In part 4 of a 6-part series, Dane Slentz, MD, of Spindel Eye; Alon Kahana, MD, PhD, of Kahana Oculoplastic & Orbital Surgery; Christine Nelson, MD, of the University of Michigan; and Karine Shebaclo, MD, MSc, of the Mayo Clinic in Florida, discuss how they approach a skin graft with amniotic membrane products.
Dane Slentz, MD:
Obviously, we know this works well for trauma, for burns. Is anyone using this in terms of, say, as part of their nose reconstructions in combination with flaps or grafts?
Alon Kahana, MD, PhD:
I don’t do that routinely. Usually I can reconstruct the defect with standard techniques, but I’m not opposed to it in a situation where I might need to do that.
Dane Slentz, MD:
If you were going to pick upper lid, lower lid, lateral canthus, medial canthus, where would you say the optimal place to put an AmnioGuard would be, if you had to? Say, if you had a defect that would not close despite doing an optimal flap, patient had some comorbidities, there wasn’t an adequate skin graft site, where would you optimally put it?
Karine Shebaclo, MD, MSc:
I actually did one case where I used it in the medial canthus for a skin substitute, I did a glabellar flap, and then just had a very small area that probably wasn’t going to granulate well, it was about 1 by 1 cm. I actually just did the flap, and then I didn’t want to do another skin graft next to it so I just put a little of the AmnioGuard in, sutured it in with the 6-0 Vicryl. I’ll use the 8-0 Vicryl in the future and it healed beautifully.
Alon Kahana, MD, PhD:
For skin, 6-0 Vicryl is great. But you brought blood supply, the whole point of the glabella flap is that you brought blood supply.
Karine Shebaclo, MD, MSc:
Yeah. It healed beautifully. I mean, I was a little worried about it, but when he came in at 2 weeks … I find that the AmnioGuard lasts about 2 to 3 weeks. The suture lasts a little bit longer. But once it re-epithelialized, it looked beautiful. You really couldn’t tell where the flap ended and where the AmnioGuard started. Healed really nicely.
Dane Slentz, MD:
Excellent.
Karine Shebaclo, MD, MSc:
That’s the only time I’ve used it in that capacity.
Christine Nelson, MD:
I’m probably along Dr. Kahana’s. I don’t use it routinely, but if I have an individual case that calls for it, I don’t have any problem. I think it’s a very good color match.
Dane Slentz, MD:
I’ve been tempted to use it a couple of times, especially with smokers. I’ve been burned a lot of times with skin grafts failing. Looking back in retrospect, AmnioGuard would’ve been a perfect opportunity. But to talk about logistically, a lot of my cases are ASC, that don’t want to cover the graft. That hopefully will change in the future. But I could see in that population, with that diabetic, smoker, that’d be an excellent choice for this.
Alon Kahana, MD, PhD:
You can use it also as a patch. Let’s say that you have a vasculopath, you take a skin graft, you suture it, it looks great, but you’re concerned. You put the umbilical cord membrane over it and suture it all over as a patch. That still provides a lot of anti-inflammatory, pro-regenerative signaling that can help this particular patient heal well the first time, so that you don’t have the complications that require a second time. I think that that’s an underutilized way of taking care of these complex patients.
Christine Nelson, MD:
The patch issue I like because it also, especially in a diabetic, will provide some antimicrobial, so there’s slightly less chance of them getting an infection. Dane, I would go back to, I hope you give them that non-smoking, quit smoking lecture. You can code for that.
Dane Slentz, MD:
Absolutely. But then I see them lighting up in the parking lot, even though I told them to quit a year ago.
Christine Nelson, MD:
Exactly. I think that’s so important to describe the risks of your outcome is wholly dependent on their getting prepared for surgery. I used to say, “At least quit smoking 2 weeks before surgery.” But then anesthesia would say, “Actually that’s really a bad time because then they’re just getting pulmonary reaction and they’re coughing all the way through your surgery.” But I think if you can get them to smoke, and I say even if you’re going to restart, that’s not my wish for you, but at least give yourself a chance to heal well the first time, like Alon says.
Alon Kahana, MD, PhD:
Now remember that you should not use ointments with amniotic membranes and umbilical cord membranes. If you’re putting it on the eye, use drops. If you’re putting it on the skin, just wet to dry, and that’s it, leave it alone. It’s going to crust, it’s going to scab, it’s going to look terrible. Don’t worry, it’s still doing what it’s supposed to be doing.
Christine Nelson, MD:
Don’t touch.
Dane Slentz, MD:
If you’re using it as a patch over a skin graft, are you putting some kind of bolster over that to help protect the skin graft?
Alon Kahana, MD, PhD:
Absolutely. I’ll put the bolster, I’ll put the patch over it, I’ll put some kind of a bandage, a pressure bandage for, I don’t know, 3, 4, 5 days. In the medial canthus, that’s hard to put a patch. If it’s in the upper or lower lid, I just put the patch over the eyes. Lateral canthus is pretty straightforward. But just don’t … the ointment for whatever reason, actually it traps the molecules. As the hyaluronic acid gets released, if you have a petroleum-based, oil-based ointment there, it’s just going to hold on to those molecules and not release them to the target tissue.
Christine Nelson, MD:
You don’t need it, you don’t need it.
Alon Kahana, MD, PhD:
You don’t need it.
Christine Nelson, MD:
Alon, I just want to be clear. You are putting down a skin graft, no bolster on your skin graft, then the patch is sutured on, and then I will put a bolster on top of my amniotic membrane patch. Then you could patch or not patch, depending on the location.
Alon Kahana, MD, PhD:
Yes. Correct. A non-adhesive dressing and patch it for a few days. Also prevents them from touching it and all of that.
Christine Nelson, MD:
Yes. Oh yes.
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