Page 80 - ARNM-2-2

Advances in Radiotherapy
& Nuclear Medicine Wound reconstruction with Intergra®

Wound Remains
Closed:
Complete Coverage Routine Graft Care
of Vital Structures: Secondary Wound
Skin Graft
Formation:
Flap Closure (primary
Negative Margins: option)
RDM left in place
for 3-4 weeks RADIATION Wound Remains Closed:
Incomplete Coverage Routine Flap Care
Excision of Primary of Vital Structures:
Tumor with Flap Closure
Application of RDM (primary option) Secondary Wound
Formation:
Flap Closure (distant
Positive Margins Re-excision +/- secondary option)
Reapplication of RDM

Figure 4. Algorithm for staged wound reconstruction using regenerative dermal matrix (RDM) and split-thickness skin grafting. When reconstructing
oncologic defects for cancer types where local control can be improved with radiation, an RDM is applied at the time of tumor removal even when vital
structures are exposed. By applying the RDM at the time of tumor removal, the first stage of reconstruction is performed while sparing a donor site should
margins come back positive and re-excision be required. Once negative margins are assured, the RDM is left in place for 3 – 4 weeks, after which time
the silicone layer is removed. The matrix is left in place for an additional 1 – 2 weeks. This delay in skin grafting allows for rapid tissue ingrowth and thus
reduction in wound depth and diminished wrinkles/deformities pre-disposing to future wound formation. If complete coverage of vital structures is
achieved, split-thickness skin grafting is performed. A wound vacuum-assisted closure is reapplied for 5 – 6 days. Once graft take is confirmed, the wound
is dressed with dry dressing. If complete healing is achieved by week 4, the patient is able to proceed with radiotherapy. Wounds that remain closed post-
radiation undergo routine graft care. If evidence of wound breakdown or radiation-induced necrosis presents itself, flap closure is pursued.

The effect of altering the timing of radiation during the Nonetheless, based on the findings from our literature
reconstructive process is ultimately uncertain. 85-87 Muller review as well as results from our case series, we developed
et al. reported a case of immediate radiotherapy after an algorithm for reconstructing large full-thickness skin
Integra® placement but before wound closure. A patient defects created following tumor extirpation when radiation
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who had undergone multiple wide, deep excisions for has been or may be involved (Figure 4). The use of this
pleomorphic sarcoma had Integra® applied to the wound, algorithm has allowed us to cover exposed vital structures
followed by immediate radiation therapy. The irradiated using simple techniques with durable radioresistant tissue.
wound was then closed with an STSG and experienced We believe that our algorithm has the potential to be
complete healing without necrosis, infection, or major applied to a wide variety of other reconstructive surgeries,
radiotoxicity. Although outcomes from this study are not only limited to irradiated tissue. This strategy not only
impossible to generalize, the findings are intriguing as decreases the morbidity associated with more complex
they suggest that the creation of a neodermis may in fact reconstructions, but it also spares local flaps to be used
be the key component for conferring radioresistance and later should a late onset radiation wound occur.
improving graft take even if applied after radiation.
Additional strategies for reconstruction in radiated 5. Conclusion
tissues have been explored with novel regenerative Our case series supports the studies identified in our
therapies based on adipose-derived stem cells (ASCs). systematic review of the literature. Integra® regenerative
Recently, many plastic surgeons have studied the dermal matrix has proven itself a valuable tool in
potential clinical application of ASCs, which represent a reconstructing surgically created wounds before or after
readily available adult stem cell population . The senior radiation.
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author has also published two papers on the use of
autologous lipotransfer in breast cancer patients following Acknowledgments
radiation. 90,91 ASCs provide an additional route to be
considered during the reconstruction of irradiated tissue. None.
It is also indeed possible that these stem cells could be Funding
combined with matrix products as delivery system in a
synergistic fashion. None.

Volume 2 Issue 2 (2024) 8 doi: 10.36922/arnm.3388