UNASSIGNED: Myelomeningocele is a severe and complex congenital malformation of the central nervous system. Failure of neural tube closure at around four weeks of gestation results in an open communication between the neural placode and the external environment with varied functional impairment. Surgery is usually required.
UNASSIGNED: The primary goals of surgical management are to preserve neural function and minimise infection. Reconstruction is dependent upon the site and size of the defect as well as the quality of the surrounding soft tissues. Surgeons may employ a range of reconstructive techniques in order to achieve closure. Skin substitutes, also known as dermal regeneration templates, have also been utilised.
UNASSIGNED: In our unit, we use NovoSorb Biodegradable Temporising Matrix to reconstruct full-thickness skin and soft tissue defects. It is a synthetic, biodegradable, dermal regeneration template, composed of polyurethane foam bonded to a transparent sealing membrane and typically requires a two stage reconstruction. Integration and vascularisation take approximately three weeks. After this time, the recipient wound bed is suitable for split thickness skin grafting. A further benefit of dermal regeneration templates is the possibility of \'stacking\' layers, which serves to increase the thickness of the final construct and to minimise overall contour defects. The authors present the case of a one-day-old full-term neonate with a large lumbosacral myelomeningocele that was successfully managed with staged, stacked NovoSorb Biodegradable Temporising Matrix and split thickness skin grafting. The authors believe this is the first case in which a \'stacked\' dermal regeneration templates has been used to achieve healing of a primary myelomeningocele defect.
UNASSIGNED: Background: NovoSorb Biodegradable Temporising Matrix (BTM) is a dermal regeneration template (DRT) and is used to reconstruct wounds following full-thickness skin and soft tissue loss resulting from burn injury, trauma, infection or surgery. It is composed of 2-millimetre thick, synthetic, biodegradable polyurethane foam bonded to a transparent (non-biodegradable) sealing membrane. Like all DRTs, it acts as a scaffold for cellular integration and vascularisation to eventually form a \'neo-dermis\'. This is usually apparent from around three weeks. A second stage procedure can then be performed, with removal of the outer sealing membrane and split thickness skin grafting of the vascularised layer.Objectives: Myelomeningocele is a severe and complex congenital malformation of the central nervous system and forms the group of anomalies commonly referred to as neural tube defects (NTDs). Neural tube closure usually occurs at around four weeks of gestation and failure to do so, results in an open communication between the neural placode and the external environment. The degree of functional impairment varies but can include: lower limb paralysis; sensory loss; bladder and bowel dysfunction. In order to preserve neural function and minimise the risk of infection, surgery is usually required to close the defect. Reconstruction is varied and is dependent upon the site and size of the defect as well as the quality of the surrounding soft tissues. The use of local flaps has the potential complication of skin necrosis. Muscle based flaps may be debilitating and limit future functionality and worsen postural development. We were presented with a one-day-old neonate with a large lumbosacral myelomeningocele. A DRT (NovoSorb BTM) was selected as the primary reconstruction. Firstly, selection provided relatively low risk, with minimal morbidity and preserved the full complement of flap based reconstructive options for a later stage should instrumentation be required. Secondly, NovoSorb BTM conferred a robust seal over the dural repair with no demonstrable cerebrospinal fluid leak. Thirdly, the ability to add layers (\'stack\') of NovoSorb BTM in stages, once integration and vascularisation of the previous layer is complete, allows reconstruction of deeper contour defects.Discussion: We have illustrated the successful use of NovoSorb BTM as a DRT to achieve closure of a large lumbosacral myelomeningocele without complication and with longstanding stability. We believe this technique provides reconstructive teams with an alternative option that is effective, safe and reproducible and which spares local tissues for future elective reconstructive procedures, should they be required.

Integra® (Integra LifeSciences) is a well-known dermal regeneration template used in partial and full-thickness wound reconstruction. It can be applied directly on to vascular tissue to create a bed for a skin graft, which is often placed in a second surgery. We present our experience of its novel use in oral and maxillofacial surgery patients, using it directly on bone and cartilage (avascular tissue) without further skin grafting. Patients who required full-thickness excision of lesions down to bone or cartilage and who were treated using Integra® were included. After scalp or ear lesion resection, the collagenous dermal layer of Integra® was placed directly on to bone or cartilage and, along with its outer silicone epidermal layer, secured to the defect with absorbable sutures and a bolster dressing. The wounds were kept dry for 14 days, at which point the dressing and silicone were removed and patients continued regular wound care. Seventeen patients were included, 15 of whom had squamous cell carcinoma. One was lost to follow up. The rest achieved complete healing of the defect. Histology showed epidermis developing on the Integra® surface and at one year, the appearance of normal scarred skin. This novel approach could redefine the uses of Integra®, avoiding the need for free-flap surgery or skin grafting when reconstructing large defects. Further resection of close margins or recurrence is easier after reconstruction using dermal regeneration material than after reconstruction with a local or free flap.

The clinical use of Integra™ has expanded to include scalp reconstruction since its FDA approval in 1996. Integra™, or dermal regeneration template, can be utilized in patients who are elderly with multiple medical comorbidities. Well-established Integra™ techniques utilize skin grafting 1-2 weeks following evidence of template vascularity. Most studies show the time to graft placement as <30 days, with almost all <52 days. No single article proposes a time frame for applying STSG after neodermis regeneration. Therefore, we aimed to describe our protocol to define a time frame for delaying scalp reconstruction with STSG following dermal regeneration. Over the last several years, the senior author has utilized a delayed reconstruction with skin grafting method where-in Integra™ is applied to either debrided bone or exposed pericranium in selected patients, and allowed to mature for ~6 weeks before performing skin grafting. The results have been predictable, reproducible, and have yielded high levels of patient and provider satisfaction due to the improved contour cosmesis. In this pictorial essay, the authors\' novel protocol is detailed.

UNASSIGNED: NovoSorbⓇ Biodegradable Temporizing Matrix (BTM) is a relatively novel, biodegradable polyurethane-based dermal regeneration template. The aim of this study was to evaluate the long-term scarring outcomes and safety of BTM in patients who underwent dermal reconstruction involving ≥5% of the total body surface area.
UNASSIGNED: This was a postmarket, multicenter, observational cohort study involving evaluation of long-term outcomes in patients treated with BTM. A total of 55 patients (35 from Royal Adelaide Hospital, South Australia, and 20 from Victoria Adult Burns Service, The Alfred, Victoria) who underwent dermal repair with BTM between 2011 and 2017 were screened for inclusion in this study. All patients had BTM implanted for ≥18 months.
UNASSIGNED: Fifteen eligible patients with a mean (SD) age of 49.1 (14.3) years completed study assessments. These patients had a total of 39 areas treated with BTM. Using the Patient and Observer Scar Assessment Scale, scar quality was reported to be good by both observers and patients, with a mean (SD) observer score across all lesions of 3.6 (1.2) and mean (SD) overall opinion of 3.8 (1.2) as well as a mean (SD) patient score of 3.5 (1.2) and overall opinion of 5.0 (2.2). No adverse events or adverse device effects were reported or identified.
UNASSIGNED: The long-term scar quality is comparable to published studies. BTM is safe in the long term with no additional risks or adverse consequences being identified.

Integra® Dermal Regeneration Template (IDRT, Integra LifeSciences, Princeton, NJ, USA) is a bilayer membrane developed, by Yannas and Burke in the 1980s, to fulfill the unmet need of surgeons having a readily available off-the-shelf dermal regeneration method. IDRT is composed of a sheet of porous cross-linked type I collagen and glycosaminoglycans, with a semi-permeable silicone sheet cover. IDRT is bio-engineered, from adult bovine Achilles tendons and chondroitin-6-sulfate derived from shark cartilage, in a multi-step process involving cross-linking using glutaraldehyde. By design, the composition, porosity, and biodegradation rate of IDRT guides the mechanism of wound repair towards a regenerative pathway. Its mechanism of action involves four distinct phases: imbibition, fibroblast migration, neovascularization, and remodeling/maturation. Originally developed for the post-excisional treatment of deep-partial to full-thickness burns where autograft is limited, over the years its use has expanded to reconstructive surgery.

UNASSIGNED: Absence of almost the entire reticular dermal layer is inherent to the use of autologous split-thickness skin grafting (STSG) to close full-thickness wounds, often resulting in hypertrophic scars and contractures. Many dermal substitutes have been developed, but unfortunately most have varying results in terms of cosmetic and/or functional improvement as well as patient satisfaction, in addition to high costs. Bilayered skin reconstruction using the human-derived glycerolized acellular dermis (Glyaderm®) has been reported to result in significantly improved scar quality using a two-step procedure. Unlike the necessary two-step procedure for most commercially available dermal substitutes, in this study we aimed to investigate the use of Glyaderm® in a more cost-effective single-stage engrafting. This is a method which, if autografts are available, is preferred by the majority of surgeons given the reduction in costs, hospitalization time and infection rate.
UNASSIGNED: A prospective, randomized, controlled, intra-individual, single-blinded study was performed, investigating the simultaneous application of Glyaderm® and STSG vs. STSG alone in full-thickness burns or comparable deep skin defects. During the acute phase, bacterial load, graft take and time to wound closure were assessed and were the primary outcomes. Aesthetic and functional results (secondary outcomes) were evaluated at 3, 6, 9 and 12 months follow-up using subjective and objective scar measurement tools. Biopsies for histological analysis were taken at 3 and 12 months.
UNASSIGNED: A total of 66 patients representing 82 wound comparisons were included. Graft take (>95%), pain management and healing time were comparable in both groups. At 1 year follow-up, the overall Patient and Observer Scar Assessment Scale assessed by the patient was significantly in favour of sites where Glyaderm® was used. Not infrequently, patients attributed this difference to improved skin sensation. Histological analysis showed the presence of a well-formed neodermis, with donor elastin present for up to 12 months.
UNASSIGNED: A single-stage bilayered reconstruction with Glyaderm® and STSG results in optimal graft take without loss of Glyaderm® nor the overlaying autografts due to infection. The presence of elastin in the neodermis was demonstrated during long-term follow-up in all but one patient, which is a crucial factor contributing to the significantly improved overall scar quality as evaluated by the blinded patients.
UNASSIGNED: The trial was registered on clinicaltrials.gov and received the following registration code: NCT01033604.

UNASSIGNED: Post ablative oral mucosal defect resulting from the removal of tumors can be treated with various techniques.
UNASSIGNED: In this paper, we are showing what, in our experience, are the advantages and disadvantages given using biosynthetic skin substitutes when dealing with this kind of lesions.
UNASSIGNED: Patients included in the sample came to our attention with both neoplastic lesions (11 subjects) and important scar retraction after previous oncologic surgery (1 subject). All patients underwent trans-oral resection surgery following the same surgical protocol and post ablative oral mucosal defect were treated using the dermal regeneration template. The surgical defect location, size, and time of removal of the silicone layer varied from one subject to the other.
UNASSIGNED: Most patients showed good healing with reduced scarring and adequate remucosalisation of the defect. The main complications were shown in a palatal lesion treated with concomitant osteal resection, which developed an oroantral fistula at follow up, and tongue lesions which showed some scarring.
UNASSIGNED: Given our experience, we would advise using dermal substitutes when reconstructing oral defects only after a cautious evaluation of the area of the lesion, the gap size, the possible adherence of the membrane to the gap, and the presence of tissue supporting the overlying membrane.

In older patients with facial basal cell carcinoma (BCC) or squamous cell carcinoma (SCC), surgery should be aimed to reduce treatment-related sequelae and burden with achieving local tumor care. Therefore, we adopted a two-step surgery (TSS) involving the application of a dermal regeneration template onto the skin defect after tumor resection and subsequent reconstruction by full-thickness skin grafting. We performed a detailed comparison of conventional one-step surgery (OSS) and TSS, including evaluation of local tumor curability, postoperative cosmetic and/or functional impairments, and patient burden. Forty-six patients who underwent TSS and 104 patients treated with OSS were retrospectively investigated. The cohort consisted of 77 men and 73 women (median age, 83 years). The BCC: SCC ratio was 56.7%: 43.3%. The tumor size and excision margin were significantly larger in the TSS group than in the OSS group (p = 0.03). The histopathological margin was positive after the first surgery in six cases, but was negative after additional resection in all cases, regardless of OSS or TSS. Local recurrence was not observed in this study. The frequency of postoperative sequelae (POS) in TSS was slightly lower than in OSS (17.4% vs. 27.9%, p = 0.16). A shorter average operation time per session was significantly associated with the location of the vertical defect [below adipose tissue vs. within adipose tissue, estimate: -0.28 (hour), p < 0.001] and surgical procedure [OSS vs. TSS, estimate: -0.13 (hour), p = 0.03] by multiple regression models. The ratio of general anesthesia was relatively lower in TSS than in OSS (9.8% vs. 17.3%, p = 0.12). Thus, TSS showed a good local curability and POS statistically equivalent to OSS, reducing the surgical burden, particularly shortening each operation time without any adverse events, despite the TSS group having significantly larger tumors than the OSS group. Since TSS is a simple procedure, it can be an outstanding option for facial BCC and SCC.

Patients can develop scalp and cranial defects as a result of neoplasm, trauma, or infection. Reconstruction of these defects can be difficult in some patients and may require a multidisciplinary approach using creative solutions usually used for disease processes in other areas of the body, such as severe burns.
A series of 9 patients were treated using multidisciplinary techniques for reconstruction of complex cranial and scalp defects. Data on patient characteristics, initial treatment, and preparatory and definitive reconstructive treatment were retrospectively collected. Outcomes were measured as full solution, partial solution, or failure.
Three patients had a full solution/wound closure, 5 had a partial solution, and 1 failed reconstructive attempt. Full solution patients tended to be younger, received reconstruction treatment modalities for longer periods of time, and had more definitive surgeries. Initial and preparatory surgeries did not tend to promote a full solution, though having fewer preparatory surgeries that were not related to wound vacuum-assisted closure use tended to be associated with a better outcome. Infection of the scalp or cranium did not tend to change the result.
Reconstructive salvage of complex cranial and scalp defects takes time, so patience and earlier recognition of need for atypical reconstruction is beneficial. Patient characteristics may influence outcomes, but judicious choice of materials and techniques is more critical to patient success. Use of a multidisciplinary approach to complex cranial and scalp reconstruction is a beneficial option for many patients for whom standard reconstruction methods are not viable.

BACKGROUND: Dermatofibrosarcoma protuberans (DFSP) is a rare skin fibroblastic tumor, with a high rate of recurrence. The treatment of DFSP is generally surgical, and wide local excision is the mainstay of surgical treatment. Therefore, complete assessment of all surgical margins is fundamental before definitive reconstruction. The reconstruction is a challenge for plastic surgeons, especially in particular anatomical areas (for aesthetic or functional problems) or in patients who are not candidates for more complex surgical treatments. We describe an alternative approach for reconstructive treatment of the lumbar area after wide excision of DFSP (without fresh-frozen sections) in a young obese woman with a history of smoking, using a new type of acellular dermal matrix (ADM) in a combined management protocol. The benefits of ADM are numerous: immediate wound closure and prevention of infections and excessive drying; minimal donor site morbidity; and good functional and aesthetic outcomes. Moreover, it is a temporary cover while the anatomical specimen is histologically analyzed, without donor site morbidity or prevention of any future surgery (if the margins are not tumor-free) or radiotherapy.
METHODS: In October 2019, a 34-year old obese Caucasian Woman with a history of smoking came to our institute for a multinodular growing polypoid mass in her lumbar region. An incisional biopsy diagnosed DFSP. The patient underwent proper staging. A wide local excision with 3 cm clinically healthy tissue margins down to the muscle fascia was performed and the defect was repaired using a combined approach with a new artificial bilaminar dermal template (Pelnac®, Gunze Ltd., Osaka, Japan) and a negative-pressure wound therapy system (V.A.C.®, KCI, San Antonio, USA). After the final histological examination revealed tumor-free margins, a split-thickness graft was harvested from the right gluteus and fixed to the new derma with negative-pressure wound therapy. Postoperative radiotherapy was not necessary. After 15 days, the wound had healed without complications, with satisfactory aesthetic outcome and with no limitation of back motion or pain. After 6 months of follow-up, the patient was free from disease.
CONCLUSIONS: This is the first reported case of Pelnac® use in DFSP reconstruction of the lumbar region. We believe that the multistep approach described herein may be a good alternative approach in selected patients with wide resections in particular anatomical areas, especially when frozen sections (with Mohs micrographic surgery) are not available.