound defect, with complete coverage of its bulbar surface by conjunctiva. In all the cases, the cornea was not affected by its contact to the AlloDerm. A mucocutaneous junction formed over the margin of the AlloDerm graft with good cosmesis.

CONCLUSION

AlloDerm has the potential to act as an effective posterior lamellar substitute in situations where there is an adequate amount of skin muscle cover available to drape over it. It is rigid enough to replace tarsus and its structure behaves as a scaffold allowing conjunctiva to readily grow over it.