Seven years' experience with Integra as a reconstructive tool

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.

Use of Dermal Substitute Matrices for Coverage of Exposed Limb Vascular Repairs: A Literature Review

Background

Prompt coverage of vascular repairs in the extremities is needed to protect from desiccation and trauma. In the absence of local soft tissues to provide early coverage pending demarcation of the tissues and the zone of injury, there is no clear data in the literature on the ideal coverage method. This article is the first to review the use of dermal substitutes for temporary coverage of extremity vascular repairs pending definitive coverage.

Methods

We conducted a review of the literature to identify previous articles indexed in PubMed and Ovid using these search terms: [(skin) OR (artificial skin) OR (Integra) OR (dermal substitute) OR (dermal substitute matrix) OR (dermal regeneration) OR (dermal regeneration matrix) OR (dermal regeneration template)] AND [(bypass) OR (graft) OR (vascular surgery) OR (revascularization) OR (salvage) OR (limb salvage) OR (vascular repair) OR (artery repair) OR (arterial repair)] AND [(limb) OR (extremity) OR (leg) OR (arm) OR (vascular injury) OR (amputation)].

Results

Of the 32 articles retrieved for initial review, five case reports with six patients of dermal substitute use for direct coverage of extremity repairs were identified. In all cases, the dermal substitute was able to provide stable coverage pending definitive coverage or was allowed to heal secondarily.

Conclusions

Dermal substitute matrices are a potential means of temporary coverage of exposed extremity vascular repairs when there is a paucity of local soft tissues pending more definitive coverage.

Reconstructing Nasal Defects With Acellular Dermal Matrix After Mohs Micrographic Surgery: A 12-year Experience

BACKGROUND AND OBJECTIVE

Large defects of the nose after Mohs surgery pose a significant reconstructive challenge to both dermatologic and reconstructive surgeons. The authors present their 12-year experience utilizing acellular dermal matrices for nasal reconstruction.

METHODS

A retrospective review of patients undergoing Mohs surgery and alloplastic nasal reconstruction with acellular dermal matrices between 2010 and 2022 was performed. Patients who underwent single-stage reconstruction and dual-stage reconstruction with skin graft with at least 90 days of follow-up were included.

RESULTS

Fifty-one patients met criteria with a median age of 77 years. Fifty-three lesions were reconstructed with acellular dermal matrices. The most common lesion location was nasal sidewall (50%) with a mean defect size of 10.8 cm 2 . 30.8% underwent same-day acellular dermal matrix reconstruction, with 69.2% undergoing two-stage reconstruction. Acellular dermal matrices successfully reconstructed acquired defects in 94.2% of lesions. Average time to re-epithelialization was 27.6 + 6.2 days. Average time to repigmentation was 145.35 + 86 days. No recurrences were recorded. Total complication rate was 9.62%. Average size for successful healing was 10.8 cm 2 . Average defect size for complication or failure was 14.7 cm 2 . Seven sites (13.46%) underwent aesthetic improvement procedures.

CONCLUSION

Acellular bilayer wound matrix is an adequate reconstructive option for single or dual-stage reconstruction of the nose with low complication and revision rates.

Biomimetic tri-layered artificial skin comprising silica gel-collagen membrane-collagen porous scaffold for enhanced full-thickness wound healing

Full-thickness wounds are severe cutaneous damages with destroyed self-healing function, which need efficient clinical interventions. Inspired by the hierarchical structure of natural skin, we have for the first time developed a biomimetic tri-layered artificial skin (TLAS) comprising silica gel-collagen membrane-collagen porous scaffold for enhanced full-thickness wound healing. The TLAS with the thickness of 3-7 mm displays a hierarchical nanostructure consisting of the top homogeneous silica gel film, the middle compact collagen membrane, and the bottom porous collagen scaffold, exquisitely mimicking the epidermis, basement membrane and dermis of natural skin, respectively. The 1-(3-Dimethylaminopropyl)-3-ethylcarbodiimide/N-Hydroxysuccinimide-dehydrothermal (EDC/NHS-DHT) dual-crosslinked collagen composite bilayer, with a crosslinking degree of 79.5 %, displays remarkable biocompatibility, bioactivity, and biosafety with no risk of hemolysis and pyrogen reactions. Notably, the extra collagen membrane layer provides a robust barrier to block the penetration of silica gel into the collagen porous scaffold, leading to the TLAS with enhanced biocompatibility and bioactivity. The full-thickness wound rat model studies have indicated the TLAS significantly facilitates the regeneration of full-thickness defects by accelerating re-epithelization, collagen deposition and migration of skin appendages. The highly biocompatible and bioactive tri-layered artificial skin provides an improved treatment for full-thickness wounds, which has great potential in tissue engineering.

Reconstruction of a Pediatric Distal Phalanx Amputation With Stacked Integra Dermal Substitute: A Case Report

Finger amputations in children present unique challenges and require special considerations compared to their adult counterparts. Maximizing length and preserving fingertip bulk and sensation is essential for maintaining a functional digit. Synthetic dermal substitutes have been recently used for soft tissue coverage for pediatric syndactyly as well as burn injuries; however, the literature discussing pediatric amputation cases with soft tissue damage proximal to the bony level is limited.In this case, we report a two-year-old patient who developed dry gangrene of her right index finger after multiple rabbit bites and underwent an amputation through the distal interphalangeal joint. Circumferential soft-tissue debridement proximal to the tip of the middle phalanx was required, leaving substantial exposed bone with no soft tissue envelope. We report our experience of single-stage stacking Integra dermal substitute directly onto the exposed bone to provide both finger bulk and soft tissue coverage.The patient displayed no functional limitations three years post-surgery.For instances when local or distant flap coverage may not be feasible, we present a novel technique to reconstruct, provide bulk, and preserve length in pediatric finger amputations. This case highlights that the utility of dermal substitutes is expanding and are providing more technical options.

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.

Dermal Regeneration Template in the Management and Reconstruction of Burn Injuries and Complex Wounds: A Review

Background

Dermal scaffolds have created a paradigm shift for burn and wound management by providing improved healing and less scarring, while improving cosmesis and functionality. Dermal regeneration template (DRT) is a bilayer membrane for dermal regeneration developed by Yannas and Burke in the 1980s. The aim of this review is to summarize clinical evidence for dermal scaffolds focusing on DRT for the management and reconstruction of burn injuries and complex wounds.

Methods

A comprehensive search of PubMed was performed from the start of indexing through November 2022. Articles reporting on DRT use in patients with burns, limb salvage, and wound reconstruction were included with focus on high-level clinical evidence.

Results

DRT has become an established alternative option for the treatment of full-thickness and deep partial-thickness burns, with improved outcomes in areas where cosmesis and functionality are important. In the management of diabetic foot ulcers, use of DRT is associated with high rates of complete wound healing with a low risk of adverse outcomes. DRT has been successfully used in traumatic and surgical wounds, showing particular benefit in deep wounds and in the reconstruction of numerous anatomical sites.

Conclusions

Considerable clinical experience has accrued with the use of DRT beyond its original application for thermal injury. A growing body of evidence from clinical studies reports the successful use of DRT to improve clinical outcomes and quality of life across clinical indications at a number of anatomical sites.

One-stage reconstruction of extensive exposed tibia on malnourished patient using single-layer Integra and amino acid supplements: A case report and literature review

RATIONALE

Extremity injuries resulting from motor vehicle collisions, especially those leading to bone-exposed wounds, present challenges for achieving effective wound coverage. Such injuries are susceptible to complications including infections, osteomyelitis, and unexpected amputations due to inadequate blood supply. Severe traumatic degloving injuries often entail damage to the surrounding blood vessels, making local or free flaps impractical choices in many cases. Consequently, treatment options may vary based on distinct clinical scenarios, with no standardized guidelines available. Our study introduces an integrated approach utilizing dermal substitutes and skin grafts as a safer treatment modality for managing large-area tibial exposure resulting from traffic accidents.

PATIENT CONCERNS

A 66-year-old male with a compromised nutritional status was struck by a car while riding a motorcycle. Previous attempts using double-layer Integra and negative pressure wound therapy (NPWT) for two-stage reconstruction have been unsuccessful.

DIAGNOSES

Computed tomography imaging studies revealed multiple comminuted and displaced fractures involving the left femoral shaft, left proximal tibia, left patella, and proximal fibula, as well as a fracture of the right fibular shaft and an avulsion fracture of the right distal medial femur. The patient's condition corresponded to Type 3B in the Gustilo classification for open fractures, and the patient had an Injury Severity Score of 25.

INTERVENTIONS

We applied a one-stage reconstruction involving single-layer Integra, split-thickness skin grafts, NPWT, and nutritional supplements containing various amino acids.

OUTCOMES

By implementing an integrated treatment approach and providing diligent wound care over a total of 2 months, the patient achieved successful healing and expressed satisfaction with the postoperative results.

LESSONS

This study offers insights into the effectiveness of employing one-stage reconstruction for traumatic injuries with extensive exposed tibias. In addition, it underscores the impact of a patient's nutritional status on wound healing and introduces a potential solution for similar challenging cases.

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.

Review of History of Basic Principles of Burn Wound Management

Thermal energy is an essential and useful resource to humans in modern society. However, a consequence of using heat carelessly is burns. Burn injuries have various causes, such as exposure to flame, radiation, electrical, and chemical sources. In this study, we reviewed the history of burn wound care while focusing on the basic principles of burn management. Through this review, we highlight the need for careful monitoring and customization when treating burn victims at each step of wound care, as their individual needs may differ. We also propose that future research should focus on nanotechnology-based skin grafts, as this is a promising area for further improvement in wound care.

Strategies for extremity reconstruction with exposed bones and tendons using acellular dermal matrices: concept of sequential vascularization

We report 3 cases of patients treated with Bilayer Wound Matrix over exposed structures. In all patients, dermal matrices revascularization occurred sequentially over the course of 6–12 weeks, leading to successful wound closure. Acellular dermal matrices allow more difficult areas with poor vascularity to be covered from the ‘inside-out’.

Snake Bite Management: A Scoping Review of the Literature

Background:

Around the world, snake bite envenomation remains an underreported human health hazard. Envenomation can cause local and systemic complications, especially when there is a lack of antivenom availability. Although there are established guidelines regarding snake bite management acute care, there is a paucity of data regarding surgical intervention and the plastic surgeon’s role treating this unique patient population.

Methods:

A review was conducted identifying relevant published articles involving snake bite management and treatment in PubMed and EMBASE.

Results:

One hundred ten articles were identified and 77 met inclusion criteria. Snake bite envenomation can result in complications that are dependent upon a variety of variables. The literature has shown the best field treatment to be timely transportation to the nearest medical facility, along with antivenom administration. The cytotoxic, hemotoxic, and neurotoxic effects of venom can cause a variety of local soft tissue and systemic complications. Surgical interventions such as fasciotomies, wound debridements, skin grafts, and tissue flaps may be necessary in these patients to optimize functional and aesthetic outcomes. Disparities in access to care in resource limited settings are discussed.

Conclusions:

Global health disparities and insufficient antivenom distribution create an inequality of care in snake bite patients. Plastic surgeons have an important role in managing acute and chronic complications of snake bite envenomations that can lead to improved patient outcomes.

Silicone Scaffold Support Using a Bilayer Dermal Regeneration Matrix Template for Correction of Primary or Recurrent Eyelid Retraction

PURPOSE

To evaluate the efficacy and safety of a bilayer dermal regenerative matrix for primary or complex/recurrent eyelid retraction.

METHODS

Retrospective review of patients undergoing eyelid retraction repair using the bilayer dermal regenerative matrix from 2005 to 2019. Nineteen eyelid surgeries from 15 patients were identified. Collected data included patient demographics, symptoms, preoperative/postoperative lower eyelid position, inferior scleral show, lagophthalmos, etiology of retraction, history of prior retraction surgeries, major/minor complications, and follow-up duration (minimum 6 months). Postoperative measurements were taken at a minimum of 1 week, 3-6 weeks, 2-4 months, and 6 months.

RESULTS

Postoperatively, 90% of cases had good improvement of lower eyelid retraction (defined as 1 mm or less below the inferior limbus). Postoperative elevation of the lower eyelid ranged 1-3.5 mm compared with preoperative measurements. When used in the upper eyelid for conjunctival scarring, the implant improved the superior fornix depth. Complications were minimal and included transient conjunctival injection, eyelid edema, and foreign body sensation. No patients requested early removal of the silicone layer due to ocular pain.

CONCLUSIONS

The bilayer dermal regeneration matrix template may be considered a reasonable alternative to other spacers to reduce the vertical palpebral fissure and eyelid malposition in primary, complex, or recurrent cases. It also worked well for first-line correction of thyroid retraction, which tend to be more challenging due to globe proptosis. Suboptimal results may have occurred due to active cicatrizing conjunctival disease, or residual negative vector of the cheek and orbit. High cost may be a consideration, and the bilayer dermal regeneration matrix template was not studied directly against hard palate and other spacer materials.

The Use of Integra Dermal Regeneration Templates and Cortical Bone Fenestrations over Exposed Tibia

We present the case of an 86-year-old woman who suffered full-thickness soft tissue loss secondary to degloving injury to the lower left limb, resulting in an exposed tibia. This patient underwent drilling to create artificial fenestrations in the cortical bone followed by placement of Integra dermal regeneration template. The technique of drilling fenestrations to expose underlying vasculature of cortical bone has not previously been described in its relationship with Integra dermal regeneration templates in large degloving injuries of the lower limb. This technique enabled us to perform earlier skin grafting and ultimately resulted in complete and timely wound closure. We present this case as a comparable alternative treatment in cases of reconstructive surgery secondary to severe burns or trauma to reduce the time required for successful wound closure over exposed bone in full-thickness tissue loss injuries of the lower limb.

Infectious Complications Associated with the Use of Integra: A Systematic Review of the Literature

Dermal regeneration templates such as Integra are effective reconstructive biomaterials used in a variety of soft-tissue defects. Fully understanding the complications associated with their use is paramount to improve outcomes and maximize patient safety. In this study, our purpose is to perform a comprehensive literature review to assess the previously reported infectious complications linked to Integra-based wound closure.

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

BACKGROUND

NovoSorb^Ⓡ Biodegradable Temporising Matrix (BTM) is a synthetic dermal template recently approved for treatment of full thickness defects of the skin. It requires a two-stage reconstruction where it is initially placed into a defect to generate a neodermis, which is later covered by a split skin graft. It has previously been described for the treatment of acute full thickness burn injury, necrotising fasciitis and free flap donor site reconstruction.

METHODS

A consecutive case series review of patients treated with BTM at Middlemore Hospital was performed. Patient demographics, defect aetiology, indications for dermal matrix use, surgical details, and complications were recorded using information gathered from the medical records.

RESULTS

This case series included 25 patients with a range of defects resulting from acute full thickness burn injury, burn scar revision, necrotising soft-tissue infection, tumour excision and traumatic loss. In these patients, 72% of wounds were identified as complex defects with exposed bone or tendon. Complications encountered included infection, non-adherence and incomplete vascularisation.

CONCLUSION

BTM provided a good reconstructive option for a wide range of defects, many of which were not amenable to immediate skin grafting. Once vascularised and ready for the second stage, it developed a red-pink colour and demonstrated capillary refill. Similar to other dermal matrices, infection was a commonly encountered problem. However, BTM proved more tolerant to this and was able to be salvaged in most cases, allowing the second stage to proceed as normal.

Combination of negative pressure wound therapy (NPWT) and integra dermal regeneration template (IDRT) in the lower extremity wound; Our experience with 4 cases

The treatment of de-gloving injuries in the lower limb with exposed tendons, bone, and/or nerve is a challenging reconstruction problem. The standard management of de-gloving injuries involve either direct closure if the skin is viable or immediate grafting with the avulsed skin or full- or split-thickness graft when the skin flap is not viable. Alternative methods are flap coverage especially when the underlying structures are not suitable for grafting such as extensive loss of paratenon and/or exposed bone or open joints The use of negative pressure wound therapy (NPWT) followed by use of Integra dermal regeneration template (IDRT) and subsequent split-thickness skin grafting (STSG) as an alternative to the previously mentioned surgical options has been described. In this series we describe the successful management of four patients with exposed tendons, bones, and joints of the distal lower extremity following road traffic accidents (RTA) using NPWT, Integra and thin split-thickness skin grafts.

Comparative long-term study between two dermal regeneration templates for the reconstruction of burn scar contractures in humans: Clinical and histological results

The advent of dermal regeneration templates has fostered major advances in the treatment of acute burns and their sequelae, in the last three decades. Both data on morphological aspects of the newly-formed tissue, and clinical trials comparing different templates, are few. The goal of this study was to prospectively analyze the outcome of randomized patients treated with two of the existing templates, followed by thin skin autograft. They are both 2 mm-thick bovine collagen templates (Matriderm® and Integra®), the latter includes a superficial silicone layer. Surgery was performed on patients with impaired mobility resulting from burn sequelae (n = 12 per template) in a two-step procedure. Negative pressure therapy was applied after surgery; patients were monitored for 12 months. No intra or postoperative complications were observed. Data on scar skin quality (Vancouver scar scale), rate of mobility recovery, and graft contraction were recorded; as well as morphological analyses at light microscopical level. Improvement in mobility and skin quality were demonstrated along with graft contraction, in all patients. The double layer template showed the best performance in retraction rate, skin quality and mobility recovery. The subepidermal newly-formed connective tissue showed no histoarchitectural differences between the templates. The double layer template was not absorbed up to 12 months after placement.

A histological analysis of artificial skin in an extensively burned child, 14 years after application: a case report

INTRODUCTION

Artificial skin has become the treatment of choice in extensive, full-thickness thermal injuries. The longest follow-up of the healing process in burn sites covered with the Integra Bilayer Matrix Wound Dressing onto the wound published to date was at around five years after application. In our case report, we describe the clinical and histological analysis of an extensive, full-thickness thermal injury 14 years on from treatment with the bilayer matrix wound dressing.

CASE STUDY

A nine-year-old boy suffered a full-thickness skin loss over 85% of his body surface area following a fire accident. The bilayer matrix wound dressing was used on both legs and covered almost 30% of his body surface area. Cosmetic and functional results were satisfactory. Histological analysis performed nine years after the application of the bilayer matrix wound dressing onto the wound showed a double-layered skin composition with changes in the fibrous component of the dermis.

CONCLUSION

Despite satisfactory short- and long-term clinical results from applications of the bilayer matrix wound dressing, we found important differences in microstructure when compared with the physiological condition.

Dermal regenerative matrix use in burn patients: A systematic review

BACKGROUND

Dermal regenerative matrices (DRMs) have been used for several decades in the treatment of acute and reconstructive burn injury. The objective of this study was to perform a systematic review of the literature to assess clinical outcomes and safety profile of DRMs in full-thickness burn injury.

METHODS

Comprehensive searches of MEDLINE, EMBASE, CINAHL, and Cochrane Library were performed from 1988 to 2017. Two independent reviewers completed preliminary and full-text screening of all articles. English-language articles reporting on DRM use in patients with full-thickness burn injury were included.

RESULTS

Literature search generated 914 unique articles. Following screening, 203 articles were assessed for eligibility, and 72 met inclusion criteria for analysis. DRM was applied to1084 patients (74% acute burns, 26% burn reconstruction). Of the twelve studies that described changes in ROM, significant improvement was observed in 95% of reconstructive patients. The most frequently treated reconstructive sites were the neck, hand/wrist, lower extremity, and axilla. Vancouver scar scale was used in eight studies and indicated a significant improvement in the scar quality with DRM. The overall complication rate was 13%, most commonly infection, graft loss, hematoma formation, and contracture.

CONCLUSIONS

Although variability in functional and cosmetic outcomes was observed, DRM demonstrates improvements in ROM and scar appearance without objective regression. Essential demographic data were lacking in many studies, highlighting the need for future standardization of reporting outcomes in burns following application of dermal substitutes.

Managing Wounds with Exposed Bone and Tendon with an Esterified Hyaluronic Acid Matrix (eHAM): A Literature Review and Personal Experience

The loss of extracellular matrix in combination with the exposure of structures such as bone and tendon pose a major challenge; the development of granulation tissue and subsequent reepithelialization over these structures is extremely slow and often may not happen at all. Replacement of the matrix has been shown to significantly increase the chances of healing since, with revascularization of the matrix, a wound bed is created that may either heal by secondary intention or via the application of a skin graft. A literature search on an esterified hyaluronic acid-based matrix (eHAM) returned five articles on the treatment of wounds with tendon and bone loss in which the eHAM was used. The etiologies of the wounds described varied among the articles, as did treatment modalities. However, all of them received proper debridement of necrosis with subsequent (although not always immediately) application of the eHAM. A very high percentage of all wounds reached the different primary endpoints in the studies, which were complete reepithelialization, complete coverage with granulation tissue and/or 10% coverage of the original wound size with epithelium, the latter being a strong indicator of the wound continuing to heal. The individual authors concluded that the esterified hyaluronic acid matrix (eHAM) is a valuable tool to assist in the complete healing of difficult to heal wounds.

Two step reconstruction of traumatic ear skin avulsion using Integra graft

Treatment of traumatic ear injuries have always been a challenge. Preservation of the auricular cartilage is key for reconstruction. Many techniques have been reported for the management of exposed ear perichondrium. We present patient who sustained right ear soft tissue avulsion. Initial examination the patient revealed skin avulsion with exposed cartilage from the concha, scapha and antihelix on the right ear. The treatment sequence included debridement and application of Integra graft. This was followed by dressing changes every three days and three weeks. Once adequate vascularization was noted a split thickness skin graft was used for final reconstruction. Integra has been widely used for the management of burns as well as exposed bone and cartilage. However, its use in traumatic ear injuries has not been reported. This technique allowed for the reconstruction of a large skin avulsion from the right ear with minimal donor site morbidity and avoidance of local rotational flaps that could hinder later reconstructions if needed.

Improved Dermal Regeneration Using a Combination of Dermal Substitutes and Dermal Fibroblast Optimization: A Hypothesis

In human adults, the repair of cutaneous wounds usually leads to scar formation rather than regeneration. Dermal substitutes have been used as a regenerative template for reducing scar formation and improving the extent of dermal regeneration. However, achievement of complete regeneration is still a long way off. Dermal substitutes are characterized by unusual regenerative activity, appearing to function by acting as temporary configurational guides for cell infiltration and synthesis of new stroma. Fibroblasts are important cells with many vital functions in wound-healing processes. They are heterogeneous with distinct characteristics according to their source location, such as subcutaneous tissue, superficial-layer dermis, and deep-layer dermis. Many studies have shown that superficial dermal fibroblasts possess the potential to form dermis-like tissue. Fibroblasts in deep-layer dermis and subcutaneous tissue may play a critical role in the formation of hypertrophic scars. Fibroblast phenotype affects the newly formed dermal architecture and influences the dermal regeneration effect induced by dermal substitutes. It is hypothesized that better regeneration of the dermis can be achieved using dermal substitutes along with dermal fibroblast optimization.

The use of IntegraTM as a novel technique in deep burn foot management

Deep burns in patients with co-morbidities carry a significant challenge for surgeons. The use of synthetic skin substitutes has played an increasingly important role in tissue reconstruction. Integra^TM is an artificial dermal substitute that allows temporary coverage after burn excision. The main advantages of this bi-layered template are its immediate availability, optimal scarring and decreased requirement for donor tissue. However, the downsides are the requirement for complex wound care, risk of infection and two stage procedure that can be both costly and prolong the stay in hospital. Here, we present the case of a patient with deep burns to the plantar aspect of both feet. Given the patient's medical history of diabetes, hypertension and peripheral neuropathy, we elected to use Integra^TM in combination with negative pressure wound therapy. Three weeks after the application of the Integra^TM matrix, the surface layer was replaced with autograft. At discharge, the patient was fully ambulatory and six months post-operatively this status was maintained without significant graft breakdown. To the best of our knowledge, the use of Integra^TM and split thickness skin graft in the management of full thickness burns to the plantar aspect of the feet has not been reported previously. Overall, our experience with Integra^TM in this setting was found to be satisfactory and can be considered as a promising treatment option in acute burn resurfacing.

A bioartificial dermal regeneration template promotes skin cell proliferation in vitro and enhances large skin wound healing in vivo

A novel bioartificial dermal regeneration template has been developed using platelet-rich plasma and acellular animal skin collagen sponge for the treatment of larger area and full thickness skin wounds. This platelet-rich plasma-collagen sponge keeps native skin structure and contains huge amounts of growth factors. The effect of this bioartificial dermal regeneration template was tested in vitro and in vivo via a mimic poor wound healing process by adding collagenase I into cell culture medium or the wound area. The in vitro experimental results indicated that the rat skin cells grew faster and produced more collagen in platelet-rich plasma-collagen sponge with collagenase than those treated either with collagen sponge plus collagenase, or collagenase, or control group without treatment. The in vivo experiments were performed by large rat skin wounds, 1.5 cm diameter, treated either with collagenase, or collagenase plus collagen sponge, or collagenase plus platelet-rich plasma-collagen sponge. The wound without treatment was used as a control. The wounds treated with collagenase-containing platelet-rich plasma-collagen sponge healed 4 times faster than the untreated wounds, 6 times faster than the collagenase treated wounds, 2.4 times faster than collagenase-containing collagen sponge treated wounds. The immunostaining indicated that the healed tissues in the wound areas treated with collagenase-containing platelet-rich plasma-collagen sponge were composed of collagen type I and collagen III with blood vessels and hair follicles. The results demonstrated that this collagenase-containing platelet-rich plasma-collagen sponge works as a bioartificial dermal regeneration template. The application of this collagenase-containing platelet-rich plasma-collagen sponge promotes the traumatic skin wound healing and permits the reconstitution of the inherent barrier functions of the skin.

Design of a Novel Two-Component Hybrid Dermal Scaffold for the Treatment of Pressure Sores

The aim of this study is to design a novel two-component hybrid scaffold using the fibrin/alginate porous hydrogel Smart Matrix combined to a backing layer of plasma polymerized polydimethylsiloxane (Sil) membrane to make the fibrin-based dermal scaffold more robust for the treatment of the clinically challenging pressure sores. A design criteria are established, according to which the Sil membranes are punched to avoid collection of fluid underneath. Manual peel test shows that native silicone does not attach to the fibrin/alginate component while the plasma polymerized silicone membranes are firmly bound to fibrin/alginate. Structural characterization shows that the fibrin/alginate matrix is intact after the addition of the Sil membrane. By adding a Sil membrane to the original fibrin/alginate scaffold, the resulting two-component scaffolds have a significantly higher shear or storage modulus G'. In vitro cell studies show that dermal fibroblasts remain viable, proliferate, and infiltrate the two-component hybrid scaffolds during the culture period. These results show that the design of a novel two-component hybrid dermal scaffold is successful according to the proposed design criteria. To the best of the authors' knowledge, this is the first study that reports the combination of a fibrin-based scaffold with a plasma-polymerized silicone membrane.

Microsurgical Burn Reconstruction

The treatment of burn-related wounds requires consideration of several factors, including defect size, available donor sites, exposure of critical structures, and the ultimate functional and aesthetic result of reconstruction. Although skin grafts and locoregional flaps are workhorses in burn reconstruction, they have inherent limitations that can directly impact reconstructive outcomes. Microsurgical free tissue transfer represents a viable option for the reconstruction of burn-related wounds in certain patients. Each anatomic region of the body has unique challenges that must be addressed to achieve a successful reconstruction. Therefore, the choice of free flap must be individualized to the wound and patients.

About ATMPs, SOPs and GMP: The Hurdles to Produce Novel Skin Grafts for Clinical Use

BACKGROUND

The treatment of severe full-thickness skin defects represents a significant and common clinical problem worldwide. A bio-engineered autologous skin substitute would significantly reduce the problems observed with today's gold standard.

METHODS

Within 15 years of research, the Tissue Biology Research Unit of the University Children's Hospital Zurich has developed autologous tissue-engineered skin grafts based on collagen type I hydrogels. Those products are considered as advanced therapy medicinal products (ATMPs) and are routinely produced for clinical trials in a clean room facility following the guidelines for good manufacturing practice (GMP). This article focuses on hurdles observed for the translation of ATMPs from research into the GMP environment and clinical application.

RESULTS AND CONCLUSION

Personalized medicine in the field of rare diseases has great potential. However, ATMPs are mainly developed and promoted by academia, hospitals, and small companies, which face many obstacles such as high financial burdens.

Viscoelastic, physical, and bio-degradable properties of dermal scaffolds and related cell behaviour

Dermal scaffolds promote healing of debilitating skin injuries caused by burns and chronic skin conditions. Currently available products present disadvantages and therefore, there is still a clinical need for developing new dermal substitutes. This study aimed at comparing the viscoelastic, physical and bio-degradable properties of two dermal scaffolds, the collagen-based and clinically well established Integra(®) and a novel fibrin-based dermal scaffold developed at our laboratory called Smart Matrix(®), to further evaluate our previous published findings that suggested a higher influx of cells, reduced wound contraction and less scarring for Smart Matrix(®) when used in vivo. Rheological results showed that Integra(®) (G'  =  313.74 kPa) is mechanically stronger than Smart Matrix(®) (G'  =  8.26 kPa), due to the presence of the silicone backing layer in Integra(®). Micro-pores were observed on both dermal scaffolds, although nano-pores as well as densely packed nano-fibres were only observed for Smart Matrix(®). Average surface roughness was higher for Smart Matrix(®) (Sa  =  114.776 nm) than for Integra(®) (Sa  =  75.565 nm). Both scaffolds possess a highly porous structure (80-90%) and display a range of pore micro-sizes that represent the actual in vivo scenario. In vitro proteolytic bio-degradation suggested that Smart Matrix(®) would degrade faster upon implantation in vivo than Integra(®). For both scaffolds, the enzymatic digestion occurs via bulk degradation. These observed differences could affect cell behaviour on both scaffolds. Our results suggest that fine-tuning of scaffolds' viscoelastic, physical and bio-degradable properties can maximise cell behaviour in terms of attachment, proliferation and infiltration, which are essential for tissue repair.

In vitro and ex vivo analysis of hyaluronan supplementation of Integra® dermal template on human dermal fibroblasts and keratinocytes

PURPOSE

Widespread application of collagen-glycosaminoglycan dermal templates in the treatment of cutaneous defects has identified the interval between initial engraftment and skin graft application as important for improvement. The aim of this study was to evaluate the effect of hyaluronan supplementation of Integra® dermal template on human dermal fibroblasts and keratinocytes in both in vitro and ex vivo models.

METHODS

This study utilized in vitro and ex vivo cell culture techniques to investigate supplementing Integra® Regeneration Template with hyaluronan (HA), as a strategy to decrease this interval. In vitro, Integra® was HA supplemented at 0.15, 1, 1.5 and 2 mg/mL-1. Primary human dermal fibroblast (PHDF) and keratinocyte proliferation, PHDF viability, migration and HA-induced signal transduction (phosphor-MAPK Array) were assessed. Ex vivo, wound models (wound diameter 4 mm) were created within 8 mm skin biopsies. Wounds were filled with Integra® or HA supplemented Integra®. Re-epithelialization was compared through hematoxylin and eosin-stained cross-sections at 7, 14 and 21 days in culture. Model viability was assessed through lactate dehydrogenase (LDH) assays.

RESULTS

In vitro, PHDF and keratinocyte proliferation were enhanced significantly (p&lt;0.001) when supplemented with HA. S-Phase and G2/M PHDFs in HA supplemented scaffolds increased. PHDF viability was enhanced to 72 hours culture with 1.5 mg/mL-1 HA (p = 0.016). PHDF migration was maximally enhanced at 1 mg/mL-1 and 1.5 mg/mL-1, whilst increased levels of phosphorylated Erk/MAPK proteins indicated increased metabolic activity. In ex vivo models, HA supplementation accelerated re-epithelialization at all concentrations. This ex vivo model provides a robust model for preclinical assessment of skin substitutes.

CONCLUSIONS

HA supplementation to Integra® demonstrates increased in vitro growth, viability and migration. Whilst ex vivo data suggest HA supplementation of Integra® may increase rapidity of wound closure.

Reconstructive Management of Devastating Electrical Injuries to the Face

BACKGROUND

Devastating fourth-degree electrical injuries to the face and head pose significant reconstructive challenges. To date, there have been few peer-reviewed articles in the literature that describe those reconstructive challenges. The authors present the largest case series to date that describes the management of these injuries, including the incorporation of face transplantation.

METHODS

A retrospective case series was conducted of patients with devastating electrical injuries to the face who were managed at two level-1 trauma centers between 2007 and 2011. Data describing patient injuries, initial management, and reconstructive procedures were collected.

RESULTS

Five patients with devastating electrical injuries to the face were reviewed. After initial stabilization and treatment of life-threatening injuries, all five underwent burn excision and microsurgical reconstruction using distant flaps. Two of the patients eventually underwent face transplantation. The authors describe differences in management between the two trauma centers, one of which had the availability for composite tissue allotransplantation; the other did not. Also described is how initial attempts at traditional reconstruction affected the eventual face transplantation.

CONCLUSIONS

The care of patients with complex electrical burns must be conducted in a multidisciplinary fashion. As with all other trauma, the initial priority should be management of the airway, breathing, and circulation. Additional considerations include cardiac arrhythmias and renal impairment attributable to myoglobinuria. Before embarking on aggressive reconstruction attempts, it is advisable to determine early whether the patient is a candidate for face transplantation in order to avoid antigen sensitization, loss of a reconstructive "lifeboat," surgical plane disruption, and sacrifice of potential recipient vessels.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, V.

Use of a bioartificial dermal regeneration template for skin restoration in combat casualty injuries

Military personnel who survive combat injuries frequently have large soft tissue wounds complicated by concomitant injuries and contamination. These devastating wounds present a therapeutic challenge to not only restore the protective skin barrier but also to preserve tendon and muscle excursion, provide protective padding around nerves and restore adequate joint motion. Accordingly, regenerative medicine modalities that can accomplish these goals are of great interest. The use of bioartificial dermal regeneration templates (DRT), such as Integra DRT (Integra Lifesciences Corporation, Plainsboro, NJ, USA), in the management of complex soft tissue injuries has an important role in the reconstruction of war wounds. These DRTs provide initial wound coverage and help establish a well-vascularized wound bed suitable for definitive soft tissue coverage.

Treatment of Foot Degloving Injury With Aid of Negative Pressure Wound Therapy and Dermal Regeneration Template

Degloving injury of the foot continues to be a challenging condition to treat. Despite current advancements in reconstructive options, most of these injuries can result in amputations, causing physical and emotional impairment. Few reports have been published on the management of these complex traumatic injuries. Typical reconstruction options have included skin grafting and reattachment of the avulsed skin. Many treating physicians have encountered challenging issues in predicting tissue viability, knowing the extent of the injury, and making a logical decision for limb salvage procedures. The present report provides an algorithm of our approach in managing degloving injuries. A case of foot degloving injury, treated by serial surgical operations with the dominant aim of salvaging the avulsed tissue, is presented. The avulsed portion of the foot, with no identifiable vessels for microsurgical reattachment, was defatted and used as a full-thickness skin graft. Negative pressure wound therapy and a dermal regeneration template were used as adjunct techniques to help obtain good soft tissue coverage. The traditional treatment methods for degloving injuries and the applications of new wound care technologies are discussed.

Soft Tissue Reconstructions with Dermal Substitutes Versus Alternative Approaches in Patients with Traumatic Complex Wounds

The use of dermal substitutes is considered an effective treatment in several pathologies involving skin damage, mainly extensive burns and trauma. Treatment alternatives entail performing flaps or autografts. The purpose of this cross-sectional study is to assess the clinical effects and cost-effectiveness of dermal substitutes in surgical procedure in complex wound healings of adult trauma patients. The study includes 52 patients who received dermal substitutes (n = 25) between 2007 and 2012 and patients treated between 2006 and 2011 who received standard treatment (n = 27). All patients presented with posttraumatic soft tissue defects with bone and/or tendon exposure. Differences in costs, mean differences in Euros and Euros per square centimeter, and clinical data were collected as outcome measures. Pearson's correlations were used to assess the relationship between total costs with sociodemographic data and clinical services to different healthcare providers (clinical data and costs were recorded for both groups). No relevant differences on acceptance rates were noticed amongst groups. Surgery costs were shown to be significantly reduced in the dermal substitutes group (P < 0.01) even though total costs (surgery + hospitalization) did not exhibit a significant difference. Surgical time was significantly reduced in the dermal substitutes group (1.81 min/cm(2) lesions) as compared with the standard group (6.08 min/cm(2) lesions). The current study suggests that not only clinical but also possible economic and logistical advantages in choosing dermal substitutes may exist.

Treatment of a paediatric patient with a distal lower extremity traumatic wound using a dermal regeneration template and NPWT

Degloving injuries are common in trauma and represent a spectrum of complex wounds, the management of which may be highly challenging especially in the paediatric population. In severe injuries leading to wounds reaching tendon and bone, vascularity is compromised precluding traditional wound management, and sometimes necessitating amputation. This report highlights the use of a dermal regeneration template combined with vacuum-assisted closure (VAC) in the treatment of complex traumatic degloving wounds. Here, we present a case of a five-year-old boy who sustained a high-energy shear injury to his lower extremity that resulted in an extensive degloving wound involving the distal third of his leg and the dorsum of his foot. After debridement, the patient underwent VAC combined with a dermal skin substitute placement, followed by split-thickness skin grafting. The extremity healed with no complications and without the need for amputation or flap reconstruction, achieving satisfactory recovery of range of motion and favourable cosmetic results.

Integra® dermal regenerative template application on exposed tendon

BACKGROUND

Tendon without paratenon presents the reconstructive surgeon with a tissue coverage challenge. Integra® dermal regenerative template has been shown to initiate a stable, vascularized bed for skin grafting over tendon. However, histological processes that occur during incorporation have not been described. The purpose of this study is to characterize the pattern of changes that occur when Integra® is applied to an avascular tendon. We hypothesize that vascular incorporation will originate from the wound periphery and proceed toward the tendon center.

METHODS

A full-thickness defect was created over a denuded Achilles tendon in a single hind limb in eight New Zealand white rabbits. Integra was placed over the avascular tendon, and the limb was dressed and splinted. Two animals were euthanized at each timepoint (weeks 1, 2, 3, and 4), and hematoxylin and eosin (H&E)-stained tissue specimens were microscopically evaluated.

RESULTS

Week 1 specimens demonstrated limited adherence between Integra and the tendon, while myofibroblasts were found encircling the tendon. No cellularity was noted centrally. At week 2, the dermis-Integra junction had increasing vascularity and the central portion developed increasing cellularity. By week 3, Integra was completely revascularized. At week 4, Integra had the histological appearance of normal dermis.

CONCLUSION

Neovascularization of Integra® over exposed tendon occurs from the peripheral tissue. Ingrowth proceeds from the dermis-Integra interface toward the center of the graft. Four weeks after application to the denuded tendon, Integra has the histological appearance of native dermis.

Tissue engineering

Ultimately much work remains to be done in the companion fields of biomaterials and stem cells. Nonetheless, the monumental progress in TE that has been reported in the studies summarized here demonstrates that regenerative approaches to problems in general surgery need to be explored in more depth. Furthermore, the surgical disciplines of reconstruction and transplantation need to recognize their research counterparts in TE, given its potential to actualize freedom from immunosuppression, one of the most elusive goals in modern surgery. The engineering and proliferation of autologous cells, tissues, and organs ex vivo before surgical operation can significantly reduce the obstacles current practitioners are intimately familiar with: donor site morbidity and immunologic rejection. Therefore, in addition to the truly exciting research and development prospects and implications for the commercial sector, patients with end-stage diseases and debilitating injury stand to gain the most from clinically adapted TE therapies.

Ease of use, safety, and efficacy of integra bilayer wound matrix in the treatment of diabetic foot ulcers in an outpatient clinical setting: a prospective pilot study

BACKGROUND

Integra bilayer wound matrix (IBWM) is a bilayer skin replacement system composed of a dermal regeneration layer and a temporary epidermal layer. It is used to treat various types of deep, large wounds via an inpatient procedure in an operating room. We sought to determine ease of use and effectiveness of IBWM in an outpatient clinical setting when treating diabetic foot ulcers. In addition, no epidermal autografting was performed in conjunction with the IBWM after silicone release, as is common in the inpatient setting.

METHODS

This 12-week, single-arm, prospective pilot study was conducted in three outpatient clinics. Weekly evaluations included monitoring the wound for signs of infection during the 12-week follow-up phase.

RESULTS

Eleven patients with diabetic foot ulcers who met the inclusion and exclusion criteria were enrolled. One patient was discontinued from the study owing to noncompliance leading to a serious adverse event. Therefore, ten patients who received the study intervention were included in the per-protocol population reported herein. The mean patient age was 60.6 years, with an average 11-year history of diabetes mellitus. Each ulcer was located on the plantar aspect of the foot. No infection was reported during the study. Patients treated with IBWM showed progressive wound healing over time: the greatest mean wound reduction was approximately 95% in week 12. Seven of ten patients (70%) achieved complete wound closure by week 12. No recurrent ulcers were reported during follow-up.

CONCLUSIONS

These results are consistent with the hypothesis that IBWM is easy to use, safe, and effective when used on diabetic foot ulcers in an outpatient clinical setting without the secondary procedure of autografting for closure.

Soft-tissue coverage of the hand: a case-based approach

Adequate soft-tissue coverage of the hand is paramount to achieve optimal aesthetic and functional results in patients with complex hand defects. In this article, the authors present four illustrative clinical cases and discuss potential reconstructive modalities. For each scenario, two surgical options are discussed: one established and one nontraditional method of reconstruction. The authors' preferred method and technical pearls for execution are presented.

A novel multiparameter in vitro model of three-dimensional cell ingress into scaffolds for dermal reconstruction to predict in vivo outcome

The clinical demand for effective dermal substitutes continues as current commercially available products present limitations. However, there are no definitive in vitro methods to predict in vivo outcomes such as integration, cellularization and contraction, which may help the development of new dermal scaffolds. This study aimed to develop a multiparameter in vitro model of three-dimensional (3D) cell ingress into dermal scaffolds to predict in vivo outcomes of new dermal scaffolds under development. A new dermal scaffold, Smart Matrix, was compared to the scar-forming contractile collagen gel model and to the clinically well-established Integra^® and Matriderm^®. Parameters studied were cell viability and proliferation, apoptosis, matrix contraction, cell morphology, α-smooth muscle actin, and growth factor expression. Combinatorial evaluation of the results in a scoring matrix showed that Smart Matrix could offer an advantage over existing products. This method would be useful as an international golden scoring matrix to develop new dermal scaffolds that effectively improve the existing products, thus enabling better treatments for burns or chronic wounds.

The Z-advancement flap for reconstruction of lateral nasal tip and medial alar defects

BACKGROUND

Reconstruction of lateral nasal tip and medial alar defects is challenging. Contour, symmetry, and skin texture of the nose, along with adequate nasal airway patency, should be preserved. The Z-advancement flap is a novel reconstruction technique designed for optimal cosmesis and function.

OBJECTIVE

To evaluate the aesthetic and functional outcomes of Z-advancement flap nasal reconstruction.

MATERIALS AND METHODS

Twenty-nine consecutive patients with defects 1 cm or less in diameter on the lateral nasal tip or medial ala underwent Z-advancement flap repair. Patients completed a survey assessing cosmesis and airway patency. Three physicians evaluated standardized photographs on visibility of scar lines, erythema and telangiectasia, and contour and symmetry of the ala and nostril opening.

RESULTS

Twenty-eight (96%) patients completed survey questionnaires. All patients were satisfied with the look and feel of their reconstructed nose. Twenty-four (86%) saw no visible scar or abnormality. Postoperative photographs were available for review in 19 (66%) patients. In 95% to 96% of physician ratings, scars were invisible or visible only on close inspection, and alar symmetry was unchanged or only slightly altered. In 88%, nostril opening symmetry was unchanged or slightly altered.

CONCLUSIONS

The Z-advancement flap preserves aesthetic subunits of the nose to produce excellent cosmesis and patient satisfaction for defects of the lateral nasal tip or medial ala 1 cm or less in diameter.

Biological therapies for the treatment of cutaneous wounds: phase III and launched therapies

INTRODUCTION

Normal wound healing mechanisms can be overwhelmed in the setting of complex acute and chronic tissue injury. Biological therapies are designed to augment and/or restore the body's natural wound healing abilities. There are a variety of available and emerging technologies utilizing this approach that have demonstrated the ability to augment wound healing.

AREAS COVERED

In this review, the clinical data on launched and emerging biological therapies for wound healing applications are summarized. The methodologies discussed include biological skin equivalents, growth factors/small molecules and stem cell-based therapies.

EXPERT OPINION

While many products possess convincing clinical data demonstrating their efficacy in comparison to standard treatment options, more robust, controlled studies are needed to determine the relative value among established and emerging biological therapies. Future bioengineering and stem cell-based approaches are of particular interest due to the simultaneous correction of multiple deficiencies present in the nonhealing wound.