Single-stage Reconstruction for Soft Tissue Defects: A Case Series
- 0 Comments
- 3863 reads
However, skin grafting over exposed bone, cartilage, or tendon generally is not recommended due to historically low graft take rates.5 In addition, outcomes related to long-term elasticity and appearance following split-thickness skin graft (STSG) are not optimal. The STSGs are prone to contraction, and meshed grafts (1:1.5, 1:2, or 1:3) may have a pebble or cobblestone appearance when re-epithelialized compared to unmeshed or sheet grafts.5-8
A dermal regeneration template (DRT) has been used for a two-stage approach in reconstruction of complicated lower extremity wounds and soft tissue defects, such as those resulting from radical skin cancer removal or trauma.9-13 DRT is applied as a bilaminate membrane consisting of a porous acellular collagen-glycosaminoglycan dermal layer bonded to a thin silicon layer. Results of a three-patient case series focusing on small area defects showed that, with normal progression, the artificial dermal scaffold is replaced by neodermis tissue with function and histology similar to normal human dermis.14 Histological studies12 demonstrate the same four phases of dermal regeneration observed in wound healing and skin graft take with use of DRT: imbibition, fibroblast migration, neovascularization, and remodeling and maturation. A prospective randomized trial by Heimbach et al10 showed less hypertrophic scarring and greater patient satisfaction with DRT compared to autograft, allograft, xenograft or a synthetic dressing in 106 patients with 139 burn sites, although the median DRT graft take was 80% compared to 90% for autograft sites. The authors concluded that DRT with STSG provides a permanent cover at least as satisfactory as control skin grafting techniques and requires a thinner donor graft, which results in faster healing of donor sites.
Despite the paucity of well-designed, controlled studies evaluating use of DRT, several case series have reported benefits of DRT in burn and reconstructive surgery, including volume stability over time,15 improved functional and cosmetic outcomes without donor-site morbidity factors,10,12,13 and minimized scar contraction, all as compared to STSGs.16 A retrospective analysis15 of 30 patients who received DRT in augmentation rhinoplasty concluded that DRT volume remained stable throughout the follow-up period of at least 12 months. In 39 patients who received DRT grafts for burn scar contractures (n = 19) or acute surgery for burn patients (n = 20), long-term results suggested improved cosmetic (eg, minimal scarring) and functional (eg, good range of motion) results in treatment of burns in the acute and late surgery stages compared to STSGs.13 In a consecutive case series12 of 20 consecutive wounds with 30 anatomical site reconstructions utilizing DRT, patients reported increased range of movement and improved appearance compared to preoperative states.
Without adjunctive therapies, Greenwood et al17 determined through clinical blood flow evaluation and confocal microscopy of wounds in a single burn patient who presented with 80% total body surface area burn that neovascularization of the DRT takes approximately 2 weeks in the acute burn setting and can take 4 to 5 weeks in reconstructive cases. However, these study results17 are limited by a population size of only one patient and therefore cannot necessarily be extrapolated to all patients.