2017-18 HSC Section 4 Green Book

Volume 135, Number 6 • Regenerative Materials

Table 3. Acellular Dermal Matrix Types and Different Applications Product Type Derivation

Applications

AlloDerm

Human

Burn wounds, abdominal, chest wall, and breast reconstructions, craniofacial repairs, hand reconstruction Abdominal and breast reconstructions Abdominal wall and breast reconstruction, facial reconstruction Abdominal wall and breast reconstruction Abdominal wall reconstructions, burn wounds, hand reconstruction, eyelid reconstruction

Strattice (LifeCell)

Porcine Human Human Porcine

DermaMatrix (Synthes, West Chester, Pa.)

FlexHD (Ethicon, Inc., Somerville, N.J.) Permacol (Covidien, Mansfield, Mass.)

AlloMax (Bard, Warwick, R.I.) Breast reconstruction, hernia repair Surgimend PRS (TEI Biosciences, Inc, Boston, Mass.) Fetal bovine Hernia repair, muscle flap reinforcement Surgisis (Cook Medical) Porcine Abdominal and chest wall reconstructions, lip augmentation Human

materials) and its lack of elasticity, ability to with- stand constant tension, and capacity for full inte- gration into the abdominal wall have all been questioned. Although biological materials appear to have an advantage in the face of potential sepsis and an improved capacity for host incorporation, the major costs involved in their use have become the center of current discussions. Breast The use of acellular dermal matrix in breast reconstruction and augmentation is a frequently debated topic. The argument for its use is often related to the setting of inadequate tissue cover- age after cancer excision, particularly in providing implant coverage in the lower pole of the breast where full mobilization and coverage with muscle is often not possible. In addition, there is some evidence that acellular dermal matrix can reduce the incidence of capsular contracture, although this is still disputed, with most studies being case series, retrospective, noncomparative, and under- powered. 2,26,30,34,57 Biocompatibility is thought to account for the improved outcomes associated with acellular dermal matrix use. In a clinically relevant large-animal model of breast reconstruction, Garcia and Scott demonstrated histologically that acellular dermal matrix integrates into native tissue after 8 weeks, with good vascularization by week 12. 58 In the setting of second-stage breast recon- struction, acellular dermal matrix use increases the ability of the surgeon to define the inframam- mary fold and better position the implant. 2,25,59 In a retrospective review, Spear et al. demonstrated that acellular dermal matrix allowed for the repair of challenging reconstructions, including fold malposition, contracture, rippling, and symmas- tia. 34 Other observed advantages of acellular der- mal matrix use in breast reconstruction include improved rates and volumes of tissue expansion.

Reviews by Sbitany and Serletti 28 and Kim et al. 31 revealed that significantly greater intraoperative fill volumes were achieved with the use of acellular dermal matrix, although the latter study’s finding was not statistically significant. The former study also demonstrated that half the number of fills were required when using acellular dermal matrix (2.4 versus 5.1). 28 An additional study concluded that use of larger acellular dermal matrix leads to fewer numbers of fills required to reach final expansion volume, with no significant increase in complications. 33 Once again, acellular dermal matrix has proven useful in providing additional tissue and expanding reconstructive options; however, the debate continues as to whether or not this has come at an extra cost and with fewer complica- tions over autogenous or synthetic alternatives. Major series have been published, although none exhibits greater than Level III evidence (Table 2), and proponents appear to be on both sides of this discussion, making definitive conclusions impos- sible at this stage. 26,27,30–32,35 Chest Wall Intuitively, the use of acellular dermal matrix in pediatric chest wall reconstruction seems logi- cal because of its integrative properties; however, a significant résumé of implementation is lacking (Table 2). The first model of thoracic wall repair with biomaterials was described in 1991, when Rudolphy et al. performed reconstructions using processed sheep dermal collagen in dogs. 60 It was not until 2004 that Tuggle et al. reported the first cases in four children using copolymer plates composed of 82 l -lactic and 18 glycolic acid with favorable outcomes. 20 Because of the observed incidence of progressive scoliosis and restrictive lung disease after primary tissue repair or syn- thetic mesh, Lin et al. examined the outcomes

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