161. Use of Fibrin Sealant to Stabilize Particulate Adipose for Single-Stage Multilaminar Reconstruction

PURPOSE: Management of large, complex, and unfavorably localized trauma remains a significant challenge, with morbidity resulting not only from the injury itself but also from the reconstruction techniques employed. Previously, we have demonstrated the viability of a single-stage technique that utilizes a split-thickness skin graft (STSG) as a sheet graft over a layer of morselized autologous fat. In our initial presentation and trail, we utilized thin (5 mm) adipose layers. While this is sufficient to resist adhesion, it can leave residual defect in the setting of particularly deep trauma. Currently the upper limit of the adipose layer that can viably support a skin graft is unknown. Additionally, as the adipose is a morselized particulate, it is unclear how additional thickness affects displacement of the adipose secondary to mechanical forces during STSG and bolster placement. Here we will test incorporation of a fibrin sealant to secure the particulate adipose tissue in place, minimizing fat displacement and enhancing graft stability. METHODS: Pre-animal testing was performed with human adipose collected from panniculectomy samples acquired under IRB exemption for discarded surgical tissues. Different layering and cementing strategies were used to test adipose malposition with bolster placement. Isolated adipose was additionally assessed under standardized compression testing. We transitioned to an experimental study involving 2 female Yorkshire swine, each sustaining 18 full-thickness burns of 16 cm² (total n=36). Surgical debridement to fascia followed by reconstruction was performed 48 hours post-injury. Control wounds were treated with STSG directly over the fascia. Experimental wounds were treated with variations: A) thin (0-5 mm) adipose, B) thick (5-10 mm) adipose, C) thin + fibrin sealant, D) thick + fibrin sealant. We have additionally assessed thickness of each reconstruction by ultrasound. RESULTS: All formulations of sealant with adipose were sufficient to mitigate displacement forces in pre-animal testing. In pigs, we noted that use of a thick layer of fat with a sealant compromised skin graft survival. Thick fat alone and/or thin fat ± sealant all demonstrated reproducible graft viability and healing of the reconstruction over time. CONCLUSION: Both thicker layers of adipose (10 mm) and use of a fibrin sealant at 5 mm thickness are viable in a single-stage multilaminar reconstruction. When combining thick fat and sealant, the additional barrier to nutrient exchange compromises STSG survival, consequently leading to worsened contracture and wound healing.