Page 79 - ARNM-2-2

Advances in Radiotherapy
& Nuclear Medicine Wound reconstruction with Intergra®

formation and moisture loss during the regenerative reconstruction with Integra® was attempted. Average graft
82
process. There is a risk of bacteria being trapped beneath take was 87%. Eight patients suffered complications mainly
the silicone, leading to a secondary infection. Because from delayed healing. Three of these patients had previously
of this, close monitoring is recommended in the post- been subjected to radiotherapy to their wound beds. One
operative wound stage. The inner layer is constructed of patient from this sample received post-operative radiotherapy
a bilaminar membrane that contains a structure of cross- and developed areas of radionecrosis after 2 years.
linked porous bovine tendon type I collagen and shark Johnson et al. performed a systematic literature review
glycosaminoglycan (chondroitin-6-sulfate). 35,77 Integra® on the effectiveness of Integra®-based reconstructions
is terminally sterilized via irradiation and pre-hydrated of scalp wounds, particularly large defects. The authors
83
in a phosphate-buffered solution. This porous material found considerable evidence in favor of RDM utilization
acts as a scaffold for regenerating dermal skin cells, which to reconstruct scalp wounds. Thirty-two of the 34 articles
enables the regrowth of a functional dermal layer of skin. they reviewed reported an average skin graft take of at
Once dermal skin has regenerated, the silicone outer layer
is removed and replaced with a thin epidermal skin graft. least 90%. Seven studies included patients who had post-
operative radiation. Four of these investigations reported
Khan et al. retrospectively evaluated 30 oncologic radiation-induced soft tissue breakdown, but the eventual
patients with full-thickness scalp defects treated with graft take was 100%. Taken together, the authors suggested
Integra® and split-thickness skin grafting. Nine patients that post-operative radiation is well tolerated by Integra®-
78
had undergone neoadjuvant radiation, while three based reconstructions.
patients had post-operative radiotherapy. No radiation-
related wound breakdown was observed. Two minor Greater variability in clinical outcome was seen in
complications were encountered: One seroma that was patients who received pre-operative radiotherapy, with the
83
successfully aspirated and one abscess leading to template graft take rate as low as 50%. Johnson et al. suggested that
resection and reapplication. Radiotherapy had no adverse radiation’s adverse effect on wound healing predisposes
effect on the take of the RDM or skin graft. The authors Integra®-based reconstructions to failure “given that
pointed out reduced operative time and inpatient stay the revascularization of a RDM is dependent on host
83 (p.7)
for this reconstructive method. These findings have cell migration and proliferation.” This finding was
been replicated by additional similar studies. Orseck contrary to our findings of previously radiated wound
et al. described a method of securing dermal regeneration beds as well as work done by Gonyon et al., who presented
template to scalp wounds via screw bolster fixation before two cases in which Integra® was applied to radiated scalp
84
split-thickness skin grafting. Three of the 13 patients wounds. The first case was a non-healing radiation
79
studied received radiation therapy. Well-vascularized ulcer that failed split-thickness skin grafting. The second
neodermis and stable wound healing were observed in all case was squamous cell cancer of the scalp that recurred
patients. Only one patient required ancillary wound care despite radiation and ultimately required resection of
for a small 2 × 2 cm area that was ultimately treated with more than 50% of the total scalp surface area. Both cases
Xeroform dressings for 5 weeks before epithelialization. were successfully treated using Integra®. The authors
Richardson et al. used Integra® and split-thickness skin hypothesize that the reason the RDM was successful for the
grafting in 10 patients with large full-thickness scalp treatment of radiated scalp wounds was the relatively slow
defects. Of the two patients that had radiotherapy, one rate of vascularization of the dermal template. Primary
80
patient experienced radiation-induced wound breakdown skin graft must revascularize in 48 – 72 h after placement
that resolved completely after 6 months. All patients had on a recipient wound bed. Irradiated tissues show delayed
good wound closure and graft take. vascular ingrowth, which likely accounts for the high failure
rate of primary skin grafting in radiated scalp wounds.
Agochukwu et al. conducted a retrospective cohort Neither patient in their case report experienced skin
study of scalp reconstruction using dermal regeneration graft failure or clinical infection when awaiting vascular
templates and skin grafting. The authors found this ingrowth. As demonstrated in our cases, using Integra®
81
technique to be a dependable option for soft tissue in previously radiated breast wounds before skin grafting
reconstruction, notably in a patient population with supports these findings as well. Newer regenerative dermal
significant medical comorbidities. One of their patients templates have been developed since the treatment of
underwent adjuvant radiotherapy following reconstruction these patients, including Kerecis, Ovitx and Primatrix that
and suffered no complications related to radiation. would presumably act in a similar manner while obviating
Chalmers et al. prospectively followed 14 cases of the potential for bacterial trap due to the silicone layer.
deep cancer excision down to bone or tendon, in which These RDMs warrant future study going forward.

Volume 2 Issue 2 (2024) 7 doi: 10.36922/arnm.3388