From the Plastic and Reconstructive Surgery Unit, Multidisciplinary Department of Medical-Surgical and Dental Specialties, University of Campania Luigi Vanvitelli, Naples, Italy.
Published online 20 June 2022.
Received for publication February 21, 2022; accepted April 12, 2022.
Presented by Dr. Giuseppe Lanzano at the XXVII edition of the Italian Society of Plastic, Reconstructive and Aesthetic Surgery (SICPRE) Meeting, January 29–February 2, 2022, Cortina d’Ampezzo, Italy.
Disclosure:The authors have no financial interest to declare in relation to the content of this article.
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Giuseppe Lanzano, MD, Plastic and Reconstructive Surgery Unit, Multidisciplinary Department of Medical-Surgical and Dental Specialties, University of Campania Luigi Vanvitelli, Piazza Luigi Miraglia, 2, 80138 Naples, Italy, E-mail: [emailprotected]
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In patients undergoing body-contouring after massive weight loss, the increased risk of wound complications is well described. These complications result in infection, seroma, or hematoma formation and wound dehiscence.1,2 In the latter case, surgical revision followed by split thickness grafting, or conservative wound treatment is required. The poor overall condition of some postbariatric patients may be incompatible with surgical procedures such as the closure of the wound by primary intention. Furthermore, it would lead to an increase in healthcare costs, and it is not always desirable for the patient. Therefore, as outpatients, it is desirable to quickly stimulate wound healing by secondary intention, through the formation of granulation tissue to fill the space inside the wound, thus avoiding any infection of the deep structures and obtaining rapid epithelialization of the wound. In these instances, several treatment methods are available.3 An example of these techniques is Vergenix Flowable Gel (CollPlant Ltd, Ness-Ziona, Israel). It is an advanced wound care device primarily comprised of lyophilized tobacco plant-purified type I recombinant human collagen for the management of acute and chronic wounds.4 It is supplied as a powder in a syringe that is hydrated with saline just before application to form a gel, which creates a collagen-fibrin matrix. It contributes to local hemostatic and chemotactic stimuli, enhancing cell migration and tissue repair, while supplying a structural support scaffold upon which new tissue can be formed at an enhanced rate. Intimate contact between therapeutic matrices and deep, irregularly shaped wound beds provides the basic elements required for tissue regeneration.5
CASE REPORT
We describe the case of a 58-year-old woman with a history of severe obesity who underwent bariatric surgery 1 year before reaching our attention. As a result of drastic weight loss, the patient had developed thigh contour deformities, particularly those of the inner thigh. For this reason, she was a candidate to undergo a medial thigh lift surgery for removing soft tissue excess at our plastic and reconstructive surgery unit. One week postoperatively, the patient presented with wound dehiscence at the upper medial left thigh of about 1 cm2 in width (Fig. 1). A swab culture was obtained from the wound bed, which confirmed the presence of Staphylococcus aureus, and the patient responded well to treatment with amoxycillin and clavulanic acid capsules 1000 mg × 2 daily for 6 days. The wound was treated with standard dressing (topical antiseptic agents, paraffin-impregnated dressings, and gauze). However, after 1 week of treatment, the patient developed a severe wound dehiscence that had reached a width of 15 × 5 cm (Fig. 2). The patient was not interested in surgical revision. Negative pressure wound therapy was offered, but due to practical reasons, it was not desirable to the patient. Therefore, a preliminary surgical wound debridement was performed until viable wound bed tissue was reached. Vergenix Flowable Gel was applied once to the wound bed by using two 2-cc doses of the gel to cover the whole wound area, particularly in the undermined parts (see Video [online], which displays the recombinant type 1 collagen application of 2-cc dose to the wound, particularly in the undermined parts), followed by placement of a sterile gauze pad. The patient returned to our unit weekly for wound debridement, wound size, granulation and epithelialization assessments, and application of sterile gauze dressing. A good continuous progress in healing was observed at the following controls. Her wound dehiscence had healed when she was seen after 3 weeks post Vergenix application (Fig. 3). Complete epithelialization was complete, avoiding the risk of additional superinfections, particularly fearful in that area, that may worsen the clinical outcomes, as seen after 12 weeks (Fig. 4). All wounds were photographed before and after the treatment with human recombinant type 1 collagen. (See Video [online], which displays the recombinant type 1 collagen application of 2-cc dose to the wound, particularly in the undermined parts.)
DISCUSSION
Wound treatment is challenging because of the multifactorial nature of skin breakdown and repair, characterized by damaged tissue homeostasis. Impediments to wound healing include the presence of necrotic tissue, hypoxia, high bacterial burden, corrupt extracellular membrane, and senescent cells within the wound bed. Therapeutic options range from healing by second intention for rather small lesions to advanced wound healing therapies and various surgical interventions for major lesions.6 In recent years, a growing number of bioengineered human fibroblast-derived skin substitutes have emerged to restore the lost dermis in full-thickness skin defects.7–9 The use of collagen matrix is well known in clinical practice for soft tissue restoration, and its applications range from breast reconstruction to acute and chronic wound treatment.10,11 One of many possibilities is Vergenix. It maximizes contact with the wound bed and surrounding tissues, enabling scaffolds to develop across the wound bed and reducing the risk of wound bacterial colonization.4,5 The cost issue using this material is of interest, in the era of managed care and cost-effectiveness. In our analysis, although the cost of Vergenix Flowable Gel (about 1300€) is higher compared with standard dressings, against which there is a superior effectiveness according to our experience, it is certainly lower than the hospitalization of the patient for a reoperation (from 3000 to 5000€, relative to the length of stay), while there is no substantial price difference between Vergenix Flowable Gel and other acellular dermal matrix products. In summary, Vergenix Flowable Gel is safe, cost-effective, and most importantly, beneficial to the patient. To our knowledge, after performing a review of current literature, no previous publication has addressed management of postsurgical wound dehiscence in postbariatric patients with this product.
CONCLUSIONS
Vergenix FG contains bioengineered recombinant human type I collagen. When mixed with normal saline, it creates a collagen-fibrin matrix, enhancing cell migration and tissue repair. It has shown efficacy for wound healing in animal models and appears promising for healing of acute surgical wound defects refractory to standard treatment. As presented in our case, its ease of use and improved safety make it an alternative tool for optimizing the treatment of complex surgical wounds with undermining areas left to heal by second intention. However, although the product is part of the therapeutic toolkit within our unit in the postoperative care, so patients do not incur any additional charge for its expensive cost, additional research is required to identify those who will benefit most from this treatment and to quantify its advantages over standard care.
PATIENT CONSENT
Written consent has been obtained from the patient for publishing the case and for the use of pre- and postoperative photographs for publication purpose. All specific patient information is deidentified.
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As a seasoned expert in the field of plastic and reconstructive surgery, particularly in the context of body-contouring after massive weight loss, I bring forth my expertise to dissect and elucidate the intricacies of the article from the Plastic and Reconstructive Surgery Unit at the University of Campania Luigi Vanvitelli in Naples, Italy. This publication, available online since June 20, 2022, provides valuable insights into the management of wound complications in patients undergoing body-contouring after significant weight loss.
The study, authored by Dr. Giuseppe Lanzano and team, delves into the challenges associated with wound complications in postbariatric patients, emphasizing the risks of infection, seroma, hematoma formation, and wound dehiscence. The article underscores the importance of addressing these complications promptly and efficiently.
One notable aspect discussed in the article is the utilization of Vergenix Flowable Gel, an advanced wound care device comprising lyophilized tobacco plant-purified type I recombinant human collagen. The gel is presented as a powder in a syringe, hydrated with saline before application to form a gel. This gel, upon application, creates a collagen-fibrin matrix that promotes local hemostatic and chemotactic stimuli, enhancing cell migration and tissue repair. The article demonstrates a specific case of a 58-year-old woman with thigh contour deformities post-bariatric surgery, where Vergenix Flowable Gel played a pivotal role in the successful management of a severe wound dehiscence.
The authors showcase the efficacy of Vergenix Flowable Gel in promoting wound healing through secondary intention, avoiding the need for surgical revision and minimizing healthcare costs. The article provides a comprehensive overview of the treatment process, including the application of the gel, subsequent wound assessments, and the positive outcomes observed in terms of healing and epithelialization.
The discussion section of the article sheds light on the challenges of wound treatment, emphasizing the multifactorial nature of skin breakdown and repair. It explores therapeutic options, including bioengineered human fibroblast-derived skin substitutes and the well-established use of collagen matrix in various clinical scenarios.
Importantly, the authors discuss the cost-effectiveness of Vergenix Flowable Gel compared to standard dressings and hospitalization costs for reoperation. The conclusion affirms the safety, cost-effectiveness, and patient benefits of Vergenix Flowable Gel, positioning it as a valuable tool in the treatment of complex surgical wounds.
In conclusion, this article contributes significantly to the literature by addressing the management of postsurgical wound dehiscence in postbariatric patients, particularly with the use of Vergenix Flowable Gel. The case study presented, along with the thorough discussion of wound healing challenges and treatment options, adds valuable knowledge to the field of plastic and reconstructive surgery.