Reconstruction of exenteration socket with Integra® dermal substitute and skin graft

Deep burn surgery of the whole dorsum of the hand: Composite skin grafting over acellular dermal matrix versus thick split-thickness skin grafting

Preservation and restoration of hand function after burn injuries are challenging yet imperative. This study aimed to assess the curative effect of a composite skin graft over an acellular dermal matrix (ADM) and a thick split-thickness skin graft (STSG) for treating deep burns on the hand. Patients who met the inclusion criteria at the First Affiliated Hospital of Wenzhou Medical University between September 2011 and January 2020 were retrospectively identified from the operative register. We investigated patient characteristics, time from operation to the start of active motion exercise, take rates of skin graft 7 days post-surgery, donor site recovery, complications and days to complete healing. Patients were followed up for 12 months to evaluate scar quality using the Vancouver Scar Scale (VSS) and hand function through total active motion (TAM) and the Jebsen-Taylor Hand Function Test (JTHFT). A total of 38 patients (52 hands) who received thin STSG on top of the ADM or thick STSG were included. The location of the donor sites was significantly different between Group A (thick STSG) and Group B (thin STSG + ADM) (p = 0.03). There were no statistical differences in age, gender, underlying disease, cause of burn, burn area, dominant hand, patients with two hands operated on and time from burn to surgery between the two groups (p > 0.05). The time from operation to the start of active motion exercise, take rates of skin graft 7 days post-surgery and days to complete healing were not significantly different between Group A and Group B (p > 0.05). The rate of donor sites requiring skin grafting was lower in Group B than in Group A (22.2% vs. 100%, p < 0.001). There were no statistically significant differences in complications between the groups (p = 0.12). Moreover, 12 months postoperatively, the pliability subscore in the VSS was significantly lower in Group A than in Group B (p = 0.01). However, there were no statistically significant differences in vascularity (p = 0.42), pigmentation (p = 0.31) and height subscores (p = 0.13). The TAM and JTHFT results revealed no statistically significant differences between the two groups (p = 0.22 and 0.06, respectively). The ADM combined with thin STSG is a valuable approach for treating deep and extensive hand burns with low donor site morbidity. It has a good appearance and function in patients with hand burns, especially in patients with limited donor sites.

Orbital exenteration reconstruction using a superficial temporalis muscle flap: The "Carpaccio flap", an innovative approach

INTRODUCTION

Malignant orbital diseases may lead surgeons to practice an orbital exenteration associated with chemotherapy and/or radiotherapy to ensure curative treatment. That radical procedure makes physicians consider reconstructive filling in order to allow prothesis wearing and reduce esthetic and social after-effects. We first describe the clinical case of a 6-year-old patient who presented an orbital rhabdomyosarcoma and underwent an orbital exenteration with immediate reconstruction by a superficial temporal pedicled on the middle temporalis muscle flap.

TECHNICAL NOTE

Through that case-report, we propose an original temporal flap to repair ipsilateral midface defects which may reduce donor site side effects and allow furthers corrections.

DISCUSSION

In pediatrics cases, our Carpaccio flap was an available regional tool to rehabilitate an irradiated orbital socket with an appropriate bulking and vascularization effect after subtotal exenteration. Furthermore, we prescribe that flap as a posterior orbital filling, when eyelid and conjunctiva are spared, to prepare orbital prosthesis implementation. A mild sunken temporal fossa appears with our procedure but by preserving the deep layer of the temporalis muscle, autologous reconstruction such as lipofilling are permitted in post-radiotherapy condition to enhance esthetic sequelae.

Orbital Exenteration Reconstruction for Medically Complex Patients: Bilaminate Dermal Substitute as an Alternative to Major Surgery

Reconstructive strategies after orbital exenteration range from the use of skin grafts to tissue flaps, depending on the classification of the defect, patient's goals, and tolerance for surgery. We present a case of a 68-year-old, medically complex patient who underwent orbital exenteration, radiation therapy, and reconstruction with a bilaminate dermal substitute. Despite the placement in an irradiated area without periosteum, the bilaminate dermal substitute graft demonstrated acceptable integration and provided an adequate base for subsequent split thickness skin grafting, sparing a medically fragile patient from a morbid operation. This case highlights the advantages of a less invasive reconstructive modality when managing a patient with multiple comorbidities and a significant chance of cancer recurrence.

Human Spheroids from Adipose-Derived Stem Cells Induce Calvarial Bone Production in a Xenogeneic Rabbit Model

ABSTRACT

Calvarial defects can result from several causes. Tissue engineering hold the potential to restore native form and protective function. We have recently shown that stemness and differentiation ability of spheroids from adipose-derived stem cells (S-ASCs) promotes osteoblasts growth within Integra in a small vertebral lesion. In our study, we aimed to test osteogenic potential of S-ASCs in aiding regeneration of a calvarial defect. Groups containing Integra showed increased bone regeneration at the calvarial defect-Integra interface compared with the control group. In particular, S-ASC-derived osteoblasts group showed a superior calvarial remodeling than undifferentiated S-ASCs group. Clusters of ossification were observed in these both groups with enhanced microvasculature density and fibrosis. In conclusion, seeding of S-ASCs in dermal regeneration templates enhanced bone healing in a rabbit calvarial defect model. These findings could prompt the elective use of S-ASCs with enhanced multilineage differentiation potential for tissue engineering purposes.

Efficacy and safety of an artificial dermal graft for the reconstruction of exenterated sockets: a preliminary report

PURPOSE

The purpose of this study is to report our experience with the use of artificial dermis grafts for orbital socket reconstruction following orbital exenteration (OE).

METHOD

A retrospective study was conducted in our ocular oncology centre from May 2018 to June 2020 in patients undergoing OE for orbital malignancies in whom an artificial dermis device (Integra® template, 2 layers) was used for reconstruction. Data recorded included demographics, previous and adjuvant treatments, aetiologies, surgical procedure, surgical reconstruction, complications and follow-up. The main outcome measure was the time between OE and the full granulation of the cavity.

RESULTS

Ten patients (mean age, 71.3 years [43-92]) were included. Tumours originated from the conjunctiva (n = 5, 50%), eyelid (n = 3, 30%) and orbit (n = 2, 20%). Nine patients underwent total OE, and one required enlarged OE. Orbital reconstruction was performed using an artificial dermis alone (n = 9, 90%) or combined with regional flaps (n = 1, 10%). The mean granulation time was 3.3 weeks (2-4). Three (30%) patients received adjuvant radiotherapy 1 month post-surgery. The mean time to spontaneous epithelialization was 9.4 weeks (6-12). Preoperative and postoperative radiotherapy was not associated with a delayed epithelialization of the socket (p = 0.463 and p = 0.236, respectively). One (10%) and 2 (20%) patients experienced postoperative socket infection and an ethmoidal fistula, respectively. The mean follow-up was 11.6 months (6-16).

CONCLUSION

Using artificial dermis grafts alone or with regional flaps appears to be a viable surgical procedure for orbital socket reconstruction. They reduce surgical morbidity and hospital stay. Preoperative and postoperative radiotherapy does not seem to delay socket healing.

Orbital exenteration: an updated review with perspectives

Orbital exenteration is a radical and disfiguring surgery mainly performed in specialized tertiary care centers. Orbital exenteration has long been considered the treatment of choice for managing periocular tumors invading the orbit or primary orbital malignancies. Over the past decades, attention has been directed toward reducing the perioperative morbidity by developing new surgical devices and new strategies and promoting cosmetic rehabilitation by providing adequate facial prostheses. Despite these advances, several studies have questioned the role of orbital exenteration in improving overall survival. The last decade has been marked by the emergence of a new paradigm: the "eye-sparing" strategies based on conservative surgery with or without adjuvant radiotherapy and/or targeted therapies and immunotherapies. We summarize the data on orbital exenteration, including epidemiology, etiologies, use of surgical ablative and reconstructive techniques, complications, outcomes, and the related controversies.