Single-institution Outcome Experience Using AlloDerm® as Temporary Coverage or Definitive Reconstruction for Cutaneous and Soft Tissue Malignancy Defects

Definitive reconstruction after excision of cutaneous and soft tissue malignancies is sometimes limited as a result of lack of native tissue coverage options, patient comorbidities, or pending permanent margin analysis. Acellular dermis (AlloDerm®) reconstruction offers an excellent coverage alternative in these situations. We describe our experience using AlloDerm for coverage of skin and soft tissue defects. An Institutional Review Board approved review of patients undergoing skin/soft tissue coverage with AlloDerm from 2006 to 2012 was performed. Clinicopathologic variables, early postoperative findings, and subjective final cosmetic outcome were analyzed. Sixty-seven patients underwent AlloDerm reconstruction. Melanoma (67%) was the most frequent diagnosis. The median defect size was 42 cm2 (range, 2 to 340 cm2), involving predominantly the lower extremity (45%) or head and neck (32%). AlloDerm was intended for use as a temporary dressing in 64 per cent (43 of 67) and permanent coverage in 24 (36%). Ten patients required reexcision for positive margins. Twenty-five (37%) underwent split-thickness skin graft or flap coverage after AlloDerm placement. Radiation was administered to 16 patients (24%) after AlloDerm reconstruction within a median of 53 days after surgery (range, 18 to 118 days). At first postoperative examination (median, 11 days after surgery), 85 per cent had evidence of healthy AlloDerm incorporation. Cellulitis was the most frequent complication (13%), all resolving with oral antibiotics. AlloDerm reconstruction after skin and soft tissue resection offers a suitable coverage alternative and may serve as a bridge to permanent reconstruction or as a permanent biologic dressing of complex surgical defects. In situations in which adjuvant radiation is needed, AlloDerm can be used without major complications.

Nonfacial Reconstructive Techniques

BACKGROUND

Nonfacial reconstruction encompasses several anatomic locations with varied topography, skin quality, and tissue reservoirs. Patients also have varied mobility concerns and wound care needs when managing wounds in these areas.

MATERIALS AND METHODS

This article includes techniques and approaches from the dermatologic surgery, plastic surgery, and podiatric surgery literature in an effort to provide a comprehensive overview of the subject matter.

RESULTS AND CONCLUSION

Functionally and esthetically acceptable reconstructions of nonfacial surgical wounds can be accomplished with a variety of techniques based on the characteristics of the wound and unique needs of the patient.

Efficacy and complication rates of full-thickness skin graft repair of lower extremity wounds after Mohs micrographic surgery

BACKGROUND

Repair of below-the-knee lower extremity defects after Mohs micrographic surgery (MMS) that are not amenable to primary closure can be challenging given the high propensity for complications. No criterion standard exists for management of these wounds, but secondary-intention healing, partial- and full-thickness skin grafts (FTSGs), and various flaps are possible options to manage these wounds. Few data exist on the efficacy of FTSG repairs for lower extremity wounds.

OBJECTIVES

Assess the efficacy and complications rates of FTSG repairs for lower extremity wounds after MMS.

METHODS

This was a retrospective review of 80 FTSG repairs performed after MMS. Data were derived from 45 cases at Beth Israel Deaconess Medical Center and 35 cases at University of California, San Diego (UCSD) Medical Center.

RESULTS

Seventy-two of 80 cases (90%) had full graft survival, six (7.5%) had partial failure, and two (2.5%) had complete failure. In the cases where grafts had failed, wounds healed by secondary intention without further complications. Other complications included infections in nine (11%) cases and hematoma formation in two (2.5%).

CONCLUSION

FTSG is a consistent and safe reconstructive option for the management of lower extremity wounds after MMS.

Full-thickness skin grafting to cover equine wounds caused by laceration or tumor resection

OBJECTIVE

To describe and evaluate full-thickness skin grafting of equine wounds.

STUDY DESIGN

Case series.

ANIMALS

Adult horses (n=6).

METHODS

A full-thickness graft was harvested from the pectoral region with the horse anesthetized or standing and sedated after local anesthetic infiltration. Grafts were attached to the cutaneous margin of the wound with staples and/or sutures if the horse was anesthetized or if the recipient site was desensitized. Cyanoacrylate glue was used to attach the grafts to the cutaneous margin of the wound of 3 horses. Medical records were reviewed for history, physical examination findings, grafting technique, postoperative complications, and outcome.

RESULTS

Three horses had full-thickness skin grafting to cover a fresh defect created by excision of a cutaneous neoplasm, and 3 horses had full-thickness skin grafting to cover a fresh or granulating laceration. Grafts were completely accepted in 5 horses. The superficial layers of all grafts sloughed, but the final cosmetic appearance of accepted grafts was good.

CONCLUSIONS

Full-thickness skin grafting can be performed in standing sedated horses with good cosmesis, especially when the meshed graft is expanded minimally.

CLINICAL RELEVANCE

Good acceptance of a full-thickness graft can be expected, regardless of whether the graft is applied to a fresh or granulating wound.

Keystone flap reconstruction of primary melanoma excision defects of the leg-the end of the skin graft?

BACKGROUND

During the last 4 years, the keystone-design fasciocutaneous island flap has become the principal form of reconstruction in our unit for primary melanoma defects of the leg distal to the knee where primary closure is not possible.

METHODS

Data describing the primary tumor, surgical management, and outcome were collected prospectively for consecutive keystone flap cases. The study's primary end points were complication rates and length of hospital stay.

RESULTS

A total of 176 patients with new primary melanomas of the lower limb were treated over 4 years. The average Breslow thickness was 1.33 mm (range, in situ to 9.0 mm), and the average width of the defect was 3 cm. The reconstructions comprised 106 standard, 65 modified, and 5 double-opposing keystone type flaps performed from the knee to the dorsum of the foot. Complications that required further therapeutic intervention were seen in eight patients (4.6%), with only one partial flap necrosis (.6%) and one total flap loss (.6%). In this series, modification of the flap design significantly decreased the complication rate (Fisher's exact test, P = .033). There was no increase in complications in the distal third of the leg. The procedure was performed in day-only surgery setting in almost a quarter of patients.

CONCLUSION

We present the largest series of flap reconstructions for melanoma of the leg. The keystone flap is extremely reliable, affords excellent cosmesis, and is technically straightforward to perform. At the Sydney Melanoma Unit, reconstruction after primary melanoma excision on the leg has been transformed so that skin grafts are now rarely performed.