Free tissue transfer has revolutionized lower extremity reconstruction; however, its use in elderly patients with multiple medical problems can be associated with elevated rate s of perioperative morbidity and mortality. This study evaluates the use of acellular dermal matrix (ADM) in conjunction with negative pressure wound therapy (NPWT) and delayed skin graft application as an alternative to free tissue transfer in this compromised population. Bilayer, ADM (Integra, Plainsboro, NJ) was used in conjunction with NPWT (Wound V.A.C, Kinetic Concepts Inc., San Antonio, TX) to achieve vascularized coverage of complex lower extremity wounds with denuded tendon and bone in elderly, medically compromised patients. Following incorporation, the matrix was covered with split-thickness skin graft. Four patients (age range, 50 to 76 years) with multiple medical comorbidities were treated with the above protocol. The average time to complete vascularization of the matrix was 29 days. Definitive closure with split-thickness skin graft was achieved in three patients and one wound healed by secondary intention. No medical or surgical complications were encountered and stable soft tissue coverage was achieved in all patients. This early experience suggests that dermal substitute and NPWT with delayed skin graft application can provide a reasonable tissue-engineered alternative to free tissue transfer in the medically compromised individual.
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