RECONSTRUCTIVE

The Use of Artificial Dermis in the

Reconstruction of Oncologic Surgical Defects
Anthony P. Tufaro, D.D.S.,
Background: Integra dermal substitute has been used in burn reconstruction
M.D. with great success. Its use in general reconstruction is currently being reported.
Donald W. Buck, II, B.S. The authors set out to evaluate the utility of Integra in the reconstruction and
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Anne C. Fischer, M.D., Ph.D. resurfacing of defects created by tumor excision.

Baltimore, Md. Methods: Since 2003, 17 patients with soft-tissue tumors involving the head
and neck, lower extremity, and anterior chest wall underwent tumor resec-
tion and reconstruction with Integra dermal substitute. These patients were
followed and clinical outcomes were assessed.
Results: Seventeen patients with a mean age of 54 ⫾ 21 years underwent tumor
resection and reconstruction with Integra dermal substitute. Twelve patients (71
percent) were male and five (29 percent) were female. Twelve cases (71 percent)
involved recurrent tumor resection. The 17 cases involved 10 different tumor
types at six different anatomical locations. The mean defect size was 172 ⫾ 260
cm2 (range, 20 to 1080 cm2). The second stage of the reconstruction occurred
on postoperative day 23 ⫾ 6. The mean follow-up was 12.3 ⫾ 7.2 months (range,
3 to 26 months). Clinically, 16 patients had 100 percent take of skin grafts and
one patient had approximately 97 percent take of his graft. All patients expe-
rienced excellent defect contouring and cosmesis.
Conclusions: Artificial bilaminate acellular dermis is an excellent option for
reconstructing defects created by tumor resection and can be used in a wide
variety of locations. It is especially useful in large defects that usually require flaps
for coverage. Patients experience minimal donor-site morbidity and have out-
standing cosmetic and functional results. (Plast. Reconstr. Surg. 120: 638, 2007.)

R
econstruction of complicated defects cre-
ated by tumor excision has primarily in-
volved the use of skin grafts and either
local or distant myocutaneous, myofascial, or fas-
ciocutaneous flaps. Although these options offer
adequate coverage, they often fail to provide
good aesthetic results and require additional re-
visions to correct muscle atrophy and contour
abnormalities.1 Skin grafts will provide coverage
but are subject to contraction and are often
unstable, particularly on bony prominences and
calvarium.2 Similarly, skin grafts are often unsta-
ble, particularly in the face of adjuvant radiation
therapy.3 Full-thickness skin grafts, though ex-
hibiting less contraction, are often not adequate
to cover large defects. The use of locoregional
From the Divisions of Plastic and Reconstructive Surgery and
Pediatric Surgery, Department of Surgery, The Johns Hop-
kins School of Medicine.
Received for publication October 9, 2005; accepted March
10, 2006.
Copyright ©2007 by the American Society of Plastic Surgeons
DOI: 10.1097/01.prs.0000270298.68331.8a
flaps is complicated in the face of preoperative
irradiation, previous surgery, and larger defect
size.
Free tissue transfers have revolutionized on-
cologic surgery. Even in the most experienced
hands, they are time consuming and often
require more than 1-day hospital stays. Irradi-
ation, previous surgery, and comorbidities can
make these operations challenging and less
predictable.1 In addition to the primary surgi-
cal site, the patient also experiences, in many
cases, significant donor-site morbidity and ab-
normality. Although every attempt is made to
reduce this donor-site morbidity, the outcome
is largely dependent on the resection defect
and site selected for donor tissue.
Biosynthetic composites have been in use for
over 20 years in the management of complicated
wounds. Artificial dermis is a synthetic bilami-
nate composed of a bovine collagen lattice co-
valently linked to chondroitin-6-sulfate and cov-
ered with a Silastic epidermis.4 At approximately
21 days after application, the Silastic sheet is
removed and a skin graft is placed on the vascu-

638 www.PRSJournal.com
Volume 120, Number 3 • Artificial Dermis
larized neodermis. Artificial dermis has also
been used in reconstructive surgery with success.
In burn reconstruction, patients with severe
burn contractures and deformities have re-
gained good functionality and aesthetic results,
with improved color, texture, and contour.5–7
There is some debate on the recurrence of post-
burn contractures in reconstruction of the neck8
and chest9 despite use of Integra (Integra Matrix
Wound Dressing; Integra LifeSciences Corp.,
Plainsboro, N.J.). Even in the field of posttrauma
reconstruction, artificial dermis has been dem-
onstrated as useful in correcting posttraumatic
deformities, particularly depressions and
adhesions.10 Despite the necessity for a two-stage
procedure, artificial dermis offers many advan-
tages, including immediate availability, ability to
cover large defects, minimal donor-site morbid-
ity, good cosmetic results with optimal contour-
ing, and reduced scarring and hypertrophy.11
The role of artificial dermis in general plastic
and reconstructive surgery is not well defined.
Recent case reports indicate its successful use in
the reconstruction of defects created by giant
hairy nevi excision12 and complex scalp defects13;
however, there have been no large patient re-
ports of its use in the reconstruction and resur-
facing of defects created by tumor excision, es-
pecially larger defects where flap reconstruction
would usually be required. It is our goal to ex-
plore the utility of artificial dermis as a successful
tool for reconstruction of tumor resection de-
fects and its ability to function under the rigors
of adjuvant therapy.
PATIENTS AND METHODS
Medical records from 17 patients who under-
went reconstruction with the use of dermal sub-
stitute (Integra Matrix Wound Dressing) were ret-
rospectively reviewed, and information regarding
clinical history; patient age; tumor type and loca-
tion; defect size; and history of previous surgery,
preoperative chemotherapy, or radiation therapy
was recorded. The series represents the experi-
ence of a single surgeon (A.P.T.). All patients who
presented to the senior author for primary or re-
current cutaneous or subcutaneous tumor resec-
tion were considered for reconstruction with der-
mal substitute. Wounds that could be closed either
primarily or by secondary retention or that were
easily amenable to locoregional flap reconstruc-
tion were not treated with this technique. Also,
patients whose wounds would present with a sig-
nificant contour deformity were not reconstructed
with artificial dermis. In every case, the recon-
struction was carried out in the same two-stage
process. The time interval between these stages
and the time to the last follow-up visit were also
recorded.
The first stage involved removal of the tumor
and application of the Integra dermal template.
The template is a bilayer xenographic dermal sub-
stitute composed of a collagen-glycosaminoglycan
matrix layer, which promotes dermal regenera-
tion, and a semipermeable silicone layer, which
functions as a temporary epidermis. All wounds
were fresh surgical resections down to and, in some
cases, including periosteum, fascia, and bone (Ta-
ble 1). In fact, six surgical wound beds extended
to bone. Defect size was determined by analogue
rulers used to measure the greatest cross-sectional
length and width with resultant area calculated.
Areas of breakdown and ulceration were likewise
measured and their area deducted from the total.
After tumor excision and adequate hemostasis,
the artificial dermal template was sutured into
place using absorbable material (Figs. 1 and 2).
In each case, the Integra was meshed before
implantation to minimize the risk of hematoma
or seroma formation. A silver-coated antimicro-
bial barrier dressing (Acticoat; Westaim Biomedical,
Calgary, Alberta, Canada) was placed over the In-
tegra. A bolster dressing was applied to the graft and
left in place for 5 days. Thereafter, the dressing,
along with the Acticoat, was changed every day and
the surgical site was examined for signs of infection,
silicone detachment, and neodermis formation. Be-
fore all surgical procedures, all patients were given
prophylactic antibiotics as dictated by our institu-
tional protocols.
At approximately 21 days after evidence of
neodermis formation, the patient was brought
back to the operating room for the second and
final stage of the procedure. During this time, the
silicone layer was removed and replaced with a
thin split-thickness skin graft. All skin grafts were
placed as sheet grafts. A bolster dressing was again
applied and left in place for 3 to 5 days. The
patient was instructed on proper wound care man-
agement and returned to the clinic for follow-up
within 7 days. At each follow-up visit, after the
initial procedure, the surgical site was examined
for infection, stability of the silicone layer, take of
the artificial dermis by the initial adherence of the
material to the bed and subsequent vascular in-
growth, and overall wound healing. At visits after
the second stage, the area was examined for in-
fection, take or adherence of the skin graft as a
percentage of total graft area, and overall wound
healing. On subsequent follow-up visits, the site
639
 Plastic and Reconstructive Surgery • September 1, 2007

Table 1. Patient and Tumor Characteristics

Graft
Age Area Prior Prior Adjuvant
Patient (yr) Sex Abnormality Tumor Location Surgical Bed (cm2) Surgery Therapy Therapy
1 49 M Melanoma Face, mandible Soft tissue 60 ⫹ IT XRT
2 74 M Melanoma Scalp Periosteum 25 ⫺ ⫺ ⫺
3 22 F Desmoid tumor Neck Soft tissue 408 ⫹ ⫺ ⫺
4 55 F Metastatic renal cell Scalp and craniectomy Bone and 85 ⫹ ⫺ ⫺
carcinoma periosteum
5 51 M Malignant nerve Scalp and craniectomy Bone and 100 ⫹ ⫺ ⫺
sheath tumor periosteum
6 77 M Liposarcoma Anterior chest wall Periosteum 104 ⫹ XRT ⫺
7 15 F Angioblastoma Lower extremity Fascia 25 ⫹ ⫺ ⫺
8 54 M Dermatofibrosarcoma Supraclavicular Bone and 300 ⫹ XRT ⫺
soft tissue
9 79 M SCC and BCC Scalp Bone 25 ⫹ CT CT
10 65 M SCC Face and craniectomy Bone and 20 ⫹ ⫺ XRT
soft tissue
11 71 M Dermatofibrosarcoma Neck Soft tissue 300 ⫹ ⫺ ⫺
12 62 M Melanoma Scalp Bone and 120 ⫺ ⫺ ⫺
periosteum
13 48 F Angiosarcoma Chest wall Periosteum 1080 ⫹ XRT XRT
14 74 M Melanoma Foot Soft tissue 50 ⫺ ⫺ XRT
15 75 F Angiosarcoma Face Soft tissue 60 ⫺ ⫺ XRT
16 22 M Dermatofibrosarcoma Scalp Periosteum 130 ⫹ ⫺ ⫺
17 26 M Melanoma Scalp Periosteum 25 ⫺ ⫺ ⫺
SCC, squamous cell carcinoma; BCC, basal cell carcinoma; XRT, radiation therapy; CT, chemotherapy; IT, immunotherapy; ⫹, prior surgery;
⫺, no prior or adjuvant therapy.

was examined for breakdown and ulceration, pain,
aesthetics (e.g., pliability, contour, color, and tex-
ture), patient satisfaction, function, and need for
further surgery. The outcomes of these evalua-
tions is reported in the Results section and illus-
trated in the figures. Statistical analysis of the pa-
tient population was determined by the arithmetic
mean and SD.
RESULTS
Patient Characteristics
A total of 17 patients underwent reconstruc-
tion of tumor resection defects with Integra der-
mal substitute at the Johns Hopkins Hospital from
December of 2003 to May of 2005. The mean age
of the patients was 54 ⫾ 21 years (range, 15 to 79
years). Of the 17 patients, 12 (71 percent) were
male and five (29 percent) were female. The 17
cases involved 10 different tumor types, including
melanoma (five cases), dermatofibrosarcoma pro-
tuberans (three cases), angiosarcoma (two cases),
squamous cell carcinoma (two cases), basal cell
carcinoma, desmoid tumor, metastatic renal cell
carcinoma, malignant nerve sheath tumor, lipo-
sarcoma, and angioblastoma. The tumors were
removed from six different anatomical locations
including the scalp (six cases), face (three cases),
neck (three cases), chest wall (two cases), lower
extremity (two cases), and posterior auricular
area. Twelve patients (71 percent) had prior sur-
gical interventions and required recurrent tumor
resection. Three patients (18 percent) received
neoadjuvant radiation therapy and two patients
received neoadjuvant chemotherapy or vaccine
immunotherapy before undergoing reconstruc-
tion, whereas five patients (29 percent) received
postoperative radiation therapy and one re-
ceived postoperative chemotherapy. The surgi-
cal bed notably was bone in six cases and peri-
osteum in seven cases. The mean defect size of
the surgical bed was 172 ⫾ 260 cm2 (range, 20
to 1080 cm2) (Table 1).
Reconstruction and Follow-Up
There were no complications associated with
the Integra template application. Two patients ex-
perienced minimal (⬍10 percent) silicone de-
tachment before skin grafting. In these cases, the
unattached silicone layer was excised and routine
daily dressing changes were carried out. In all
cases, well-vascularized neodermis formation was
observed before the second procedure. The split-
thickness skin graft was applied as a sheet graft on
postoperative day 23 ⫾ 6 and sutured with absorb-
able material. No staples were used. Sixteen pa-
tients had 100 percent take of their grafts and one
patient had approximately 97 percent take. Clin-
ically, these patients experienced excellent con-
tour and cosmesis without complication. The
mean follow-up was 12.3 ⫾ 7.3 months (range, 3

640
Volume 120, Number 3 • Artificial Dermis
Fig. 1. Patient 1 had recurrent desmoplastic melanoma. (Above)
Melanoma was resected with template and Integra in place before
suturing. (Center) Integra was sutured in place and prepared for tie-
over bolster dressing. (Below) At 8-month follow-up after comple-
tion of postoperative radiation therapy, Integra showed no signifi-
cant contraction or distortion of the commissure of the lip.
to 26 months). Our shortest follow-up was seen in
patient 4, who died as a result of metastatic disease
after 3 months of follow-up, with no evidence of
locoregional recurrence or breakdown.
Fig. 2. Patient 15 had angiosarcoma of the right temporal brow
area. (Above) View of the defect before Integra placement. (Be-
low) Integra is shown in place and ready for tie-over dressing.
Five patients experienced minor complica-
tions, which were unrelated to the application of
the artificial dermis. One patient (patient 8) had
tumor involvement of the clavicle and underwent
partial resection of the involved bone. This pa-
tient, who had undergone two prior attempts at
resection and prior radiation therapy, developed
osteomyelitis in the residual bone and a local soft-
tissue infection months after placement of the
dermal substitute and the skin graft. The debride-
ment and resection of the residual portion of the
clavicle led to a loss of 20 percent of the recon-
struction. The surgical site was treated with serial
dressing changes and the patient went on to heal
without incident. Patient 14 developed a pressure
ulcer in the central portion of the foot reconstruc-
tion requiring debridement. Approximately 25
percent of the reconstruction was debrided and
skin-grafted again, and it healed without incident.
Three of five patients who received postoperative
641
 Plastic and Reconstructive Surgery • September 1, 2007
radiation therapy subsequently developed mild ra-
diation-related complications, including blister
formation and minimal graft ulceration. On sub-
sequent follow-up visits, these three patients
healed well, without residual deficits. Notably, the
longest follow-up is in a patient with postoperative
radiation therapy, and those patients undergoing
postoperative radiation therapy had on average a
longer follow-up (17.8 ⫾ 7.5 months) without any
sequelae besides those noted above.
For a reconstructive technique to be accept-
able in oncologic resections, it must be able to
tolerate adjuvant radiation therapy. Figure 1, below
shows patient 1 at 8 months after resection and
adjuvant radiation therapy. The patient has a sta-
ble result, with no significant contraction or dis-
tortion of the commissure of the lip or adjacent
structures. The surgical site exhibits erythema that
is consistent with the surrounding native skin’s
response to radiation. Figure 3, right shows such a
patient (patient 13) 6 months after resection and
adjuvant irradiation for a large angiosarcoma of
the trunk. The patient developed areas of blister
formation and a small amount of ulceration, less
than 20 percent of the total grafted area. The
blistering and ulceration were managed with rou-
tine wound care and the area went on to heal
without sequelae.
A plan for reconstruction of an oncologic re-
section must be durable on bone or periosteum;
notably in this series, six cases included bone and
seven included periosteum. Skin graft on the cal-
Fig. 3. Patient 13 had recurrent angiosarcoma. (Left) Postoperative view, 5 days after resection and
Integra placement. (Right) Follow-up view at 6 months after Integra placement and postoperative radi-
ation therapy.
642
varia, particularly in the presence of an outer table
craniectomy, is often unstable and exhibits fre-
quent breakdown and ulceration. Figure 4, below
shows a 6-month postoperative photograph of pa-
tient 5 with a recurrent malignant nerve sheath
tumor. The reconstruction is soft and supple, with
no evidence of breakdown, as is also illustrated in
Figure 5 (patient 12). This photograph was ob-
tained at 6 weeks postoperatively and demon-
strates a patient with a well-healed sheet graft on
neodermis. Likewise, Figure 6 is a 3-month fol-
low-up photograph from a similar complex prob-
lem of grafting on the calvaria. The sheet graft is
supple and pliable and the skin easily wrinkles with
movement and is not fixed to the underlying bone
(Fig. 7).
DISCUSSION
The reconstruction of soft-tissue defects cre-
ated by radical resection of benign and malignant
tumors presents a difficult surgical challenge. The
standard reconstructive ladder is usually applied;
however, every rung of the ladder has its own set
of problems.1 Large defects, particularly those sec-
ondary to resection of a malignancy, are not ame-
nable to healing by secondary intention. The use
of full-thickness skin grafts works very well for
smaller defects. Larger wounds will require a split-
thickness skin graft. Although full-thickness skin
grafts will exhibit fewer of these problems, these
grafts will exhibit contraction and can distort ad-
jacent structures such as lips and eyelids. Skin
Volume 120, Number 3 • Artificial Dermis
Fig. 4. Patient 5 with recurrent malignant nerve sheath tumor.
(Above) Tumor before resection with margins marked. (Center) At
3 weeks after Integra placement, before split-thickness grafting,
demonstrating neodermis formation. (Below) At 6-month fol-
low-up after Integra placement, a soft, supple result, with no ev-
idence of breakdown.
grafts on the calvaria, even when placed on peri-
cranium, are unstable and often exhibit break-
down and chronic ulceration. Similar problems
Fig. 5. Patient 12 at 6-week follow-up after stage III melanoma
excision and Integra placement with well-healed sheet graft on
neodermis.
Fig. 6. Patient 17 had melanoma of the posterior scalp. At 3
months after Integra placement, the pliability of the skin sheet
graft and the Integra is demonstrated by the skin’s ease of wrin-
kling without fixation to the underlying bone.
can arise with placement of split-thickness grafts
on ribs and other bony prominences. If we add the
insult of radiation to the skin graft, the problem
is exacerbated and the need for stable coverage is
even more imperative. Local soft-tissue flaps have
the advantage of similar skin color and quality;
however, the larger defect size often required for
tumor resection makes a fasciocutaneous flap dif-
ficult to apply. Unlike the anterior and lateral face,
tissues of the scalp and distal lower extremity are
not easily moved, and donor sites often require a
separate procedure for closure. Many of our pa-
tients have had multiple surgical procedures be-
fore presentation at our institution. Numerous
643
 Plastic and Reconstructive Surgery • September 1, 2007
Fig. 7. Patient 7 had recurrent angioblastoma of the right lower
extremity. (Above) Magnetic resonance imaging scan of lower
extremities showed hyperintensity of the angioblastoma ex-
tending down to the fascia. (Center) The angioblastoma was re-
sected before Integra placement. (Below) Integra was sutured in
place before placement of the tie-over bolster dressing.
crossing incisions and scarring make the design
and elevation of local flaps difficult and somewhat
unpredictable. If rotational muscle flaps are used,
644
donor-site morbidity and contour abnormality
need to be addressed.
The use of free tissue transfers has revolution-
ized our approach to oncologic surgery. The use
of microsurgery is time consuming, even in the
most experienced hands. Often, the resections
discussed in this article required a fasciocutaneous
reconstruction. Large fasciocutaneous flaps for
free tissue transfers often leave large donor-site
defects that require surgical reconstruction as
well. Adequate recipient vessels may be difficult to
identify in patients who have undergone numer-
ous previous operations and/or irradiation. Con-
tour may be a problem in patients with a thicker
subcutaneous fat layer, requiring subsequent de-
bulking and touch-up procedures.
With this problem set in mind, we sought a
new approach to the management of these com-
plicated defects. The use of a safe, readily available
material with a significantly long shelf life would
be a great advantage to the management of our
patient populations. The two-stage nature of the
surgery allows for the thorough review of all ma-
terial and margins before definitive reconstruc-
tion: if a margin is reported positive or close, it can
be resected at the time of final skin grafting. The
use of the dermal substitute on the calvaria and
bony prominences produces a much more supple
result that stands up to the rigors of daily life much
better than a split-thickness skin graft. In cases
where an outer table craniectomy was required
(patients 4, 5, and 10) (Fig. 4), the dermal sub-
stitute was applied to the diploe after burring
down the outer table. The area was then treated in
the same fashion as all the other surgical sites.
There were no problems in integration of the
material, with 100 percent take of all skin grafts
and excellent long-term follow-up.
The outcomes of a small number of patients
with preoperative and postoperative irradiation in
this series may indicate that this therapy is possible
regardless of the effects of irradiation on the re-
construction. In three patients (patients 6, 8, and
13), the surgical site had been irradiated before
resection and reconstruction. Much of the previ-
ously irradiated tissue was resected. In the cases of
five patients (patients 1, 10, 13, 14, and 15), the
entire bed was irradiated postoperatively. The suc-
cessful use of Integra for these patients demon-
strated that we can offer a better solution than a
skin graft for these complicated problems. Fur-
thermore, in this subsection of patients with post-
operative irradiation, we have the longest average
follow-up times (17.8 months).
Volume 120, Number 3 • Artificial Dermis
The vast majority of experience with the neo-
dermis material was obtained in the manage-
ment of acute burns.14 –16 The problems seen in
the burn population are not seen in the onco-
logic population for the most part. Problems
with wound infection, hypertrophic scarring,
and the need for multiple operations and con-
tractures were not seen. Even in the face of
numerous previous operations and preoperative
and postoperative irradiation, the patients in
our series experienced excellent postoperative
results. The standard criteria for any reconstruc-
tion were applied for the evaluation of the re-
sults of the use of dermal substitute in our pa-
tients: Was the reconstruction functional? Did it
exhibit contractures? Was there limited func-
tion of the affected part? Was it painful? Did it
stand up to the rigors of daily life and adjuvant
therapy? Was there donor-site morbidity? Were
the patients satisfied aesthetically? The recon-
structive technique was relatively easy to carry
out when compared with regional flaps and free
tissue transfer. The ease of application led to
short operative times. The patients were hospi-
talized only overnight for the first stage, and
often the second stage of surgery was performed
on an outpatient basis. No patient required re-
vision of the reconstruction. The dermal substi-
tute held up extremely well in the face of radi-
ation therapy and in sites that had undergone
prior surgical interventions. In these patients,
flap coverage would have been difficult because
of altered underlying anatomy. Skin grafts ap-
plied to the neodermis did not contract and
often demonstrated good pliability on follow-up
visits (patient 17) (Fig. 6). Unlike flap recon-
struction, defect size was not a factor. We were
successful in resurfacing defects as large as 1080
cm2 (patient 13) (Fig. 3). On the basis of our
patient series, we believe artificial dermis to be
an excellent option for the treatment of onco-
logic surgical defects.
CONCLUSIONS
The current techniques for reconstruction of
oncologic tumor defects include the use of local
tissue rearrangement, flaps, and skin grafting. Al-
though tissue transfer is a reliable method of re-
construction, it is often associated with many aes-
thetic complications. On the basis of this clinical
series, it appears that the use of artificial dermis for
general reconstruction of oncologic tumor defects
results in excellent cosmetic and functional results
and less donor-site morbidity. Thus, it is a viable
alternative to flaps and should be considered in
oncologic tumor reconstruction, especially in
patients with large defects, patients with recur-
rent tumors, and patients who require adjuvant
therapy.
Anthony P. Tufaro, D.D.S., M.D.
Division of Plastic and Reconstructive Surgery
Department of Surgery
The Johns Hopkins School of Medicine
601 North Caroline Street
8130-D McElderry
Baltimore, Md. 21287
aptufaro@jhmi.edu
DISCLOSURES
The authors have no commercial or current research
relationship with Integra LifeSciences Corporation or
Westaim Biomedical, Inc. The authors received expe-
dited, de-identified institutional review board approval
for this research. The authors have no conflict of interest
regarding this research.
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 Plastic and Reconstructive Surgery • September 1, 2007

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Online CME Collections

Plastic and Reconstructive Surgery is pleased to offer you Online CME Collections. Each collection represents
a number of CME articles published in the Journal. These articles are suitable for use as study guides for board
certification and/or re-certification, to help readers re-familiarize themselves on a particular topic, or to serve as useful
reference articles. Articles less than 3 years old can be taken for CME credit.
Articles are grouped in the following compilations:
• According to year of publication (14 articles/collection)
– 7 complete collections, 1999 to 2005
– 1 collection in process, 2006
• By topic (articles through October of 2006)
– Breast (9 articles)
– Cosmetic (17 articles)
– Hand/Peripheral Nerve (13 articles)
– Pediatric/Craniofacial (26 articles)
– Reconstructive–Head and Neck (20 articles)
– Reconstructive–Trunk (15 articles)
– Reconstructive–Lower Extremity (5 articles)
Article Format
The CME articles reflect the evolution of online presentation: CME articles from 1999 are viewable in HTML
format only. All CME articles from 2000 onward are in PDF format. All articles can be printed out if desired.
Tests
All CME articles from 1999 to 2003 have the tests included at the end of the article. These CMEs cannot be
taken for credit. Answer keys are not available, but answers to every question can be found within the article.
All CME articles less than 3 years old (beginning with the January 2004 CME article) are still “active”; their
tests can be taken for CME credit. Tests for these CME articles can be found on the Journal Web site, under
the “Online CME Articles/Tests” link. If you have not yet taken these CME tests, we encourage you to do
so.

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