Two-stage reconstruction of head and neck defects after tumor resection with a dermal regeneration template

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.

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.

Clinical Factors Influencing the Outcomes of an Acellular Dermal Matrix for Skin Cancer Treatment: A Retrospective Study

OBJECTIVE

To evaluate the efficacy and safety of a biologically engineered dermal matrix used in reconstructive surgery after skin tumor resection, focusing on the frequency of successful grafting and identifying potential factors influencing treatment outcomes.

DESIGN AND PARTICIPANTS

This retrospective analysis involved consecutive patients diagnosed with skin cancer in any area of the body and for which treatment with a dermal skin template was recommended as alternative to traditional surgery.

MAIN OUTCOME MEASURES

Percentage of successful grafting and the patient and tumor characteristics influencing treatment outcome via univariate analysis.

MAIN RESULTS

A total of 302 patients were included. Surgical reconstruction with the matrix was effective in 88.9% of the patients within 21 days of surgery. Notably, the matrix was successful regardless of tumor location, type, or size. Infection was the only variable significantly associated with graft failure (P < .001).

CONCLUSIONS

The studied dermal matrix provides an efficient alternative to traditional reconstructive surgery in patients who present specific comorbidities or risk factors. The only variable significantly associated with graft failure was infection, which should be properly controlled through appropriate treatment.

Malignant Skin Cancer Excision in Combined Therapy with Electro-Chemotherapy and Dermal Substitute

Squamous cell carcinoma (SCC) is the second most common malignancy skin cancer. It is characterized by abnormal, accelerated growth of squamous cells (SCs). SCC occurs when DNA damage from exposure to ultraviolet radiation or other damaging agents trigger abnormal changes in the SCs, presenting as painless lesions on areas of high sun exposure, such as the dorsum of the hand and upper extremity. For most skin SCC, the surgical excision alone is standard practice. However, recent efforts in new treatment strategies have involved around adjuvant or concomitant electrochemotherapy (ECT). ECT is a non-thermal tumor ablation modality, safe and effective on any type of solid tumor. An 87-year-old patient affected by hand SCC with invasion of deep structures including tendons was treated with neoadjuvant intra-tumoral ECT sessions followed by a selective surgical removal and reconstruction of the substance loss with collagen dermal template (CDT). Two neoadjuvant intra-tumoral ECT procedures, at distance of 3 months, with the aim to reduce the tumor size before a selective surgery, were performed. This study shows that combined surgical selective excision with ECT and CDT is a valid technique for the extended-deep dorsal hand tumor lesions reconstruction.

Reconstruction following Excision of Malignant Scalp Tumors with Split Thickness Skin Graft with and without Acellular Dermal Matrix: A Comparative Study

BACKGROUND

Basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) are the most common malignancies, which occur on the scalp. There are various therapeutic methods for managing these malignancies in which the standard treatment method of both is surgical excision with a good margin. Sometimes, the patients need full-thickness excision due to the deep invasion, so exposing the underlying calvarium may be a challenge for surgeons.

OBJECTIVES

We evaluated the outcomes of using the combined therapy of acellular dermal matrix and split-thickness skin graft (STSG) in comparison with using only STSG in the treatment of defects caused by the excision of scalp malignant tumors among the patients who attended Imam Khomeini Hospital Complex and Razi Hospital of Tehran, Iran. We also evaluated the satisfaction of both surgeons and patients among these two methods of treatment.

MATERIALS AND METHODS

All the candidates were divided into the two groups, that is, of case and control, randomly. The case group underwent the treatment using acellular dermal matrix and STSG, whereas the control group underwent the treatment by only STSG on the wound. In both groups, BCC and SCC were excised with a margin of 6 and 10 mm, respectively, on the skull bone. Then, a layer of bone was removed by osteotomy in order to reach the bleeding points. All patients were followed up for 7, 30, and 90 days after the surgery, and the results were recorded.

RESULTS

A significant difference in Manchester Scar Scale, wound contour formation, the mobility of the repair site, and patients and surgeon satisfaction was observed among both groups based on visual analog scale. We found better outcomes in the case group, especially in wound contour formation during 90 days of follow-up. However, the satisfaction of both surgeons and patients was achieved in the case group. Satisfaction of surgeons was achieved in the case group with a relative superiority to the control group according to the Manchester Scar Scale.

Reconstruction of Nasal Defects With Dermal Skin Substitutes-A Retrospective Study of 36 Defects

OBJECTIVES

It is uncertain whether dermal regeneration templates (DRTs) are helpful to reconstruct nasal defects. The aim of this study was to assess whether the aesthetic subunits determine the outcome.

METHODS

In this unicentric, retrospective study, the surgical procedures and outcomes of patients who received DRTs to reconstruct nasal defects were assessed and compared with the involved aesthetic subunits.

RESULTS

DRTs were used for reconstruction of 36 nasal defects in 35 patients with involvement of 76 aesthetic subunits: nasal sidewall (n = 21), nasal ala (n = 13), nasal tip/columella (n = 12, n = 1, respectively), nasal dorsum (n = 12), and extranasal aesthetic areas (n = 17). Fifty-eight nasal and 8 extranasal aesthetic subunits were reconstructed with DRTs, 10 subunits with a flap. Twenty-nine of 36 defects healed without any complications (80.5%). All reconstructed nasal tips/columella and the nasal dorsa healed without any complications. Region-specific complications were retraction of the ala rim (4/12; 33.3% of the patients with involvement of the nasal ala) and the formation of a fistula in the nasal sidewall (1/21; 4.8%). Region-specific complications of extranasal subunits were the development of an ectropium (2/3; 66.7% of the patients with involvement of the lower lid).

CONCLUSIONS

DRTs can be helpful to reconstruct nasal defects. However, if the defect involves the aesthetic subunits nasal ala or the infraorbital region, different techniques should be preferred.

Skin cancers and dermal substitutes: Is it safe? Review of the literature and presentation of a 2-stage surgical protocol for the treatment of non-melanoma skin cancers of the head in fragile patients

Non-melanoma skin cancers (NMSC) represent the most common skin tumours of the head region. We describe the use of dermal substitute in a 2-stage surgery protocol for selected fragile patients to remove NMSC of the head region. A review of the literature focusing on dermal substitutes' safety after skin tumours excision is provided. A total of 45 fragile patients with NMSC in the head region were selected and scheduled for the 2-stage surgical protocol. The first stage consisted of traditional surgical excision and immediate coverage with Hyalomatrix (Fidia Advanced Biopolymers, Abano Terme, Italy). After histology confirmed diagnosis and clearance of the margins, full-thickness skin autografts were performed. All of the patients reached complete tumour excision and wound healing. No local recurrences were registered during 24 months follow up. The 2-stage surgical therapeutic-diagnostic-reconstructive approach represents a less stressful and oncologically safe surgical protocol in selected fragile patients. When patients cannot tolerate invasive and long surgical procedures, general anaesthesia, and long hospitalisation, skin grafting following temporary skin substitute coverage can achieve oncological clearance and provide good functional and aesthetic results. The use of dermal substitutes represents a valid alternative surgical option in cases of ASA III, fragile patients non-eligible for complex reconstructive surgery. To our knowledge, this is the first paper reviewing literature focusing on dermal substitutes' applications and safety after skin tumour excision.

The caudolaterally inserted transposition flap and its variations for reconstruction of defects of the nasal ala

Closure of non-full-thickness defects of the nasal ala can be a surgical challenge. While there is a plethora of various reconstructive techniques, not all of them are easy to learn and carry out. Recently, the dermatosurgeon Andreas Lösler from the Department of Dermatology at the Hornheide Medical Center, Germany, developed and published the caudolaterally inserted transposition flap for the reconstruction of alar defects. Given its relative novelty, this technique, which is characterized by a very low complication rate, is still unknown to most dermatosurgeons and has not yet found its way into standard dermatosurgery textbooks. The present review describes the caudolaterally inserted transposition flap and two modifications thereof, which allow for the closure of large alar defects as well as defects of the alar crease. Comparisons are made to the two flaps most commonly employed for alar reconstruction, the bilobed flap and the cranially inserted nasolabial transposition flap (melolabial flap).

The Use of Integra Dermal Regeneration Template Versus Flaps for Reconstruction of Full-Thickness Scalp Defects Involving the Calvaria: A Cost-Benefit Analysis

Background

INTEGRA^® Dermal Regeneration Template is a well-known and widely used acellular dermal matrix. Although it helps to solve many challenging problems in reconstructive surgery, the product cost may make it an expensive alternative compared to other reconstruction procedures. This retrospective study aims at comparing INTEGRA-based treatment to flap surgery in terms of cost and benefit.

Patients and Methods

We considered only patients treated for scalp defects with bone exposure in order to obtain two groups as homogeneous as possible. We identified two groups of patients: 17 patients treated with INTEGRA and 18 patients treated with flaps. All patients were admitted in our institution between 2004 and 2010, and presented a defect of the scalp following trauma or surgery for cancer, causing a loss of the soft tissues of the scalp with bone exposure without pericranium. To calculate the cost in constant euros of each treatment, three parameters were evaluated for each patient: cost of the surgical procedure (number of doctors and nurses involved, surgery duration, anesthesia, material used for surgery), hospitalization cost (hospitalization duration, dressings, drugs, topical agents), and outpatient cost (number of dressing changes, personnel cost, dressings type, anti-infective agents). The statistical test used in this study was the Wilcoxon Mann–Whitney (α = 0.05).

Results

No significant difference was characterized between the two groups for gender, age, presence of diabetes, mean defect size, and number of surgical procedures. All patients healed with good quality and durable closure. The median total cost per patient was €11,121 (interquartile range (IQR) 8327–15,571) for the INTEGRA group and €7259 (IQR 1852–24,443) for the flap group (p = 0.34). A subgroup of patients (six patients in the INTEGRA group and five patients in the flap group) showing defects larger than 100 cm² were considered in a second analysis. Median total cost was €11,825 (IQR 10,695–15,751) for the INTEGRA group and €23,244 (IQR 17,348–26,942) for the flap group.

Conclusion

Both treatments led to a good healing of the lesions with formation of soft and resistant tissue. No significant difference was characterized between the two groups for days of hospitalization and costs. In cases of patients with defects larger than 100 cm² for whom major surgery is needed, the treatment with INTEGRA seemed to be less expensive than the treatment with free flaps or pedicle flaps.

Level of Evidence V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the A5 online Instructions to Authors.www.springer.com/00266.

Dermal Matrix for Intraoral Lining Following Composite Mandibular Defect Reconstruction With Chimeric Fibular Osseocutaneous Flap

BACKGROUND

This report aims to first present Integra as an adjunct to complex mandibular reconstruction for intraoral lining resurfacing, and to review the literature on the use of dermal matrices for mucosal resurfacing of the floor of the mouth.

CLINICAL REPORT

A 62-year-old female patient with previous ablation surgery for squamous cell carcinoma of the floor of the mouth, presented with extrusion of the mandibular plate through the chin skin and serious tongue tethering. The patient was managed with a chimeric osseocutaneous free fibula flap to restore the mandibular bone and chin skin defect, followed by a second-stage reconstruction of the intraoral defect with bilayer Integra. Complete release of tongue tethering was achieved enabling normal speech and deglutition and allowing for dental rehabilitation.

CONCLUSIONS

Integra was safely used as an alternative for intraoral lining, in composite mandibular reconstruction, downgrading reconstructive demands and offering optimal functional results.

One-Stage Reconstruction of Scalp after Full-Thickness Oncologic Defects Using a Dermal Regeneration Template (Integra)

The use of Dermal Regeneration Template (DRT) can be a valid alternative for scalp reconstruction, especially in elderly patients where a rapid procedure with an acceptable aesthetic and reliable functional outcome is required. We reviewed the surgical outcome of 20 patients, 14 (70%) males and 6 (30%) females, who underwent application of DRT for scalp reconstruction for small defects (group A: mean defect size of 12.51 cm²) and for large defects (group B: mean defect size of 28.7 cm²) after wide excision of scalp neoplasm (basal cell carcinoma and squamous cell carcinoma). In group A, the excisions were performed to the galeal layer avoiding pericranium, and in group B the excisions were performed including pericranium layer with subsequent coverage of the exposed bone with local pericranial flap. In both the groups (A and B) after the excision of the tumor, the wound bed was covered with Dermal Regeneration Template. In 3 weeks we observed the complete healing of the wound bed by secondary intention with acceptable cosmetic results and stable scars. Scalp reconstruction using a DRT is a valid coverage technique for minor and major scalp defects and it can be conducted with good results in elderly patients with multiple comorbidities.

Complete skin resection of the dorsum of the hand: a prophylactic approach using a dermal regeneration template

BACKGROUND

Surgical treatment of multiple and recurring invasive carcinomas on the dorsum of the hand often results in a reconstructive challenge. Reconstruction is limited due to reduced adjacent tissue. Preserving the functionality of the hand is pivotal and needs to be respected while planning reconstruction.

OBJECTIVE

We present a case of extensive, multiple, and recurring invasive squamous cell carcinoma on the dorsum of the hand and describe a prophylactic surgical approach.

METHODS

We performed a radical excision of the skin on the dorsum of the hand and surgical reconstruction using a bilayer dermal skin substitute and split-thickness skin grafting.

RESULTS

After a 1-year follow-up, we observed an excellent cosmetic and functional result with no signs of recurrence.

CONCLUSIONS

In case of extensive invasive squamous cell carcinoma on the dorsum of the hand, prophylactic resection and surgical reconstruction using a dermal regeneration template should be considered.