2017-18 HSC Section 4 Green Book

Plastic and Reconstructive Surgery • June 2015

Abdominal Wall Complex abdominal wall defects including large hernias and fistulas remain a significant challenge for the reconstructive surgeon. The use of traditional synthetic materials such as polypro- pylene, polyethylene terephthalate, and polytet- rafluoroethylene has lost favor to the lightweight absorbable or partially absorbable materials that include polyglactin (Vicryl; Ethicon, Inc., Somer- ville, N.J.) or poliglecaprone. 56 Unfortunately, none of these materials is particularly well-suited for abdominal wall reconstruction when dealing with a contaminated field where its removal is required in 50 to 90 percent of cases. 45 In addi- tion, complications are extensive and include the risk of visceral adhesions, fistula formation, infection, seroma, and skin breakdown. 44 In this setting, acellular dermal matrix has emerged as a viable alternative. A group in The Netherlands conducted a systematic review of 25 studies on the use of bio- logical grafts in ventral hernia repair and found that the overall recurrence rate was 13.8 percent and depended on the type of wound; however, that number jumped to 23.1 percent if the bio- logical grafts were placed in a contaminated field. Interestingly, of the 15.9 percent of infected grafts encountered, graft removal was required in only 4.9 percent of the cases. 49 Complications are inevitable when deal- ing with complex and contaminated abdominal wounds. There is wide variation reported in the literature, but in one review comparing the out- comes of different biological meshes, Bellows et al. reported an incidence of at least one compli- cation in 87 percent of cases. Unfortunately, this literature review is limited by the lack of a stan- dardized procedure reporting on studies that used varied techniques, including overlay, underlay, sandwich, bridging, and interposition. The most common complications include infection, seroma formation, recurrence, enterocutaneous fistulas, and dehiscence. 47 Currently, there appears to be a trend toward the use of xenograft (animal-derived matrix) over allograft (human-derived matrix) in various complicated settings, with some sug- gesting an observed decrease in the incidence of recurrence and infection. 46–49 Despite these find- ings, it is evident that randomized, prospective trials are needed to reveal the true benefit of a medical device that costs anywhere from $2845 to $5311 per 150 cm 2 . 49 The most comprehensive studies and reviews to date are all composed of Level III evidence (Table 2). The true integrity of acellular dermal matrix (as opposed to synthetic

Table 2. Relevant Studies by Application and Levels of Evidence

Level of Evidence

Reference Chest wall

IV IV III

 Tuggle et al., 2004 20  Von Wattenwyl et al., 2011 21  Lin et al., 2012 22  Rocco et al., 2012 23  Miller et al., 2013 24  Basu et al., 2010 25  Salzberg et al., 2011 26  Hester et al., 2012 30  Kim et al., 2012 31  Ibrahim et al., 2013 32  Cayci et al., 2013 33  Spear et al., 2014 34  Tessler et al., 2014 35  Mesimaki et al., 2009 36  Sherris and Oriel, 2011 37  Meara et al., 2012 38  Shiridharani et al., 2012 39  Yoshioka et al., 2012 40  Jansen and Macadam, 2011 27  Sbitany and Sirletti, 2011 28  Glasberg et al., 2012 29  Gunarajah and Samman, 2013 41

V

III

Breast

III III III III III III III III III IV IV IV IV III III III V III III III III IV IV IV IV IV IV IV V V V IV III V

Craniofacial

 Sandor et al., 2013 42  Fulco et al., 2014 43  Leber et al., 1998 44  Cavallaro et al., 2010 45  Beale et al., 2012 46  Bellows et al., 2013 47  Iacco et al., 2013 48  Slater et al., 2013 49  Lattari et al., 1997 9  Tsai et al., 1999 10  Chen et al., 2008 13  Jiong et al., 2010 14  Yim et al., 2010 18  Askari et al., 2011 6  Pan et al., 2011 15  Tang et al., 2011 17  Chen et al., 2012 11  Chen et al., 2013 12  Pirayesh et al., 2014 16  Zhang et al., 2014 19  Brown et al., 2011 51  Schutz et al., 2012 52   Kølle et al., 2013 53  Ozturk et al., 2013 54

Abdominal wall

Dermal substitutes and burn wounds  Wainwright, 1995 50

V II II

IV

Cosmetic

I

IV

I

IV

of biocompatible tissue when transferable autol- ogous tissue has been exhausted, improved resistance to infection and increased durability when placed in a contaminated field, 2 and the ability of the tissue to integrate and adapt dur- ing remodeling that occurs during the growth phase. Despite these advantages, acellular der- mal matrix is associated with its own set of com- plications and high costs.

3