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A Novel Approach to Keloid Reconstruction with Bilaminar Dermal Substitute and Epidermal Skin Grafting

Pascone, Christian M.D.; Tassinari, Juri M.D.; Agostini, Tommaso M.D.; Lazzeri, Davide M.D.; Figliuolo, Francesco M.D.; Sisti, Andrea M.D.

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Plastic and Reconstructive Surgery: January 2017 - Volume 139 - Issue 1 - p 320e-321e
doi: 10.1097/PRS.0000000000002917
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We read with great interest the brilliant article from Nguyen et al. entitled “A Novel Approach to Keloid Reconstruction with Bilaminar Dermal Substitute and Epidermal Skin Grafting.”1 They present a series of five patients undergoing excision of keloids and a staged reconstructive approach using a dermal regeneration substrate (Integra; Integra LifeSciences Corp., Plainsboro, N.J.) and epidermal grafting to minimize recurrence and donor-site morbidity.

The use of dermal substitutes such as Integra in the reconstruction of postoncologic losses of substance involving the lower third of the face and other anatomical districts offers a precious reconstructive tool for the plastic surgeon, whereas it is not possible or is contraindicated for use with other possible flaps or tissue expanders.2–4

Moiemen et al. reported long-term clinical and histologic evaluation of Integra dermal regenerate template.5 We appreciated the complete analysis they did about the clinical and histologic features of the regenerated tissue: in particular, we focused our attention on the increased number of random and abnormal arrangements of collagen fibers and the abnormal morphology associated with an abnormal degree of fragmentation of elastic fibers in the reticular dermis. The histologic pattern of dermis regenerated in vivo by dermal substitutes has not always been defined, along with pathognomonic characteristics of absolute “benignity,” thus creating in many cases problems of differential diagnosis between a recurrence of the original tumor or a new tumor arising de novo on the regenerated tissue.

The use of dermal substitutes with epidermal grafting has been shown to provide safe and durable soft-tissue cover for full-thickness defects.4 We commonly use dermal regeneration substrate (Integra) and epidermal grafting to repair skin defects located in any body district, after surgical excision for cutaneous cancers, after trauma (Fig. 1), or for treatment of postburn scars (Fig. 2).

Fig. 1.
Fig. 1.:
Dermal substitute use for treatment of a full-thickness skin defect, following hand trauma.
Fig. 2.
Fig. 2.:
Dermal substitute repair of a neck full-thickness skin defect, after surgical removal of postburn scar.

Our experience with this type of repair is very positive, and we agree with Dr. Nguyen on the usefulness of this technique, especially on wound healing, donor-site morbidity, and scarring response. Moreover, we have never observed recurrence of disease in our patients.


The authors have no financial interest in any of the products or devices mentioned in this communication.

Christian Pascone, M.D.
Burn Center Unit
Cisanello Hospital of Pisa
Pisa, Italy

Juri Tassinari, M.D.
Brisighella, Italy

Tommaso Agostini, M.D.
Department of Maxillofacial Surgery
University of Florence
Florence, Italy

Davide Lazzeri, M.D.
Plastic Reconstructive and Aesthetic Surgery
Villa Salaria Clinic
Rome, Italy

Francesco Figliuolo, M.D.
Plastic and Reconstructive Surgery Unit
University Hospital of Bari
Bari, Italy

Andrea Sisti, M.D.
Montecatini Terme, Italy


1. Nguyen KT, Shikowitz L, Kasabian AK, Bastidas N. A novel approach to keloid reconstruction with bilaminar dermal substitute and epidermal skin grafting. Plast Reconstr Surg. 2016;138:235239.
2. Burd A, Wong PS. One-stage Integra reconstruction in head and neck defects. J Plast Reconstr Aesthet Surg. 2010;63:404409.
3. Felcht M, Koenen W, Sassmann G, Goerdt S, Faulhaber J. Two-stage reconstruction of head and neck defects after tumor resection with a dermal regeneration template. J Cutan Med Surg. 2011;15:259265.
4. Khan MA, Ali SN, Farid M, Pancholi M, Rayatt S, Yap LH. Use of dermal regeneration template (Integra) for reconstruction of full-thickness complex oncologic scalp defects. J Craniofac Surg. 2010;21:905909.
5. Moiemen N, Yarrow J, Hodgson E, et al. Long-term clinical and histological analysis of Integra dermal regeneration template. Plast Reconstr Surg. 2011;127:11491154.


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