Acellular Dermal Matrices: Applications in Plastic Surgery

Chest Wall Reconstruction Using Biologic Mesh to Cover Soft Tissue Defects: A Narrative Review

INTRODUCTION

Chest wall reconstruction (CWR) is used in functional and/or aesthetic impairments of the thoracic wall following resection. This review summarizes literature for soft tissue coverage with biologic mesh in CWR and reports use of a porcine-derived acellular dermal matrix in CWR.

METHODS

A literature search identified studies that use biologic mesh in CWR, and expert opinion for the use of a porcine acellular dermal matrix and muscle flap reconstruction to repair large chest wall defects is provided.

RESULTS

CWR with biologic mesh is used to provide soft tissue coverage for various medical conditions, including oncologic tumor resections, trauma, congenital malformations, and in complex procedures, such as large thoracic defects, presence of infection, and prior radiation of the chest wall. Compared with synthetic mesh, fewer overall complications, infections, and mesh explantations have been reported with biologic mesh in retrospective studies of patients who underwent CWR with surgical mesh. However, there are limited published data on the use of biologic mesh for CWR, and there are no published randomized controlled trials comparing synthetic versus biologic mesh in CWR. A case study for the use of a porcine acellular dermal matrix and muscle flap reconstruction to repair large chest wall defects demonstrates a successful outcome with more than 6 y of follow-up.

CONCLUSIONS

Use of biological mesh in CWR is supported by literature and expert opinion. However, more robust clinical data on risks and benefits of types of mesh are needed to aid surgeons in selecting mesh.

Testosterone Promotes Nerve Tethering and Acellular Biomaterial Perineural Fibrosis in a Rat Wound Repair Model

Objective: Nerve scarring after traumatic or iatrogenic exposure can lead to impaired function and pain. Nerve-adjacent biomaterials promoting a regenerative tissue response may help reduce perineural fibrosis. Our prior work suggests that testosterone may promote fibrotic skin scarring, but it is unknown how testosterone alters nerve fibrosis or shifts the response to biomaterials. Approach: Sterilized Lewis rats received either testosterone cypionate (+T) or placebo (-T) biweekly. Fifteen days later, wounds were created over the sciatic nerve and covered with an acellular matrix (AM) or closed via primary closure (PC). At day 42, force gauge testing measured the force required to mobilize the nerve, and wound tissue was analyzed. Results: Nerve mobilization force was greater in +T versus -T wounds (p < 0.01). Nerves tore before gliding in 60% of +T versus 6% of -T rats. Epidermal gap (p < 0.01), scar width (p < 0.01), and cross-sectional scar tissue area (p = 0.02) were greater in +T versus -T rats. +T versus -T rats expressed less Col-3 (p = 0.02) and CD68 (p = 0.02). Nerve mobilization force trended nonsignificantly higher for PC versus AM wounds and for +T versus -T wounds within the AM cohort. Innovation: Testosterone increases nerve tethering in the wound healing milieu, altering repair and immune cell balances. Conclusion: Testosterone significantly increases the force required to mobilize nerves in wound beds and elevates histological markers of scarring, suggesting that testosterone-induced inflammation may increase perineural adhesion. Testosterone may reduce the potential anti-tethering protective effect of AM. Androgen receptor antagonism may represent a therapeutic target to reduce scar-related nerve morbidity.

Effect of Acellular Dermal Matrix on Long-Term Speech Outcomes in Primary Palatoplasty with Radical Intravelar Veloplasty

OBJECTIVE

This study investigates whether the use of acellular dermal matrix (ADM) affects the long-term speech outcomes in patients undergoing primary palatoplasty with radical intravelar veloplasty.

DESIGN

Retrospective cohort study.

SETTING

Tertiary university-affiliated hospital.

PARTICIPANTS

A consecutive cohort of 112 patients who underwent primary palatoplasty with radical intravelar veloplasty from August 2014 to March 2018 were included.

MAIN OUTCOME MEASURES

A 2 × 2 cm-sized ADM was incorporated as an interpositional graft between the oral and nasal lining at the soft-hard palate junction. The perceptual analysis of hypernasality and articulation was performed when the age of the patient reached at least 36 months. Cleft-related characteristics and surgical factors affecting the speech outcomes were investigated.

RESULTS

The ADM was applied in 57 patients with a mean follow-up of45.76 months (SD, 10.69), while no ADM was used in 55 patients with a mean follow-up of 48.43 months (SD, 14.98). Regarding the hypernasality outcome, 33.3% (19 of 57 patients) of the ADM group and 27.3% (15 of 55 patients) of the control group showed a greater than mild-to-moderate degree. The distribution of hypernasality and articulation grade showed no significant difference between the two groups. After controlling for potential risk factors that may affect the speech outcomes, the use of ADM showed no significant relationship with velopharyngeal insufficiency.

CONCLUSION

The use of ADM use in primary palatoplasty with radical intravelar veloplasty is not associated with the alteration of speech function in early childhood.

The Future of Microsurgery: Vascularized Composite Allotransplantation and Engineering Vascularized Tissue

Background

Microsurgical techniques have revolutionized the field of reconstructive surgery and are the mainstay for complex soft tissue reconstruction. However, their limitations have promoted the development of viable alternatives. This article seeks to explore technologies that have the potential of revolutionizing microsurgical reconstruction as it is currently known, reflect on current and future vascularized composite allotransplantation (VCA) practices, as well as describe the basic science within emerging technologies and their potential translational applications.

Methods

A literature review was performed of the technologies that may represent the future of microsurgery: vascularized tissue engineering (VCA) and flap-specific tissue engineering.

Results

VCA has shown great promise and has already been employed in the clinical setting (especially in face and limb transplantation). Immunosuppression, logistics, cost, and regulatory pathways remain barriers to overcome to make it freely available. Vascularized and flap-specific tissue engineering remain a laboratory reality but have the potential to supersede VCA. The capability of creating an off-the-shelf free flap matching the required tissue, size, and shape is a significant advantage. However, these technologies are still at the early stage and require significant advancement before they can be translated into the clinical setting.

Conclusion

VCA, vascularized tissue engineering, and flap-specific bioengineering represent possible avenues for the evolution of current microsurgical techniques. The next decade will elucidate which of these three strategies will evolve into a tangible translational option and hopefully bring a paradigm shift of reconstructive surgery.

Use of human acellular dermal matrix in rhinoplasty: a systematic review of the literature and meta-analysis

Alloplastic implants such as acellular dermal matrix (ADM) have been used for various aesthetic and reconstructive purposes since the 1990s. Rhinoplasty addresses both aesthetic and functional nasal impairments, often involving the adoption of grafting materials. Currently, autologous grafts, such as those using septal cartilage, are the gold standard. However, they pose the risk of donor site morbidity, technical challenges, and additional operative time. We review total complications, resorption/re-operation and success rates associated with the use of ADM in rhinoplasty. A literature search was conducted on PubMed, Prospero, DynaMed, DARE, EMBASE and COCHRANE databases. (Registry: CRD42023428019). A total of 462 patients from 15 studies were included, the mean (range) age was 30 (12-65) years, with a female-to-male ratio of 2:1. The most common indications for ADM were for cosmetic (35%, n = 163) and functional rhinoplasty (5%, n = 24). The most common type of ADM used was Alloderm (46%, n = 211). The most common indication for ADM was dorsal nasal augmentation (68%, n = 314). Eleven patients (2%) required revision surgery. The pooled success of ADM in rhinoplasty was 96% (95% CI 94 to 99, p = 0.93; I2 = 0%). 2% of patients developed postoperative complications and no statistically significant difference was seen in complications or success rates when comparing the different types of ADM. ADM in rhinoplasty was associated with fewer complications and re-operation rates, and similar if not less resorption compared to traditional autografts. Therefore, it can be a viable alternative to current autologous grafts in rhinoplasty surgery.

National Trends in Acellular Dermal Matrix Utilization in Immediate Breast Reconstruction

BACKGROUND

Implant-based reconstruction is the most common method of immediate breast reconstruction in the United States, with acellular dermal matrices (ADMs) playing a significant role in implant support and coverage. This study evaluated recent national trends in ADM use in immediate breast reconstruction and assessed patient characteristics and 30-day complication rates.

METHODS

The authors queried the American College of Surgeons National Surgical Quality Improvement Program database for all patients undergoing immediate breast reconstruction from 2015 to 2020. Primary outcomes were major surgical and medical complications, as well as ADM use per year. Subset analysis was performed to compare patients undergoing immediate breast reconstruction with ADM in 2015 versus 2020.

RESULTS

In 39,800 immediate breast reconstructions, ADMs were used in 55.5% of cases ( n = 22,087). ADM usage increased annually from 2015 through 2020. Direct-to-implant reconstruction was significantly associated with ADM use ( P < 0.001). Compared with the no-ADM cohort, there was a significantly increased rate of return to the operating room for any reason ( P < 0.001). When comparing the 2015 and 2020 ADM cohorts, the 2020 ADM cohort had a significantly higher rate of superficial infections. Obesity, smoking history, and insulin-dependent diabetes were independent risk factors for superficial wounds in patients receiving ADM.

CONCLUSIONS

ADM use in immediate breast reconstruction increased significantly from 2015 to 2020, likely reflecting national trends in increasing direct-to-implant and prepectoral breast reconstruction. Obesity, smoking history, and insulin-dependent diabetes were independent risk factors for superficial wound infections in the ADM cohort. Patients with ADM had a slight increased incidence of return to the operating room.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

Efficacy of Acellular Dermal Matrix Type in Treatment of Capsular Contracture in Breast Augmentation: A Systematic Review and Meta-Analysis

BACKGROUND

Capsular contracture is a known complication of breast augmentation and is among the top reasons for revisional breast augmentation procedures. The use of acellular dermal matrix (ADM) has been shown to reduce the rate of capsular contracture in breast reconstruction and augmentation, theorizing that it acts as a protective barrier between the implant capsule and inflammatory process responsible for capsular contracture. The role of ADM in treatment of capsular contracture has been investigated in numerous studies, with a variety of ADMs.

OBJECTIVES

The aim of this study was to perform a systematic review of existing literature on the use of ADM for treatment of capsular contracture in aesthetic breast augmentation patients to investigate differences in efficacy of ADM types.

METHODS

The PubMed, Embase, and CINAHL databases were systematically reviewed for articles pertaining to capsular contracture, acellular dermal matrices, and breast augmentation. Number of patients, type of ADM, Baker grade, follow-up time, complication rate, and capsular contracture rate were recorded from identified articles. Data was pooled from studies to calculate a capsular contracture rate for each ADM type, with a chi-squared test performed for analysis. Identified studies with a comparative group were included in a meta-analysis utilizing risk ratio (RR) to assess the efficacy of ADM.

RESULTS

Nine articles including ADM for treatment of capsular contracture in breast augmentation met criteria for inclusion, with a total of 481 breasts. Strattice was the most commonly utilized ADM (n = 391), followed by AlloDerm (n = 57). There was a statistically significant difference in efficacy of ADM among the studied ADM types (P < .001). AlloDerm, FlexHD, and DermaMatrix had the lowest capsular contracture rates (0%). NeoForm and SurgiMend had the highest capsular contracture rates (each 25%, but with n = 4 and n = 8, respectively). Strattice had a capsular contracture rate of 1.53% in the pooled data, and meta-analysis showed that Strattice reduced the risk of capsular contracture (RR 0.14 [95% CI 0.06, 0.31]) compared with conventional treatment.

CONCLUSIONS

Acellular dermal matrices appear to be effective at treating capsular contracture after breast augmentation while maintaining a low complication rate. Overall capsular contracture rates are low with the use of ADM. There is a statistically significant difference in efficacy among ADM types. Meta-analysis shows that Strattice is effective at reducing the risk of capsular contracture in breast augmentation patients when compared to conventional treatment. Future research, especially in the form of randomized controlled trials, is needed to further investigate the efficacy of various ADMs in the treatment of capsular contracture.

LEVEL OF EVIDENCE: 4

Tissue adjuncts in primary cleft palate reconstruction: A systematic review

BACKGROUND

Tissue adjunct is non-palatal tissue used to manage tension at the defect site by providing additional coverage. This review aimed to compare outcomes of various adjuncts employed in primary palatoplasty.

METHODS

A literature search was conducted of MEDLINE, EMBASE, and Cochrane Library with keywords cleft palate, palatoplasty, surgical flaps, and allografts. Data extracted included demographics, cleft severity, primary/adjunctive techniques, outcomes, and follow-up periods. Logistic regression analyses and chi-squared tests were performed to investigate associations among variables.

RESULTS

A total of 1332 patients (aged 3 months-5 years) with follow-up of 1 month to 21 years were included. Cleft severity included submucous cleft (1.7%), Veau I/II (33.3%), Veau III (46.3%), and Veau IV (15.1%). Most reported techniques were Furlow (52%) and intravelar veloplasty (14.3%) for soft palate, Bardach (27.2%), and V-Y Pushback (11.1%) for hard palate. Buccal myomucosal flap (BMMF) was performed in 45.4% of cases, followed by buccal fat pad flap/graft (BFP) in 40.8% and acellular dermal matrix (ADM) in 14%. Severe clefts (Veau III/IV) were repaired more frequently with BMMF compared with ADM (p = 0.003) and BFP (p = 0.01). Oronasal fistula occurred in 3.1% of patients, and velopharyngeal insufficiency (VPI) in 4%, both associated with Veau IV (fistula: p = 0.002, VPI: p = 0.0002). No significant differences were found in fistula (p = 0.79) or VPI (p = 0.14) rates between adjuncts. In severe clefts (Veau III/IV), ADM was associated with fistula formation (p = 0.03).

CONCLUSIONS

Adjuncts in primary palatoplasty may mitigate unfavorable outcomes associated with severe clefts. BMMF is superior, given its inherent tissue properties, whereas BFP is effective in reducing fistula formation.

A Novel Technique for the Permanent Restoration of Pretarsal Fullness of the Lower Eyelids

Background

The presence of static pretarsal fullness is an essential aesthetic feature in Asian culture that endows a youthful and smiling attractive look to the face. The restoration of static pretarsal fullness using acellular dermal matrix implantation or autogenous fascia grafting can result in suboptimal outcomes because of the unpredictable resorption rate. Therefore, a new method is required to achieve a stable, long-term, and natural result.

Objectives

The authors describe a new method to address the deficiency of static pretarsal fullness.

Methods

Sixteen Asian female patients with a deficiency of static pretarsal fullness who received implantation of a bundle of implants consisting of segmented Gore-Tex sutures (W. L. Gore & Associates, Inc., Flagstaff, AZ) overlaid with a mastoid fascia graft were retrospectively evaluated in a 15-year period from July 2007 to July 2022. Patients were assigned to categories based on the pretarsal fullness contour.

Results

Sixteen female patients aged between 22 and 40 years (mean age: 30.375 ± 7.580) underwent the procedure. The mean follow-up period was 52.25 (±33.757) months (range, 6-120 months). Fourteen patients were considered to have satisfactory results. However, 2 patients encountered complications, one of which was a case of infection that was successfully managed through revision and led to an excellent outcome. The other patient experienced malposition, which was also corrected successfully through revision.

Conclusions

Our new method for creating pretarsal fullness using Gore-Tex suture implants overlaid with a retroauricular mastoid fascia graft is effective in achieving aesthetic static pretarsal fullness and obtaining excellent permanent cosmetic outcomes.

Level of Evidence 4

Acellular dermal matrix in reconstructive surgery: Applications, benefits, and cost

Modern tissue engineering has made substantial advancements that have revolutionized plastic surgery. Acellular dermal matrix (ADM) is an example that has gained considerable attention recently. ADM can be made from humans, bovines, or porcine tissues. ADM acts as a scaffold that incorporates into the recipient tissue. It is gradually infiltrated by fibroblasts and vascularized. Fortunately, many techniques have been used to remove cellular and antigenic components from ADM to minimize immune system rejection. ADM is made of collagen, fibronectin, elastin, laminin, glycosaminoglycans, and hyaluronic acid. It is used in critical wounds (e.g., diabetic wounds) to protect soft tissue and accelerate wound healing. It is also used in implant-based breast reconstruction surgery to improve aesthetic outcomes and reduce capsule contracture risk. ADM has also gained attention in abdominal and chest wall defects. Some studies have shown that ADM is associated with less erosion and infection in abdominal hernias than synthetic meshes. However, its higher cost prevents it from being commonly used in hernia repair. Also, using ADM in tendon repair (e.g., Achilles tendon) has been associated with increased stability and reduced rejection rate. Despite its advantages, ADM might result in complications such as hematoma, seroma, necrosis, and infection. Moreover, ADM is expensive, making it an unsuitable option for many patients. Finally, the literature on ADM is insufficient, and more research on the results of ADM usage in surgeries is needed. This article aims to review the literature regarding the application, Benefits, and costs of ADM in reconstructive surgery.

Acellular dermal matrix for one-stage treatment of lower extremity full-thickness skin defect: a case series

BACKGROUND

Self-repair of lower limb wounds has always been one of the research hotspots. Flaps and skin graft are the preferred treatment for lower extremity wound reconstruction. However, these treatments have many disadvantages, such as secondary damage, poor healing quality. In recent years, the use of acellular dermal matrix has emerged as an alternative treatment option for extremity ulcers.

METHODS

This study aimed to explore whether acellular dermal matrix can be used as a single treatment to promote wound healing. 7 patients with lower extremities cutaneous deficiency exposing bone or tendon, were covered by Pelnac, which was an acellular dermal matrix product approved by China Food and Drug Administration. All the wound was treated by Pelnac without flaps and skin graft. The external dressing was changed every 10 days.

RESULTS

After a maximum of 20 weeks, all the wounds were completely healed. During the 12 months follow-up period none of the patients developed skin wear on the treatment area. All patients maintained their postoperative ambulatory ability. All patients were satisfied with the appearance and feeling after wound healing.

CONCLUSION

These findings may mean acellular dermal matrix is a novel method offering opportunity for treatment of lower extremities cutaneous deficiency exposing bone or tendon. It also has the potential to close wounds of all uninfected, non-ischemic, full-thickness cutaneous deficiency.

Frozen bean curd-inspired Xenogeneic acellular dermal matrix with triple pretreatment approach of freeze-thaw, laser drilling and ADSCs pre-culture for promoting early vascularization and integration

Xenogeneic acellular dermal matrix (ADM) is widely used in clinical practice given its good biocompatibility and biomechanical properties. Yet, its dense structure remains a hindrance. Incorporation of laser drilling and pre-culture with Adipose-derived stem cells (ADSCs) have been attempted to promote early vascularization and integration, but the results were not ideal. Inspired by the manufacturing procedure of frozen bean curd, we proposed a freeze-thaw treatment to enhance the porosity of ADM. We found that the ADM treated with -80°C3R+-30°C3R had the largest disorder of stratified plane arrangement (deviation angle 28.6%) and the largest porosity (96%), making it an optimal approach. Human umbilical vein endothelial cells on freeze-thaw treated ADM demonstrated increased expression in Tie-2 and CD105 genes, proliferation, and tube formation in vitro compared with those on ADM. Combining freeze-thaw with laser drilling and pre-culture with ADSCs, such tri-treatment improved the gene expression of pro-angiogenic factors including IGF-1, EGF, and VEGF, promoted tube formation, increased cell infiltration, and accelerated vascularization soon after implantation. Overall, freeze-thaw is an effective method for optimizing the internal structure of ADM, and tri-treatments may yield clinical significance by promoting early cell infiltration, vascularization, and integration with surrounding tissues.

Clinical observation on healing of tarsal plate defect after reconstruction with xenogeneic acellular dermal matrix

Objective

To evaluate the safety, function, and cosmetic outcome of eyelid reconstruction using a xenogeneic acellular dermal matrix as a tarsal plate replacement in the repair of 50 to 100% eyelid defects following excision of large malignant tumours.

Methods

A retrospective, non-comparative, interventional study of 21 eyes was performed over 26 months. Fourteen patients were female and seven were male. In all cases, a xenogeneic acellular dermal matrix was used for total or subtotal replacement of the tarsal plate. The central vertical height of the palpebral fissure was measured immediately after eyelid margin incision and at 1 and 6 months postoperatively.

Results

In patients who underwent surgery, the mean palpebral fissure height (PFH) was not significantly different between immediately and 1 month after incision (8.10 ± 0.562 mm vs 8.17 ± 0.577 mm, respectively; P > 0.05). After 6 months, PFH was 8.26 ± 0.605 mm, which was significantly different from that immediately after incision (P < 0.05). After 6 months of follow-up, all patients had a good aesthetic appearance after eyelid reconstruction, with no obvious graft dissolution or rejection, normal eyelid activity, and normal opening, closing, and lifting function. None of the 21 patients experienced tumour recurrence during postoperative follow-up.

Conclusion

The xenogeneic acellular dermal matrix was a successful tarsal plate replacement. This material is readily available, and a second surgical site is avoided. The xenogeneic acellular dermal matrix is considered a promising alternative material for tarsal replacement in future generations.

Anti-calcification potential of collagen based biological patch crosslinked by epoxidized polysaccharide

Biological patch is a kind of tissue substitute material derived from natural polymer materials for the repair of human soft tissue defects. The serious calcification of biological patch after implantation is one of the reasons for the decline and failure of patch. In previous studies, we synthesized a new biomaterial crosslinker epoxidized chitosan quaternary ammonium salt (EHTCC) and used it for the crosslinking of porcine acellular dermal matrix (pADM). The prepared EHTCC-pADM had good mechanical properties, biocompatibility and healing promoting properties. In order to broaden its application scenarios, the related properties of EHTCC-pADM as implant patch were further explored in this study. The results of X-ray diffraction (XRD) measurements showed that the structure of pADM did not change much before and after the crosslinking of EHTCC, which was conducive to the maintenance of the excellent biological properties of pADM. According to the enzymatic degradation resistance test in vitro, the resistance of EHTCC-pADM to type I collagenase degradation was significantly improved compared with non -crosslinked pADM. And with the increase of the amount of EHTCC, its degradation resistance was stronger. The experimental results showed that EHTCC-pADM can well support the growth of L929 fibroblasts and has good anti-calcification properties in vitro and in vivo.

[Clinical effects of in situ perforation of preserved split scar matrix in combination with scalp transplantation and vacuum sealing drainage in the treatment of hypertrophic scar in non-functional sites after burns]

Objective: To investigate the clinical effects of in situ perforation of preserved split scar matrix in combination with scalp transplantation and vacuum sealing drainage in the treatment of hypertrophic scar in non-functional sites after burns. Methods: A retrospective observational study was used. From June 2017 to June 2019, 33 patients (24 males and 9 females, aged 8-50 years) who met the inclusion criteria with hypertrophic scars in non-functional sites outside the face after burns were treated in General Hospital of TISCO (the Sixth Hospital of Shanxi Medical University). All patients underwent scalp transplantation after perforation of retained split scar matrix in situ (with scar thinning area of 90-500 cm2), and then the vacuum sealing drainage was performed. The hematoma and infection of wounds were observed on the 7th day after operation. At the same time, the survival rate of skin grafting was observed and calculated. The flatness and thickness of the scar in the operative area were observed in 12 months after operation, and the itching and pain of the patients were recorded. Vancouver Scar Scale was used to score the scar of patients before operation and at 3, 6 and 12 months after operation. The healing time and hair growth of donor site were observed. Data were statistically analyzed with repeated analysis of variance, paired sample t test and bonferroni correction. Results: On the 7th day after operation, local subcutaneous hematoma appeared in the wound of 2 patients, which healed after dressing change; no infection occurred. On the 7th day after operation, the survival rate of skin grafting of patients was 94.6%-99.0%(96.8±1.2)%. Scar flatness was well, the thickness of scar was not significantly higher than that of normal skin in 12 months after operation, and the symptoms of itching pain of patients disappeared or significantly relieved. Vancouver Scar Scale scores of patients before operation and at 3, 6, and 12 months after operation were 12.1±2.8, 8.5±1.5, 7.6±1.6, 6.7±1.3, respectively, and the scores of 3, 6, and 12 months after operation were all significantly lower than that before operation (with t values of 4.48, 4.06, and 3.97, respectively, P<0.01). All the donor sites of the head healed well in 4-7 days after operation. By 3-6 months after operation, all patients had good hair growth in the donor site and achieved no scar healing. Conclusions: The treatment of hypertrophic scar in non-functional sites outside the face after burns by in situ perforation of preserved split scar matrix in combination with scalp transplantation and vacuum sealing drainage can effectively improve the appearance of hypertrophic scar in non-functional areas after burn and reduce its degree of hyperplasia, with scar-free donor site healing.

Technical Refinements with the Use of Biologic Healing Agents

Soft tissue defects resulting from trauma, vascular disease, burns, and postoncologic resections require reconstructive surgery for appropriate wound coverage and support. Dermal substitutes have been applied to a vast array of reconstructive settings across nearly all anatomical areas with demonstrable success. However, they require meticulous handling and operative technical expertise to optimize management of these soft tissue defects. In this review, we will address three dermal substitutes, their operative techniques, and their surgical applications.

Clinical applications of acellular dermal matrices: A review

INTRODUCTION

The extracellular matrix (ECM) plays an integral role in wound healing. It provides both structure and growth factors that allow for the organised cell proliferation. Large or complex tissue defects may compromise host ECM, creating an environment that is unfavourable for the recovery of anatomical function and appearance. Acellular dermal matrices (ADMs) have been developed from a variety of sources, including human (HADM), porcine (PADM) and bovine (BADM), with multiple different processing protocols. The objective of this report is to provide an overview of current literature assessing the clinical utility of ADMs across a broad spectrum of applications.

METHODS

PubMed, MEDLINE, EMBASE, Scopus, Cochrane and Web of Science were searched using keywords 'acellular dermal matrix', 'acellular dermal matrices' and brand names for commercially available ADMs. Our search was limited to English language articles published from 1999 to 2020 and focused on clinical data.

RESULTS

A total of 2443 records underwent screening. After removing non-clinical studies and correspondence, 222 were assessed for eligibility. Of these, 170 were included in our synthesis of the literature. While the earliest ADMs were used in severe burn injuries, usage has expanded to a number of surgical subspecialties and procedures, including orthopaedic surgery (e.g. tendon and ligament reconstructions), otolaryngology, oral surgery (e.g. treating gingival recession), abdominal wall surgery (e.g. hernia repair), plastic surgery (e.g. breast reconstruction and penile augmentation), and chronic wounds (e.g. diabetic ulcers).

CONCLUSION

Our understanding of ADM's clinical utility continues to evolve. More research is needed to determine which ADM has the best outcomes for each clinical scenario.

LAY SUMMARY

Large or complex wounds present unique reconstructive and healing challenges. In normal healing, the extracellular matrix (ECM) provides both structural and growth factors that allow tissue to regenerate in an organised fashion to close the wound. In difficult or large soft-tissue defects, however, the ECM is often compromised. Acellular dermal matrix (ADM) products have been developed to mimic the benefits of host ECM, allowing for improved outcomes in a variety of clinical scenarios. This review summarises the current clinical evidence regarding commercially available ADMs in a wide variety of clinical contexts.

DUROPLASTY: REVIEW OF MATERIALS AND TECHNIQUES

Introduction. Degenerative disc disease is one of the most common diseases of the musculoskeletal system, characterized by dystrophic changes in the intervertebral disc and vertebral bodies adjacent to it. The main symptoms of this disease are pain and sensory and motor disorders, which, according to various authors, occur in 50–80% of adults. The main objective of the study was to find and implement the optimal set of treatment measures for degenerative disc disease depending on the age of a patient. Materials and Methods. The medical records of inpatients who were treated in the Neurosurgical Department of the Sumy Regional Clinical Hospital in 2019–2020 were analyzed. The course of treatment of 93 patients (61 men and 32 women) was studied. The patients were divided into groups according to their age: young age (under 25) – 13 men and 8 women; middle age (under 60) – 24 men and 19 women; and elderly age (over 60 years) – 18 men and 11 women. The combined use of pathogenetically justified physiotherapeutic measures in the treatment complex is gaining more and more interest. Their distinctive features are physiologic nature, absence of allergic manifestations, the ability to influence most of the pathogenesis of the disease, and the organic combination with other therapeutic factors. Unfortunately, there is an increase in the incidence of temporary incapacitation and progressive course, which often leads to disability and significant financial costs associated with expensive modern methods of diagnosis, treatment, and further provision of employment to patients. The results of our study show that complex treatment including pathogenetic drug therapy, complex paravertebral block, therapeutic physical exercise, and physiotherapy treatment methods provides adequate recovery of spinal function regardless of dystrophic and degenerative changes severity and patient's age. Treatment of degenerative disc disease should be comprehensive and directed at the various symptoms and links of the pathological process.

Resorbable Synthetic Ventral Hernia Repair in Contaminated Fields: Outcomes with Poly-4-Hydroxybutyrate Mesh

BACKGROUND

Hernia repair in the setting of contamination poses unique challenges, including complications such as recurrence and mesh infection. The ideal contaminated hernia repair including type of mesh use remains controversial. Poly-4-hydroxybutyrate is a biosynthetic scaffold for soft-tissue reinforcement and hernia repair and is potentially useful in contaminated hernia repair. The authors aim to describe postoperative outcomes, recurrence, and patient-reported outcomes after contaminated hernia repair with poly-4-hydroxybutyrate.

METHODS

Adult patients (≥18 years) undergoing a contaminated hernia repair with poly-4-hydroxybutyrate (Phasix) performed by a single plastic surgeon between January of 2015 and May of 2020 were identified. Patients with a ventral hernia defect and a Centers for Disease Control and Prevention wound class of II, III, or IV were included. Primary outcomes included recurrence, surgical-site infection, surgical-site occurrences, and surgical-site infection/occurrences requiring procedural interventions. As a secondary outcome, the authors assessed patient-reported outcomes as defined by the Abdominal Hernia-Q and Hernia-Related Quality of Life Survey.

RESULTS

Sixty patients were included with a median age of 52.5 and body mass index of 31 kg/m2. Median defect size was 300 cm2. Twenty-eight patients (46.7 percent) experienced a complication. The most common complications were surgical-site occurrence [n = 20 (33.3 percent)] and surgical-site infection [n = 10 (16.7 percent)]. Median follow-up was 24.2 months, with a recurrence rate of 8.3 percent (n = 4). Overall patient-reported outcomes improved postoperatively, and improvement was not affected by the presence of a complication.

CONCLUSIONS

Poly-4-hydroxybutyrateuse in contaminated hernia repair shows promising results with an acceptable safety profile. Although complications are frequent in this complex cohort, patient-reported outcomes improvement was significant even in patients with complications.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Prevention and management of oronasal fistulas

PURPOSE OF REVIEW

The aim of this article is to present the current opinion on the prevention and management of oronasal fistulas in cleft palate patients.

RECENT FINDINGS

Though cleft palate repair has seen numerous modifications and improvements, oronasal fistulas remain one of the most common complications of palatoplasty. There are various techniques available for preventing and managing this complication.

SUMMARY

Oronasal fistulas can be minimized by employing proper principles for palatoplasty. Once a fistula occurs, the repair technique should be appropriate for the fistula type. Oronasal fistula classifications, various repair techniques, tissue adjuncts, and biomaterials used in both the primary palate repair and oronasal fistula repair are discussed in this review.

First use of Braxon® acellular dermal matrix for complex revision aesthetic breast surgery-revision augmentation mastopexy

Acellular dermal matrices (ADMs) have ushered in a paradigm shift in prosthetic breast reconstruction; however, there has hitherto been no reported use of Braxon® ADM in aesthetic breast surgery. Here, we describe the case of a 42-year-old woman who presented for revision of her bilateral aesthetic augmentation-mastopexy following multiple revision surgeries. The predominant concerns were persistent pain, implant malposition and a wide intermammary distance. Her predicament was worsened by inability to tolerate monopolar diathermy owing to a spinal stimulator-the least invasive operation was sought and Braxon® ADM met this criterion. The procedure was a success, and she remains symptom-free, with soft breasts and stable implant positions. Braxon® ADM, with its preformed shape, total implant-wrapping design and easy suture fixation, lends itself to easy use in cosmetic breast surgery. Its role in cosmetic breast surgery has yet to be established, but this case marks the beginning of this endeavor.

Prosthetic meshes for hernia repair: State of art, classification, biomaterials, antimicrobial approaches, and fabrication methods

Worldwide, hernia repair represents one of the most frequent surgical procedures encompassing a global market valued at several billion dollars. This type of surgery usually requires the implantation of a mesh that needs the appropriate chemical, physical and biological properties for the type of repair. This review thus presents a description of the types of hernias, current hernia repair methods, and the state of the art of prosthetic meshes for hernia repair providing the most important meshes used in clinical practice by surgeons working in this area classified according to their biological or chemical nature, morphology and whether bioabsorbable or not. We emphasise the importance of surgical site infection in herniatology, how to deal with this microbial problem, and we go further into the future research lines on the production of advanced antimicrobial meshes to improve hernia repair and prevent microbial infections, including multidrug-resistant strains. A great deal of progress has been made in this biomedical field in the last decade. However, we are still far from an ideal antimicrobial mesh that can also provide excellent integration to the abdominal wall, mechanical performance, low visceral adhesion and minimal inflammatory or foreign body reactions, among many other problems.

Early Clinical and Patient-Reported Outcomes of a New Hybrid Mesh for Incisional Hernia Repair

INTRODUCTION

Consensus on the safety and efficacy of various types of mesh in reconstructing the abdomen has yet to be reached. Hybrid mesh products have been designed to address the need for a cost-effective mesh leveraging the tensile strength of a synthetic mesh while minimizing the prosthetic footprint within the abdominal wall through resorbable materials. In this study we evaluate early clinical outcomes and health related quality of life (HR-QOL) of a new Hybrid mesh, Synecor^TM, for Ventral Hernia Repair (VHR).

METHODS

Adult (>18 y old) patients undergoing VHR with Synecor^TM mesh by a single surgeon between 2017-2019 with ≥1-y follow-up were identified. We analyzed a composite of postoperative outcomes as well as the incidence of hernia recurrence, readmissions, mortality, and HR-QOL.

RESULTS

Thirty-five patients were included in our analysis with a median follow up of 2.1 y. The median age and BMI were 54.1 y and 33.2 kg/m², respectively. The rate of surgical site occurrences was 37.1%, with only one patient (2.9%) requiring surgical intervention. No patients developed a hernia recurrence. Overall HR-QOL improved significantly (preoperative mean 2.5 [SD 0.7] versus postoperative 3.4 [0.4]; P< 0.01), particularly in regards to pain, functional status, self-esteem and body image (all P < 0.05).

CONCLUSIONS

Abdominal reinforcement with Synecor^TM mesh at the time of VHR results in promising early recurrence rates, an acceptable safety risk profile, and an improvement in overall HR-QOL.

Onlay Poly-4-Hydroxybutyrate (P4HB) Mesh for Complex Hernia: Early Clinical and Patient Reported Outcomes

BACKGROUND

While mesh re-enforcement and advanced surgical techniques are cornerstones of complex ventral hernia repair (CVHR), the risk of complications and recurrence is common. We aim to evaluate the efficacy, safety, and patient reported outcomes (PROs) of patients undergoing CVHR with onlay Poly-4-hydroxybutyrate (P4HB).

METHODS

Adult (>18 y old) patients undergoing VHR with P4HB (Phasix) in the onlay plane by a single surgeon from 01/2015 to 05/2020 were reviewed. VHR was considered complex if patients had significant co-morbidities, large abdominal wall defects, a history of extensive abdominal surgery, and/or concurrent intra-abdominal pathology. A composite of postoperative outcomes including surgical site occurrences (SSO), surgical site infection (SSI), and surgical site occurrences requiring procedural intervention (SSOpi), as well as PROs as defined by the Abdominal Hernia-Q (AHQ), were analyzed.

RESULTS

A total of 51 patients were included with average age and body mass index of 56.4 and 29.9 kg/m². Median follow up was 20 mo with a hernia recurrence rate of 5.9% (n = 3). 21 patients had an SSO (41.2%), 8 had an SSI (15.7%), and 6 had an SSOpi (11.8%). There was an association with Ventral Hernia Working Group ≥ 2 and development of SSO. There was a significant improvement in overall PROs (P < 0.0001) with no difference in those patients with and without complications (P > 0.05).

CONCLUSION

For hernia patients with large defects and complex intra-abdominal pathology, a safe and effective repair is difficult. The use of onlay P4HB was associated with acceptable postoperative outcomes and recurrence rate.

Application of acellular dermal matrix to reconstruct the defects after hypopharyngeal carcinoma resection

PURPOSE

Reconstruction of the defects and recovery of the laryngopharyngeal function after resection of hypopharyngeal carcinoma are crucial for patients to promote the rate of survival and the quality of life. We launched this study to explore the advantages and limitations of acellular dermal matrix applied in the reconstruction of the defects after hypopharyngeal carcinoma surgery.

MATERIALS AND METHODS

Collected the clinical and pathological data of patients with hypopharyngeal carcinoma, divided them into 2 groups according to the repair materials used (pectoralis major myocutaneous flap or acellular dermal matrix). The clinical data and postoperative complications were analyzed and compared.

RESULTS

No matter whether the pectoralis major myocutaneous flap or acellular dermal matrix was used to repair hypopharyngeal cancer resection defects, the postoperative complications, especially the pharyngeal fistula rate, were not significantly different. The postoperative drainage volume of patients with acellular dermal matrix was less than that of patients with pectoralis major myocutaneous flap.

CONCLUSIONS

Acellular dermal matrix is a safe and effective biomedical material for hypopharyngeal cancer operation defects repair and pharyngeal function reconstruction, which can simplify the operation process, reduce the postoperative drainage volume, and decrease the risk of wound infection or pharyngeal fistula.

Use of a Bioabsorbable Implant-Acellular Dermal Matrix Construct to Facilitate Oncoplastic Breast-conserving Surgery

Supplemental Digital Content is available in the text.

Deformity after partial mastectomy for breast cancer is not uncommon. The immediate replacement of breast volume by a bioabsorbable implant has been shown to facilitate tissue ingrowth, maintain breast contour, reduce scarring and fibrosis, and preserve cosmesis. Soft tissue coverage is critical to minimize palpability and to prevent infection and extrusion of this device, especially after radiotherapy. This coverage is often not possible after significant oncological resection or in leaner patients. Here, we describe the use of a bioabsorbable implant-acellular dermal matrix construct in patients with insufficient soft tissue coverage after wide local excision.

The Role of Dermal Regenerative Templates in Complex Lower Extremity Wounds

Dermal regenerative templates (DRTs) provide an option for management of complex lower extremity wounds. DRTs may be used to achieve definitive wound closure by serving as a scaffold for local tissue infiltration. Healing with a DRT interface leads to histologic and structural properties similar to native skin. DRTs can be applied over deep wounds with exposed critical structures that may have required a local or free flap. DRTs are a valuable option for lower extremity limb reconstruction.