Lower Extremity Fascial Reconstruction Using an Acellular Dermal Matrix Graft
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Abstract: Background. AlloDerm® acellular dermal matrix ([ADM], Lifecell Corp, Branchburg, NJ) is gaining increasing popularity in virtually every surgical subspecialty for use in the closure of soft tissue defects, structural support, or tissue augmentation. There is limited experience in lower extremity fascial reconstruction secondary to trauma, as this can be a challenging problem for the plastic surgeon. The purpose of this case report is to demonstrate the reliability of acellular dermal matrix grafts in lower extremity fascial reconstructions. Methods. We present a patient who underwent tensor fascia lata reconstruction with ADM following a large fascial defect. The patient previously underwent a lateral thigh fasciotomy for compartment syndrome and developed a large fascial hernia of the thigh. Results. The defect was repaired using an ADM graft, which resulted in excellent aesthetic and functional outcomes. Conclusion. In selected patients, the use of acellular dermal matrix grafts for lower extremity fascial reconstructions produces adequate soft tissue coverage and optimal aesthetic and functional results.
Address correspondence to:
Milton B. Armstrong, MD, FACS
Division of Plastic and Reconstructive Surgery
Jackson Memorial Hospital/University of Miami
1611 NW 12th Ave.
Miami, FL 33136
The use of human acellular dermal matrix (AlloDerm®, Lifecell Corp, Branchburg, NJ) in reconstructive and aesthetic plastic surgery has increased exponentially over the past several years. Numerous experimental animal studies have investigated the biocompatibility and tissue integration of acellular dermal matrix in efforts to support its clinical application in humans.1,2 Subsequent clinical use of acellular dermal matrix grafts has been widely published, for instance in abdominal wall hernia repair, particularly in the contaminated setting.3,4 Likewise, the grafts are gaining popularity in virtually every surgical subspecialty for the closure of soft tissue defects, structural support, or tissue augmentation.5 Large fascial defects of the lower extremity can result from tumor excision, soft tissue flap harvest, history of direct trauma or fasciotomy, or the result of a necrotizing infection. The reconstructive surgeon facing this problem currently has limited options to repair such defects.
Experience with treating posttraumatic fascial defects using ADM is scant and to our knowledge, no reports using ADM in lower extremity fascial defect reconstruction have been published. The biomechanical properties of ADM have been studied and demonstrated that the tensile strength of ADM (or maximal load to failure) was superior to synthetic and autologous tissue.6 This supports our use of ADM in this clinical scenario where the deformational forces across the defect are high.
Technique. The thigh hernia defect was identified and outlined preoperatively and measured (16-cm in length by 7-cm in diameter [Figure 1]). The previous fasciotomy scar was excised in a full-thickness fashion extending down to the tensor fascia lata hernia defect. The fascial edges were undermined circumferentially and the adhesions to the underlying muscle were divided. A 20-cm x 16-cm sheet of medium-thickness ADM was used to reconstruct the fascial defect in the underlay fashion, with the dermal side facing downward (Figures 2 and 3). The dermal matrix was placed under moderate tension and sutured to the fascial edges using 2-0 polydioxanone (PDS) suture. The free edges of the fascia were tacked down to the ADM to minimize exposed areas of the graft, while ensuring the underlying muscle was not incorporated into the sutures.
1. Livesey SA, Herndon DN, Hollyoak MA, Atkinson YH, Nag A. Transplanted acellular allograft dermal matrix. Potential as a template for the reconstruction of viable dermis. Transplantation. 1995;60(1):1–9.
2. Holton LH 3rd, Chung T, Silverman RP, et al. Comparison of acellular dermal matrix and synthetic mesh for lateral chest wall reconstruction in a rabbit model. Plast Recontr Surg. 2007;119(4):1238–1246.
3. Butler CE, Langstein HN, Kronowitz SJ, Thornton JF. Pelvic, abdominal, and chest wall reconstruction with Alloderm in patients at increased risk for mesh-related complications. Plast Reconstr Surg. 2005;116(5):1263–1277.
4. Buinewicz B, Rosen B. Acellular cadaveric dermis (AlloDerm): a new alternative for abdominal hernia repair. Ann Plast Surg. 2004;52(2):188–194.
5. Sclafani A, Romo T 3rd, Jacono AA, McCormick S, Cocker R, Parker A. Evaluation of acellular dermal graft in sheet (AlloDerm) and injectable (micronized AlloDerm) forms for soft tissue augmentation. Clinical observations and histological analysis. Arch Facial Plast Surg. 2000;2(2):130–136.
6. Nahabedian MY. Does AlloDerm stretch? Plast Reconstr Surg. 2007;120(5):1276– 1280.
7. Glasberg SB, D’Amico RA. Use of regenerative human acellular tissue (AlloDerm) to reconstruct the abdominal wall following pedicle TRAM flap breast reconstruction surgery. Plast Reconstr Surg. 2006;118(1):8–15.
8. Eppley BL. Revascularization of acellular human dermis (AlloDerm) in subcutaneous implantation. Aesthet Surg J. 2000;20(4):291–295.
9. Wong AK, Schonmyer BH, Singh P, Carlson DL, Li S, Mehrara BJ. Histologic analysis of angiogenesis and lymphangiogenesis in acellular human dermis. Plast Reconstr Surg. 2008;121(4):1144–1152.
10. Sinha UK, Shih C, Chang K, Rice DH. Use of AlloDerm for coverage of radial forearm free flap donor site. Laryngoscope. 2002;112(2):230–234.