Acellular Dermal Matrix Reconstruction Research Articles

Minimally invasive hand surgery

fitting the scope portrayed in the title. There are good descriptions of surgical technique and how to avoid the pitfalls when performing nipple reconstruction. Sadly, there are no photographs or medical illustrations to help visualise the techniques. In conclusion, the book has great promise in its title but, unfortunately, the chapters do not deliver to a satisfactory level. It is difficult to know who would benefit most from this book. There is certainly not enough surgical technique in the book to satisfy plastic surgeons wishing to learn the techniques. For breast surgeons, the general discussion of the free flaps and pedicled flaps will be useful. However, the other chapters lack the detail to fulfil tantalising promise of solving complications and avoiding unfavourable results. One would also expect a book such as this to be discussing, in depth, acellular dermal matrix reconstruction, secondary pedicles, dual plane techniques for implant replacement and, of course, lipomodelling. I look forward to the next edition of this book where I hope many of the deficiencies will be addressed.

The scarless latissimus dorsi flap provides effective lower pole prosthetic coverage in breast reconstruction.

Background:The evolution of surgical breast cancer treatment has led to the oncologically safe preservation of greater amounts of native skin, yet we are still often using flaps with large skin paddles, thereby resulting in significant donor-site scars. This explains the increasing appeal of acellular dermal matrix reconstructions. Acellular dermal matrices can, however, have significant problems, particularly if there is any vascular compromise of the mastectomy skin flaps. We have developed a method of raising the latissimus dorsi flap through the anterior mastectomy incisions without requiring special instruments or repositioning. This can provide autologous vascularized cover of the prosthesis.Methods:A clear surgical description of the scarless latissimus dorsi flap harvest is provided, and our results of a retrospective cohort review of 20 consecutive patients with 27 traditional latissimus dorsi breast reconstructions were compared with those of 20 consecutive patients with 30 scarless latissimus dorsi breast reconstructions.Results:Operative time, length of stay, and complication rates were reduced in the scarless group. Patients Breast-Q scores were equivalent in each group. The aesthetic assessment was good/excellent in 77% of both groups; however, subscale assessment was better in the scarless group. This was statistically significant (P = 0.0).Conclusions:Breast reconstruction using the scarless latissimus dorsi flap is time effective, requires no patient repositioning, and uses standard breast instrumentation. It is safe and versatile while reducing the risk of exposed prosthesis if native skin necrosis occurs. It is a vascularized alternative to acellular dermal matrices.

A Meta-Analysis of Human Acellular Dermis and Submuscular Tissue Expander Breast Reconstruction

Sir:FigureWe are writing in response to the article, “A Meta-Analysis of Human Acellular Dermis and Submuscular Tissue Expander Breast Reconstruction,” by Kim et al. (Plast Reconstr Surg. 2012;129:28–41).1 In this study, the authors performed two separate analyses. In the first, pooled estimates of complication rates for each procedure were calculated from 48 studies, 42 of which analyzed only one of the procedures. The second was a meta-analysis of six of these studies that compared both procedures. Kim et al. concluded that acellular dermal matrix reconstruction causes more complications, but their analyses do not support this conclusion. Although the meta-analysis showed significant differences for four of the six measured outcomes, the other analysis showed no significant differences between complication rates for any of the six outcomes, indicating that the studies included in the meta-analysis are not representative of all available data. The authors used uncontrolled cohort studies in the analysis, which has a high potential to introduce bias in the analysis, and an assessment of study quality was not conducted to address this. Likewise, sensitivity analyses were not conducted to address whether removing studies of lower quality, such as those with a lot of missing data, affected results. Although Kim et al. stated that they conducted a sensitivity analysis, they did not present the results. This is of particular concern given the significant amount of heterogeneity among the studies. Without results of sensitivity analyses to address this, it cannot be known whether pooling results was appropriate.2,3 Finally, although the authors present their search terms, they do not explicitly state the Boolean operators they used. The authors mention using the reference list of publications to manually identify 22 articles suitable for their analysis, but they do not report the details of this strategy. Moreover, MEDLINE was the only database used. These issues raise concern about the comprehensiveness of the search according to the established guidelines.4,5 Based on the foregoing limitations, results of this study and their interpretations should be viewed with caution. Kaveh Hajifathalian, M.D. David G. Zacharias Luis A. Gonzalez-Gonzalez, M.D. Julie Goodman, Ph.D. Departments of Biostatistics and Epidemiology, Harvard School of Public Health, Harvard University, Boston, Mass. DISCLOSURE The authors have no financial interest in any of the products or devices mentioned in this communication.

Complications of Acellular Dermal Matrices in Abdominal Wall Reconstruction

Acellular dermal matrices have been increasingly used in abdominal wall reconstruction. Unique characteristics of these grafts have allowed surgeons to reconstruct increasingly complex abdominal wall defects. This has resulted in a myriad of complications related to the acellular dermal matrix with unique management strategies as compared with synthetic mesh. A review of the literature was performed to identify studies evaluating the use and efficacy of acellular dermal matrices in abdominal wall reconstruction. Complication profiles were identified and are compared. Differences between porcine and human derivatives were identified. Hernia recurrence, infection, skin necrosis, and fluid collections were among the most common complications following abdominal wall reconstruction identified in the literature. Differences among various acellular dermal matrix products make certain types more suitable for abdominal wall reconstruction. Complications are frequent in abdominal wall reconstruction. Many acellular dermal matrices have properties that allow for conservative management and maintenance of reconstruction when complications occur. With traditional synthetic mesh reconstruction, complications likely result in mesh explantation and prolonged morbidity. With acellular dermal matrix reconstruction, however, more conservative treatment strategies will allow for mesh salvage.

Complications in Tissue Expander Breast Reconstruction

Acellular dermal matrix (ADM) is frequently used in tissue expander breast reconstruction (TEBR) for coverage of the inferior pole. Several published studies have suggested increased rates of complications with the use of ADM. It is unknown, however, if the type of ADM used for TEBR impacts complication rates. The aim of this study is to compare 3 different types of ADM for TEBR in regard to clinically significant complications, specifically infection. We performed a retrospective analysis of primary breast cancer-related TEBR with or without ADM. Exclusion criteria consisted of prior major breast surgery, inadequate data, or loss to follow-up. Reconstructions were grouped by dermal sling type, AlloDerm, DermaMatrix (DM), FlexHD (FHD), or no ADM. Complications included cellulitis, abscess, seroma, expander leak or puncture, skin necrosis, wound dehiscence, or hematoma. Those requiring admission to hospital or reoperation were considered significant. Of 284 breasts reconstructed, 49 used AlloDerm, 110 used DM, 62 used FHD, and 64 used no ADM. The total complication rate with AlloDerm was 22% [95% confidence interval (CI), 11-34], with DM was 15% (95% CI, 8-21), and with FHD was 18% (95% CI, 8-28) (P=0.47). Infectious complication rates for AlloDerm, DM, and FHD were equal at 10% (P=0.97). The total complication rate of all ADM reconstructions as a grouped cohort was 17% compared to 11% without ADM (P=0.48). The overall incidence of infectious complications with ADM was 10% compared to 2% without ADM (P=0.09). There is no difference in the clinically significant overall complication rate or incidence of infection between AlloDerm, DM, and FHD. Isolating infectious complications, there is a trend toward increased incidence with ADM compared to reconstructions without.

Application of Acellular Dermal Matrix in Reconstruction of Oral Mucosal Defects in 36 Cases

Artificial grafts have been investigated for use in the repair of oral mucosal defects. The aim of this retrospective study was to present the outcomes of the use of acellular dermal matrix (ADM) grafts to repair oral mucosal defects. Data from 36 patients with oral mucosal defects reconstructed with ADM grafts from 2003 through 2009 were reviewed. All patients were followed-up for at least 6 months to observe the graft repair, wound-healing time, contracture, color, infection, pain, immunologic reaction, texture of the graft, and clinical course. Graft success was defined as the ADM graft being replaced by new mucosa-like tissue and the oral mucosal defect being covered with the new mucosa-like tissue. Any evidence of incomplete graft re-epithelialization or graft sloughing was considered a graft failure (complete or incomplete). Of the 36 cases, 34 grafts (94.4%) were successfully replaced with new mucosa-like tissues and only 2 grafts (5.6%) failed. No complaints such as pain, immunologic reaction, or infection were observed during the follow-up. Mild graft contraction occurred in 7 patients with lip or buccal defects, especially at approximately 3 to 5 weeks after the reconstructive surgery. The ADM grafts for oral mucosal defects were safe and effective. The present data support the clinical application of ADM grafts in reconstructing oral mucosal defects caused by various oral diseases.

Acellular Dermal Matrix Reconstruction of the Head and Neck: A Versatile Reconstructive Option

Objective: Ablative procedures of the head and neck often result in significant contour defects. Acellular dermal matrices (ADM) are relatively resistant to infection and accommodate long term facial growth. Our objective is to confirm the benefits of acellular dermal matrix reconstruction in post-ablative head and neck defects. Method: Patients who underwent ADM reconstruction of the head and neck since 1997 were identified. Of 265 patients identified, 205 met the inclusion criteria. The pathology, surgical location, long term imaging, cosmetic outcome, and complications were analyzed. Postoperative cosmetic results were assessed by a novel patient-based numerical grading scale. Results: The mean age was 60.4 years. One hundred thirty-two patients were male (77%) and 40 patients were female (23%). ADM were used to correct a variety of defects with the most common location being the parotid gland (n = 65) followed by the neck (n = 60), low neck/thyroid bed (n = 35), and skull base (n = 30). A majority of patients had a diagnosis of benign parotid lesions (n = 40) although numerous pathologies were identified. Only 3 patients had a complication related to their ADM recipient site (4%). The patient postoperative cosmesis survey is still pending. Conclusion: With regard to function and cosmesis, ADM is an excellent head and neck reconstructive option with few complications. Moreover, ADM can be used in a variety of locations and patients tend to be very happy with their final cosmetic outcome.

The Use of Acellular Dermal Matrix in Reconstruction of Complex Scalp Defects

Multi-focal basal or squamous cell carcinomas of the scalp, as well as recurrent tumors or previously irradiated lesions, always require large full thickness excision to achieve successful and complete healing. Loco-regional or micro-vascular flaps are the gold standard for closure of complex defects of the scalp but in some, especially older, patients, these techniques may be contraindicated. Over the last few years, the introduction of dermal substitutes has improved wound healing and modified surgical strategies in the treatment of complex tissue loss. Matriderm s (Eurosurgical Limited, Guildford, UK) is an acellular dermal substitute constituted by a matrix of type 1 bovine collagen and elastin, with a thickness of 1 to 2mm and pores of about 75mm. Since its introduction in clinical practice, it has been used in the reconstruction of tissue following burns or complex wounds, 1,2 but few studies have focused on its use in the craniofacial region and no studies appear to have evaluated its usefulness in scalp reconstruction. Herewith, we report our personal experience using this acellular dermal matrix in a complex scalp reconstruction, comparing the esthetic outcome to that of a previous full-thickness skin graft in the same region.