1
|
Shah R, Rodrigues R, Phillips V, Khatib M. The use of artificial dermal substitutes for repair of the donor site following harvesting of a radial forearm free flap: A systematic review. J Plast Reconstr Aesthet Surg 2024; 88:501-516. [PMID: 38101265 DOI: 10.1016/j.bjps.2023.11.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 11/01/2023] [Accepted: 11/26/2023] [Indexed: 12/17/2023]
Abstract
BACKGROUND Artificial dermal substitutes (ADMs) have been trialled to improve outcomes at the donor site following the harvesting of a radial forearm free flap (RFFF). This systematic review compares donor site aesthetic and functional outcomes, with the use of an ADM versus conventional practice. METHODS The databases Medline, Embase, Cochrane Library, Web of Science (Core Collection), and Scopus were searched for retrospective, prospective, and case-control studies and randomised control trials (RCTs) involving any ADM. Studies with adult patients having undergone RFFF harvesting and donor site repair with an ADM, commenting on appropriate clinical outcomes and without high risk of bias, were included. Direction-of-effect analysis was performed on relevant groupings of studies since heterogeneity in outcome measurement precluded meta-analyses. RESULTS Across eight non-comparative studies included, 132 patients had donor site coverage with AlloDerm™, Integra™, Matriderm™, or Rapiderm. Across 11 comparative studies included, 240 patients had donor site coverage with fish-skin matrix, AlloDerm™, amniotic membrane, MegaDerm™, Hyalomatrix, Integra™, or Matriderm™. Five out of 11 comparative studies demonstrated superior aesthetic outcomes with ADMs according to at least one aesthetic metric compared to controls, whilst 6/11 demonstrated superior functional outcomes with ADMs. No study demonstrated poorer aesthetic or functional outcomes with an ADM compared to conventional practice. CONCLUSIONS In summary, the lack of studies reporting poorer outcomes with them compared to conventional practices, and a cumulative effect direction in their favour, provide strong indications in support of the use of AlloDerm™, Integra™, or Matriderm™ grafts. Further comparative studies, including RCTs, are needed to reinforce these initial indications.
Collapse
Affiliation(s)
- Rahul Shah
- University of Cambridge, School of Clinical Medicine, Cambridge, UK.
| | - Raina Rodrigues
- Lister Hospital, East and North Hertfordshire NHS Trust, Stevenage, UK
| | | | - Manaf Khatib
- Lister Hospital, East and North Hertfordshire NHS Trust, Stevenage, UK
| |
Collapse
|
2
|
Mosquera C, Weyh A, Malik M, Fernandes R, Bunnell A, Nedrud S. Comparison of the outcomes of split thickness skin graft versus thickness skin graft for closure of the radial forearm free flap donor site: A systematic review. Microsurgery 2024; 44:e31126. [PMID: 37990820 DOI: 10.1002/micr.31126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 09/18/2023] [Accepted: 10/05/2023] [Indexed: 11/23/2023]
Abstract
BACKGROUND Radial forearm free flap (RFFF) donor site closure is traditionally performed with split thickness skin grafts (STSG), which can be associated with poor aesthetics, wrist stiffness, paresthesia, reduced strength, and tendon exposure. Full thickness skin grafts (FTSG) are potentially beneficial as they provide a more durable coverage, and the skin graft donor site can be closed primarily, which is more aesthetic. The aim of this systematic review is to compare the outcomes of STSG versus FTSG for closure of the RFFF donor site. METHODS A systematic review was performed, following Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. The primary objective was to answer: do subjects undergoing RFFF harvest, utilizing FTSG to close the RFFF donor site, compared to STSG, achieve superior aesthetics at the RFFF donor site? Included papers compared FTSG and STSG with statistical data. Means were compared with t-test and proportions with Fisher's exact test. RESULTS The initial search resulted in 1851 studies. After applying the inclusion/exclusion criteria, the search resulted in eight studies, with 366 total skin grafts, 197 STSG and 169 FTSG. Six studies evaluated aesthetics utilizing a Likert scale, with the scaled average aesthetic score for FTSG being 7.9/10 compared to 6.9/10 for STSG (p < .001). Tendon exposure was measured in five studies, with a rate of 13.1% for STSG versus 10.6% for FTSG (p = .555). No significant difference in function was observed, however, methods to quantify function were heterogeneous. CONCLUSION FTSG compared to STSG, resulted in statistically significant improved aesthetics, with comparable rates of tendon exposure and function.
Collapse
Affiliation(s)
- Camilo Mosquera
- Department of Oral and Maxillofacial Surgery, University of Florida College of Medicine, Jacksonville, Jacksonville, Florida, USA
- Department of Surgery, Division of Oral and Maxillofacial Surgery, University of Texas Medical Branch, Galveston, Texas, USA
| | - Ashleigh Weyh
- Department of Oral and Maxillofacial Surgery, University of Florida College of Medicine, Jacksonville, Jacksonville, Florida, USA
- Department of Oral and Maxillofacial Surgery, University of Illinois Chicago, Chicago, Illinois, USA
| | - Michael Malik
- Department of Oral and Maxillofacial Surgery, University of Florida College of Medicine, Jacksonville, Jacksonville, Florida, USA
| | - Rui Fernandes
- Department of Oral and Maxillofacial Surgery, University of Florida College of Medicine, Jacksonville, Jacksonville, Florida, USA
| | - Anthony Bunnell
- Department of Oral and Maxillofacial Surgery, University of Florida College of Medicine, Jacksonville, Jacksonville, Florida, USA
| | - Stacey Nedrud
- Department of Oral and Maxillofacial Surgery, University of Florida College of Medicine, Jacksonville, Jacksonville, Florida, USA
- Private Practice, Jacksonville, FL, USA
| |
Collapse
|
3
|
Saleki M, Noor MA, Hurt P, Abul A. Full-Thickness Skin Graft Versus Split-Thickness Skin Graft for Radial Forearm Free Flap Transfer in Oral Cavity Reconstruction: A Systematic Review and Meta-Analysis. Cureus 2023; 15:e49279. [PMID: 38143661 PMCID: PMC10746958 DOI: 10.7759/cureus.49279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2023] [Indexed: 12/26/2023] Open
Abstract
The radial forearm free flap (RFFF) is a surgical technique for addressing intraoral reconstruction. However, with the limitation of an unavoidable defect at the RFFF donor site, split-thickness skin grafts (STSGs) have been a solution for repairing these defects, but they are not without challenges. This study aimed to evaluate an approach using full-thickness skin grafts (FTSGs), comparing their effectiveness in terms of aesthetics, pain, complications, and scarring. A systematic review and meta-analysis were conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies comparing FTSG with STSG for RFFF donor site repair in head and neck cancer patients were included. Primary outcomes measured were appearance and pain at the RFFF site, and secondary outcomes were infection, tendon exposure, graft loss, and scar assessment. A meta-analysis and systematic review of eight studies demonstrated that FTSG provided a superior aesthetic appearance at the RFFF donor site compared to STSG (p = 0.001), with low heterogeneity among the studies. The analysis found no significant difference in donor site pain between techniques. There were no significant differences in infection, tendon exposure, or skin graft loss between the two graft methods. This study suggests that FTSG is comparable to STSG in terms of donor site pain, scarring, and infection while offering superior aesthetic outcomes.
Collapse
Affiliation(s)
| | | | - Patrick Hurt
- Medicine & Surgery, Barts and The London School of Medicine, London, GBR
| | - Ahmad Abul
- Medicine, University of Leeds, Leeds, GBR
| |
Collapse
|
4
|
Lee SK, An YS, Choy WS. Management of Hardware-Exposed Soft Tissue Defects Using Dermal Substitutes and Negative Pressure Wound Therapy. Ann Plast Surg 2023; 90:242-247. [PMID: 36796046 DOI: 10.1097/sap.0000000000003440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
INTRODUCTION Reconstruction of complex injuries of the extremities with full-thickness wounds is a challenging but important task. If primary closure is not feasible, more complex procedures are required, such as split-thickness skin graft or flap surgery. Recently, several studies have shown good results when combined with negative pressure wound therapy (NPWT) and artificial dermal replacement therapy after extensive surgical debridement and NPWT administration for severe complex wounds accompanied by tendon or bone exposure. However, flap surgery remains the only treatment for wounds in which the hardware is exposed after fracture fixation. Therefore, in this study, we attempted to prove the usefulness of the combined treatment using artificial dermal substitutes (MatriDerm) and NPWT by focusing on hardware-exposed wounds, which have not been studied before. METHODS From 2019 to 2021, we treated with our wound management procedure 14 patients with hardware-exposing wounds after internal fixation using plates, out of 48 patients with full-thickness posttraumatic skin defect. Before skin grafting, after surgical debridement and thorough washouts, MatriDerm was placed and NPWT was applied over it. This staged approach aimed at conditioning even the most complex wounds so that closure with MatriDerm-augmented skin grafting would become possible in a one-step approach. RESULTS We stratified the duration of treatment and number of replacements in NPWT according to the type of injury. Cases with open fractures required significantly longer NPWT than those with closed fractures (P = 0.01); however, there was no significant difference between the Gustilo-Anderson classification within open fractures (P > 0.05). Patients with open fractures underwent a mean of 6.6 changes while those with closed fractures underwent 2.5 (P = 0.002) until the final wound closure with MatriDerm-augmented skin grafting was performed. There was no significant difference in the treatment period based on the location and size of the wound, and there was no significant difference in the number of NPWT replacements. Skin grafting was successful in all 14 patients. CONCLUSIONS This study revealed that NPWT and artificial dermis-augmented skin grafting after combined treatment with NPWT and artificial dermis were sufficiently useful for hardware-exposed wounds, where flap surgery has been considered the only treatment to date.
Collapse
Affiliation(s)
- Sang Ki Lee
- From the Department of Orthopedic Surgery, Eulji University College of Medicine, Daejeon, South Korea
| | | | | |
Collapse
|
5
|
Reducing morbidity in radial forearm free flap donor site: a review of closure techniques. Curr Opin Otolaryngol Head Neck Surg 2022; 30:363-367. [PMID: 36004786 DOI: 10.1097/moo.0000000000000834] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Radial forearm free tissue transfer (RFFF) has been an extremely reliable reconstructive option for head and neck oncologic defects for over 30 years. With high reliability, interest has shifted in minimizing donor site morbidity, much of which results from closure techniques. RECENT FINDINGS Portable negative pressure wound devices, newer dermal substitutes, and local flap techniques have improved donor site aesthetics and function. SUMMARY Outcomes of the RFFF donor site may benefit from newer techniques in closure.
Collapse
|
6
|
Burn Wound Healing: Clinical Complications, Medical Care, Treatment, and Dressing Types: The Current State of Knowledge for Clinical Practice. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19031338. [PMID: 35162360 PMCID: PMC8834952 DOI: 10.3390/ijerph19031338] [Citation(s) in RCA: 59] [Impact Index Per Article: 29.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 01/13/2022] [Accepted: 01/21/2022] [Indexed: 02/01/2023]
Abstract
According to the World Health Organization (WHO), it is estimated that each year approximately 11 million people suffer from burn wounds, 180,000 of whom die because of such injuries. Regardless of the factors causing burns, these are complicated wounds that are difficult to heal and are associated with high mortality rates. Medical care of a burn patient requires a lot of commitment, experience, and multidirectional management, including surgical activities and widely understood pharmacological approaches. This paper aims to comprehensively review the current literature concerning burn wounds, including classification of burns, complications, medical care, and pharmacological treatment. We also overviewed the dressings (with an emphasis on the newest innovations in this field) that are currently used in medical practice to heal wounds.
Collapse
|
7
|
Di Giuli R, Dicorato P, Kaciulyte J, Marinari N, Conversi F, Mazzocchi M. Donor Site Wound Healing in Radial Forearm Flap: A Comparative Study Between Dermal Substitute and Split-Thickness Skin Graft Versus Full-Thickness Skin Graft Primary Coverage. Ann Plast Surg 2021; 86:655-660. [PMID: 33661229 DOI: 10.1097/sap.0000000000002777] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Radial forearm flap (RFF) is one of the most used flaps in reconstructive surgery. Despite its versatility and effectiveness, the donor site is affected by aesthetic and functional issues. In the group of techniques described to improve the donor site morbidity, dermal substitutes offer a valid approach in the wound management. A bilayered bioresorbable dermal substitute (Hyalomatrix) was used to provide the primary coverage of the RFF harvest site followed after 3 weeks by a split-thickness skin graft placement. In this study, 37 patients underwent RFF donor site reconstruction and subjected to a minimum follow-up of 1 year. The dermal substitute was applied on 15 patients, and their outcomes were compared with the data achieved by 22 patients submitted to immediate reconstruction with autologous full-thickness skin graft. Results were documented by digital photographs, the visual analog scale, the Vancouver Scar Scale, and the Disabilities of the Arm, Shoulder, and Hand questionnaire. Data were analyzed and compared through statistical analysis. Total wound coverage was achieved in 4 to 6 weeks, and no tendon impairments were reported in the dermal substitute group. In our experience, the use of the dermal substitute is a valuable mean to minimize RFF donor site morbidity with excellent functional and aesthetic outcomes.
Collapse
Affiliation(s)
- Riccardo Di Giuli
- From the Unit of Plastic and Reconstructive Surgery, Santa Maria della Misericordia Hospital, University of Perugia, Perugia
| | - Paolo Dicorato
- Unit of Plastic and Reconstructive Surgery, Department of Surgery "P.Valdoni," Policlinico Umberto I, Sapienza University of Rome, Roma, Italy
| | | | - Niccolò Marinari
- From the Unit of Plastic and Reconstructive Surgery, Santa Maria della Misericordia Hospital, University of Perugia, Perugia
| | - Francesco Conversi
- From the Unit of Plastic and Reconstructive Surgery, Santa Maria della Misericordia Hospital, University of Perugia, Perugia
| | - Marco Mazzocchi
- From the Unit of Plastic and Reconstructive Surgery, Santa Maria della Misericordia Hospital, University of Perugia, Perugia
| |
Collapse
|
8
|
Przekora A. A Concise Review on Tissue Engineered Artificial Skin Grafts for Chronic Wound Treatment: Can We Reconstruct Functional Skin Tissue In Vitro? Cells 2020; 9:cells9071622. [PMID: 32640572 PMCID: PMC7407512 DOI: 10.3390/cells9071622] [Citation(s) in RCA: 77] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 06/17/2020] [Accepted: 06/21/2020] [Indexed: 12/12/2022] Open
Abstract
Chronic wounds occur as a consequence of a prolonged inflammatory phase during the healing process, which precludes skin regeneration. Typical treatment for chronic wounds includes application of autografts, allografts collected from cadaver, and topical delivery of antioxidant, anti-inflammatory, and antibacterial agents. Nevertheless, the mentioned therapies are not sufficient for extensive or deep wounds. Moreover, application of allogeneic skin grafts carries high risk of rejection and treatment failure. Advanced therapies for chronic wounds involve application of bioengineered artificial skin substitutes to overcome graft rejection as well as topical delivery of mesenchymal stem cells to reduce inflammation and accelerate the healing process. This review focuses on the concept of skin tissue engineering, which is a modern approach to chronic wound treatment. The aim of the article is to summarize common therapies for chronic wounds and recent achievements in the development of bioengineered artificial skin constructs, including analysis of biomaterials and cells widely used for skin graft production. This review also presents attempts to reconstruct nerves, pigmentation, and skin appendages (hair follicles, sweat glands) using artificial skin grafts as well as recent trends in the engineering of biomaterials, aiming to produce nanocomposite skin substitutes (nanofilled polymer composites) with controlled antibacterial activity. Finally, the article describes the composition, advantages, and limitations of both newly developed and commercially available bioengineered skin substitutes.
Collapse
Affiliation(s)
- Agata Przekora
- Department of Biochemistry and Biotechnology, Medical University of Lublin, Chodzki 1 Street, 20-093 Lublin, Poland
| |
Collapse
|
9
|
Dill V, Mörgelin M. Biological dermal templates with native collagen scaffolds provide guiding ridges for invading cells and may promote structured dermal wound healing. Int Wound J 2020; 17:618-630. [PMID: 32045112 PMCID: PMC7949003 DOI: 10.1111/iwj.13314] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 12/20/2019] [Accepted: 01/10/2020] [Indexed: 01/14/2023] Open
Abstract
Dermal substitutes are of major importance in treating full thickness skin defects. They come in a variety of materials manufactured into various forms, such as films, hydrocolloids, hydrogels, sponges, membranes, and electrospun micro- and nanofibers. Bioactive dermal substitutes act in wound healing either by delivery of bioactive compounds or by being constructed from materials having endogenous activity. The healing success rate is highly determined by cellular and physiological processes at the host-biomaterial interface during crucial wound healing steps. Hence, it is important to design appropriate wound treatment strategies with the ability to work actively with tissues and cells to enhance healing. Therefore, in this study, we investigated biological dermal templates and their potential to stimulate natural cell adherence, guidance, and morphology. The most pronounced effect was observed in biomaterials with the highest content of native collagen networks. Cell attachment and proliferation were significantly enhanced on native collagen scaffolds. Cell morphology was more asymmetrical on such scaffolds, resembling native in vivo structures. Importantly, considerably lower expression of myofibroblast phenotype was observed on native collagen scaffolds. Our data suggest that this treatment strategy might be beneficial for the wound environment, with the potential to promote improved tissue regeneration and reduce abnormal scar formation.
Collapse
Affiliation(s)
- Veronika Dill
- Department of Clinical Sciences, Division of Infection MedicineLund UniversityLundSweden
| | - Matthias Mörgelin
- Department of Clinical Sciences, Division of Infection MedicineLund UniversityLundSweden
- Colzyx ABLundSweden
| |
Collapse
|