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OriginalArticle TheUseofaDehydratedCompleteHumanPlacental MembraneAllograftforMohsSurgicalDefectsof theNose KellyM.Wilmas,MD,*JigarPatel,MD, † SirunyaSilapunt,MD, ‡ HungQ.Doan,MD,PhD, † andMichaelR.Migden,MD§ BACKGROUNDRepairoptionsforMohssurgicaldefectsincludeprimaryclosure,flaporgraft,orhealingbysecondintention. Theseoptionsmaynotbeoptimalinallcases.Adehydratedcompletehumanplacentalmembrane(dCHPM)allograftmayserve asanalternativerepairoption. OBJECTIVEToassesstheaestheticandfunctionaloutcomesofanalternativerepairtechniqueforMohssurgicaldefects ofthenose. METHODSTwentypatientswithMohssurgicaldefectsofthenoserepairedwithadCHPMallograftwereretrospectively identified.Photographswereusedtodemonstratesurgicaltechniqueandoutcomes.Twoblindedobserversevaluated finaloutcomesusingthePatientandObserverScarAssessmentScale. RESULTSObserversratedthescaroutcomeacombinedmeanscoreof8.4 6 3.2(scale5 – 50).Patientsratedtheir outcomesameanof12.6 6 7.4(scale6 – 60).Themean “ OverallOpinionscore ” was2.5 6 1.8bypatientsand1.9 6 1.3by observers(scale1 – 10). LimitationsThiswasasingleinstitutionstudywithasmallsamplesize. CONCLUSIONOurstudydemonstratesthatdCHPMallograftsareaviablealternativerepairoptionforMohssurgical defectsofthenose. R epairoptionsforsurgicaldefectsafterMohsmi- crographicsurgery(MMS)includeprimaryclosure, useofaflaporgraft,orhealingbysecondintention. Reconstructiveoptionsinvolvediscussingtheplanwiththe patient,thetimecommitmenttoremaininthesurgicalsuite untilcompletion,andtheadministrationofadditionallocal anesthesia.Administeringlocalanesthesiainvolvesdis- comfortandpatientsmaypreferanoutcomewithnoad- ditionalsuturelines.Furthermore,somepatientsareaverse totheideaofanyadditionalsurgeryoncethecancerhas beenremoved.Areaswithhightissuetensionandlow elasticitymayinvolvemoreefforttoobtainoptimalout- comes.Whenapatientdeclinesrepairwithaflapor autologousgraft,thereisapaucityofalternativerepair optionsotherthanhealingbysecondintention. Humanplacentalmembraneallograftsareskinsubsti- tutes,containingnonviablecells,thatmaybeplacedinacute andchronicwoundbedstoacceleratewoundhealingand decreasewoundcareneeds. 1,2 Weassessedadehydrated completehumanplacentalmembrane(dCHPM)allograft (Revita,StimLabsLLC,Roswell,GA)containingthe amnion,intermediatelayer,andchorionfromscreened donorplacentasthatarethenfreeze-driedandhaveashelf- lifeof5yearsatambienttemperature. 1,3,4 Placental membranesnativelycontainavarietyofgrowthfactors, cytokines,andchemokinesknowntopromotere- epithelialization,angiogenesis,andregulatefibrosis. 4 – 6 A proteomicanalysisofdCHPMallograftsdemonstratedthe retentionofplatelet-derivedgrowthfactor,basicfibroblast growthfactor,andepidermalgrowthfactor,withno statisticaldifferenceinconcentrationcomparedwithnative tissue. 3 – 5 TheintermediatelayerretainedinthedCHPM allograftcontributestotheoverallgrowthfactorconcen- tration,andcontainscollagens,glycoproteins,andmuco- polysaccharides,includinghyaluronicacid. 4 Theretention oftheintermediatelayerincreasesthegraftthickness. 4 Additionalpropertiesassociatedwithplacentalmembrane allograftsincludeantimicrobialproperties,reductionof painandinflammation,andlackofimmunologic markers. 3,7 Theefficacyofamnioticmembranesinthe treatmentofchronicwoundshasbeenestablishedin multiplerandomizedcontrolledtrialsshowingimproved healingrates;however,itsuseinsurgicaldefectshasnot Fromthe*DepartmentofDermatology,TheUniversityofCaliforniaSanFrancisco, SanFrancisco,California; † DepartmentofDermatology,UniversityofTexasMD AndersonCancerCenter,Houston,Texas; ‡ DepartmentofDermatology,The UniversityofTexasHealthScienceCenteratHouston,McGovernMedicalSchool, Houston,Texas; § DepartmentsofDermatologyandHeadandNeckSurgery, UniversityofTexasMDAndersonCancerCenter,Houston,Texas Theauthorshaveindicatednosignificantinterestwithcommercialsupporters. Contentsofthemanuscripthavenotbeenpreviouslypublishedandarenotcurrently submittedelsewhere. ReviewedandapprovedbyMDAndersonCancerCenterIRB(2020-1317). Addresscorrespondenceandreprintrequeststo:MichaelR.Migden,MD, DepartmentsofDermatologyandHeadandNeckSurgery,UniversityofTexasMD AndersonCancerCenter,1400PresslerSt.,Unit1452,Houston,TX77030,ore-mail: mrmigden@mdanderson.org ©2023bytheAmericanSocietyforDermatologicSurgery,Inc.Publishedby WoltersKluwerHealth,Inc.Allrightsreserved. DermatolSurg2023;49:343 – 347 http://dx.doi.org/10.1097/DSS.0000000000003711 dCHPMAllograftforMohsSurgicalDefects • Wilmasetalwww.dermatologicsurgery.org343 ©2023bytheAmericanSocietyforDermatologicSurgery,Inc.PublishedbyWoltersKluwerHealth,Inc.Unauthorizedreproductionofthisarticleisprohibited. Downloaded from http://journals.lww.com/dermatologicsurgery by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIH o4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8K2+Ya6H515kE= on 04/04/2023beenwidelystudied. 2 Becauseofalackofpublisheddata supportingitsuseinsurgicaldefects,Medicareistheonly medicalinsuranceprogramthatcurrentlycoversthecostof thisproductforsame-daydermatologicprocedures.The pricerangeisbetween$500and$1,000withMedicare coveragefora1.5- 3 1.5-cmto2- 3 3-cmallograft. Thisstudyassessestheaestheticandfunctionaloutcomes ofanalternativerepairtechniqueusinganoveldCHPM allograftforsurgicaldefectsofthenoseafterMMS. Methods Thissingle-centerretrospectivestudywasreviewedand approvedbytheMDAndersonCancerCenterInstitutional ReviewBoard.TwentypatientswhounderwentMMSon thenosewithsubsequentrepairusingadCHPMallograft wereidentified.Allpatientsdeclinedrepairwithaflapor autologousskingraft.Surgeriesandrepairswereperformed byoneMohsmicrographicsurgeon. SurgicalTechnique Thesurgicaltechniqueusedinthisstudyisdemonstratedin Figure1.AfterMMS,atemplateofthesurgicaldefectis outlinedonanonadherentcelluloseacetatedressingwitha markingpen,allowingtheinktotransfertothedressing. Thedressingisthenfoldedin2equal-sizedlayersand trimmedtoslightlylargerthanthesurgicaldefectwitha2- mmmargincircumferentially.The2equal-sizedlayersof dressingaresecuredtothedefectwith5to0polybutester simplerunningsuturesalong75%ofthedefect.The remaining25%ofthecircumferenceisleftopenasa “ pocket. ” ThedCHPMallograftiscuttothemidlineat3- mmintervalsfromopposingends,creatinga “ fringe ” on bothends.Afterfringing,thedCHPMallograftisfolded andplacedthroughtheopenpocket,underthedressing. Normalsalineisusedsparinglytohydratetheallograft.The pocketisthenclosedwithsimpleinterruptedsuturesto securethedCHPMallograftbeneaththenonadherent celluloseacetatedressingmembrane.Thepatientwould needtoonlychangetheouterdressingoncedaily,which includesapplicationofatopicalantibioticsuchas mupirocin2%ointmentorwhitepetrolatum,anon- adherentdressingpad,andtape.After2to4weeks,the patientreturnstoclinicforevaluation.Ifthematurationof thedefectisincompleteandacontourdepressionisevident, theoriginalsutured-indressingisremovedandanew dCHPMallograftanddressingareplacedaspreviously described.Ifnocontourabnormalityisnoted,dressingis leftinplace.Thenonadherentcelluloseacetatedressing membraneistypicallyremovedatapproximately6to8 weeksfollow-up. OutcomeAssessment Datarelevanttooutcomesincludingpatientdemographics, tumortype,defectsize,numberofallograftsused,and complicationswereabstractedfrompatientcharts.Photo- graphsofthesurgicalsitetakenimmediatelypostopera- tivelyandatclinicalfollow-upwereused.ThePatientand ObserverScarAssessmentScale(POSAS)wasusedto evaluateoutcomes(TableI). 8 Thisvalidatedtoolassesses aestheticandfunctionaloutcomesofpostsurgicalscars basedon2scales:theobserverscaleandthepatientscale. 8,9 The “ Observer ” portionoftheinstrumentmeasures6 componentsofthescar:vascularity,pigmentation,thick- ness,relief,pliability,andsurfacearea.Because Figure1. “ Surgicaltechnique. ” (A)Patient1immediatelypostoperatively(B)atemplateofthedefectisoutlinedonanonadherent celluloseacetatedressing(C)thedressingistrimmed(D)thedCHPMallograftiscuttothemidline(E)thedCHPMis “ fringed ” on bothends(F)thedressingissecuredtothedefectwithsimplerunningsuturesandtheallograftisplacedthroughanopenpocket(G) thefinalsuturedconfiguration(H)scaratthe19-weekfollow-up.dCHPM,dehydratedcompletehumanplacentalmembrane. 344DERMATOLOGICSURGERY • April2023 • Volume49 • Number4www.dermatologicsurgery.org ©2023bytheAmericanSocietyforDermatologicSurgery,Inc.PublishedbyWoltersKluwerHealth,Inc.Unauthorizedreproductionofthisarticleisprohibited. Downloaded from http://journals.lww.com/dermatologicsurgery by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIH o4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8K2+Ya6H515kE= on 04/04/2023photographswereusedtoassessoutcome,pliabilitywas excludedfromthisanalysis. 9 The “ Patient ” portionofthe instrumentevaluates6componentsofthescar:pain, itching,color,stiffness,thickness,andirregularity.Each componentisscoredonaratingscaleof1to10,with1 representingnormalskinand10representingtheworst possiblescarquality.Thescoresofthe5components evaluatedbyeachobserverwerecombinedforatotalscore rangingfrom5to50.Thescoresofthe6components evaluatedbypatientswerecombinedforatotalscore rangingfrom6to60.Inaddition,patientsandobservers gavean “ OverallOpinion ” scoreofthescarrangingfrom1 Table.1ModifiedPOSASObserverScale ItemRatingExplanation Vascularity1Normalskin 2 – 3Palepink 4 – 5Palered 6 – 7Red 8 – 9Darkred 10Violaceous Pigmentation1Normalskincolor 2 – 3Palewhite/mildhypopigmentationorlightbrown/mild hyperpigmentation 4 – 5White/moderatehypopigmentationorbrown/ moderatehyperpigmentation 6 – 7Mixedhypoandhyperpigmentation 8 – 9Darkbrown/markedhyperpigmentationorbrightwhite/ markedhypopigmentation 10Blackordepigmented Thickness1Normalskin 2 – 3 , 2mm 4 – 52 – 3mm 6 – 7 . 3 – 4mm 8 – 9 . 4 – 5mm 10 . 5mmorkeloid Relief(surfaceirregularities)1Normalskin/levelwithsurroundingskin 2 – 31 – 3contourirregularities(papulesoratrophicpapules) 4 – 54 – 5contourirregularities 6 – 76 – 7contourirregularities 8 – 98 – 9contourirregularities 1010: $ 10contourirregularities Surfacearea1Normalskin/withinwounddefect 2 – 3 , 2mmbeyondwounddefect 4 – 52 – 3mmbeyondwounddefect 6 – 7 . 3 – 4mmbeyondwounddefect 8 – 9 . 4 – 5mmbeyondwounddefect 10 . 5mmbeyondwounddefect POSAS,ThePatientandObserverScarAssessmentScale. dCHPMAllograftforMohsSurgicalDefects • Wilmasetalwww.dermatologicsurgery.org345 ©2023bytheAmericanSocietyforDermatologicSurgery,Inc.PublishedbyWoltersKluwerHealth,Inc.Unauthorizedreproductionofthisarticleisprohibited. Downloaded from http://journals.lww.com/dermatologicsurgery by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIH o4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8K2+Ya6H515kE= on 04/04/2023to10,with1representingthebestpossibleoutcomeand10 representingtheworstpossibleoutcome. Eachpatientcompletedthe “ Patient ” componentofthe POSASsurveyattheirfollow-upappointments.Two independentboard-certifieddermatologistswhodidnot participateinthesurgeriesorrepairscompletedthe “ Observer ” componentofthePOSASsurveyafterassessing photographsofeachpatient ’ ssurgicalsiteimmediately postoperativelyandatthepatient ’ sfollow-upappointment. Eachobservercompletedthescaleforthesamescarthatthe patientsevaluated.Mean,SD,andmedianwerecalculated foreachpatientandobservervariable. Results Weidentified20patientswhounderwentMMSwitha dCHPMallograftplacedimmediatelypostoperativelyat ourinstitution.Atotalof12menand8womencomprised thepatientpopulation.Themeanpatientagewas63.5,with arangeof28to83.Thetumorsconsistedof18basalcell carcinomas,1cutaneoussquamouscellcarcinoma,and1 desmoplastictrichoepithelioma.Themeanpostoperative defectsizewas1.4cm 2 (range:0.7 – 3.6cm 2 ).Mostpatients had1dCHPMplaced(14/20),whereas4patientshad2 dCHPMs,and2patientshad3dCHPMsplaced.Meantime tofollow-upandcompletionofthePOSASsurveywas11.4 weeks( 6 3.6)andrangedfrom7to20weekspost- operatively.Noadverseeventssuchastissueischemia, necrosis,hematoma,seroma,infection,orsutureabscess wereobserved. Surveyresponsesfrom20of20patientswerecollected. Themeanpatientratingforeachcomponentofthescar assessmentwas1.1 6 0.2forpain,1.8 6 1.4foritching,2.4 6 1.7forcolor,2.0 6 2.0forstiffness,2.4 6 2.3for thickness,and3.0 6 2.6forirregularitywith1representing normalskinand10representingtheworstpossiblescar. Themeantotalscorebypatientswas12.6 6 7.4onscale from6to60.Themeanratingforeachcomponentofthe scarassessmentbyobserverswas2.4 6 1.8forvascularity, 1.6 6 1.0forpigmentation,1.5 6 0.8forthickness,1.8 6 0.9forrelief,and1.1 6 0.2forsurfaceareawith1 representingnormalskinand10representingtheworst possiblescar.Themeancombinedscorebyobserverswas 8.4 6 3.2onascalefrom5to50.Themean “ Overall Opinion ” scorewas2.5 6 1.8bypatientsand1.9 6 1.3by observersonascalefrom1to10. Conclusion OurstudydemonstratesthatdCHPMallograftsareaviable alternativerepairoptionforMohssurgicaldefectsofthe nosebecauseoftheirfavorablefunctionalandaesthetic outcomes(Figure2).Patientsandobserversprovided favorableoverallassessmentsofthescars.Oneadvantage ofusingadCHPMallograftistheeaseofpostprocedure woundcarethatthepatientmayperformathomewithout needforacaregiverorhomehealthcare.Another advantageofthedCHPMallograftistheinfrequencyof postprocedurepainreportedbypatients.Nopainmedica- tionsororalantibioticswereprescribed.Patientswith surgicaldefectsofthenoseafterMMSbenefitedfromthe dCHPMallograftthroughrapidwoundhealing,minimal scarring,lowmaintenancewoundcare,andfavorable patientsatisfaction. Limitationsofthisstudyincludethelackofacontrol groupandsmallsamplesizeatasinglecenter.Subjective interobserveroutcomeevaluationusingphotographsand variedfollow-uptimesfurtherlimitsthestudy.Future studiesmayincludelong-termcosmeticandfunctional follow-upusingthedCHPMallograftinadditiontoitsuse indifferentanatomicsitesandskinofcolor.Despitethese limitations,theuseofavalidatedscarassessmenttool, Figure2. “ Outcomes. ” woundimmediatelypostoperatively(top)andatrespectivefollow-up(bottom). 346DERMATOLOGICSURGERY • April2023 • Volume49 • Number4www.dermatologicsurgery.org ©2023bytheAmericanSocietyforDermatologicSurgery,Inc.PublishedbyWoltersKluwerHealth,Inc.Unauthorizedreproductionofthisarticleisprohibited. Downloaded from http://journals.lww.com/dermatologicsurgery by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIH o4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8K2+Ya6H515kE= on 04/04/2023blindedobservers,andtechniqueperformedbythesame surgeonstrengthensourobservations. References 1.HerndonDN,BranskiLK.Contemporarymethodsallowingforsafe andconvenientuseofamnioticmembraneasabiologicwound dressingforburns.AnnPlastSurg2017;78:S9 – S10. 2.HaughA,WittJ,HauchA,DardenM,etal.Amnionmembranein diabeticfootwounds:ameta-analysis.PlastReconstrSurgeryGlob Open2017;5;e1302. 3.ZelenC,SnyderR,SerenaT,LiW.Theuseofhumanamnion/chorion membraneintheclinicalsettingforlowerextremityrepair:areview. ClinPodiatrMedSurg2015;32:135 – 46. 4.RoyA,GriffithsS.Intermediatelayercontributioninplacental membraneallografts.JTissueEngRegenMed2020;14:1126 – 35. 5.L´opez-ValladaresM,TeresaRodr´ ı guez-AresM,TouriñoR,GudeF, etal.Donorageandgestationalageinfluenceongrowthfactorlevels inhumanamnioticmembrane.ActaOphthalmol2010;88:e211 – 6. 6.BarrientosS,StojadinovicO,GolinkoM,BremH,etal.Growth factorsandcytokinesinwoundhealing.WoundRepairRegen2008; 16:585 – 601. 7.VigK,ChaudhariA,TripathiS,DixitS,etal.Advancesinskinre- generationusingtissueengineering.IntJMolSci2017;18:789. 8.DraaijersL,TempelmanF,BotmanY,TuinebreijerWE,etal.The patientandobserverscarassessmentscale:areliableandfeasibletool forscarevaluation.PlastReconstrSurg2004;113:1960 – 5. 9.LindeboomJ,BruijnesteijnvanCoppenraetE,KuijperE,Polsbroek RM,etal.Interpretationandprecisionoftheobserverscarassessment scaleimprovedbyarevisedscoring.JClinEpidemiol2008;61: 1289 – 95. dCHPMAllograftforMohsSurgicalDefects • Wilmasetalwww.dermatologicsurgery.org347 ©2023bytheAmericanSocietyforDermatologicSurgery,Inc.PublishedbyWoltersKluwerHealth,Inc.Unauthorizedreproductionofthisarticleisprohibited. Downloaded from http://journals.lww.com/dermatologicsurgery by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIH o4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8K2+Ya6H515kE= on 04/04/2023Next >