Clinical application of a silk fibroin protein biologic scaffold for abdominal wall fascial reinforcement.

BACKGROUND: Preclinical studies have demonstrated that macroporous silk fibroin protein scaffolds are capable of promoting physiologically durable supportive tissue, which favors application of these engineered tissues for clinical implantation. The safety and effectiveness of a long-lasting, transitory, 510(k)-cleared purified silk fibroin biologic scaffold (SBS) are investigated for soft-tissue support and repair of the abdominal wall. METHODS: We conducted a multicenter retrospective review of all consecutive patients who underwent abdominal wall soft-tissue reinforcement with an SBS device between 2011 and 2013. Indications, comorbid conditions, surgical technique, complications, and outcomes were evaluated. RESULTS: We reviewed the records of 172 consecutive patients who received an SBS for soft-tissue support. Of those, 77 patients underwent abdominal wall fascial repair, with a mean follow-up of 18.4 ± 7.5 months. Procedures using an SBS included reinforcement of an abdominal-based flap donor site (31.2%), ventral hernia repair (53.2%), and abdominoplasty (15.6%). The overall complication rate was 6.5%, consisting of 2 wound dehiscences, 1 with device exposure, 1 seroma, 1 infection with explantation, and a perioperative bulge requiring reoperation. There were no reports of hernia. CONCLUSIONS: Postoperative complication rates after 18 months were low, and most surgical complications were managed nonoperatively on an outpatient basis without mesh removal. To our knowledge, this is the only series to report on a long-lasting, transitory SBS for abdominal wall repair and reinforcement. Procedure-specific outcome studies are warranted to delineate optimal patient selection and define potential device characteristic advantages.

The genioplasty and beyond: an end-game strategy for the multiply operated chin.

BACKGROUND: Genioplasty has been a useful and frequently employed technique. In previous publications, the authors discussed the benefits and versatility of the genioplasty. Here, they briefly examine the entire experience of the senior author, from 1975 to the present. METHODS: The authors examined a series of 580 genioplasties performed in 567 patients over a 28-year period by the senior author. This was done by chart review, which involved collection of demographic data and tabulation of the number of operations and type of genioplasty, as well as inspection of operative notes and clinical photographs. The focus was on the subgroup of patients who required multiple procedures to obtain a final satisfactory result. In one subgroup of patients, largely those with severe developmental or syndromic retrogenia, staged procedures were part of the original plan. A second subgroup included patients who had had problems with alloplastic chin implants; for these patients, further operations were not part of the original plan. RESULTSIn the first group of patients, with severe developmental or syndromic retrogenia, an osseous genioplasty was often associated with orthognathic surgery and could be repeated later as a staged procedure. In the second group of patients, who had multiple problems with alloplastic chin implants, an osseous genioplasty often provided the solution to difficult problems. CONCLUSIONS: In both groups of patients, an autogenous costal cartilage graft may be of great help after one has accomplished as much as one can with an osseous genioplasty. In rare cases, microsurgical free tissue transfer may be required.

Management of giant congenital nevi with artificial skin substitutes in children.

Giant congenital nevi are one of several skin conditions in the pediatric patient population whose treatment leaves the patient with large skin defects. The giant congenital nevus is a rare pigmented skin lesion that covers large skin areas or affects any major or difficult-to-treat region of the body, such as the face. Congenital nevi should be excised fully because of the increased risk for malignant transformation to melanoma, as well as cosmetic considerations. However, after excision patients are left with large wounds that are difficult to close. Traditionally these defects have been repaired with split-thickness skin grafts, full-thickness skin grafts, the use of tissue expanders, and a variety of flaps. However, each of these methods has its disadvantages and thus cannot be used in all cases. Recently, new methods have been developed for the closure of large skin defects in pediatric patients with the use of artificial skin substitutes. Advantages include coverage of large wounds, decrease or elimination of donor site pain and morbidity, and decreased scarring and wound contractures. The authors present these experiences through two case reports.

Use of skin substitutes in pediatric patients.

There are various artificial skin substitutes available commercially. The authors have used Integra, cultured epithelium, and Apligraf in their clinic. In the present report, they present their experiences based on two case reports. The first patient was a 12-year-old boy with widespread skin defects and left axillary contracture due to epidermolysis bullosa (EB). Apligraf was used to cover the skin defects on the trunk and face and to manage ectropion and axillary contracture. The second patient was a 6-year-old boy who suffered neurocutaneous melanosis. Partial excision of a pigmented lesion on the back created a large defect. Integra application followed by repair with cultured autologous skin was accomplished, and the results were satisfactory. Skin substitute products 1) are commercially immediately available; 2) are effective for management of contractures, chronic wounds, and chronic skin illnesses; 3) decrease or avoid the risk of donor area morbidity, which is more difficult to treat in children; 4) provide long-term coverage of the wound; and 5) can be used in conjunction with autologous tissue (e.g., Integra followed by cultured epithelium applications).