Page 75 - ARNM-2-2

Advances in Radiotherapy
& Nuclear Medicine Wound reconstruction with Intergra®

Once graft take was confirmed, the wound was dressed (3) to decrease animation deformities of skin grafting via
with dry dressing. The patient was able to proceed with the creation of a gliding plane on top of muscle. Rather
radiation when necessary once complete healing was than putting a skin graft directly on muscle, using the RDM
achieved. Wounds that remained closed post-radiation to create a neodermis allows us to replace like with like.
underwent routine graft care. If evidence of wound After the application of RDM, a wound vacuum-
breakdown or radiation-induced necrosis was noted, flap assisted closure (VAC) was applied and the patient was
closure would be pursued.
discharged home the following day. He returned to the
3. Presentation of cases clinic on post-operative day 5 for his first VAC change,
which was uncomplicated. The patient proceeded to
Four female patients and two male patients with multiple undergo home VAC changes performed by a visiting nurse
comorbidities, ranging in age from 62 years to 88 years, every 2 – 3 days. Three weeks after the index procedure,
were included in this study. Our cases included three the patient returned to the clinic again for a VAC change
patients with breast defects, of which two patients had and planned removal of the silicone layer (Figure 1C).
lower extremity defects and the other one had a large Excellent integration of the matrix was observed, but
chest wall defect. The original defects ranged in size from persistent contour irregularity existed. To encourage
4 × 8 cm to 25 × 32 cm with various exposed structures additional granulation tissue ingrowth and minimize
(Table 1). Our algorithm was applied before radiotherapy contour irregularity, the wound VAC was reapplied and
in four cases and after radiotherapy in two cases. Graft size skin grafting was delayed by 1 week.
ranged from 3 × 5 cm to 19 × 19 cm. Five of our patients
had a skin graft take rate of 100% and the remaining case After returning to the operating room (OR) for the
had a 95% skin graft take rate. One case also showed wound split-thickness skin grafting (STSG) (Figure 1D), the
formation during radiation that subsequently healed. Split- wound VAC was applied once more and removed 5 days
thickness skin grafting was performed after approximately later. The patient was found to have a near complete
4 weeks for the majority of cases. Follow-up was conducted (95%) take of the graft with only a very small area of
on the patients, ranging from 3 months to 2 years. No slough in the most superior portion of the wound within
major adverse events were seen in this group of patients. the axilla (Figure 1E). Moist antibiotic-impregnated
Three individual cases are described in detail below: gauze (Xeroform) was applied to the entire graft site and
changed every 3 days. When seen in clinic 2 and 3 weeks
3.1. Case 1: Right chest sarcoma postoperatively, the patient demonstrated complete healing
A 62-year-old male presented to the plastic surgery clinic of the graft site (Figure 1F and G). During that time, the
in preoperative consultation for reconstruction following patient’s oncologist recommended radiation of the surgical
planned excision of a right chest wall/flank soft tissue mass, site for improved local control. The patient was cleared
measuring 14 × 7.5 × 10 cm in size (Figure 1A). Chest to begin radiation after the week 3 visit, which he went
computed tomography of this biopsy-confirmed spindle through without complication. At 6 months (Figure 1H)
cell sarcoma revealed extension into the subcutaneous and 2 years (Figure 1I) post-radiotherapy, the patient still
tissue without obvious muscle involvement or chest wall demonstrated no graft breakdown and excellent range
penetration. As such, a wide local excision was planned by of motion of his arm and chest wall with an acceptable
his surgical oncologist with curative intent. Based on the contour deformity and cosmetic result.
expected chest wall defect, the reconstructive surgeon was
consulted to discuss definitive closure options. 3.2. Case 2: Right leg sarcoma

To ensure complete tumor clearance before definitive An 88-year-old female with a past medical history of
reconstruction, the decision was made to perform staged hypertension, atrial fibrillation, coronary artery disease
reconstruction after the initial extirpation. The patient, requiring three-vessel coronary artery bypass grafting
therefore, underwent wide local excision resulting in a 25 15 years prior, chronic kidney disease, congestive heart
× 32 cm skin deficit with exposed ribs, muscle, and fascia failure, and peripheral edema presented to the plastic
throughout the base (Figure 1B). As there were three surgery clinic in pre-operative consultation for lower
exposed ribs with varying degrees of periosteal stripping, extremity reconstruction following planned excision of a
the decision was made to apply Integra® RDM to the large sarcoma of the right anterior lower leg. The patient
entire surgically created wound. The rationale behind had noted a small mass approximately 1 year before
using this RDM was multifactorial: (1) To protect the ribs presentation which gradually increased in size and became
from desiccation, (2) to build up soft tissue and minimize a large exophytic, erythematous, draining mass. Biopsy test
expected contour irregularities from skin grafting, and confirmed that the mass was spindle cell sarcoma. Formal

Volume 2 Issue 2 (2024) 3 doi: 10.36922/arnm.3388