Reconstruction of scalp defects with exposed bone after surgical treatment of basal cell carcinoma: the use of a bilayer matrix wound dressing

Engineered Skin Substitutes in Dermatologic Surgery: A Systematic Review

BACKGROUND

Artificial skin substitutes are a flexible alternative to autografting in Mohs micrographic surgery (MMS), but the characteristics and clinical outcomes of skin substitutes are not well defined.

OBJECTIVE

Summarize clinical data of skin substitutes in MMS for cutaneous malignancy.

METHODS

A MEDLINE/Embase/Web of Science search was conducted. Articles with original data on outcomes after skin substitute use in MMS for cutaneous malignancy were included. Articles not in English or without original data were excluded. Bias was assessed using the Oxford CEBM Levels of Evidence Table. Outcomes were synthesized using weighted averages. This study was prospectively registered in PROSPERO.

RESULTS

Of 1,007 articles, 40 met eligibility for inclusion. In total, 898 patients who underwent MMS and received a skin substitute were included. Xenografts were most commonly used ( n = 613). Semi-synthetic grafts (∼$<1/cm 2 ) and xenografts (∼$10/cm 2 ) are most affordable. Overall, outcomes were excellent for all skin substitutes, with a small proportion of patients experiencing correctable complications.

CONCLUSION

Skin substitutes are highly effective in MMS, with enormous potential. While the data demonstrate positive outcomes, they predominately draw from small, retrospective studies or case reports. There is also a scarcity of data comparing skin substitutes with each other or controls. Prospective studies are recommended.

Single-stage full-depth scalp reconstruction with Matriderm®: a clinical case report and a brief literature review

Reconstructing scalp defects after basal cell carcinoma removal in elderly patients is challenging. This case report emphasizes Matriderm® as a successful alternative, addressing limitations of traditional methods. The application of Matriderm® in resource-limited scenarios adds insights to surgical literature, and its' usage addresses challenges in patients, contributing to surgical knowledge.

Skin substitutes for the management of mohs micrographic surgery wounds: a systematic review

The data on skin substitute usage for managing Mohs micrographic surgery (MMS) wounds remain limited. This systematic review aimed to provide an overview of skin substitutes employed for MMS reconstruction, summarize clinical characteristics of patients undergoing skin substitute-based repair after MMS, and identify advantages and limitations of skin substitute implementation. A systematic review of Ovid MEDLINE, EMBASE, Cochrane Library, and Web of Science databases, from inception to April 7, 2021, identified all cases of MMS defects repaired using skin substitutes. A total of 687 patients were included. The mean patient age was 70 years (range: 6-98 years). Commonly used skin substitutes were porcine collagen (n = 397), bovine collagen (n = 78), Integra (n = 53), Hyalofill (n = 43), amnion/chorion-derived grafts (n = 40), and allogeneic epidermal-dermal composite grafts (n = 35). Common factors influencing skin substitute selection were cost, healing efficacy, cosmetic outcome, patient comfort, and ease of use. Some articles did not specify patient and wound characteristics. Skin substitute usage in MMS reconstruction is not well-guided. Blinded randomized control trials comparing the efficacy of skin substitutes and traditional repair methods are imperative for establishing evidence-based guidelines on skin substitute usage following MMS.

A brief synopsis on scalp melanoma

Melanoma constitutes one of the most sinister and troublesome malignancies encountered by humanity. Generally, the diagnosis of advanced melanoma connotes a grave prognosis, prompting a sense of looming threat of death, however, the early-stage detected disease responds well to robust treatment resulting in reasonable survivorship. Scalp melanomas are even more troublesome, because they typically exhibit more aggressive biologic behavior and are often diagnosed at a late stage. This review tries to comprehensively highlight the various diagnostic, therapeutic, and outcome aspects of scalp melanomas. The literature research includes peer-reviewed articles (clinical trials or scientific reviews). Studies were identified by searching electronic databases (MEDLINE and PubMed) till May 2020 and reference lists of respective articles. Only articles published in English language were included.

The impact of COVID-19 pandemics on dermatologic surgery: real-life data from the Italian Red-Zone

BACKGROUND

The COVID-19 pandemic is challenging healthcare systems worldwide. Dermatology had to re-prioritize visits, guarantee urgent care, and ensure continuity for chronic patients.

OBJECTIVES

To evaluate the COVID-19 impact on dermatologic surgery outpatient management.

MATERIAL AND METHODS

In this real-life retrospective observational study, we evaluated both major and minor outpatient surgeries (MaOS and MiOS) performance in 2020, before and during the first month of lockdown declaration, in a primary referral center in Northern Italy. During the lockdown, all lifesaving and cancer surgery, (approximately 80% of our usual activities), were continued. Data from 2020 were compared with the 2019 corresponding periods to assess the real-life impact of COVID-19 in dermatologic surgical activities.

RESULTS

From January 1st to April 3rd, 2020 we performed 769 interventions, compared to 908 over the corresponding 2019 period. After the lockdown, scheduled surgeries were reduced by 14.8%; overall performed ones displayed a reduction of 46.5% (51.6% MaOS, 44.2% MiOS). 52.9% and 12.5% procedures were canceled due to patients' renunciation and due to confirmed/suspected COVID-19, respectively.

CONCLUSIONS

While reduced in number, dermatologic surgeries, similarly to other surgical specialties, remained operative to provide oncological and/or life-saving procedures.

Scalping Surgery - Dermatologic Indications beyond Curative Primary Skin Cancer Surgery

Skin tumours are among the most frequent tumour types of mankind. In the case of large tumours, field cancerization, or satellitosis scalping surgery is a possible option. The procedure can also be used in a palliative setting with tumour debulking. Less common indications are multiple benign tumours of the scalp and chronic inflammatory scalp dermatoses not responding to medical treatment. We present a case series and discuss surgical modalities beyond curative surgery of primary skin cancer.

Integra-based Reconstruction of Large Scalp Wounds: A Case Report and Systematic Review of the Literature

Background:

Large complex scalp wounds that have traditionally required free vascularized tissue transfer have been successfully reconstructed with skin substitutes such as Integra. Although there are multiple reports of Integra-based reconstructions of scalp wounds, there has not been a comprehensive assessment of this body of literature that critically examines this method. Our goal was to conduct a systematic review to determine the effectiveness of Integra-based reconstructions of scalp wounds, with emphasis on large defects.

Methods:

A comprehensive systematic review was completed using key search terms, including Integra, dermal regeneration template, bovine collagen, skin substitute, forehead, and scalp. Selected articles reported characteristics of patients and their reconstructions. The primary outcome measures were wound complications and percent graft take.

Results:

Thirty-four articles were included in this systematic review. Wound sizes ranged from 5.7 to 610 cm², with 35.3% of articles reporting a mean defect size >100 cm². Thirty-two articles reported mean percent take of skin graft ≥90%. Sixteen articles reported a minor complication. There were no major complications associated with the reconstructions.

Conclusions:

There is a substantial evidence base for the use of Integra to reconstruct scalp wounds. To date, the dermal regeneration template is generally reserved for salvage procedures or when the patient cannot tolerate free tissue transfer. Based on the findings of this systematic review and the authors’ clinical experience, Integra can be used to achieve predictable results in large complex scalp defects.

Management of skin defect following resection of Stage IV scalp melanoma: A case report

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Large defects following giant scalp melanoma resection pose a challenge to surgeon.

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Excision beyond galea difficult to close with skin grafts & flaps.

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INTEGRA^® following split-thickness-skin-graft may be used to cover the wound.

Introduction

Surgical defect left following excision of a large and neglected scalp melanoma of can pose a significant challenge for the surgeon. Scalp reconstruction encompasses options such as skin flaps, grafts, and various mechanical techniques. In scalp excision that involves dissection beyond the galea, skin grafts and flaps may not take well and not enough tissue may be available for a skin flap.

Presentation of case

We present the case of a 64 year-old male with a giant scalp melanoma. The patient underwent excisional surgery of the tumor that left behind a large, galeal scalp wound defect. We used a dermal regeneration template (INTEGRA^®) followed by negative pressure wound therapy (wound V.A.C.^®), followed by split-thickness-skin-graft (STSG) to cover the wound. The patient was operated on and discharged home the same day and home health wound care was utilized for wound V.A.C.^® maintenance. The patient underwent same day surgery for STSG two weeks later with great results. His one-month follow-up visit showed 100% graft take and a well-healing wound.

Discussion

The combination of INTEGRA^®, negative pressure dressing, and skin graft proved to be a safe and effective solution to dealing with large wound defects following surgical excision of the tumor. This is likely secondary to neovascularization and regeneration of a dermal template that is achieved with the dermal regeneration matrix INTEGRA^®. Other studies have shown that combination of negative pressure wound therapy with INTEGRA^® promotes faster integration of the matrix and decreases wound complications such as infection.

Conclusion

The excellent results for this case present a very effective, time-expedient operative approach to surgical challenges in treating giant scalp melanomas. A four-week follow-up visit after INTEGRA^® and wound V.A.C.^® application indicated that Integra was well integrated to the calvarium with good neovascularization and granulation tissue evident. Skin grafting not only covered the defect completely, but also took to the scalp 100% with no wound breakdown or wound-healing issues.