Extracellular matrix graft for reconstruction over exposed structures: a pilot case series
Soft tissue defects, especially those involving exposed vital structures, present a reconstructive challenge because poor vascularity of such defects typically makes immediate skin grafting unviable. Where flap procedures are inappropriate or not possible, dermal matrices represent an alternative reconstructive option for defects with denuded vital structures. With dermal matrices becoming increasingly available and technologically advanced, we evaluated an ovine-derived extracellular matrix graft in the reconstruction of complex soft tissue defects involving exposed vital structures.
Six cases of soft tissue defects exhibiting denuded vital structures underwent reconstruction using an ovine forestomach matrix graft as a dermal matrix. Grafts were fixed directly into defects for immediate coverage and subsequently temporised defects via granulation tissue formation for later skin graft or secondary closure. Defect granulation and epithelialisation were monitored until closure and the final aesthetic and functional outcomes were evaluated.
Complete healing was achieved in all cases, with defect granulation becoming observable within one to two weeks and complete granulation occurring within one to six weeks. Granulation tissue resulting from the graft was suitable for skin grafting, with 100% take of skin grafts after one week and complete re-epithelialisation in two to three weeks in the four cases that received a skin graft. Good cosmetic, functional and patient satisfaction outcomes were achieved in all cases.
The present series demonstrates our initial use of an extracellular matrix-based dermal matrix in reconstructing defects with exposed vital structures. While such dermal matrices do not supersede or replace flap procedures, they represent an alternative option on the reconstructive ladder in cases where flap procedures are not appropriate or possible.
Reconstruction of defects presenting denuded vital structures is challenging. Exposed vessels, nerves, tendons, joints and bone must be promptly covered but immediate closure via a split-thickness skin graft (STSG) is not always a viable option. If not covered with adequately perfused soft tissue, exposed vital structures are at high risk of desiccation, necrosis and/or infection, posing severe functional consequences.1 As exposed vital structures often have insufficient vascularisation to support an STSG, more complex surgical techniques from the reconstructive ladder are required.2 Flap reconstruction is typically employed for coverage of exposed structures and to provide definitive closure. Depending on the nature of the defect and surrounding tissues, flap reconstruction options can range from relatively straightforward fasciocutaneous flaps to free flaps requiring more complex microvascular surgery. Flap techniques are recognised as reliable options for reconstruction of complex defects but, depending on the specific defect, flap type and patient factors, flap reconstruction may be complicated by dehiscence, infection, thrombosis, seroma/haematoma, ischaemia and necrosis.3 Such complications require medical intervention to stabilise compromised flaps and additional surgery may be necessary to attempt salvage because flap failure has severe impacts on the reconstructive outcomes.
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