Zhongwei Aesthetic Medicine, Vol. 19, No. 7, July 2010
Advances in the application of acellular dermis in the field of plastic surgery
Zhao Gaofeng reviewed, He Leren reviewed
(Department of Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing 1, 001 44, China)
Acellular dermal matrix, which is divided into allogeneic acellular dermal matrix and xenogeneic acellular dermal matrix, is obtained after treatment from allogeneic skin and xenogeneic animal skin, respectively. It arises from the practice of treating boils in burns, and the lack of donor area in the treatment of acute deep burns is one of the most difficult problems in the field of plastic surgery. Patients with extensive and deep burns often have severe scar hyperplasia and contracture deformities in the later stage, and scar excision, release of scar contracture, and skin grafting are effective treatments, but patients often find it difficult to accept new scars in the donor area psychologically [1]. The above two problems prompted scholars at home and abroad to find a treatment that can solve these two problems, and gave birth to the acellular dermal matrix. In the early 90s of the 20th century, Livesey et al. [2] in the United States took the lead in trying to apply the allogeneic dermal matrix with decellularized cells to the repair of burn wounds, and the results achieved great success. Subsequently, allogeneic dermal cell-free matrices began to be widely used in the surgical field. Despite this, the source of allogeneic dermis is still limited, and the problem of skin origin remains unresolved. Feng Xiangsheng et al. [3] successfully tried to use (porcine) acellular dermal matrix to treat deep burn wounds, and the study confirmed that xenogeneic (porcine) acellular dermal matrix has similar biological effects to human allogeneic acellular dermal matrix [4-5], and the use of acellular dermis to treat burn wounds can reduce the damage to the donor area compared with autologous skin grafting, and at the same time, the tissue source is abundant. This article reviews the research progress of acellular dermis as follows.
1 Structure of acellular dermis
1.1 Normal dermal structure: Dermal components include the basement membrane of the epidermis at the junction of the dermis, collagen, elastin, glycoprotein and special vascular plexus. Among them, the dermal vascular plexus plays an important role in the reshaping of tissues. The immune response produced by xenogeneic and allogeneic skin mainly acts on cell components such as epidermal cells, fibroblasts and endothelial cells in the dermis, and the non-cellular component (ECM) protein and gel principle of the dermis are relatively inactive.
1.2 Acellular dermal structure: The structure of the acellular dermal matrix, whether allogeneic or xenogeneic, is similar in structure and biological [4]. The basic structure of the acellular dermis is the collagen mesh, in which cellular components and cytocompatible antigens have been eliminated [6], but intact collagen morphology and basement membrane structure have been maintained. Because the antigenic components of the decellularized dermis have been completely cleared, the immune activity is low, so it does not induce specific cellular immune responses and non-specific foreign body reactions.
1.3 Advantages of acellular dermis over normal dermis: Acellular dermis retains the two sides of the basement membrane complex to form the basement membrane and the dermis, which can provide a natural plane for the migratory colonization of epithelial cells, which is conducive to the epithelialization of the acellular dermis, and the dermal surface is conducive to host cell growth and rapid vascularization [7-9]. As a biological scaffold, acellular dermis retains the matrix components of collagen fibers and small blood vessels, all of which help guide the growth of recipient cells and neovascularization to form a new cellular polonium matrix, thereby replacing the acellular dermis [7]. Acellular dermis transplantation into the host provides tissues with toughness, elasticity, water retention, and buffering against mechanical forces, and provides a microenvironment for cells to survive and engage in various activities, making it an ideal biological scaffold [10].
2. Basic research on acellular dermis
Gu Jianjun et al. used acellular dermis for eyelid reconstruction to study the tissue outcomes of acellular dermis and allogeneic sclera after eyelid replacement. In the study, 16 adult healthy female New Zealand white rabbits were randomly divided into two groups, implanted with acellular dermis and allogeneic sclera, and operated on the right eye only. The results showed that the conjunctival hyperemia and edema subsided quickly after acellular dermal implantation into the eyelids, there was no implant rejection, there was no significant difference in the changes of antibodies and CD4 and CD8 cells in the blood between the two groups, and histological examination showed that the immune and inflammatory reactions caused by acellular dermis were mild. They believe that acellular dermis can act as a biological scaffold to guide the growth of receptor neovascularization and collagen fibers. Acellular dermis has good histocompatibility after implantation in rabbit eyelids, and can guide the growth of new collagen and play a role in replacing the tarsal plate. Acellular dermis can be used as a meislab substitute for eyelid defect repair, and has the advantages of good repair effect and low antigenicity. Xiao Qiang et al. [11] discussed the biocompatibility of xenogeneic acellular dermal matrix implanted into rats as a soft tissue filler, and randomly divided the test rats into xenogeneic group, allogeneic group and autologous control group, and implanted xenogeneic acellular dermal matrix, allogeneic acellular dermal matrix and autologous dermis matrix, respectively, and evaluated the biocompatibility of xenogeneic acellular dermal matrix according to the pathological histology and patinological changes from 2 to 32 weeks after surgery. However, there was no significant difference in inflammatory response between the late stage (16~32) and the allogeneic group, and the peripheral capsule formation was not obvious. They believe that xenogeneic acellular dermal matrix has good biocompatibility and is suitable as a biological soft tissue filling material, which has a good and broad application prospect.
3. Clinical application of acellular dermis
3.1 Burn repair: Before the production of acellular dermis, the treatment of burn wounds is mainly autologous skin grafting, including free skin sheet transplantation, skin flap transplantation, autologous skin implantation with large allogeneic skin opening, autologous particle skin grafting and mesh skin transplantation. All of these methods have the problems of insufficient skin source and damage to the donor site, so acellular dermis is first widely used in the repair of burn wounds (especially deep burn wounds) and subsequent scars [12-18]. Composite transplantation of acellular dermis with autologous blade thick skin patches is a common method for repairing burn wounds [12].
The allogeneic decellularized dermal matrix has low antigenicity, which can make the composite skin piece survive for a long time, and can promote the formation of epidermal-dermal connection, so that the wound can recover its inherent barrier effect after healing, but does not affect the appearance and function, greatly reduces the scarring contracture deformity and dysfunction, can maximize the recovery of the patient's function, reduce the number of surgeries, shorten the treatment period, reduce the patient's pain, and obtain good long-term results [7-9].
3.2 Scar treatment: Feng Xiangsheng et al. [19] performed complete scar resection at the base of the scar in 47 patients with severe scar hyperplasia, retained the adipose tissue or deep fascia under the scar, and then used the one-step method and two-step method for composite transplantation on the fat wound or deep fascia wound. The results showed that the quality of composite grafting was significantly better than that of simple blade thick skin grafting, and the effect was similar to that of autologous medium thick skin grafting, and its later shrinkage rate was also smaller, and the elasticity was good, which was suitable for the repair of limb joints in the later stage of scarring, cosmetic plastic surgery and large-scale severe burns. Huo Ran et al. [20] used it for the treatment of chest keloids, and applied acellular dermal matrix to cover 12 wounds after chest keloid resection in the first stage, and applied autologous blade thick skin slice transplantation to acellular dermal matrix in the second stage. They found that the use of this surgical method can greatly reduce the risk of surgery, minimize the secondary damage of the donor field, and the surgical method is easy to operate and the efficacy is certain.
3.3 Breast augmentation and breast reconstruction: Shao Wenhui et al. used J-1 acellular dermis for breast augmentation, and used acellular dermal matrix medical tissue mesh for breast augmentation for pectoralis major muscle lengthening and widening breast augmentation, and followed up for 3~12 months. The postoperative breast feels good, and there is no fibrous capsular contracture case, and the effect is satisfactory. The acellular dermal matrix medical tissue patch has good histocompatibility and biomechanical properties, and the tensioning effect on the pectoralis major muscle obviously achieves the dynamic effect after breast augmentation. Sbitany et al. [22] used acellular dermal matrix for breast augmentation, and he found that the complication rate was similar to that of those who did not use acellular dermal matrix, but it had a potentially better aesthetic effectTsoutsos et al. [23] used acellular dermal combined dilator method to reconstruct the breast after burn injury, and the reconstructed breast contour was stable after 17 months, and no contracture occurred, and the patient was satisfied. This surgical method is a safe and reliable method of breast reconstruction after burns.
3.4 Nipple reconstruction: Garramone et al. [24] used acellular dermal matrix for nipple reconstruction, in which the acellular dermal matrix was placed in the center of the reconstructed nipple and the reconstructed nipple was measured at 3, 6, and 12 months after surgery, respectively, and the effect was satisfactory, no infection and complications occurred, and the patient satisfaction was high. They believe it is a safe, easy, and long-term method of nipple reconstruction.
3.5 Facial plastic surgery: Shao Wenhui [25] used acellular dermal matrix medical tissue mesh for nasolabial fold filling to make the deepened nasolabial folds shallow. The subcutaneous adhesions of the nasolabial folds were dissolved and peeled off through the oral approach, and the acellular dermal matrix medical tissue mesh was used to fill the subcutaneous depression of the nasolabial folds, and all cases were followed up for 3~6 months. ResultsExcept for 1 case of uneven placement, and 1 case of replacement due to cavity hemorrhage and bruising, all of them achieved satisfactory results. In the author's opinion, in addition to the positive effect of incision and tightening of the skin fascia on the middle face, other filling materials are effective, but the effect is not very satisfactory or prone to recurrence. Nasolabial fold filling for acellular dermal matrix medical tissue mesh not only has good histocompatibility, simple surgical operation, small damage, easy to survive, etc., the filling effect is satisfactory, and the nasolabial fold will not show the contour of the filling with facial movement in terms of dynamic expression, which is an ideal new biomaterial for nasolabial fold filling. Bozkurt [26] used acellular dermis for the repair of lower lip depression resection in Van der Woude syndrome with satisfactory results. They consider the use of acellular dermal and mucosal modified "V-Y" flap for post-inferior lip depression resection repair in Van der Woude syndrome as a successful approach to achieve the best aesthetic results. Pu Xingwang et al. [27] used acellular dermis for filling the secondary deformity tissue after cleft lip surgery, and the effect was satisfactory, which solved the problem of secondary injury of autologous tissue and cosmetic scar residue. Li Guangqiang [28] used acellular allogeneic dermal matrix medical tissue mesh for rhinoplasty, performed "V-Y" lengthening of the columella, and inserted the mesh model with a guide needle and thread traction patch into the dorsum of the nose, and the excess mesh at the tip of the nose was folded and sutured on the cartilage of the new nasal tip in a cap-like shape. to further elevate the tip of the nose and the results are satisfactory. At present, the commonly used rhinoplasty materials have certain shortcomings: silicone rubber has a poor hard feel, and there are shortcomings such as the prosthesis moving down and breaking the exposed skin in the later stage; Expanded PTFE infection is often difficult to control, and in most cases the prosthesis needs to be removed; Autologous cartilage has the disadvantages of absorption deformation, difficulty in carving, secondary damage, and limited amount of materials. The acellular dermal matrix has good histocompatibility, which is significantly better than silicone and bulk, so that when performing rhinoplasty, it can better shape a nose tip with no contour, natural feel, more erect and completely autologous nose. Wang Fujun et al. used it for the repair of nasal septal defects, using nasal endoscopy combined with labial-gingival sulcus human application of double-layer valves, that is, the left side of the nasal septum, nasal floor and lower nasal passage mucoperichondrium/periosteum, the right side of the allogeneic acellular dermal matrix mucosal tissue patch (ADW), the use of medical ear and brain glue (EC glue) adhesive to repair the nasal septal perforation, the success rate of l00%, follow-up for 6 months ~ 2 years without re-perforation. They believed that the valve area was large, the root pedicle was wide, the blood supply was abundant, the ADM had no rejection, it had good biocompatibility, and the survival rate of the EC glue adhesive double-layer valve was high. In addition, the surgical field is clear, the materials are convenient and easy to take, the operation time is shortened, and the trauma of the donor area is reduced, which is the best surgical plan for repairing the nasal septum perforation.
3.6 Urethral reconstruction: Lin et al. "03 found that urethral reconstruction with acellular dermal matrix is anatomical and functional repair, and compared with traditional urethral alternative materials, it has the advantages of metalogous materials, wide range of sources, and low antigenicity [30]. There are fewer complications, reduce the pain of patients, can be industrialized, and the repaired urethra has similar tissue structure and physiological characteristics to the original urethra, which greatly simplifies the surgical process and improves the cure rate, especially suitable for the repair of long urethral defects. It has been preliminarily confirmed that human allogeneic dermis is an ideal alternative material for urethra, and has a very broad development prospect.
3.7 Other areas of plastic surgery: In addition to the above-mentioned areas, acellular dermis can also be used for filling various congenital and acquired defects [31-39], depressions [40], etc. The application of acellular dermal matrix can effectively repair dermal defect wounds and alleviate scar hyperplasia after wound healing [41].
4. Outlook
As an alternative material to human autologous dermis, acellular dermis has the advantages of small species difference, weak antigenicity, low host immune rejection, good biocompatibility and good biodegradability, and plays an important role in the repair of various congenital or acquired tissue defects and wounds involved in the field of plastic surgery. The acellular dermis has no cells and antigenic substances, but it preserves the structure of collagen and other scaffolds, and collagen can still be maintained for a long time after being implanted as a biological scaffold (the change in collagen content and the ratio of type I and III collagen at 4 months after transplantation is not significant) [42], thus becoming a scaffold for the growth of recipient cells. The surgical method of acellular dermis can greatly reduce the risk of surgery, minimize the secondary damage to the donor area, solve the problems of scar hyperplasia due to autologous tissue transplantation, and completely solve the problem of tissue source. The acellular dermis itself has many imperfections, such as the control of its degradation and absorption time in vivo and its final outcome in vivo [43]. Acellular dermis has been around for more than ten years, but its application is not very widespread, and I personally believe that it is related to the potential risk of disease transmission due to its lack of thorough research and lack of sufficient clinical evidence for safety. In addition, no articles were found on the ethical aspects of acellular dermis, and it is recommended that research be conducted in this area. In conclusion, we believe that acellular dermis will be more widely used and developed in the future due to its advantages of reducing donor site damage and abundant tissue sources, especially in the treatment of burn wounds and scars caused by various causes.
References
[1] Wang Yang, Xue Zongsheng, Xu H, et al., Experimental study on composite transplantation of autologous microparticle skin and allogeneic dermis[J].Chinese Journal of Burns,2002,18(4): 232.
[2] Livesey SA,Herndon DN,Hollyoak MA,et al. Transplanted acellular allografi dermal matrix. Potential as a template for the reconstruction of viable dermis [J]. Transplantation,1995,60(1):1-9.
[3] Feng Xiangsheng, Pan Yingen, Tan Jiaqiang, Study on xenogeneic (porcine) acellular dermis and autologous epidermal composite transplantation[J]q-Hua Journal of Plastic Surgery,2000,16(1):40-42.
[4] Ge L,Zheng S,Wei H.Comparison of histological structure and biocompati- bility between human acellular dermal matrix (ADM) and porcine ADM[J]. Burns,2009,3 5(1):46-50.
[5] Chen Jinhui, Qi Shunzhen, Sun Huichen, et al, Comparative study of acellular dermis and autologous dermal composite transplantation of different species[J].Chinese Journal of Burns,2003,19(5):300-302.
[6] Chen RN,Ho HO,Tsai YT,et al. Process development of an acellular dermal matrix (ADM) for biomedical applications[J]. Biomaterials,2004,25(13):2679-2686.
[7] Gu Jianjun, Chen Jiaqi, Peng Hongjun, et al., Experimental study of acellular dermis and allogeneic sclera in eyelid reconstruction[J], Ophthalmology Research, 2003, 21(3):229-233.
[8] Huang Zhiyong, Chen Dafu, Wang Xiao, et al., Acellular allogeneic dermal tomb and autologous blade thick dermal composite transplantation in the treatment of deep burns in the joint[J].Chinese Journal of Aesthetic Medicine,2007,16(9):1195-1196.
[9] Sheridan RL,Morgan JR,Cusick JL,et al.lnitial experience with a composite autologous skin substitute[Jl.Bums,2001,27(5); 421-424.
[10] Lin Jian, Hao Jinrui, Jin Jie, et al., Clinical application of human allogeneic dermal decellularized matrix in urethral reconstruction[J], Chinese Medical Journal, 2005, 85(15):1057-1059.
[11] Xiao Qiang, Zhang Yingfan, Pan Yinggen, et al., Biocompatibility study of xenogeneic acellular dermal matrix as soft tissue filler[J].Chinese Journal of Aesthetic Plastic Surgery,2009,20(4):236-239.
[12] Chai Jiake, Sheng Zhiyong. Further attention should be paid to the research on skin substitutes for large-scale burns[J].Medium
Chinese Journal of Burns,2002,18(1):73-74.]
[13] Sun Weiguo, Fan Xing, Clinical observation of acellular allodermal repair of burn scars[J].Chinese Journal of Aesthetic Medicine,2008,17(7):974-975.
[14] Li A,Dearman BL,Crompton KE,et al. Evaluation of a novel biodegradabfe polymer for the generation of a dermal matrix [J]. J Burn Care Res,2009,30(4):717. 728.
[15lWain Wright DJ. Use of an acellular alloUafi dermal matrix (Allo-Derm) in management offull-thickness [J]. Burns,1995,21(4):243-248.
[16] Huang Zhiyong, Chen Dafu, Wang Xiao, et al., Application of allogeneic acellular dermal matrix in post-burn deformity[J].Chinese Journal of Aesthetic Medicine,2006,15(7):773-774.
[17ljiong C,Jiake C,Chunmao H,et aI.Clinical application and Iong-term follow- up study of porcine acellular dermal matrix combined with autoskin grafiing [Jl.j Burn Care Res,2010,31(2) :280-285.
[18] Xu Huiling, Jiang Changqing, Wu Zhaoya, et al., Xenogeneic acellular dermis and white body skin composite repair of limb skin defects[J].Chinese Journal of Reconstructive and Reconstructive Surgery,2001,15(4):255.)
[19] Feng Xiangsheng, Chen Xiaodong, Tan Jiaju, et al., Xenogeneic (porcine) acellular dermal matrix in scar reshaping
Chinese Journal of Plastic Surgery,2007,23(5):391-393.
[20] Huo Ran, Fu Hongbin, Lv Renrong, et al. Application of acellular dermal matrix in the treatment of chest keloids[J].Chinese Journal of Reconstructive and Reconstructive Surgery,2004,18(6):474.)
[21] Shao Wenhui, Pu Xingwang, Li Guangqiang, et al., Application of acellular dermal matrix medical tissue mesh in breast augmentation[J].Chinese Journal of Aesthetic Medicine,2007,16(10):1371-1373
[22] Sbitany H,Sandeen S,Amalfi AN,et al. Acellular dermis-assisted prosthetic breast reconstruction versus complete submuscular coverage:A head-to-head com- parison ofoutcomes[J]. Plast Reconstr Surg,2009,124(6):1735-1740.
[23lTsoutsos D,Stratigos A,Gravvanis A,et al. Burned breast reconstruction by expanded artificial dermal substitute [J]. J Burn Care Res,2007,28(3):530-532
[24] Garramone CE,Lam B.Use of AIloDerm in primary nipple reconstruction to improve long-term nipple projection [J]. Plast Reconstr Surg,2007,1 19(6):1663-1668.
[25] Po Wenhui, Pu Xingwang, Li Guangqiang, et al, Application of acellular dermal matrix medical tissue mesh in nasolabial fold filling[J].Journal of Tissue Engineering and Reconstructive Surgery,2006,2(5):261-263.
[26] Bozkurt M,Kulahci Y,Zor F,et al. Reconstruction of the lower lip in Van der Woude syndrome[J]. Ann Plast Surg,2009,62(4):451-455
[27] Qing Xingwang, Xiao Qingchang, Shao Wenhui, et al., Preliminary application of acellular allogeneic dermal matrix in the repair of labial and nasal deformities secondary to cleft lip surgery, Chinese Journal of Aesthetic Medicine 2008, 17(10): 1475-1476
[28] Li Guangqiang, Pu Xingwang, Shao Wenhui. Application experience of acellular allogeneic dermal matrix medical tissue mesh in rhinoplasty[J].Chinese Journal of Aesthetic Medicine,2007,16(12):1661-1662.)
[29] Wang Fujun, Yuan Juncang, Gong Weihong, et al, Allogeneic acellular dermal matrix mucosal tissue mesh repair of nasal septal perforation[J] China Otolaryngology-Head and Neck Surgery,2008,15(9):522-524.
[30] Liu Liu, Liang Dejiang, Shen Pengfei, et al. Experimental and clinical study on allogeneic dermal extracellular matrix reconstitution of urethra[J].Chinese Journal of Urology,2001,22(7):428-431.)
[31] Chen Jie, Wei Wei, Yu Jianjun, et al, Application of acellular dermal matrix mucosal tissue mesh in the repair of oral mucosal defects[J].Chinese Journal of Otolaryngology-Head and Neck Surgery,2007,42 (11):860-861.
[32] Sun Yan, Zhang Qingquan, Song Xicheng, et al., Short-term efficacy of the use of xenogeneic acellular dermal matrix to repair mucosal defects[J]Journal of Zhongyuan Reconstructive and Reconstructive Surgery,2008,22(1):53-55.
[33] Soejima K,Chen X,Nozaki M,et al. Novel application method of artificial dermis: one-step grafiing procedure of artificial dermis and skin,rat experimental study[J]. Burns,2006,32(3):312-318.
[34] Koga Y,Komuro Y,Yamato M,et al. Recovery course of full-thickness skin defects with exposed bone: an evaluation by a quantitative examination of new blood vessels [Jl-J Surg Res, 2007，137(1):30-37.
[35] Momoh AO,Lypka MA,Echo A,et al. Reconstruction of full- thickness calvarial defect.a role for artificial dermis [J]. Ann Plast Surg,2009,62 (6):656-659.
[36] Lee LT,Kwan PC,Wong YK. Novel Application of Artificial Dermis Plus Autologous Vital Epithelial Cells: Improved Wound Epithelialization[J]. J Chin Med Assoc,2010,73(2):108-112.
[37] Yura S,Kato T,Ooi K,et al. Oral tumor resection and salivary duct relocation with an ultrasonic surgical aspirator [J]. J Craniofac Surg, 2009,20(4):1250-1251.
[38] Mao Shengxian, Liao Zhenjiang, Huang Bogao, et al. Clinical application of composite transplantation of cell-free dermal matrix and autologous skin piece[J]Chinese Journal of Plastic Surgery,2001,l7(4):227-229.
[39] Li Jiapeng, Chen Jufeng, Fu Zhifeng, et al., Analysis of 82 cases of oral mucosal defects repaired by allogeneic acellular dermal matrix[J]Chinese Journal of Oral and Maxillofacial Surgery,2006,4(5):336-340.
[40] Tian Xu, Zhao Ying acellular allogeneic dermal matrix implantation for the treatment of eyelid and periocular depression[J].Ophthalmology,2005,14(4):231,
[41] Wang Zhiyong, Dou Yi, Liao Zhenjiang, et al, Efficacy and safety analysis of xenoacellular dermal matrix membrane in the repair of full-thickness skin lesions~Multicenter, randomized, controlled trial[J].Chinese Journal of Tissue Engineering Research and Clinical Rehabilitation,2008,12(40):7837-7840.
[42] Huo Menghua, Qi Keming, Huang Jinjing, et al., Dynamic changes of collagen after acellular allograft dermal matrix subcutaneous transplantation[J]Chinese Journal of Plastic Surgery,2004,20(1):51-52.
[43] Li Desheng, Xu Bainan, application of allogeneic acellular dermal matrix in dural repair[J].Foreign Medicine(Biomedical Engineering),2005,28(5):295-297.
[Received:l2010-04-20 [Revised]2010-06-23