Matrix Graft Research Articles

Three-Dimensional Microfilament Printing of a Decellularized Extracellular Matrix (dECM) Bioink Using a Microgel Printing Bath for Nerve Graft Fabrication and the Effectiveness of dECM Graft Combined with a Polycaprolactone Conduit.

Various synthetic and decellularized materials are being used to reconstruct peripheral nerve defects and replace autologous nerve grafts. In this study, we developed a microgel printing bath to three-dimensionally (3D) print a peripheral nervous system decellularized extracellular matrix nerve graft reinforced by a polycaprolactone (PCL) conduit. The straightforward fabrication method of an alginate microgel-supplemented printing bath allows a 30 μm filament resolution of a low viscous decellularized extracellular matrix hydrogel with neutral pH. When applied to a sciatic nerve defect model of rats, the total number of regenerated axons and relative gastrocnemius muscle weight ratio were comparable to those of the autologous nerve graft group. Meanwhile, the results were superior to those of the porcine decellularized nerve graft group or the 3D printed decellularized extracellular matrix graft group. This study will be the first step demonstrating that the 3D printed decellularized extracellular matrix (dECM) graft with a PCL conduit is an effective and reliable choice to replace an autologous nerve graft in the near future.

Engineering hypertrophic cartilage grafts from lipoaspirate for critical-sized calvarial bone defect reconstruction: An adipose tissue-based developmental engineering approach.

Developmental engineering of living implants from different cell sources capable of stimulating bone regeneration by recapitulating endochondral ossification (ECO) is a promising strategy for large bone defect reconstruction. However, the clinical translation of these cell‐based approaches is hampered by complex manufacturing procedures, poor cell differentiation potential, and limited predictive in vivo performance. We developed an adipose tissue‐based developmental engineering approach to overcome these hurdles using hypertrophic cartilaginous (HyC) constructs engineered from lipoaspirate to repair large bone defects. The engineered HyC constructs were implanted into 4‐mm calvarial defects in nude rats and compared with decellularized bone matrix (DBM) grafts. The DBM grafts induced neo‐bone formation via the recruitment of host cells, while the HyC pellets supported bone regeneration via ECO, as evidenced by the presence of remaining cartilage analog and human NuMA‐positive cells within the newly formed bone. However, the HyC pellets clearly showed superior regenerative capacity compared with that of the DBM grafts, yielding more new bone formation, higher blood vessel density, and better integration with adjacent native bone. We speculate that this effect arises from vascular endothelial growth factor and bone morphogenetic protein‐2 secretion and mineral deposition in the HyC pellets before implantation, promoting increased vascularization and bone formation upon implantation. The results of this study demonstrate that adipose‐derived HyC constructs can effectively heal large bone defects and present a translatable therapeutic option for bone defect repair.

594 Dermal Matrix versus Autologous Grafting for Full-Thickness Burns of Head and Neck: Trends, Outcomes, Cost

IntroductionBurns of the head and neck are particularly devastating, commonly occurring due to accidental flame or scald injury. Autologous grafting has traditionally been used for reconstruction in this area. Recently the use of dermal matrices as a reconstructive alternative has increased. This study compares annual trends, outcomes, and hospital costs between head and neck burn patients who underwent reconstruction with dermal matrix or autologous grafting.MethodsThe U.S Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project Nationwide Inpatient Sample database was queried from 2012 to 2016. Patients with head and neck burns treated with dermal matrix or autologous graft were identified using International Classification of Disease Ninth and Tenth Revision diagnosis and procedure codes. Demographic, clinical characteristics, and outcome measures were reported. χ 2 and Student’s t-tests were used for univariate survey-adjusted comparisons between groups. Multivariate survey-adjusted linear regressions were used to identify associations between surgical intervention, length of stay and cost of hospitalization. Analyses were conducted with RStudio (1.4.1717).ResultsA total of 6,730 patients met inclusion criteria; 2,855 underwent reconstruction dermal matrix and 3,875 with autologous graft. There was an increasing number of patients undergoing dermal matrix reconstruction each year, peak in 2016 (1,450, 50.8%). The dermal matrix group was younger (33.7 vs 39.9, p< 0.001) had fewer females (27.3% vs 38.2%, p=0.003) and fewer inhalation injury (4.0% vs 11.0%, p< 0.001). The dermal matrix group had a shorter length of stay (11.2 vs 27.8, p< 0.001) and more home discharges (80.4% vs 53.4%, p< 0.001); they had lower Elixhauser Comorbidity Index score for readmission (6.57 vs 11.92, p< 0.001) and in hospital mortality (4.76 vs 9.69, p< 0.001). Median cost of care was lower for the dermal matrix group ($17,858 vs $59,860, p< 0.001). Multivariable regression demonstrated that reconstruction with dermal matrix was independently associated with decreased length of stay (11.01 [7.95 - 14.07], p< 0.001) and decreased cost ($38,297 [23,813], p< 0.001).ConclusionsOperative management of head and neck burns with dermal matrix is associated with a shorter hospital stay, greater likelihood of home discharge, and decreased hospital costs. Patients with autologous grafting had higher rates of inhalation injury, which may account for longer hospital stays and increased discharges to nursing facilities. A limit of this study is the inability to differentiate patients undergoing staged procedures. Further study is needed to evaluate factors contributing to faster discharges home in the head and neck burn population.

724 Role of synthetic dermal matrix for reconstruction of complex non-graftable wound defects

IntroductionThe aim of this study was to investigate the role of a synthetic dermal matrix, Biodegradable Temporising Matrix (BTM), for coverage of complex wounds. The authors defined complex wounds as wounds not amenable to reconstruction with skin grafting alone due to an inherent avascularity of the wound bed, such as the presence of exposed bone, tendinous or neural structures.MethodsA retrospective review of a prospectively maintained database of complex wounds as defined above was carried out. Clinical and operative notes were reviewed along with review of an extensive photographic database demonstrating wound healing progress using staged dermal matrix (BTM) and autologous skin graft reconstruction.Results55 patients were identified who underwent staged dermal matrix and autologous skin graft reconstruction for complex wounds affecting a wide variety of patient demographics, treatment indications and body sites. Wound aetiology varied between burn injury, non-burn related trauma including degloving injury and infective complications. We discuss caveats relating to successful application of a dermal matrix, technique tips, prevention and management of complications.Dermal substitutes play an integral role in providing biological wound cover for avascular wound beds which may otherwise require complex distant flap or microsurgical free flap reconstruction. BTM is a completely synthetic dermal matrix comprised of a 2-mm-thick sheet of biodegradable polyurethane foam bonded to a non-biodegradable polyurethane sealing membrane. Our department has developed significant expertise in the use of BTM throughout its development from initial animal studies through to recent human clinical trials. The synthetic composition of BTM does not require rapid neo-vascularisation for its integrity or survival. As such, two-stage BTM reconstruction has proven robustness in the face of unfavourable wounds compared with other popular dermal matrices, physiologically covering avascular structures, allowing for early graft take, expediting rehabilitation and mobilisation with excellent scar cosmesis and limited contracture formation.ConclusionsDermal matrices such as BTM play an important role in complex wound healing, frequently achieving excellent results with a low complication profile. BTM has been used successfully in cases where biological matrices would not routinely be considered as demonstrated by this clinical series. It has provided a valuable alternative to free-tissue transfer in patients with significant co-morbidities, vascular insufficiency and/or those for whom long operations are undesirable.

722 Collagen-elastin matrix for defect coverage in exposed bradytrophic tissue after severe burn and degloving injuries

IntroductionDespite successful defect coverage by means of complex skin or muscle flaps, particularly large and deep problematic wounds with exposed bradytrophic tissues after soft tissue loss are very susceptible to surgical revision.A dermal matrix, consisting of native collagen (collagen type I, III and V) supplemented by an elastin hydolyzate was first used for the treatment of burns, predominantly those that were full-thickness. Subsequently, its use was extended to defect coverage especially after soft tissue loss caused by degloving injuries.Methods52 patients with exposed bradytrophic tissues caused by severe burn or degloving injuries were treated the same way.In all patients operative debridement showed soft tissue loss with free bone or free periostal structures, exposed tendons or joint capsules.In all patients after accurate wound bed preparation defect coverage was performed with collagen-elastin matrix and unmeshed split skin grafts in combination with negative pressure wound therapy for fixation of dermal matrix and split skin grafts.ResultsTwo-years follow up of these collagen-elastin matrix procedures in defect coverage showed an excellent functional outcome:Up until now, no areas with unstable scars have occurred, no surgical scar revisions were required. The patients were still able to wear normal footwear, clinical gait analysis showed perfect functional outcome.ConclusionsThe application of collagen-elastin matrix in patients with exposed bradytrophic tissues after severe burn or degloving injury treated so far represents an excellent reconstruction method, from initial coverage to scar development.

Research update of adipose tissue-based therapies in regenerative dermatology.

Mesenchymal stromal/stem cells (MSCs) have a spontaneous propensity to support tissue homeostasis and regeneration. Among the several sources of MSCs, adipose-derived tissue stem cells (ADSCs) have received major interest due to the higher mesenchymal stem cells concentration, ease, and safety of access. However, since a significant part of the natural capacity of ADSCs to repair damaged tissue is ascribable to their secretory activity that combines mitogenic factors, cytokines, chemokines, lipids, and extracellular matrix components, several studies focused on cell-free strategies. Furthermore, adipose cell-free derivatives are becoming more attractive especially for non-volumizing purposes, such as most dermatological conditions. However, when keratinocytes, fibroblasts, melanocytes, adipocytes, and hair follicle cells might not be locally sourced, graft of materials containing concentrated ADSCs is preferred. The usage of extracellular elements of adipose tissue aims to promote a self-autonomous regenerative microenvironment in the receiving area restoring physiological homeostasis. Hence, ADSCs or their paracrine activity are currently being studied in several dermatological settings including wound healing, skin fibrosis, burn, and aging.The present work analyzing both preclinical and clinical experiences gives an overview of the efficacy of adipose tissue-derivatives like autologous fat, the stromal vascular fraction (SVF), purified ADSCs, secretome and extracellular matrix graft in the field of regenerative medicine for the skin.

Disseminated Tuberculosis in an Immunocompetent Patient Associated With the Use of Contaminated Bone Matrix Graft in Spine Surgery

Abstract Miliary tuberculosis (TB) is a rare and potentially fatal form of disseminated TB. Disseminated TB involving the central nervous system (CNS) may be seen in up to nearly a third of miliary TB cases. We describe a case of miliary TB with CNS involvement and suspected hepatobiliary involvement in an immunocompetent patient after an elective spine surgery. Given the patient's unusual presentation in the absence of risk factors for TB, diagnosis was delayed. We were later informed that the bone graft he received during spine surgery, FiberCel (“FiberCel”) Fiber Viable Bone Matrix (Aziyo Biologics, Inc, Richmond, Calif), was contaminated with TB. This patient is 1 of almost 2 dozens reported to be affected. This case represents a novel presentation of TB due to contaminated cadaveric bone allograft matrix implantation, with notable rapid dissemination and CNS involvement.

English

BACKGROUND Watertight dural closure is a vital and desirable step following all intracerebral operations to prevent CSF leakage, consequent infection and wound dehiscence and delayed wound healing which in turn increases patient morbidity and mortality. Various autologous and synthetic materials have been tried for duraplasty. This study was done to compare two types of synthetic materials used for duraplasty. METHODS This randomised prospective study was done at our institute on 56 patients who underwent decompressive craniectomy. Patients were randomly divided into two groups, one group underwent duraplasty with synthetic fabric patch graft and the other group underwent duraplasty with collagen matrix graft and results were compared between the two groups. RESULTS Patients who underwent duraplasty with collagen matrix graft were found to have a significantly reduced operating time of nearly 34 minutes as compared to the synthetic fabric patch and also there was no incidence of CSF leakage or wound infection in those patients in whom collagen matrix was used. CONCLUSIONS Collagen matrix graft is far superior to synthetic fabric graft for duraplasty as it saves valuable operating time and has fewer complications as compared to synthetic fabric grafts. KEY WORDS Duraplasty, Collagen Matrix Graft, Synthetic Fabric Patch Graft

Effectiveness of acellular dermal matrix graft with a coronally advanced flap for the treatment of Miller Class I/II single gingival recession with thin gingival phenotype: study protocol for a split-mouth randomised controlled trial

IntroductionGingival recession is one of the most common mucogingival deformities requiring surgical correction. The American Academy of Periodontology Regeneration Workshop recommended connective tissue graft (CTG) combined with coronally advanced flap...

Acellular cadaveric dermal matrix grafts for orbital wall reconstruction in patients with sinonasal malignancies

ABSTRACT Purpose To describe the utilization of acellular cadaveric dermal matrix (ACDM) in patients undergoing orbital wall reconstruction after orbital preservation surgery for sinonasal malignancy. Methods Retrospective case series of seven patients with sinonasal malignancy who had orbital reconstruction with ACDM implants from January 2012 to August 2020. Orbital preservation was performed in all patients with tumor extension up to and including periorbital. The main outcome measures were implant exposure, orbital infection, diplopia in primary gaze, enophthalmos, and eyelid malposition. Results Patients ranged 37–78 years old (median: 66 years) and included 4 females and 3 males. The median follow-up time was 9 months (range 6–43 months) from the date of surgery. Squamous cell carcinoma comprised the majority of tumors with all patients needing medial wall reconstruction. Three patients received postoperative radiation therapy. No patients had any implant exposure, orbital infection, enophthalmos, or eyelid malposition. Conclusions ACDM grafts can be used safely in orbital wall reconstruction in patients with sinonasal malignancies.

Effects of acellular dermal matrix on the prevention of complications and esthetic outcome after parotidectomy: A propensity score matched analysis.

The present study was designed to investigate whether acellular dermal matrix (ADM) grafts could prevent Frey's syndrome (FS) and improve esthetic scores following parotidectomy. From January 2015 to December 2019, 175 patients underwent parotidectomy. We divided the patients into two groups: the ADM group and the control group. We included in each group 30 patients according to a propensity score matched analysis. FS was subjective in 1 patient (3%) from the ADM group and 9 patients (30%) from the control group (P=0.015). Patients in the ADM group had a subjective esthetic score of 6.1 + 1.7 compared with 5.2 + 1.7 in the control group. The subjective esthetic score for patients in the ADM group was higher than that for patients in the control group (P =0.040). The present clinical study suggests that ADM grafts are effective in preventing FS and improving esthetic scores after parotidectomy.

A Multilayered Dural Repair Technique Using Duragen for Early Cranioplasty Following Decompressive Craniotomy

Decompressive craniotomy is a neurosurgical emergency procedure in which a large skull bone is removed and the dura matter is extensively opened. Duraplasty is required to avoid cerebrospinal fluid (CSF) leakage during the decompressive craniotomy. DuraGen® is a safe and effective type I collagen matrix graft, which is frequently used in decompressive craniotomy procedures. Since DuraGen® does not require labor-intensive suturing, the operative time is shortened by DuraGen® closure with sufficient tightness preventing CSF leakage. Recently, early cranioplasty is preferred to achieve efficient rehabilitation after decompressive craniotomy. Although evidence of efficacy and safety of DuraGen® has been increasing in the management of duraplasty, no reports have previously discussed the condition of DuraGen® during the second surgery (cranioplasty) at this early timing. DuraGen®-derived neodura develops a mature dura 1 year post its placement, and the neodura remain fragile at this early time point. A deconstructed fragile neodura may result in postoperative CSF leakage. Here, we illustrated a multilayered dural repair technique with DuraGen® to avoid disruption of the fragile neodura during early cranioplasty.

Acellular Dermal Matrix Grafts Decrease Radiation-Induced Contracture and Dermal Thickening

Acellular Dermal Matrix Grafts Decrease Radiation-Induced Contracture and Dermal Thickening

Reconstruction of the Swine Pulmonary Artery Using a Graft Engineered With Syngeneic Cardiac Pericytes.

The neonatal heart represents an attractive source of regenerative cells. Here, we report the results of a randomized, controlled, investigator-blinded preclinical study, which assessed the safety and effectiveness of a matrix graft cellularized with cardiac pericytes (CPs) in a piglet model of pulmonary artery (PA) reconstruction. Within each of five trios formed by 4-week-old female littermate piglets, one element (the donor) was sacrificed to provide a source of CPs, while the other two elements (the graft recipients) were allowed to reach the age of 10 weeks. During this time interval, culture-expanded donor CPs were seeded onto swine small intestinal submucosa (SIS) grafts, which were then shaped into conduits and conditioned in a flow bioreactor. Control unseeded SIS conduits were subjected to the same procedure. Then, recipient piglets were randomized to surgical reconstruction of the left PA (LPA) with unseeded or CP-seeded SIS conduits. Doppler echocardiography and cardiac magnetic resonance imaging (CMRI) were performed at baseline and 4-months post-implantation. Vascular explants were examined using histology and immunohistochemistry. All animals completed the scheduled follow-up. No group difference was observed in baseline imaging data. The final Doppler assessment showed that the LPA’s blood flow velocity was similar in the treatment groups. CMRI revealed a mismatch in the average growth of the grafted LPA and contralateral branch in both treatment groups. Histology of explanted arteries demonstrated that the CP-seeded grafts had a thicker luminal cell layer, more intraparietal arterioles, and a higher expression of endothelial nitric oxide synthase (eNOS) compared with unseeded grafts. Moreover, the LPA stump adjacent to the seeded graft contained more elastin and less collagen than the unseeded control. Syngeneic CP engineering did not accomplish the primary goal of supporting the graft’s growth but was able to improve secondary outcomes, such as the luminal cellularization and intraparietal vascularization of the graft, and elastic remodeling of the recipient artery. The beneficial properties of neonatal CPs may be considered in future bioengineering applications aiming to reproduce the cellular composition of native arteries.

Patient-reported outcome measures and clinical outcomes following peri-implant vestibuloplasty with a free gingival graft versus xenogeneic collagen matrix: a comparative prospective clinical study

BackgroundThe objective of this study was to compare patient-reported outcome measures (PROMs) and clinical outcomes after augmentation with xenogeneic collagen matrix (XCM) or free gingival graft (FGG) during different postoperative phases.MethodsForty-two patients (21 per group) with keratinized mucosa width (KMW) of < 2 mm at buccal implant sites in the posterior mandible were enrolled. All underwent vestibuloplasty and were allocated to either FGG (control) or XCM (test) group. Intraoperative morbidity of pain, stress, nausea, tolerance to time, and acceptance of surgery were evaluated immediately after surgery. The severity and duration of subjective pain, swelling, and bleeding were compared within a 2-week postoperative period. The willingness to retreat and satisfaction were assessed at 6 months. All PROMs were obtained using questionnaires and visual analog scales. The buccal KMW and other peri-implant parameters were also evaluated.ResultsNo significant between-group differences were observed in PROMs immediately after surgery, except acceptance of surgery (0, 0–30.0 vs. 30, 0–50.0, p = 0.025). At 2 weeks, pain severity (46.7 ± 25.9 vs 61.9 ± 20.2, p = 0.040) and duration (5.52 ± 3.57 vs 8.48 ± 2.80, p = 0.005) were significantly lower in the test group, and pain perception during speaking and chewing was significantly higher for FGG, with no significant between-group differences in swelling and bleeding. At 6 months, the test group showed a higher willingness to retreat (76% vs 43%, p = 0.021); however, satisfaction with treatment outcomes was similar in both groups. At 6 months, the gain of KMW was significantly higher in FGG than in XCM (XCM: 1.57 ± 1.69 mm, FGG: 2.68 ± 1.80 mm, p = 0.003). Other peri-implant parameters did not show significant differences.ConclusionsWithin the limitation of the present nonrandomized study, XCM demonstrated more positive PROMs than FGG during different postoperative phases, mainly for less pain perception during the early healing stage, but was inferior to FGG in terms of gain of KMW. For KMW augmentation in the posterior mandible, XCM may be indicated when patients can bear little pain.Clinical trial registrationChiCTR1900022575, date of registration: 17/4/2019, retrospectively registered,

Surgical reconstruction of pilonidal sinus disease with concomitant extracellular matrix graft placement: a case series.

Pilonidal sinus disease (PSD) is a chronic inflammatory disease affecting the soft tissue of the sacrococcygeal region and remains a challenging disease for clinicians to treat. The optimal treatment for PSD remains controversial and recent reports describe several different surgical approaches offering different benefits. Approximately 40% of initial incision and drainage cases require subsequent surgery. Due to high recurrence rates and postoperative complications, a more complex revision surgery involving a flap reconstruction may be required. We hypothesised that the combination of an extracellular matrix (ECM) graft with tissue flap reconstruction may decrease the postoperative complications and recurrence rates for PSD. We report a retrospective case series using a surgical flap reconstruction with concomitant implantation of an ovine forestomach ECM graft under a fasciocutaneous flap with an off-midline closure for recurrent PSD, where previously surgical intervention had failed due to wound dehiscence and/or recurrent disease. The case series included six patients. After three weeks, all patients except one were fully healed, and the sixth was fully healed by week 4; all wounds remained fully healed at 12 weeks. All patients achieved good cosmesis and were able to return to normal function without any residual symptoms. This pilot case series explored augmenting a flap reconstruction for complex PSD with advanced ECM graft materials, demonstrating that it may improve outcomes and minimise typical complications seen in flap closure, such as inflammation, infection, haematoma/seroma and hypoperfusion. Although the study had a limited number of participants, long-term outcomes were promising and suggest that further studies are warranted.

Biocompatibility Evaluation of Human and Porcine Acellular Dermal Matrix on Human Primary Gingival Fibroblasts: In Vitro Comparative Study.

Objective Allogeneic and xenogeneic acellular dermal matrix (ADM) grafts have been used to treat periodontal soft tissue defects. The purpose of the current study was to compare the effect of human ADM (AlloDerm) and porcine ADM (Derma) on human primary gingival fibroblasts in vitro regarding the biocompatibility test. Materials and Methods Gingival fibroblasts were obtained from healthy adult gingiva and seeded on AlloDerm or Derma ADM in 96-well plate. The control cells were grown on a surface-treated polystyrene cell-culture plate without matrix. The cells were cultured for 3, 7, and 14 days. The fibroblasts morphology was examined using inverted microscopy, and the cell viability of fibroblasts adherent to the dermal matrix was evaluated using 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) cell viability assay after 3, 7, and 14 days in culture. The data were statistically evaluated by one-way analysis of variance. p -Value of 0.05 was considered significant. Results Gingival fibroblasts adjacent to the AlloDerm and Derma matrices were healthy, attached to the well, and did not exhibit any cytopathic changes similar to control. There were no statistically significant differences in the cell viability between the gingival fibroblasts attached to Derma and AlloDerm on day 3 ( p = 0.841), day 7 ( p = 0.198), and day 14 ( p = 0.788). Conclusion Considering this in vitro study’s limitations, both human and porcine ADM were compatible with the surrounding human primary gingival fibroblasts. No significant differences were observed in the cell viability between the gingival fibroblasts that were attached to Derma and AlloDerm.

Regeneration of muscular wall of the bladder using a ureter matrix graft as a scaffold

ABSTRACT We investigated a method for bladder augmentation in rats using a decellularized ureter graft. We used 16 rats divided into two groups of eight. After partial cystectomy, the bladders in group 1 were grafted with a 1 cm2 patch of human decellularized ureter. Rats in group 2 were untreated controls. Biopsies of the graft were taken at 1, 3 and 9 months postoperatively for histological investigation. Total removal of cells and preservation of extracellular matrix (ECM) was confirmed in the decellularized ureter. Histological examination after 1 month revealed few cells at the border of the graft. Three months after the operation, the graft was infiltrated by vessels and smooth muscle and the mucosal lining was complete. All bladder wall components resembled native bladder wall by 9 months after implantation. CD34, CD31, α-smooth muscle actin, S100, cytokeratin AE1/AE3 and vimentin were detected 9 months after the operation. We demonstrated the potential of decellularized biocompatible ureteric grafts for use as a natural collagen scaffold for bladder repair in rats.

Existing clinical evidence on the use of cellular bone matrix grafts in spinal fusion: updated systematic review of the literature.

Spinal fusion surgery is increasingly common; however, pseudarthrosis remains a common complication affecting as much as 15% of some patient populations. Currently, no clear consensus on the best bone graft materials to use exists. Recent advances have led to the development of cell-infused cellular bone matrices (CBMs), which contain living components such as mesenchymal stem cells (MSCs). Relatively few clinical outcome studies on the use of these grafts exist, although the number of such studies has increased in the last 5 years. In this study, the authors aimed to summarize and critically evaluate the existing clinical evidence on commercially available CBMs in spinal fusion and reported clinical outcomes. The authors performed a systematic search of the MEDLINE and PubMed electronic databases for peer-reviewed, English-language original articles (1970-2020) in which the articles' authors studied the clinical outcomes of CBMs in spinal fusion. The US National Library of Medicine electronic clinical trials database (www.ClinicalTrials.gov) was also searched for relevant ongoing clinical trials. Twelve published studies of 6 different CBM products met inclusion criteria: 5 studies of Osteocel Plus/Osteocel (n = 354 unique patients), 3 of Trinity Evolution (n = 114), 2 of ViviGen (n = 171), 1 of map3 (n = 41), and 1 of VIA Graft (n = 75). All studies reported high radiographic fusion success rates (range 87%-100%) using these CBMs. However, this literature was overwhelmingly limited to single-center, noncomparative studies. Seven studies disclosed industry funding or conflicts of interest (COIs). There are 4 known trials of ViviGen (3 trials) and Bio4 (1 trial) that are ongoing. CBMs are a promising technology with the potential of improving outcome after spinal fusion. However, while the number of studies conducted in humans has tripled since 2014, there is still insufficient evidence in the literature to recommend for or against CBMs relative to cheaper alternative materials. Comparative, multicenter trials and outcome registries free from industry COIs are indicated.

Reconstruction of Large Upper Eyelid Defects Using the Reverse Hughes Flap Combined With a Sandwich Graft of an Acellular Dermal Matrix.

To investigate the usefulness of the reverse Hughes flap procedure combined with a sandwich graft of an acellular dermal matrix for reconstruction of large full-thickness defects of upper eyelids after cancer excision. Clinical data were obtained from patients who underwent upper eyelid reconstruction using a reverse Hughes flap combined with a sandwich graft of an acellular dermal matrix (AlloDerm) as a tarsal substitute. The tarsoconjunctival flap of the donor lower eyelid was mobilized to reconstruct the posterior lamella, and acellular dermal matrix was grafted onto the tarsoconjunctival flap. A skin-orbicularis muscle flap superior to the defect was advanced to cover the acellular dermal matrix graft, followed by application of lid crease formation sutures to prevent postoperative entropion. The tarsoconjunctival pedicle was divided 3-8 weeks after the surgery. Six patients with sebaceous carcinoma were included, and all had ≥70% full-thickness upper eyelid defects after tumor excision. After a median follow-up of 40 months (range 6-62 months), all 6 showed satisfactory functional and cosmetic outcomes. Tumor recurrence, exposure keratopathy, upper eyelid entropion, persistent use of bandage contact lenses, lower eyelid deformity, and dermal matrix-related complications were not observed by the last follow-up. Reverse Hughes flap combined with a sandwich graft of an acellular dermal matrix as a tarsal substitute was successful in reconstructing large upper eyelid defects. Acellular dermal matrix graft and lid crease formation sutures enhance marginal stability and prevent postoperative entropion of the reconstructed upper eyelid.