2017-18 HSC Section 4 Green Book

Volume 135, Number 6 • Regenerative Materials

have been developed for various uses, includ- ing the treatment of diabetic, chronic, and burn wounds (Table 1). In practical terms, both cellular and acellular biological skin substitutes have proven useful in difficult-to-treat burn reconstructions. 6–8 However, because it only functionally serves to replace the dermal layer, epidermal coverage in the form of a split-thickness skin graft is still needed. Regard- less, numerous studies have demonstrated that the addition of acellular dermal matrix use in this setting results in a faster healing time, 9,10 bet- ter aesthetic outcome with improved skin elastic- ity, and reduced scar contracture 11–19 ; can serve as a temporizing measure to avert the need for emergency surgery 19 ; and allows improved mobil- ity and function of joints that require skin cover- age. 10,12–14,18 Although there are clear benefits to its use, acellular dermal matrix will never serve as a complete replacement for autologous tissue trans- fer in this setting, and more prospective data are needed (Table 2). 6,9–54

Certain techniques, such as meshing of skin substitutes combined with negative-pressure wound therapy, have improved take of these grafts and ensured improved outcomes. The products in Table 3 address acellular dermal matrix types that are used for other diverse soft-tissue applications that include, but are not limited to, abdominal and thoracic wall reconstructions, breast recon- structions, and hernia repair. However, as with all indications with biomaterials, the cost-effective- ness and true benefits over traditional reconstruc- tive options have yet to be clearly defined. 55 ABDOMINAL WALL, BREAST, AND CHEST WALL RECONSTRUCTION Although first introduced as an adjunct for soft-tissue coverage in the setting of full-thick- ness burns, 50 the applications of acellular der- mal matrix have grown tremendously over the past two decades (Table 3). Its advantages over synthetic materials include an exogenous source

Table 1. Skin Substitutes Product Type Cell therapy  CellSpray (Avita Medical, Woburn, Mass.)

Structure

Application

Keratinocytes harvested in proliferating state and sprayed on wound bed

Partial-thickness and donor-site wounds

Cells plus scaffold/carrier  BioSeed-S (BioTissue Technologies, Freiburg, Germany)  Epicel (Genzyme Corp., Cambridge, Mass.)  MySkin (Altrika, Sheffield, United Kingdom)  VivoDerm (ER Squibb and Co., Princeton, N.J.)  Dermagraft (Advanced BioHealing, Inc., LaJolla, Calif.)  Hyalograft 3D (Fidia Advanced Biopolymers, Padova, Italy)  Transcyte (Advanced BioHealing)  Apligraf (Organogenesis, Inc., Canton, Mass.)  OrCel (Ortec International, Inc., New York, N.Y.)  Biobrane (Smith & Nephew, Hull, United Kingdom)  EZ Derm (Genzyme Corp., Cambridge, Mass.)  Integra (Integra LifeSciences Corp., Plainsboro, N.J.)  OASIS Wound Matrix (Cook Medical, Inc., Bloomington, Ind.) Biomaterial alone  AlloDerm (LifeCell Corp., Branchburg, N.J.)

Autologous keratinocytes in fibrin glue Venous leg ulcers

Cultured autograft of keratinocytes cultured for 3 wk Cultured autograft of keratinocytes

Deep dermal and full-thickness burns

Partial-thickness burns; skin graft sites; diabetic, pressure, and neuropathic ulcers Partial-thickness burns, venous and pressure ulcers Diabetic foot ulcers, epidermolysis bullosa Full- or partial-thickness wounds, scleroderma ulcers Full- and partial-thickness burns Venous, diabetic, and pressure ulcers; pyoderma gangrenosum; vasculitic ulcers; scleroderma; donor sites Split-thickness donor sites, epidermolysis bullosa, and venous and diabetic ulcers Full-thickness wounds, burns, in cosmetic and reconstructive surgery Partial-thickness burns and donor sites Partial-thickness burns; diabetic, pressure, and neuropathic ulcers Deep partial-thickness and full-thickness burns, postsurgical wounds, diabetic ulcers Partial- and full-thickness burns; diabetic, venous, and pressure ulcers

Autologous keratinocytes on hyaluronic acid material Fibroblasts from neonatal skin on biodegradable polyglactin mesh Autologous fibroblasts on hyaluronic acid matrix Allogenic human dermal fibroblasts on nylon mesh of Biobrane Bovine collagen and human keratinocytes from human neonatal foreskin

Neonatal fibroblasts and keratinocytes on cross-linked bovine collagen

Cadaveric acellular dermal matrix

Porcine collagen

Cross-linked porcine collagen

Acellular silicone epidermal substitute over dermal scaffold of collagen and chondroitin-6-sulfate Porcine small intestine submucosa

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