The Role of Dermal Regeneration Templates in Severe Soft Tissue Defects. Management of “Critical Zones”. Case Series
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Published:
Apr 14, 2021
Keywords:
Dermal substitute, acelullar dermal matrix, soft tissue coverage, reconstructive surgery
Main Article Content
Abstract
Introduction: The aim of this study is to report outcomes and complications in a series of patients suffering soft tissue defects in critical areas treated using an acellular dermal matrix.
Materials and Method: A retrospective review of patients with soft tissue coverage deficits in critical areas treated with acellular dermal matrix in our center over a five-year period was conducted. The preoperative variables analyzed were: age, sex, comorbidities, number of previous surgeries, size and characteristics of the critical area and cause of the coverage defect. The intraoperative variables analyzed were: size of the dermal substitute used, surgical time and complications. The postoperative variables were: incorporation of the dermal substitute, time elapsed until the placement of the skin graft, and postoperative complications.
Results: The initial diagnoses were tumor (3 patients), acute trauma (3 patients) and sequelae of compartment syndrome (2 patients). The soft tissue defect was located in the leg (3 cases), in the hand (2 cases), in the thigh (1 case), in the forearm (1 case) and in the foot (1 case). In 5 cases the critical zone was characterized by tendon exposure with loss of peritenon; in one case bone exposure and loss of periosteum; in one case exposure of nerve graft and in one case exposure of osteosynthesis material. Three complications were recorded.
Conclusion: Dermal substitutes are characterized by their versatility. This technique can provide protection in situations of bone exposure, in addition to providing a gliding plane in case of tendon exposure. In situations of failure or impossibility of performing a biological reconstruction, dermal substitutes havea role within reconstructive options.
Level of Evidence: IV
Materials and Method: A retrospective review of patients with soft tissue coverage deficits in critical areas treated with acellular dermal matrix in our center over a five-year period was conducted. The preoperative variables analyzed were: age, sex, comorbidities, number of previous surgeries, size and characteristics of the critical area and cause of the coverage defect. The intraoperative variables analyzed were: size of the dermal substitute used, surgical time and complications. The postoperative variables were: incorporation of the dermal substitute, time elapsed until the placement of the skin graft, and postoperative complications.
Results: The initial diagnoses were tumor (3 patients), acute trauma (3 patients) and sequelae of compartment syndrome (2 patients). The soft tissue defect was located in the leg (3 cases), in the hand (2 cases), in the thigh (1 case), in the forearm (1 case) and in the foot (1 case). In 5 cases the critical zone was characterized by tendon exposure with loss of peritenon; in one case bone exposure and loss of periosteum; in one case exposure of nerve graft and in one case exposure of osteosynthesis material. Three complications were recorded.
Conclusion: Dermal substitutes are characterized by their versatility. This technique can provide protection in situations of bone exposure, in addition to providing a gliding plane in case of tendon exposure. In situations of failure or impossibility of performing a biological reconstruction, dermal substitutes havea role within reconstructive options.
Level of Evidence: IV
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How to Cite
Abrego, M. O., Sánchez Saba, J., Zaidenberg, E. E., Rellán, I., Donndorff, A., Gallucci, G., De Carli, P., & Boretto, J. G. (2021). The Role of Dermal Regeneration Templates in Severe Soft Tissue Defects. Management of “Critical Zones”. Case Series. Revista De La Asociación Argentina De Ortopedia Y Traumatología, 86(2), 167-174. https://doi.org/10.15417/issn.1852-7434.2021.86.2.1117
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Clinical Research
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References
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template: clinical and histologic study. Plast Reconstr Surg 2001;108: 93-103. https://doi.org/10.1097/00006534-200107000-00015
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4. Shores JT, Hiersche M, Gabriel A, Gupta S. Tendon coverage using an artificial skin substitute. J Plast Reconstr
Aesthet Surg 2012;65:1544-550. https://doi.org/10.1016/j.bjps.2012.05.021
5. Weigert R, Choughri H, Casoli V. Management of severe hand wounds with Integra® dermal regeneration template. J Hand Surg Eur 2011;36:185-93. https://doi.org/10.1177/1753193410387329
6. Dai C, Shih S, Khachemoune A. Skin substitutes for acute and chronic wound healing: an updated review. J
Dermatolog Treat 2020;31(6):639-48. https://doi.org/10.1080/09546634.2018.1530443
7. Leclère FM, Desnouveaux E, Choughri H, Casoli V. Acellular dermal matrix: New applications for free flap pedicle coverage - A prospective study in 10 patients. J Cosmet Laser Ther 2018;20:200-4.
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degloving soft-tissue injuries. J Emerg Trauma Shock 2014;7:228-32. https://doi.org/10.4103/0974-2700.136870
9. De Angelis B, Orlandi F, Fernandes Lopes Morais D’Autilio M, Scioli MG, Orlandi A, Cervelli V, et al. Long-term
follow-up comparison of two different bi-layer dermal substitutes in tissue regeneration: Clinical outcomes and
histological findings. Int Wound J 2018;15: 695-706. https://doi.org/10.1111/iwj.12912
10. Debels H, Hamdi M, Abberton K, Morrison W. Dermal matrices and bioengineered skin substitutes: a critical review of current options. Plast Reconstr Surg Glob Open 2015;3 e284. https://doi.org/10.1097/GOX.0000000000000219
11. Shores JT, Gabriel A, Gupta S. Skin substitutes and alternatives: a review. Adv Skin Wound Care 2007;20:493-508; quiz 509. https://doi.org/10.1097/01.ASW.0000288217.83128.f3
12. Rehim SA, Singhal M, Chung KC. Dermal skin substitutes for upper limb reconstruction: current status, indications, and contraindications. Hand Clin 2014;30:239-52, vii. https://doi.org/10.1016/j.hcl.2014.02.001
13. Nathoo R, Howe N, Cohen G. Skin substitutes: an overview of the key players in wound management. J Clin
Aesthet Dermatol 2014;7:44-8. PMID: 25371771
14. Winters CL, Brigido SA, Liden BA, Simmons M, Hartman JF, Wright ML. A multicenter study involving the use of a human acellular dermal regenerative tissue matrix for the treatment of diabetic lower extremity wounds. Adv Skin Wound Care 2008;21:375-81. https://doi.org/10.1097/01.ASW.0000323532.98003.26
15. Greaves NS, Iqbal SA, Baguneid M, Bayat A. The role of skin substitutes in the management of chronic cutaneous wounds. Wound Repair Regen 2013;21:194-210. https://doi.org/10.1111/wrr.12029
16. González Alaña I, Torrero López JV, Martín Playá P, Gabilondo Zubizarreta FJ. Combined use of negative pressure wound therapy and Integra® to treat complex defects in lower extremities after burns. Ann Burns Fire Disasters 2013;26:90-3. Disponible en: http://www.medbc.com/annals/review/vol_26/num_2/text/vol26n2p90.pdf
17. Bello YM, Falabella AF, Eaglstein WH. Tissue-engineered skin. Current status in wound healing. Am J Clin
Dermatol 2001;2:305-13. https://doi.org/10.2165/00128071-200102050-00005
18. Demiri E, Papaconstantinou A, Dionyssiou D, Dionyssopoulos A, Kaidoglou K, Efstratiou I. Reconstruction of skin avulsion injuries of the upper extremity with Integra(®) dermal regeneration template and skin grafts in a singlestage procedure. Arch Orthop Trauma Surg 2013;133:1521-6. https://doi.org/10.1007/s00402-013-1834-2
19. Hanft JR, Surprenant MS. Healing of chronic foot ulcers in diabetic patients treated with a human fibroblast-derived dermis. J Foot Ankle Surg 2002;41:291-9. https://doi.org/10.1016/s1067-2516(02)80047-3
20. Hansbrough JF, Doré C, Hansbrough WB. Clinical trials of a living dermal tissue replacement placed beneath
meshed, split-thickness skin grafts on excised burn wounds. J Burn Care Rehabil 1992;13:519-29.
https://doi.org/10.1097/00004630-199209000-00004
21. Molnar JA, Defranzo AJ, Hadaegh A, Morykwas MJ, Shen P, Argenta LC. Acceleration of Integra incorporation in complex defects with subatmospheric pressure. Plast Reconstr Surg 2004;113:1339. https://doi.org/10.1097/01.prs.0000112746.67050.68
22. Sando IC, Chung KC. The use of dermal skin substitutes for the treatment of the burned hand. Hand Clin
2017;33:269-76. https://doi.org/10.1016/j.hcl.2016.12.008
23. Danin A, Georgesco G, Touze AL, Penaud A, Quignon R, Zakine G. Assessment of burned hands reconstructed with Integra(®) by ultrasonography and elastometry. Burns 2012;38:998-1004. https://doi.org/10.1016/j.burns.2012.02.017
skin in the treatment of extensive burn injury. Ann Surg 1981;194: 413-28. https://doi.org/10.1097/00000658-198110000-00005
2. Moiemen NS, Staiano JJ, Ojeh NO, Thway Y, Frame JD. Reconstructive surgery with a dermal regeneration
template: clinical and histologic study. Plast Reconstr Surg 2001;108: 93-103. https://doi.org/10.1097/00006534-200107000-00015
3. Reynolds M, Kelly DA, Walker NJ, Crantford C, Defranzo AJ. Use of integra in the management of complex hand wounds from cancer resection and nonburn trauma. Hand (N Y) 2018;13:74-9. https://doi.org/10.1177/1558944717692090
4. Shores JT, Hiersche M, Gabriel A, Gupta S. Tendon coverage using an artificial skin substitute. J Plast Reconstr
Aesthet Surg 2012;65:1544-550. https://doi.org/10.1016/j.bjps.2012.05.021
5. Weigert R, Choughri H, Casoli V. Management of severe hand wounds with Integra® dermal regeneration template. J Hand Surg Eur 2011;36:185-93. https://doi.org/10.1177/1753193410387329
6. Dai C, Shih S, Khachemoune A. Skin substitutes for acute and chronic wound healing: an updated review. J
Dermatolog Treat 2020;31(6):639-48. https://doi.org/10.1080/09546634.2018.1530443
7. Leclère FM, Desnouveaux E, Choughri H, Casoli V. Acellular dermal matrix: New applications for free flap pedicle coverage - A prospective study in 10 patients. J Cosmet Laser Ther 2018;20:200-4.
https://doi.org/10.1080/14764172.2016.1248439
8. Latifi R, El-Hennawy H, El-Menyar A, Peralta R, Asim M, Consunji R, et al. The therapeutic challenges of
degloving soft-tissue injuries. J Emerg Trauma Shock 2014;7:228-32. https://doi.org/10.4103/0974-2700.136870
9. De Angelis B, Orlandi F, Fernandes Lopes Morais D’Autilio M, Scioli MG, Orlandi A, Cervelli V, et al. Long-term
follow-up comparison of two different bi-layer dermal substitutes in tissue regeneration: Clinical outcomes and
histological findings. Int Wound J 2018;15: 695-706. https://doi.org/10.1111/iwj.12912
10. Debels H, Hamdi M, Abberton K, Morrison W. Dermal matrices and bioengineered skin substitutes: a critical review of current options. Plast Reconstr Surg Glob Open 2015;3 e284. https://doi.org/10.1097/GOX.0000000000000219
11. Shores JT, Gabriel A, Gupta S. Skin substitutes and alternatives: a review. Adv Skin Wound Care 2007;20:493-508; quiz 509. https://doi.org/10.1097/01.ASW.0000288217.83128.f3
12. Rehim SA, Singhal M, Chung KC. Dermal skin substitutes for upper limb reconstruction: current status, indications, and contraindications. Hand Clin 2014;30:239-52, vii. https://doi.org/10.1016/j.hcl.2014.02.001
13. Nathoo R, Howe N, Cohen G. Skin substitutes: an overview of the key players in wound management. J Clin
Aesthet Dermatol 2014;7:44-8. PMID: 25371771
14. Winters CL, Brigido SA, Liden BA, Simmons M, Hartman JF, Wright ML. A multicenter study involving the use of a human acellular dermal regenerative tissue matrix for the treatment of diabetic lower extremity wounds. Adv Skin Wound Care 2008;21:375-81. https://doi.org/10.1097/01.ASW.0000323532.98003.26
15. Greaves NS, Iqbal SA, Baguneid M, Bayat A. The role of skin substitutes in the management of chronic cutaneous wounds. Wound Repair Regen 2013;21:194-210. https://doi.org/10.1111/wrr.12029
16. González Alaña I, Torrero López JV, Martín Playá P, Gabilondo Zubizarreta FJ. Combined use of negative pressure wound therapy and Integra® to treat complex defects in lower extremities after burns. Ann Burns Fire Disasters 2013;26:90-3. Disponible en: http://www.medbc.com/annals/review/vol_26/num_2/text/vol26n2p90.pdf
17. Bello YM, Falabella AF, Eaglstein WH. Tissue-engineered skin. Current status in wound healing. Am J Clin
Dermatol 2001;2:305-13. https://doi.org/10.2165/00128071-200102050-00005
18. Demiri E, Papaconstantinou A, Dionyssiou D, Dionyssopoulos A, Kaidoglou K, Efstratiou I. Reconstruction of skin avulsion injuries of the upper extremity with Integra(®) dermal regeneration template and skin grafts in a singlestage procedure. Arch Orthop Trauma Surg 2013;133:1521-6. https://doi.org/10.1007/s00402-013-1834-2
19. Hanft JR, Surprenant MS. Healing of chronic foot ulcers in diabetic patients treated with a human fibroblast-derived dermis. J Foot Ankle Surg 2002;41:291-9. https://doi.org/10.1016/s1067-2516(02)80047-3
20. Hansbrough JF, Doré C, Hansbrough WB. Clinical trials of a living dermal tissue replacement placed beneath
meshed, split-thickness skin grafts on excised burn wounds. J Burn Care Rehabil 1992;13:519-29.
https://doi.org/10.1097/00004630-199209000-00004
21. Molnar JA, Defranzo AJ, Hadaegh A, Morykwas MJ, Shen P, Argenta LC. Acceleration of Integra incorporation in complex defects with subatmospheric pressure. Plast Reconstr Surg 2004;113:1339. https://doi.org/10.1097/01.prs.0000112746.67050.68
22. Sando IC, Chung KC. The use of dermal skin substitutes for the treatment of the burned hand. Hand Clin
2017;33:269-76. https://doi.org/10.1016/j.hcl.2016.12.008
23. Danin A, Georgesco G, Touze AL, Penaud A, Quignon R, Zakine G. Assessment of burned hands reconstructed with Integra(®) by ultrasonography and elastometry. Burns 2012;38:998-1004. https://doi.org/10.1016/j.burns.2012.02.017