LAUSR

matrix, lasting months on unfavorable wound beds. Although other skin substitutes are less expensive, their fast disintegration requires repeated placement for slow healing wounds. Our cases demonstrate AHD’s role as an effective replacement for porcine xenografts in slow healing post-MMSdefects.We recommend its application for larger second intent wounds with cartilage/bone exposure in areas with thicker skin and minimal laxity. ForAHDrepair, the defect’s skin edges are underminedwith a periosteal elevator. AHD is trimmed, slid into the pocket between skin and exposed bone, and secured along the periphery with interrupted sutures to prevent graft dislodging and tissue strangulation. The sutures are placed through the graft and then the deep surface of the raised wound bed edge. Given the thickness of scalp and acral skin, needle and suture of larger diameters are recommended; we used 4-0 or 3-0 polyglactin, nylon, or polypropylene sutures with PS-2 needle. Wound care for porcine xenografts and AHD is similar. For porcine xenografts, we recommend daily dressing changes and light washing, whereas daily nonstick dressing with surface petrolatum jelly is used for AHD. Water exposure must be avoided at the graft site for the first 2-3 weeks because it can dislodge or separate the product from the wound base. In some cases of AHD application, a short course oral antibiotic and dilute 2% vinegar soaks are recommended. Weekly or bi-monthly monitoring is recommended for the first 1-2 months. Small hematomas can be evacuated by creating a slit with an 11 blade, a similar technique to venting a split-thickness skin graft. If noticeable slowing of healing or lack of granulation tissue prior to complete re-epithelization occurs, gentle debridement is performed. With minor debridement, we have observed reformation of granulation tissue and continued activewound healing. AHD will eventually disintegrate with slow deterioration in color and texture without the “gumminess” and odor seen in most instances of human tissue necrosis or xenograft disintegration. Even with slow disintegration, AHD provides a more robust scaffold for granulation tissue formation than porcine xenografts. Although it has an epidermal and dermal side, AHD tends to facilitate autologous human tissue formation both below and above the graft. Despite its benefits, AHD is difficult to use on rugged surfaces with thinner skin, such as the ear, because the product is thicker and less flexible; nonetheless, the authors intend to trial the thinner versions for phalanges or exposed cartilages in the future. Furthermore, because it is not intended to be removed, AHD is best avoided in anticipated staged repairs. This case series demonstrates the promising use of AHD in the repair of post-MMS defects with bone exposure. Further studies are needed to examine the efficacy of second intention repair with AHD on sites outside the scalp and phalanges, especially with thinner sheets.