Refinement of Deep Nasolabial Fold by Soft Tissue Augmentation

A nasolabial fold is one of the most typical process on an aged face. Face lifting, one of the frequent methods of correcting nasolabial folds, involves innate burdens as it is a form of surgery and involves many difficulties related to the surgical procedure in improving the nasolabial fold. Therefore, soft tissue augmentation is increasingly being performed on nasolabial folds. We achieved a good outcome and a high level of patient satisfaction after correcting a nasolabial fold using Surederm(TM), AlloDerm(R), and a autologous fat strip. From October 2002 to December 2010, a total of 19 patients have inserted Surederm(TM), AlloDerm(R) and a autologous fat strip in nasolabial fold using our special instrument. Sex, age, patient's satisfaction, and side effects were examined and the outcome was assessed by two plastic surgeons, excluding these authors, in a blind manner by comparing the nasolabial fold in the pre- and post- treatment pictures. Of the 19 patients, 1 was male and 18 were female. Their mean age was 45 years(range: 21~61 years). They showed a relatively high level of satisfaction with the outcomes. In one patient, although the Surederm(TM) was removed due to infection, the patient's deep nasolabial fold was corrected even after the Surederm(TM) removal. The two plastic surgeons judged that the nasolabial folds of the 19 patients improved considerably. Our procedure is more invasive than filler or fat injection. But with this procedure, augmentation effect can be lasting longer. So, the outcome was satisfactory.

Reconstruction of Burn Scar Contracture with Split-Thickness Skin Graft Taken from the Scalp and Alloderm(R): Case Report

A 13 year old male patient had limitation of foot motion due to burn scar contracture on right ankle area. The scar contracture was released and Alloderm(R) was applied over the raw surface. Split thickness skin was harvested from the scalp and harvested skin was applied over Alloderm(R). Epithelialization of donor site began from the post-op 5th day. Graft was well taken without any problem. There was no complications during 6 months of follow-up period.

Reconstruction of the Bone Exposed Soft Tissue Defects in Lower Extremities using Artificial Dermis(AlloDerm(R))

PURPOSE: In extensive deep burn of the lower limb, due to less amount of soft tissue, bone is easily exposed. When it happens, natural healing or reconstruction with skin graft only is not easy. Local flap is difficult to succeed, because adjacent skins are burnt or skin grafted tissues. Muscle flap or free flap are also limited and has high failure rate due to deep tissue damage. The authors acquired good outcome by performing one-stage operation on bone exposed soft tissue defect with AlloDerm(R)(LifeCell, USA), an acellular dermal matrix producted from cadaveric skin. METHODS: We studied 14 bone exposed soft tissue defect patients from March 2002 to March 2009. Average age, sex, cause of burn, location of wound, duration of admission period, and postoperative complications were studied. We removed bony cortex with burring, until conforming pinpoint bone bleeding. Then rehydrated AlloDerm(R)(25/1000 inches, meshed type) was applicated on wound, and thin split thickness(6-8/1000 inches) skin graft was done at the immediately same operative time. RESULTS: Average age of patients was 53.6 years(25 years-80 years, SD=16.8), and 13 patients were male (male:female=13:1). Flame burn was the largest number. (Flame burn 6, electric burn 3, contact burn 4, and scalding burn 1). Tibia(8) was the most affected site(tibia 8, toe 4, malleolus 1, and metatarsal bone 1). Thin STSC with AlloDerm(R) took without additional surgery in 12 of 14 patients. Partial graft loss was shown in four cases. Two cases were small in size under 1x1cm, easily healed with simple dressing, and other two cases needed additional surgery. But in case of additional surgery, granulation tissue has easily formed, and simple patch graft on AlloDerm(R) was enough. Average duration of admission period of patients without additional surgery was 15 days(13-19 days). CONCLUSION: AlloDerm(R) and thin split thickness skin graft give us an advantage of short surgery time and less limitations in donor site than flap surgery. Postoperative scar is smaller compared to in conventional skin graft because of firmer restoration of dermal structure with AlloDerm(R). We propose that AlloDerm(R) and thin split thickness skin graft could be a solution to bone exposured soft tissue defects in extensive deep burned patients on lower extremities, especially when adjacent tissue cannot be used for flap due to extensive burn.

An experimental study and case analysis of acellular dermal matrix implantation for restoration of soft tissue defects

Usefulness of acellular dermal matrix graft on the tissue regeneration in rabbits

PURPOSE: The present study was aimed to examine the effect of acellular dermal matrix (AlloDerm(R)) grafted to the experimental tissue defect on tissue regeneration. MATERIALS AND METHODS: Male albino rabbits were used. Soft tissue defects were prepared in the external abdominal oblique muscle. The animals were then divided into 3 groups by the graft material used: no graft, autogenous dermis graft, and AlloDerm(R) graft. The healing sites were histologically examined at weeks 4 and 8 after the graft. In another series, critical sized defects with 8-mm diameter were prepared in the right and left iliac bones. The animals were then divided into 5 groups: no graft, grafted with autogenous iliac bone, AlloDerm(R) graft, AlloDerm(R) graft impregnated with rhBMP-2, and AlloDerm(R) graft with rhTGF-beta(1). The healing sites of bone defect were investigated with radiologic densitometry and histological evaluation at weeks 4 and 8 after the graft. RESULTS: In the soft tissue defect, normal healing was seen in the group of no graft. Inflammatory cells and foreign body reactions were observed in the group of autogenous dermis graft, and the migration of fibroblasts and the formation of vessels into the collagen fibers were observed in the group of AlloDerm(R) graft. In the bone defect, the site of bone defect was healed by fibrous tissues in the group of no graft. The marked radiopacity and good regeneration were seen in the group of autogenous bone graft. There remained the traces of AlloDerm(R) with no satisfactory results in the group of AlloDerm(R) graft. In the groups of the AlloDerm(R) graft with rhBMP-2 or rhTGF-beta(1), there were numerous osteoblasts in the boundary of the adjacent bone which was closely approximated to the AlloDerm(R) with regeneration features. However, the fibrous capsule also remained as in the group of AlloDerm(R) graft, which separated the AlloDerm(R) and the adjacent bone. CONCLUSIONS: These results suggest that AlloDerm(R) can be useful to substitute the autogenous dermis in the soft tissue defect. However, it may not be useful as a bone graft material or a carrier, since the bone defect was not completely healed by the bony tissue, regardless of the presence of osteogenic factors like rhBMP-2 or rhTGF-beta(1).

Usefulness of acellular dermal matrix graft on the tissue regeneration in rabbits

PURPOSE: The present study was aimed to examine the effect of acellular dermal matrix (AlloDerm(R)) grafted to the experimental tissue defect on tissue regeneration. MATERIALS AND METHODS: Male albino rabbits were used. Soft tissue defects were prepared in the external abdominal oblique muscle. The animals were then divided into 3 groups by the graft material used: no graft, autogenous dermis graft, and AlloDerm(R) graft. The healing sites were histologically examined at weeks 4 and 8 after the graft. In another series, critical sized defects with 8-mm diameter were prepared in the right and left iliac bones. The animals were then divided into 5 groups: no graft, grafted with autogenous iliac bone, AlloDerm(R) graft, AlloDerm(R) graft impregnated with rhBMP-2, and AlloDerm(R) graft with rhTGF-beta(1). The healing sites of bone defect were investigated with radiologic densitometry and histological evaluation at weeks 4 and 8 after the graft. RESULTS: In the soft tissue defect, normal healing was seen in the group of no graft. Inflammatory cells and foreign body reactions were observed in the group of autogenous dermis graft, and the migration of fibroblasts and the formation of vessels into the collagen fibers were observed in the group of AlloDerm(R) graft. In the bone defect, the site of bone defect was healed by fibrous tissues in the group of no graft. The marked radiopacity and good regeneration were seen in the group of autogenous bone graft. There remained the traces of AlloDerm(R) with no satisfactory results in the group of AlloDerm(R) graft. In the groups of the AlloDerm(R) graft with rhBMP-2 or rhTGF-beta(1), there were numerous osteoblasts in the boundary of the adjacent bone which was closely approximated to the AlloDerm(R) with regeneration features. However, the fibrous capsule also remained as in the group of AlloDerm(R) graft, which separated the AlloDerm(R) and the adjacent bone. CONCLUSIONS: These results suggest that AlloDerm(R) can be useful to substitute the autogenous dermis in the soft tissue defect. However, it may not be useful as a bone graft material or a carrier, since the bone defect was not completely healed by the bony tissue, regardless of the presence of osteogenic factors like rhBMP-2 or rhTGF-beta(1).

Acellular Dermal Allograft Transplantation in Patients with Scleromalacia After Pterygium Excision

PURPOSE: To report two cases of successful acellular dermal allograft transplantation for scleromalacia following pterygium excision. CASE SUMMARY: A 72-year-old female patient developed scleromalacia on the nasal side of the right eye, and a 79-year-old female patient developed scleromalacia with inflammation on the nasal side of the left eye. They had previous histories of pterigia removal on the sites of scleromalacia. Acellular dermal allograft (AlloDerm(R), Lifecell, NJ, USA) transplantations were done. After the operations, inflammation and pain ameliorated and the grafts survived without any particular complications. CONCLUSIONS: In treating scleromalacia, the transplantation of acellular dermal allografts produced relatively satisfactory results without undesirable problems commonly encountered when using conventional materials.

Consideration of Necrotizing Fasciitis

PURPOSE: A necrotizing fasciitis is a rare, but insidiously advancing fatal soft tissue infection characterized by extensive fascial necrosis. Diagnosis & treatment of this disease are difficult. Necrotizing fasciitis tend to begin with constitutional symptoms of fever and chills. Quite a many lab studies and imaging studies such as standard radiography, computerized tomography can be used, but nothing can confine the extent of affected tissue. Aggressive surgical interventions are often required because of large skin and soft tissue deformity. However, many patients with necrotizing fasciitis are not healthy enough to overcome aggressive surgical intervention. METHODS: Since 2000, we treated 10 patients with necrotizing fasciitis. In 4 patients, we used magnetic resonance imaging(MRI) as a tool for diagnosis as soon as necrotizing fascitiis was doubted. We treated patients with delayed coverage with Alloderm(R) & split thickness skin graft or delayed wound closure in as many cases as possible. RESULTS: In 4 patients using preoperative MRI, diagnosis could be made in earlier stage of the disease compared to other patients. Our treatment modality was debridement and coverage with Alloderm(R) & split thickness skin graft. We could reconstruct deformities without significant limitation of movement in 7 cases. CONCLUSION: We diagnosed and treated 10 necrotizing fasciitis with MRI and Alloderm(R) graft, and results were good.

Histologic Changes and Photographic Analysis of AlloDerm(R) at Tip Plasty of the Nose

AlloDerm(R) is human cadaveric dermis that has been decellularized. It is easy to handle and simple to use, and has superb tissue compatibility; hence it has been used in several fields. But studies about the effect and the histologic changes of AlloDerm(R) in soft tissue augmentation are lacking. We measured the heights of pronasale and supretip breakpoint through Pre-and post- operative photographs in 13 patients who had undertaken AlloDerm(R) tip plasty surgery from April 2004 to July 2005. Histologic changes were investigated by H&E and CD34 immunochemistry staining of tissue samples from 10 patients who had AlloDerm(R) removed by re-operative procedures from January 2005 to March 2006. The result of photographic analysis is as follows supratip breakpoint heights were 2.43+/-0.36, 2.64+/-38, 2.52+/-0.38mm in the pre-operative(T1), early post-operative(T2) and late post-operative(T3) periods, respectively. Pronasale heights were 2.68+/-0.33, 2.93+/-0.44, and 2.79+/-0.38mm, respectively. Statistical analysis of corrective value of T1-T2, T2-T3 and T1-T3 revealed a statistically significant difference in both pronasale and supratip breakpoint heights. Histological analysis showed chronic inflammatory signs with foreign body reactions around grafted AlloDerm(R). We concluded that AlloDerm(R) neovascularization and fibroblast ingrowth were also noted. AlloDerm(R) is effective in raising the nasal tip, but considering the late-term partial absorption, an overcorrection of about 50% is recommended.

Augmentation Rhinoplasty Combined with Tip Plasty Using AlloDerm(R)

Because the Korean nose has a flat dorsum and depressed tip, tip projection procedure has frequently been performed as an ancillary procedure of dorsal augmentation. Although various materials have been used for tip plasty, an ideal technique has not yet been described. The authors performed classic augmentation rhinoplasty using a silicone implant to correct flat dorsum. Alloderm(R)(Life Cell Corporation, the Woodlands, Texas), acellular human dermis, was used for soft and smooth projection of the nasal tip. From January of 2000 to August of 2003, 20 patients underwent this procedure in Department of Plastic and Reconstructive Surgery. The patients were followed up for 2 to 26 months. Postoperative course was uneventful. Although partial graft resorption was noted in 3 patients, long-term follow-up showed good results. Alloderm(R) usage for tip plasty allows natural contour of the nasal tip, decreases donor site morbidity, and obviates time consuming procedures for graft harvesting. In conclusion, Alloderm(R) graft could be an appropriate alternative in tip projection procedure.

Management of Exposed Hydroxyapatite Implant with Acellular Dermal Allograft

PURPOSE: To evaluate the clinical effect of AlloDerm(R) graft on the management of exposed hydroxyapatite orbital implants. METHODS: Seven eyes of 7 patients with large exposure of hydroxyapatite orbital implants were included. After the spicules of hydroxyapatite implants were smoothened with a drill, AlloDerm(R) was applied to the exposed site and sutured with 8-0 Vicryl. One or two layers of amniotic membrane were transplanted on the AlloDerm(R) graft. RESULTS: All patients underwent the drilling, and the mean intervals from drilling to exposure was 73.4 +/- 46.6 months. The mean follow-up period was 11.17 +/- 2.0 months (range, 9-14 months). Complete conjunctival epithelization occurred in 3 eyes, and partial conjunctival epithelization in 3, including one eye which underwent reoperation with AlloDerm(R). In one eye which had been associated with previous infection, hydroxyapatite was removed due to progressive exposure and inflammation of the implant. CONCLUSIONS: AlloDerm(R) graft is useful in the management of exposed hydroxyapatite implant.

Sensory Recovery After Skin Graft Using Allogenic Dermis

It is well known that the thicker dermis is grafted, the lesser adhesion and contracture can be resulted. In spite of all advantages, thicker layer of dermis can also cause pain, infection, hypertrophic scar and delayed healing at the donor site. In addition, full thickness skin graft can result in best quality in recipient site, but it is limited in donor site and harvested size. Processed allogenic dermis(Alloderm(R)) has been developed and applied to solve the above-mentioned problems as permanent dermal augmentation for full thickness skin defect. From March 2002 to December 2003, we have applied allogenic dermis (Alloderm(R)) and ultra-thin split thickness skin graft on 30 patients (Group A) who had hypertrophic scar, 3rd degree burn, full thickness skin defect and various cosmetic problems. The control patients (Group B) are treated by conventional autologous thick split thickness skin graft only. We evaluated wound contracture, degree of sensory recovery, color change, functional and histological aspect between Group A and B. In Group A, by providing a dermal augmentation, the grafted dermal matrix permitted a thin autograft from the donor site. The harvested ultra-thin split-thickness skin remained fewer complications on the donor site and had faster healing process. And allogenic dermis exhibited excellent elastisity and good pigmentation with minimal scarring and wound contracture. But in sensory reinnervation study, Group A was not fully recovered compared to the conventional skin graft in Group B. In histological study, small nerve fiber bundles are scattered in the mid-dermis of processed allogenic dermis in Group A, but in Group B nerve fiber bundles extended into the upper dermis. Most nerve fibers were not sufficiently innervated into upper dermis in allogenic dermis because it was assumed that allogenic dermis play an important role as a barrier. In conclusion, if we perform ultra-thin split thickness skin graft using an allogenic dermis, wounds can be covered in a single stage with an adequate layer of dermal augmentation with minimal donor site morbidity, and we can also get good functional recovery, and avoid undesirable complications. However, application of allogenic dermis in the important area of sensation, such as hands and feet, should be conservative at present. Further scientific refinement is necessary for the improvement of sensory recovery in using allogenic dermis and a large scale experimental study should be performed.

Reconstruction of Injured Muscle Roll of Lower Eyelid with Alloderm(r)

The periorbital region including upper and lower eyelids is a decisive area for attractive appearance. Therefore, the blepharoplasty is one of the most frequent facial plastic surgeries performed today. In the lower eyelids region, the orbicularis oculi muscle roll gives young, charming and cute impression in general. However, in the process of lower blepharoplasty, the muscle roll can be often injured or damaged by a surgeon. In this case, the patients can complain about the loss of muscle roll and unnaturalness, Yet, the literature for reconstruction of injured muscle roll can be hardly found. By this point, we would like to introduce the methods and results of using Alloderm(R) in reconstruction of orbicularis oculi muscle roll damaged after lower blepharoplasty. From June, 2000, to May, 2002, we had reconstructed orbicularis oculi muscle roll of lower eyelids by implanting rolled Alloderm(R) in subcutaneous tunnel for 10 patients. It satisfied the patients and the revision was not performed. The reconstruction of injured muscle roll with Alloderm(r) after lower blepharoplasty is not only a simple procedure but also provides satisfactory.

Formation of Philtral Column using AlloDerm(R) in Secondary Cleft Lip Deformity

It is essential to reconstruct philtral column correctly during cheiloplasty because philtrum has an important role in facial contouring and cosmetics of the human face. Regarding to the appropriate time of the philtral reconstruction, it is generally accepted that Millard rotation- advancement flap at the primary cheiloplasty has the advantages of decreasing tension and obtaining a remnant skin. But, many surgeons still have a tendency to reconstruct the philtrum during secondary cheiloplasty. From June 2000 to June 2001, at department of plastic and reconstructive surgery of Chonnam National University Hospital, 20 patients of secondary cleft lip and nasal deformity who previously received primary cheiloplasty were reconstructed the philtral column with acelluar human dermis(AlloDerm(R)) In conclusion, this technique have the several advantages such as simplicity, shorter operation time, absent donor site scar and effectiveness, compared with other surgical methods.

Vermilion Augmentation of Secondary Cleft Lip and Nose Deformity by AlloDerm(R)

Secondary deformities can exist after repair of cleft lip by sophisticated method of primary cheiloplasty and can affect some or all of the previously cleft regions. There may be lip scar, nasal deformity, vermilion deficiency, and maxillary hypoplasia. The correction of secondary cleft deformities is difficult and requires efforts of a multidisciplinary team. There are many operative techniques for correction of the vermilion deficiency, for example double V-Y advancement mucosal flap or double pendulum flap etc. But, these methods are very complex and can remained the scar on vermilion. Twenty six patients of secondary cleft lip and nose deformity with vermilion deficiency were operated in our department from January 1999 to June 2002. The secondary cleft lip and nose deformity was corrected by various operative methods, and the vermilion deficiency corrected by using acellular human dermis(AlloDerm(R), Life Cell Corp., Woodlands, Texas). The three cases suspected for AlloDerm(R) to be absorbed showed that the augmentation of vermilion was poor but another cases showed satisfactory result with good augmentation of vermilion and minimal scar. In conclusion, vermilion augmentation using AlloDerm(R) has the several advantages such as simplicity, shorter operation time, and effectiveness compared with other surgical methods.

Reevaluation of Medial tarsorrhaphy in the management of paralytic ectropion / 나학회지

Paralytic lagophthalmos and ectropion in the treatment of leprosy patients are serious complications of facial paralysis, which may lead to exposure keratitis and corneal ulceration, which can further lead to blindness. In 1995, 1997, 1999 and 2001, we reported in this journal on the surgical treatment of paralytic lagophthalmos and ectropion. In the 1st report, made in 1995, for lid closing, I (Ahn) performed various methods of traditional surgery such as temporal muscle transfer, medial and lateral canthoplasty, as well as gold implantation. In the 2nd report, made in 1997, we (Ahn and Park) presented a combination treatment of gold plate with minor changes of design and weight in the upper lid and medial canthoplasty with horizontal shortening in the lower lid. In the 3rd report, made in 1999, we described an additional graft of conchal cartilage in the lower lid. However, the lateral end of the cartilage would warp and create new partial ectropion several months later. Therefore, we shifted from cartilage to Alloderm(R), acellular dermal graft. In the 4th report, made in 2001, we reported that Alloderm(R) is a good substitute for the cartilage and is also an effective volume filler to the atrophic lower lid. The medial portion of the lower lid often presented with a recurrence of the ectropion, despite having tightened the bilateral plication of the medial and lateral canthal ligaments with an Alloderm(R) graft in the inferior border of the tarsus. In order to treat the recurring ectropion, a modified permanent tarsorrhaphy was performed. We have noted that a modified permanent tarsorrhaphy on the medial canthal area in Z-plasty successfully corrected the partial ectropion and resulted in decreased epiphora and increased esthetic satisfaction.

Palatoplasty with AlloDerm(R) Graft

Recently, Furlow's palatoplasty, intravelar veloplasty and other procedures have become popular for cleft palate. However, the push-back method holds an important position among the various palatoplasties because it is safe and reliable. Previous reports have shown that normal or nearly normal speech is attained in between 70 and 90 percent of the patients of push-back method. Early palatoplasty might influence maxillary growth more than late palatoplasty. There are some problems after operation of push-back method. The raw surface causes bleeding, pain, poor oral intake, growth interference for scar contracture and tension on central suture line. This lateral defect can be closed directly but tension on central suture area is increased, and the risk of wound dehiscence is increased. We used AlloDerm(R) graft for covering of this bony exposed raw surface on both lateral palatal area. Thus exposed surface was protected by AlloDerm(R) graft and then patient suffered from pain less than conventional method. The bony surface was compressed by AlloDerm(R) and bleeding was not found after AlloDerm(R) graft. Patient was not irritable and intake of patient was good after operation. The recovery was faster than conventional push-back method.

Reconstruction of Soft Tissue Defects using Multilayer of Acellular Human Dermal Allograft and Terudermis

Classically autologous split-thickness skin graft or flap surgery has been applied to the case of full-thickness skin defects. However, simple skin graft causes postoperative adhesion and scar contracture, and flap surgery could cause functional and aesthetic trouble due to the scar at the donor site. It is well known that the thicker dermis is transplanted, the lesser adhesion and contracture can be resulted. In spite of all advantages, this thicker layer of dermis can also cause pain, infection, hypertrophic scar and delayed healing at the donor site. Two treatments have been developed and applied to solve the problems mentioned above: one is acellular dermal matrix(Alloderm(R)) and the other is Terumo(R) as a silicon coated artificial dermis on the complex of fiberized collagen from calf skin and athecollagen. In the conventional treatment, skin graft is executed when one layer of Terumo(R) or Alloderm(R) is covered and its survival is sure. This method, however, showed certain limits in the appliance: delayed healing time, longer period of hospitalization and limits of dermis supplying, etc. We have applied multi-layer coverage of these materials with simultaneous or delayed skin graft to shorten healing time and to achieve a better effect of dermis. Among those who need flap surgery because of soft tissue defect, or when severe depression or scar contracture can be expected after surgery, a total of 13 cases have been studied: 7 multilayer Alloderm(R) graft with simultaneous thin split-thickness skin graft, and 6 multilayerTerumo(R) graft with delayed skin graft. In all cases, transplants were successful without any difficulties in healing process: no delayed healing time, no functional deficit as contracture, no contour deformity as depression or hypertrophy.

Management of the paralyzed ectropion by implanting the Alloderm(R) / 나학회지

Paralytic lagophthalmos and ectropion in leprosy are serious complications of facial paralysis, which may lead to expose keratitis, corneal ulceration, further lead to blindness. In 1995, 1997 and 1999, we had reported in this journal on the surgical treatment of paralytic lagophthalmos and ectropion. In the first report of 1995 for lid closing, I(Ahn) performed various method of traditional surgery such as temporal muscle transfer, medial and lateral canthoplasty as well as gold implantation. In the 2nd report of 1997, We(Ahn and Park) presented combination treatment of gold plate with minor change of design and weight in the upper lid and medial canthoplasty with horizontal shortening in the lower lid. In the 3rd report of 1999, We described an additional graft of conchal cartilage in the lower lid. However, the lateral end of the cartilage would warp and create new partial ectropion several months later. Therfore, we shifted from cartilage to Alloderm(R), acellular dermal graft. We applied it to the lower border of the tarsus instead of cartilage and fixed each end to medial and lateral canthal ligaments respectively. We think Alloderm(R) is a good substitute for the cartilage and is an effective volume expander to the atrophic lower lid.

Clinical Experiences in Reconstruction of Postburn Scar Contractures Using AlloDerm(R)

No abstract available.