Tissue-engineered skin is a significant advance in the field of wound healing and was developed due to limitations associated with the use of autografts.  This document addresses the use of skin substitutes in wound healing and surgical procedures.

For the purposes of this document the following terms are defined as below:

• Autologous: A product derived from the individual's own body or body products.
• Allogeneic: A product derived from humans, other than the individuals themselves.
• Xenographic: A product derived from non-human organisms (e.g., Cows, pigs, horses, etc.)
• Synthetic: A product derived from man-made materials.
• Composite: A product derived from a mix of materials of various origins.

Note: The use of non-engineered allogeneic cadaver-derived skin grafts is not addressed in this document

Note: This document does not address the use of meshes or patches of non-biologic origin when used for standard hernia repair procedures.

Note: For additional information please see:

• MED.00110 Growth factors, Silver-based Products and Autologous Tissues for Wound treatment and Soft Tissue Grafting
• SURG.00023 Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures.
• TRANS.00015 Meniscal Allograft Transplantation of the Knee
• TRANS.00035 Mesenchymal Stem Cell Therapy For Orthopedic Indications

Medically Necessary:

Alloderm^® is considered medically necessary for either of the following uses:

• Surgical repair of complex abdominal wall wounds (e.g., due to infection, fascial defect, etc.); or
• Breast reconstruction surgery.

Apligraf^® is considered medically necessary for a total of five (5) applications for either of the following indications:

• Venous insufficiency skin ulcers with all the following characteristics:
  • Chronic, non-infected, partial or full thickness ulcers due to venous insufficiency; AND
  • Standard therapeutic compression also in use; AND
  • At least one month of conventional ulcer therapy (such as standard dressing changes, and standard therapeutic compression) has been ineffective; OR
• Diabetic foot ulcers with all the following characteristics:
  • Full-thickness neuropathic diabetic foot ulcers; AND
  • Extends through the dermis but without tendon, muscle, joint capsule, or bone exposure; AND
  • At least three weeks of conventional ulcer therapy (such as surgical debridement, complete off-loading and standard dressing changes) has been ineffective.

Dermagraft^® is considered medically necessary when used for either of the following indications:

• The treatment of full-thickness diabetic foot ulcers of greater than six weeks duration that extend through the dermis, but without tendon, muscle, joint capsule, or bone exposure; OR
• When used on wounds with dystrophic epidermolysis bullosa. 

Integra^™ Bilayer Matrix Wound Dressing, an artificial skin substitute, is considered medically necessary in the post-excisional treatment of full-thickness or deep partial-thickness burns when autografting is not feasible due to the individual's weakened physiological condition or a lack of suitable healthy tissue.

OrCel^™_, a composite skin substitute, is considered medically necessary in children with recessive dystrophic epidermolysis bullosa who are undergoing reconstructive hand surgery.

TransCyte^™_, a biosynthetic skin substitute, is considered medically necessary as a temporary wound covering to treat second and third degree burns.

Investigational and Not Medically Necessary:

The following products are considered investigational and not medically necessary when criteria above are not met and for any use not listed above:

• Alloderm
• Apligraf
• Dermagraft
• Integra Bilayer Matrix Wound Dressing
• OrCel
• TransCyte

The use of all other allogeneic, xenographic, synthetic and composite products for wound healing or soft tissue grafting, including but not limited to the following products, is considered investigational and not medically necessary for all uses:

• AlloMax™
• Allopatch HD™
• Alloskin™
• Alloskin RT™
• AmnioFix™
• Arthroflex™
• Avaulta Plus™
• Biobrane^®
• C-QUR™
• CellerateRX^®
• CollaFix™
• Collamend™
• Conexa™
• CorMatrix^®
• CRXa™
• Cuffpatch™
• Cymetra^® 
• Dermacell™
• Dermamatrix^®
• Endoform
• ENDURAgen™
• Epicel^®
• Epidex^®
• EpiFix™
• E-Z Derm™
• Flex HD^®
• Gammagraft™
• GORE BIO-A^® Fistula Plug
• Grafix^® CORE
• Grafix^® PRIME
• GraftJacket™
• Graftjacket™ Xpress injectable
• Hyalomatrix^®
• Inforce^®
• Integra^® Dermal Regeneration Template
• Integra™ Matrix Wound Dressing
• Matriderm^®
• Matristem^®
• MediHoney^®
• Medeor™
• Mediskin^®
• Memoderm™
• Menaflex™ Collagen Meniscus Implant
• Meso BioMatrix™
• Neoform Dermis™
• Neuragen^®
• NeuraWrap™
• Neuroflex™
• NeuroMatrix™
• Oasis™
• OrthADAPT™
• Pelvicol^®
• Pelvisoft^®
• Permacol™
• PTFE felt
• PriMatrix
• Promogran™
• Puracol^®
• SportMesh™
• Strattice™
• SurgiMend^®
• Surgisis^® (including Surgisis^® AFP™ Anal Fistula Plug, Surgisis^® Gold™ Hernia Repair Grafts, and Surgisis^® Biodesign™ )
• Talymed™
• TenoGlide™
• TheraSkin^®
• TissueMend^®
• Unite™
• Veritas^® Collagen Matrix
• X-Repair
• XenMatrix™

There are currently a wide variety of products available for soft tissue grafting and wound treatment.  These products may be derived from allogeneic, xenographic, synthetic, or a combination of any or all of these types of materials.  All of these products are procured, produced, manufactured or processed in sufficiently different manners that they cannot be addressed and evaluated as equivalent products.  Therefore, each product must be reviewed and judged on the basis of the available scientific evidence specific to that product.  Unfortunately, the majority of these products have no full-text, peer reviewed, published studies available to assist in the evaluation of their safety and efficacy.  When such circumstances exist, these products are considered investigational and not medically necessary based on a lack of data addressing both the safety and efficacy of the product in question.  For other products, there may be one or more published studies of varying quality.  Below, we summarize the findings of the most recent or most rigorous studies available. Please note that the discussion below is not meant to be an exhaustive review of the evidence available, but to address the most significant studies available for each product.  Many studies have been omitted because they were considered poorly designed or too small to adequately demonstrate efficacy for a more general population.

Alloderm
There are over a dozen small case series studies and non-randomized controlled trials published in the peer-reviewed medical literature describing the use of Alloderm to partially or completely enclose an implanted breast prosthesis during post-mastectomy breast reconstruction (i.e., Becker, 2009; Bindingnavele, 2007; Breuing, 2005, 2007; Gamboa-Bobadilla, 2006; Preminger, 2008; Salzberg, 2006, 2011; Spear, 2008 ).  The goal of using Alloderm for this type of procedure is to reduce complications related to contracture, periprosthetic atrophy, and development of thin capsules.  The results provided in these case series studies indicate good symmetry, increased soft tissue padding, and decreased rippling and implant visibility.  While the available data is limited regarding the long-term benefits and outcomes of this procedure, it has become a widely used and accepted method of breast reconstruction.  Expert opinion of breast surgeons supports the use of Alloderm for this indication. 

The treatment of infected or contaminated abdominal wall wounds and defects is difficult.  Standard fascial prostheses such as polypropylene and polyester mesh, which are routinely used for non-complex cases, may exacerbate wound infection, fistula and adhesion formation, and erosion, leaving few real options for such individuals.  The use of Alloderm for the treatment of complex abdominal wall wounds has been reported in over thirty peer-reviewed journal articles (i.e., Espinosa-de-los-Monteros 2007; Glasberg, 2006; Maurice 2009; Lee, 2009; Lin, 2009; Patton, 2007; Vertrees, 2009).  These studies demonstrate a high rate of successful wound healing with relatively low numbers of complications.  As with the use of Alloderm for breast reconstruction, Alloderm for complex abdominal wall wounds has been widely used and is an accepted treatment method, although data is limited regarding the long-term benefits and outcomes of this use.  Expert opinion of surgeons who routinely treat these types of wounds support the use of Alloderm for this indication.

At this time there is limited data addressing the use of Alloderm in treating chronic wounds.  There is very limited evidence available regarding the use of Alloderm in the treatment of burns or for surgical reconstruction procedures such as in the treatment of lid retraction in individuals with Graves' disease or in the prevention of Frey's Syndrome.  Additionally, Alloderm has been proposed for use in a wide variety of other surgical applications. 

The use of Alloderm has been proposed for the treatment of various nasal and oral surgical surgeries, including palatal fistula.  At this time there are only a limited number of small studies addressing this use in clinical trials (Helling, 2006, Steele, 2006).  These studies show promising results, but are small and use weak study designs. Additional studies are needed to demonstrate the efficacy of this use of Alloderm.

In the one available clinical trial of Alloderm in people with lid retraction due to Graves' disease, only 14 participants were studied in a non-blinded fashion (Sullivan, 2003).  While the findings of this study were promising, further controlled studies with larger numbers of participants are needed to confirm the efficacy of this procedure. 

There are currently two studies available in the peer-reviewed literature addressing the use of Alloderm for treatment of burns.  The first study involved 19 participants randomized to Alloderm with an autograft overgraft vs. Alloderm with an allograft overgraft which was replaced with an autograft overgraft after one week (Munster, 2001).  Graft uptake was not different between groups.  Immediate use of Alloderm with thin autograft was associated with more healing than spilt thickness grafts.  The second study involved 52 non-randomized participants all of whom received Alloderm covering to radial arm free flap donor sites (Sinha, 2003).  The results of this study indicated that there were minimal contractures or restrictions to the healed graft.  While these studies suggest some benefit from the use of Alloderm for burns, larger randomized trials are needed to confirm efficacy of this procedure.

At this time there are two available studies in the peer-reviewed literature regarding the use of Alloderm to treat Frey's syndrome.  The first involved 64 participants randomly assigned to the use of Alloderm placement in the parotid bed following removal of the parotid gland vs. no Alloderm (Govindaraj, 2001).  While the rate of gustatory sweating in the Alloderm group was found to be statistically lower than the control group, the Alloderm group also had an almost 3-fold increase in complications, including both a higher frequency of seroma as well as one wound infection.  In a second study, 30 participants were randomized into three groups; 1) superficial parotidectomy with placement of Alloderm, 2) superficial parotidectomy without placement, and 3) deep-plane rhytidectomy (Sinha, 2003).  The incidence of both subjective and objective Frey's syndrome was significantly higher in group 2 when compared to both groups 1 and 3. However, given the small numbers of subjects in each group, the results of this study do not allow strong conclusions to be drawn as to the effectiveness of this procedure.

Apligraf

Apligraf has been considered for a wide variety of uses, but primarily for treatment of diabetic ulcers and burn wounds.

Veves and others published the results of a randomized controlled trial (RCT) addressing the use of Apligraf for the treatment of neuropathic diabetic ulcers (2001).  In this trial, 208 subjects were randomly assigned to be treated with either Apligraf (n=112) or standard care (n=96).  At the 12 week follow-up, 63 (56%) subjects in the Apligraf group achieved complete wound healing vs. 36 (38%) in the control group (P = 0.0042).  The Kaplan-Meier median time to complete closure was 65 days for Apligraf, significantly lower than the 90 days observed in the control group (P = 0.0026).  The rate of adverse reactions was similar between the two groups, with the exception of individuals with osteomyelitis or lower-limb amputations, both of which were less frequent in the Apligraf group. Steinberg and colleagues conducted an RCT study following the methodology used by Veves et al (2010).  This study involved 72 subjects, 33 of whom received treatment with Apligraf and 39 control subjects who received standard care.  However, this study was discontinued early, due to non-safety related reasons.  The authors do not elaborate on this further.  Because this study was stopped before full enrollment, results from this study are underpowered for demonstrating statistically significant differences. However, even though the study was halted prematurely, the results are similar to those reported by Veves; in particular the Steinberg study showed significant (P = 0.049) superiority of Apligraf to achieve complete healing at 12-weeks follow-up in comparison to the control group. 

These results, taken together support the use of Apigraft for the treatment of foot ulcers. 

Apligraf has been investigated for the treatment of burns in only one peer-reviewed published study (Waymack, 2000).  In this randomized controlled trial, 40 subjects with burn injuries were treated with either meshed autograft covered by meshed allograft or meshed autograft covered by Apligraf.  There was no difference in take rate or the median days to 75% graft take.  The unblinded investigators rated 22 (58%) of Apligraf sites as superior to controls, 10 (26%) equivalent to controls, and 6 (16%) worse than controls (p=0.0037).  Pigmentation of the Apligraf sites was also rated as superior to control sites at 2 years (p=0.0005), and normal vascularity was seen in 18 (47%) of Apligraf sites vs. 6 (16%) of controls for the same time period (p value not provided).  Further study is needed to fully evaluate the use of Apligraf for the treatment of burns.

Dermagraft 

The use of Dermagraft has been described in several peer-reviewed studies (Gentzkow, 1996; Marston, 2003; Warriner, 2011).  The largest and most rigorous of these was an RCT by Marston and colleagues (2003).  This study involved 314 subjects with diabetic foot ulcers present for at least 2 weeks, 245 of these were considered chronic ulcers (>6 weeks).  Of the 245 chronic ulcer subjects, 19% (46) did not complete the 12 week study period.  All participants were randomized to receive treatment with Dermagraft (n=130) or standard care (n=115).  The final analysis showed that among subjects with chronic ulcers, the Dermagraft group healed significantly better at 12 weeks than standard care (30% vs. 18%, p=0.023).  Additionally, for subjects with forefoot or toes ulcers, 29.5% of the Dermagraft-treated ulcers were closed compared to 19.6% of the controls (p=0.065).  Similar findings were reported for heel ulcers, with 33% vs. 8% of ulcers healed, respectfully (p=0.01).  Dermagraft-treated subjects were significantly faster to heal (p=0.04), and at 12 weeks, the median percent with closure was 91% for the Dermagraft group compared to 78% for the control group (p=0.044).

Another RCT using Dermagraft was published by Gentzkow et al (1996).  This study involved 50 subjects with diabetic foot ulcers randomized to receive treatment with either standard of care (n=13) or one of three Dermagraft regimens plus standard care: 1) one piece of Dermagraft applied weekly for a total of eight pieces and eight applications (n=12); 2) two pieces of Dermagraft applied every 2 weeks for a total of eight pieces and four applications (n=14); and 3) one piece of Dermagraft applied every 2 weeks for a total of four pieces and four applications (n=11).  At 12 weeks, the percentage of subjects who achieved complete wound closure was significantly higher in the high frequency Dermagraft (Group 1) than in the control group (50.0% vs.7.7%, p= .03), and those that achieved at least 50% closure was 75% in Group 1 vs. 23.1% in controls.  No recurrences were reported at the 14 month follow-up period.

Label warnings and precautions indicate that Dermagraft is contraindicated for use in ulcers that have signs of clinical infection or in ulcers with sinus tracts.  

Dermagraft was granted an FDA Humanitarian Device Exemption (HDE 2002) for the treatment of dystrophic epidermolysis bullosa.  Additional clinical trials are needed to investigate the safety and effectiveness of this product for other applications.

Integra™ Bilayer Matrix Wound Dressing 

The use of Integra^™ Bilayer Matrix Wound Dressing has been found to be efficacious in the post-excisional treatment of full-thickness or deep partial-thickness burns when autografting is not feasible.  This conclusion is supported by well-designed randomized studies (Branski, 2007; Heimbach, 2003).  However, efficacy has not been demonstrated in the literature for other uses.

OrCel 

OrCel is a living skin equivalent (composite cultured skin) that was granted an FDA Humanitarian Device Exemption (HDE) in 2001 for use in children with recessive dystrophic epidermolysis bullosa (RDEB), who are undergoing reconstructive hand surgery.  However, there is still little clinical data to support the use of OrCel for other applications.

TransCyte

The available literature for TransCyte consists of three small randomized controlled trials investigating its use for the treatment of burns (Demling, 1999; Kumar, 2004; Noordenbos, 1999).  The study by Kumar involved 33 partial-thickness burn subjects with 58 wound sites, randomly assigned to treatment with TransCyte (n=20), Biobrane (n=17), or Silvazine cream (n=21).  Mean time to re-epithelialization was 7.5 days for TransCyte, 9.5 days for Biobrane, and 11.2 days for Silvazine.  The number of wounds requiring autografting were 5/21 (24%) for Silvazine, 3/17 (17%) for Biobrane, and 1/20 (5%) for TransCyte.  The study by Noordenbos involved 14 subjects with partial-thickness burns assigned to receive treatment with either silver sulfadiazine (n=7) or TransCyte (n=7).  The authors report that wounds treated with TransCyte healed more quickly (mean 11.14 days to 90% epithelialization vs. 18.14 days, P = .002).  There were no infections in the 32 wound sites treated with TransCyte.  Late wound evaluations at 3, 6, and 12 months post-burn were performed with use of the Vancouver Scar Scale, which indicated that wound sites treated with TransCyte healed with less hypertrophic scarring than sites treated with silver sulfadiazine (P < .001 at 3 and 6 months, P = .006 at 12 months).  Finally, the study by Demling and others involved 31 subjects assigned to receive treatment with either TransCyte (n=21) or open technique using bacitracin ointment applied 2-3 times daily (n=10).  The findings include significant improvements in the TransCyte group compared to the antibiotics group in relation to wound care time (p<0.05), decrease in pain (p<0.05), and re-epithelialization time (p<0.05).

Products addressed in the Investigational and Not Medically necessary statement:

Biobrane

Data regarding the use of synthetic Silicone/Nylon Membrane wound dressing (e.g., Biobrane^®) has been described in four separate randomized controlled trials (RCTs) in peer-reviewed published medical journals (Lal, 2000; Barret, 2000, Feldman, 1991; Gerding, 1990).  While all of these studies found that in comparison to their various control groups, the use of Biobrane significantly improved pain scores and healing times, unfortunately all of these studies involved small numbers of participants and were not conducted in a blind fashion.  Further data are required to allow a thorough assessment of the efficacy of this technology.

CorMatrix 

At this time, there is very limited peer-reviewed published evidence addressing the use of CorMatrix.  The data that is available addresses its use in cardiovascular surgical procedures.  The largest of these studies is a retrospective, non-randomized control study involving 111 subjects undergoing coronary artery bypass surgery (CABG) who had pericardial reconstruction with CorMatrix, compared to 111 control subjects who underwent a standard CABG procedure without pericardial reconstruction (Boyd, 2010).  The authors reported that postoperative atrial fibrillation occurred in 39% of controls vs. 18% of CorMatrix subjects.  No other results were significantly different.  The safety and value of CorMatrix is difficult to interpret in this study, as it is the pericardial reconstruction procedure that seems to be the significant variable.  Another publication by Quarti and colleagues describes the use of CorMatrix in a wide variety of cardiovascular surgeries, with no comparison groups provided.  While the authors report no significant complications due to the use of CorMatrix, this study provides little in the way of helpful data to determine the safety and efficacy of this product. 

Cymetra

Cymetra, an injectable micronized particulate form of Alloderm, has been proposed as a minimally invasive tissue graft product.  At this time, there are only three peer-reviewed published articles addressing the use of this product.  All these studies involve participants with vocal cord paralysis.  One study by Morgan and colleagues (2007) was a retrospective non-randomized controlled trial involving 19 participants undergoing injection laryngoplasty with Cymetra or medialization laryngoplasty.  The authors reported no significant difference between groups at 3 month follow-up.  No long-term comparison data was provided.  Another report of a retrospective case series study involving 10 participants all receiving injection laryngoplasty was reported by Milstein et al. (2005).  The authors of this study reported significant improvement in voice quality, glottal closure, and vocal fold bowing.  Of the study population, only eight participants (40%) were found to have lasting benefit.  Finally, Karpenko and others (2003) reported the results of a small (n=10) case series study.  The results indicated that there were no significant quantitative or subjective voice quality improvements.  They also stated that significant improvements were identified in maximum phonation time, relative glottal area, and subjective judgment of glottal competency.  However, these results were not maintained at the 3-month study interval.

DermaMatrix

DermaMatrix has been studied for a variety of indications.  Below are discussions of several of the most recent controlled studies.

The use of DermaMatrix was evaluated in a retrospective non-randomized controlled trial involving 30 subjects who were assigned to undergo breast reconstruction with DermaMatrix (n=25) or Alloderm (n=25) (Becker, 2009).  The authors reported that there were no significant differences between groups with regard to complication rates.  Both groups exhibited good incorporation, with evidence of neovascularization.  Further study is warranted to evaluate the safety and efficacy of DermaMatrix for breast reconstruction.

Athavale and colleagues published the results of a retrospective non-controlled study of the complication rate for parotid reconstruction surgery involving 100 subjects who received treatment with either Alloderm (n=69) or DermaMatrix (n=31) (2012).  Sixty-nine Alloderm implants were associated with a total of 5 complications (7%), whereas 31 DermaMatrix implants were associated with a total of 8 complications (26%) (p=0.0107).  Subgroup analyses found that for subtotal parotidectomies, the incidence of complications was found to be 8% for the AlloDerm group and 37% for the DermaMatrix group (p=0.004).  The authors conclude that, "…this study suggests that DermaMatrix was associated with increased postoperative complications compared with AlloDerm when used for reconstruction of parotidectomy defects.  To better define the complication profile of AlloDerm versus DermaMatrix in the postoperative parotid bed, a prospective study should be considered to determine implant performance following parotidectomy reconstruction."  This study does not support the use of DermMatrix for parotid reconstruction surgery.  Additional studies are warranted to determine the safety and efficacy of this product for this indication.

Enduragen

McCord and others have published the only available study addressing the use of Enduragen.  Their retrospective case series involved 69 subjects who underwent 192 reconstructive or cosmetic eyelid procedures with Enduragen grafts.  Eight procedures were spacers in the upper lid, 104 were for spacers in the lower lid, and 17 were for lateral canthal reinforcement.  There were 13 eyelid complications, for a complication rate of 10 percent.  Nine cases required surgical revision, and there were four cases of infection, all of which were successfully treated with oral and topical antibiotics.  The results of this study are insufficient to adequately evaluate the safety and efficacy of Enduragen.  Further research is needed.

Epifix

At this time there are no peer-reviewed published studies addressing the use of Epifix, a processed allograft made from human amniotic membranes. While there have been several studies addressing the use of amniotic membrane-derived grafting materials, these trials have used locally sourced products and not Epifix (Adly, 2012; Amer, 2012; Branski, 2008; Mostaque, 2011).  There is significant variation in the processing, storage, and preparation of biologically derived grafting materials.  Because of this variation, the clinical performance of these products may also result in significant variation in outcomes. Therefore, the data from the available trials cannot be assumed to reflect the outcomes expected from use of the Epifix-brand product.  Data from trials using amniotic membrane derived grafts specifically identified as Epifix is necessary to properly evaluate the safety and efficacy of this product.

E-Z Derm

The available evidence addressing the use of E-Z Derm brand minimally processed porcine-derived skin graft is limited to two small trials from over a decade ago (Vanstraelen, 1992; Healy, 1989).  While both of these studies are controlled trials, they are hampered by small numbers of participants (20 and 32 respectively).  The Vanstraelen study concluded that hypertrophic scarring occurred in 25% of xenograft-dressed sites, but none was seen in the comparison group.  In addition, several allergic reactions were reported to the porcine xenograft.  The conclusions of the Healy study found, in comparison to burned participants treated with Jelonet, individuals treated with E-Z Derm did not vary significantly in terms of bacterial colonization rate, need for surgical treatment, and time for spontaneous healing, analgesic requirements or frequency of dressing changes.  Data from more recent trials is not available but is needed.

Flex HD

Rawlani and others conducted the largest published study investigating Flex HD (2011).  This case series study describes the use of Flex HD during tissue expander breast reconstruction.  During a mean follow-up time of 44 weeks, 121 subjects underwent several expansions prior to expander to implant exchange.  Complications occurred in 20 (16.5%) of the subjects including 9 soft tissue infections, 8 partial flap necroses, and 2 seromas.  Eleven subjects ultimately required explantation.  Subjects undergoing radiation therapy (n=26) were significantly more likely to have complications (30.8% vs. 13.7%).  Another case series study was conducted using Flex HD in skin sparing mastectomy procedures (Cahan, 2011).  This study involved 98 subjects undergoing 159 mastectomies.  The authors report that successful reconstruction was achieved in 93% of cases.  Complications were seen in 23% of subjects, including dehiscence seroma, full thickness necrosis and infection.  Removal of the implant was needed in 5 cases as a result of persistent infection (5%).

No comparison groups were used in either of these studies, so the relative performance of Flex HD in this setting is unclear.  Further evidence is needed to properly evaluate the safety and efficacy of Flex HD.

GraftJacket

The current body of evidence available in the peer-reviewed medical literature addressing the use of GraftJacket for the treatment of diabetic skin lesions is limited to a few small studies.  One randomized controlled trial compared the use of standard surgical debridement followed by GraftJacket placement vs. standard surgical debridement alone (20 participants in each group) (Brigido, 2004).  The findings of the study found significant differences between the two groups, with the experimental group demonstrating much faster healing progression.  While the results of this study are promising, the small sample size, as well as its single-blind design, limits its utility.  The same authors conducted a second RCT with 28 subjects with chronic diabetic foot ulcers who were assigned to receive either GraftJacket (n=14) or standard care (n=14) (Brigido, 2006).  At 16 weeks, 12 of 14 (85.7%) of GraftJacket subjects demonstrated complete wound closure, compared with 4 of 14 (28.6%) in the control group (p value not provided).  Subjects treated with GraftJacket demonstrated a statistically significant higher percentage of wound healing with respect to wound area, and clinically significant differences in wound depth and wound volume (p<0.001).  A third RCT involved 85 subjects with diabetic foot ulcers to receive treatment with either GraftJacket (n=46) vs. standard care (n=39) (Reyzelman, 2009).  The authors reported significantly better complete and mean healing times in the GraftJacket group (69.6% and 5.7 weeks) compared to the controls (46.2% and 6.8 weeks), who received standard care (p= 0.029).  Furthermore, there was a significantly higher non-healing rate for the control group (53.9%) compared with the study group (30.4%) at 12 weeks (P=0.015).  Neither the subjects nor the investigators were blind to group assignment.  These studies do not provide sufficient data to allow full evaluation of GraftJacket.  Further investigation is warranted.

GraftJacket has also been proposed for use in shoulder surgery to repair soft tissue injuries.  Barber and colleagues reported on an RCT involving 42 subjects with rotator cuff injuries randomized to undergo repair with GraftJacket (n=20) or standard surgical procedures (n=22).  At the 2 year follow-up period, significant benefits were noted on several scales, including the American Shoulder and Elbow Surgeons (ASES) (p=0.035) and Constant (p=0.008) assessment tools.  No significant difference was seen on the University of California, Los Angeles (UCLS) tool (p=0.43).  Imaging studies found that at 2 years, 85% of the GraftJacket group had intact grafts, compared to only 40% in the standard care group (p<0.01).  Another study by Gupta and others involved 24 subjects with rotator cuff tears who were followed for 3 years postoperatively (2012).  The authors report significant improvements with regard to pain, (p=0.002), mean active forward flexion and external rotation (p=0.002), mean shoulder abduction (p=0.0001), supraspinus strength (p=0.0003), and ASES scores (p=0.0003).  Ultrasonography showed 76% of repairs were fully intact, with the remainder of subjects with partially intact repairs.

While the data reviewed shows some benefit of GraftJacket use, further studies with larger populations are warranted to better evaluate the safety and efficacy of this product.

Integra Matrix Wound Dressing

Bovine-derived tendon collagen and glycosaminoglycan (e.g., Integra Matrix Wound Dressing) is a type of wound care device comprised of a porous matrix of cross-linked bovine tendon collagen and glycosaminoglycan.  At this time there are no peer-reviewed published studies regarding the efficacy of this device in the clinical setting.  Such data is needed for an appropriate evaluation of this technology.

MatriDerm 

There is limited peer-reviewed literature addressing the use of MatriDerm.  The largest available study involves 30 subjects undergoing nasal tip skin grafts non-randomly assigned to receive conventional full-thickness skin grafting, retroauricular perichondrodermal composite grafts, and skin transplantation supplemented with MatriDerm (Riml, 2011).  Ten subjects were assigned to each group.  This retrospective study was conducted in a randomized and blind manner by assigned reviewers using the Manchester scale.  The authors report that two (20%) of the MatriDerm subjects developed fistulae, and concluded that MatriDerm was not suitable for nasal tip reconstruction. 

Another study by Haslik and colleagues evaluated the use of MatriDerm for the management of full thickness skin grafts (2010).  This small case series study involved 17 subjects with upper extremity skin wounds, all of whom received MatriDerm in conjunction with unmeshed skin grafts.  The reported take rate was 96%.  A 12-month follow-up Vancouver scale score of 1.7 and DASH (disability of arm-shoulder-hand) score showed excellent hand function in subjects with burn injury and subjects with a defect due to the harvest of a radial forearm flap achieved satisfying hand function.

Further study with larger, better designed trials is required in order to fully evaluate the safety and efficacy of MatriDerm.

MediHoney

The use of honey (e.g., MediHoney^®) has been proposed for the treatment of various skin conditions including burns, chronic ulcers, and superficial abrasions.  It has been hypothesized that honey, with its antibacterial properties, can significantly improve skin healing when applied topically to skin wounds.  Several randomized controlled trials have been published, most addressing the treatment of venous leg and foot ulcers.  Jull and colleagues published the largest of these trials, which included 368 subjects randomized to receive treatment with either calcium alginate dressing impregnated with manuka honey or standard care with whatever dressings were appropriate for the individual at that time (2008).  After following the participants for a total of 12 weeks of follow-up, the authors concluded that there was no significant difference in outcomes between the two groups.  It was noted that the honey-treated group experienced significantly greater numbers of adverse events (p = 0.013).  Contradicting these findings is a study by Gethin and Cowman (2008).  In this study 108 subjects with venous ulcers were randomized to receive treatment with either honey dressing or standard hydrogel therapy.  The findings were that the honey treated group had significantly better results in terms of median reduction in wound size at 12 weeks (44% vs. 33% , p=0.037), but no significant differences between groups in other primary endpoints were reported. 

The other most studied condition addressed in the literature is the treatment of burns.  The largest study currently available addressing burns involved 150 subjects randomized to receive treatment with either silver sulphadiazine (SSD) or honey (Malik, 2010).  Each subject acted as his or her own control, with one burn site randomly treated with SSD and the other with honey.  The authors report that the honey treated sites had significantly faster re-epithelialization and healing of superficial and partial thickness burns than the SSD sites (13.47 days vs. 15.62 days, p < 0.0001).  Additionally, the honey treated sites achieved complete healing significantly faster than SSD sites (21 days vs. 24 days, p < 0.0001). 

Lund and colleagues compared the use of honey-coated dressing for breast malignant wounds.  In this study 67 subjects, 79% of whom had breast cancer, were randomized to receive treatment with either honey-coated dressing (n=34) or silver dressing (n=33).  The authors report no significant differences between groups, and they concluded that the possible antibacterial effect of either treatment "could not be confirmed in these malignant wounds".

At this time the evidence addressing the use of honey for skin wounds is lacking.  The current studies are mostly unblinded controlled studies, but the choice of controls used has a great variety, making the effectiveness of comparing study outcomes difficult.  Further investigation with large well-done blinded trials using standardized controls is warranted.

Menaflex (formerly "Collagen meniscus implant" or CMI)

Collagen meniscus implants (e.g., Menaflex™) have been proposed as a treatment method for individuals with a damaged knee meniscus.  At this time there is only one large trial of this type of procedure (Rodkey, 2008).  This study involved 311 subjects with irreparable injury of the medial meniscus or a previous partial medial meniscectomy.  The study population was divided into two groups, those with prior meniscal surgery (chronic group) and those with no prior surgery (acute group).  These populations were further randomized to receive either treatment with a collagen meniscus implant or a partial meniscectomy only.  The mean duration of follow-up was fifty-nine months (range, sixteen to ninety-two months).  Repeat arthroscopies done in the experimental group at one year showed significantly (p = 0.001) increased meniscal tissue compared with that seen after the original index surgery.  In the chronic group, participants who had received the collagen implant regained a significantly higher degree of pre-surgery activity than did the controls (p = 0.02).  This group also underwent significantly fewer non-protocol reoperations (p = 0.04).  The authors reported no significant differences between the two treatment groups in the acute arm of the study. 

Zaffahnini and colleagues conducted a long-term trial of the performance of the Menaflex implant in 33 subjects.  This non-randomized controlled trial allowed subjects to choose treatment with either Menaflex (n=17) or partial medial meniscectomy (n=16).  Subjects were evaluated at baseline, 5years and then 10 years after surgery.  At 10 years, the authors report that the Menaflex group showed significant improvement compared to meniscectomy with regard to visual analog scale for pain (p=0.004), International Knee Documentation Committee knee form (p=0.0001), Teger index (p=0.026), SF-36 Physical Health Index (p=0.026), and SF-36 Mental Health Index (p=0.004).  Radiographic evaluation showed significantly less medial joint space narrowing in the Menaflex group than in controls (p=0.0003).  There were no significant differences reported between groups regarding Lysholm score (p=0.062) and Yulish score (p=0.122).  Genovese score remained constant between 5 and 10 years after surgery (p=0.5).

A much smaller case series study of 22 subjects followed for 10 years was reported by Monllau and colleagues (2011).  The results of this study demonstrated that several measures improved, including the visual analog pain scale and radiographic joint line narrowing.  The Lysholm score was significantly improved, from 59.9 at baseline and 89/6 at 1 year (p<0.001), and 87.5 at 10 years (p<0.001).  Failure rate was only reported to be 8% in the 25 subjects initially implanted.

While these studies show that there is some potential benefit to the use of meniscal collagen implants in some populations, further data from rigorously designed and conducted trials is warranted to further understand the clinical implications of this technology.

Neuragen

Neuragen collagen tube conduits have been proposed for use in peripheral nerve repair.  At this time only two studies have been published in peer-reviewed journals describing this use (Farole, 2008; Wangensteen, 2010).  The study by Wangensteen and colleagues was a retrospective analysis of 96 subjects with various nerve injuries who underwent 126 nerve repairs with Neruogen conduits.  Only 64 (66.7%) subjects were seen at follow-up.  Twenty six of 126 repairs had quantitative testing of nerve recovery, with 35% reporting improvement and 31% going on to additional surgery.  Sixty of 126 repairs underwent qualitative testing, with 45% reporting improvement and 5% going on to additional surgery.  Overall, sensory recovery was between 35-45%.

The Farole study is a small case series study involving only 8 subjects with facial nerve damage followed for at least 1 year.  The authors report 4 subjects had good improvement.  Using the criteria described by another author, 4 cases were found to have good improvement, 4 with some improvement, and 1 had no improvement.  None of the cases had worsening of symptoms. 

Further study is needed to fully evaluate the safety and efficacy of this product.

OASIS

At this time there are only a limited number of peer-reviewed published studies addressing the use of OASIS-brand porcine-derived decellularized intestinal mucosa.  The first was published by Mostow and colleagues (2005), and they describe a randomized controlled trial (RCT) involving 62 participants who received OASIS and compression therapy for venous stasis leg ulcers vs. a control group of 58 participants who received compression therapy alone.  The authors reported significantly better healing rate of the OASIS group over the control group at 12 weeks.  Another publication described an RCT involving individuals with diabetic foot ulcers (Neizgoda, 2005).  The experimental group included 37 participants who were treated with the OASIS graft and 36 who were treated with Regranex gel.  As with the previously described trial, the authors reported significantly improved results with the Oasis graft.  Romanelli and colleagues describes a study comparing OASIS against a product not currently available in the U.S., Hyaloskin (2007).  The result of this trial, while favorable to Oasis, is not particularly useful in the evaluation of Oasis.  This is due to the fact that the comparison product is unknown here in the U.S. and there is no currently available scientific literature addressing its use in the clinical setting.  The same group published a second study involving 50 subjects with either mixed venous/arterial ulcers (n=25) or venous ulcers (n=25) (Romanelli, 2010).  Participants were randomized to receive treatment with either OASIS or standard petrolatum impregnated gauze and followed for 8 weeks.  At the completion of the study the authors report that for all measures the OASIS group was significantly superior compared to the control group, including average healing (5.4 weeks vs. 8.3 weeks, p=0.02) and complete wound closure 80% vs. 65%,  (p<0.05).  Granulation of tissues increased from 50% to 65% in the OASIS group and decreased in the control group (p<0.02).  The OASIS group also required fewer dressing changes, more than doubling the time between dressing changes. 

In summary, the available evidence addressing the use of OASIS is limited to small unblinded studies with limited generalizability.  At this time the available data addressing the use of OASIS is insufficient to allow conclusions to be drawn regarding its efficacy and safety.  Data from larger, randomized blinded trials is warranted to fully understand these aspects of OASIS use in the clinical setting.

Pelvicol

The use of Pelvicol was evaluated in 132 subjects with pelvic organ prolapse.  This RCT involved 64 subjects who underwent anterior and posterior colporrhaphy and 68 who received colporrhaphy with Pelvicol.  At three months follow-up, there were significantly more surgical failures and recurrences in the Pelvicol group, but by the three-year follow-up period recurrence rates were similar.  No significant differences were noted with regard to symptom resolution, sexual activity, or complications rates.  The authors conclude that, "Pelvicol did not provide advantages over conventional colporrhaphy in recurrent pelvic organ prolapse concerning anatomical and subjective outcomes".

Permacol  

Currently, the peer-reviewed published data addressing the use of Permacol is limited to a single retrospective non-randomized controlled study of 37 subjects undergoing congenital diaphragmatic hernia repair.  Subjects received treatment with either Permacol (n=29) or synthetic Gore-Tex (n=8), with a median follow-up of 57 months for Gore-Tex and 20 months for Permacol.  Overall recurrences were reported in 8 (28%) Gore-Tex subjects with the median time to recurrence of 12 months.  There were no recurrences reported in the Permacol group.  These results are interesting, but due to the small sample size, retrospective nature, and lack of randomization it is not possible to generalize the results to other populations.  Further investigation into the safety and efficacy of Permacol is needed.

Promogran

The use of Promogran has been evaluated in two RCTs.  The first, by Veves and others, involved 276 subjects with diabetic foot ulcers randomized to receive treatment with either Pomogran (n=138) or moistened gauze (control group; n=138).  At 12 weeks of treatment, there was no statistically significant difference between groups with regard to complete wound closure (p=0.12), in healing in either the subgroup of subjects with wounds of less than 6 months' duration (p=0.056), or the group with wounds of at least 6 months' duration (p=0.83).  No differences were seen in the safety measurements between groups.  The other study by Vin, et al involved 73 subjects with venous leg ulcers randomly allocated to receive either Promogran (n=37) or a non-adherent dressing (Adaptic) (n=36).  Only 29 subjects completed the 12 week study period (39.7%).  No intent to treat analysis was provided. Because of this, the data reported is not particularly useful.

Further study is required to fully assess the safety and efficacy of Promogran.

Surgisis 

At this time, there are a large number of case series studies published on the use of the Surgisis anal fistula plug (Ellis, 2010; Champagne, 2006; Ky, 2008; O'Connor, 2006; Schwandner, 2009; Thekkinkattil, 2009).  The vast majority of these involve very small sample sizes and short follow-up times.  The uncontrolled nature of these studies minimizes the scientific value of this data.

Two RCTs are currently available addressing the use of Surgisis for the treatment of anal fistulae.  The first study, reported by Ortiz et al., involved 43 subjects randomized to receive either endorectal advancement flap surgery or insertion of an anal fistula plug (2009).  The drop-out rate was greater than 20% for each group.  The authors reported that the relative risk for recurrence was 6.4 for those who received the plug intervention during the one year follow-up.  Additionally, of the 16 who had previous fistula surgery, 9 had recurrence and 8 of these were from the plug group.  Overall the authors concluded that the anal fistula plug was associated with a low rate of fistula healing, especially in individuals with a history of fistula surgery.  The second study included 60 subjects with perianal fistulas who were randomly assigned to receive treatment with Surgisis (n=31) or a mucosal advancement flap (n=29) (van Koperen, 2011).  Both subjects and investigators were blinded to group assignment.  At a follow-up of 11 months the recurrence rates were 71% (n = 22) in the Surgisis group vs. 52% (n = 15) in the mucosal advancement flap group, which was not significantly different.  Additionally, no significant differences were reported with regard to postoperative pain, pre- and postoperative incontinence scores, soiling, and quality of life.

Several studies have reported on the results from non-randomized controlled retrospective trials.  Ellis and colleagues describes the results of a study that involved 95 control subjects who had transsphincteric or rectovaginal fistulas repaired via advancement flap repair (2007).  The experimental group included only 18 subjects who received treatment with Surgisis.  The results indicated a significant benefit to the Surgisis procedure.  Another study included 80 subjects who received treatment with either anal fistula plug or endorectal advancement flap (Christoforidis, 2009).  The results of this trial demonstrated that treatment success was close to over twice as likely with the flap procedure compared to treatment with a fistula plug after a mean follow-up period of 56 months.  Chung and colleagues (2009) reported on the results of a retrospective study that involved 245 subjects who underwent anal fistula repair surgery with either Surgisis (n=27), fibrin glue (n=23), Seton drain (n=86), or an endorectal advancement flap procedure (n=96).  The results indicate that the rate of success was similar between the Surgisis group and the endorectal advancement flap group.  Hyman and others conducted a study that involved 245 subjects who received one of seven procedures, including the Surgisis plug (n=43), endorectal advancement flap (n=4), Seton drain (n=34), fibrin glue (n=5), fistulotomy (n=156), and other unspecified procedures (n=3) (2009).  In contrast to the findings of the Chung study, the authors reported that the Surgisis plug demonstrated the lowest success rate, with only 32% healed at 3 months vs. 87% for the fistulotomy group.

Due to the conflicting evidence discussed above, further data is needed in the form of large, well done, double-blind RCTs in order to properly understand the efficacy of Surgisis.

Talymed

At this time only a single RCT is available addressing the use of Talymed (Kelechi, 2011).  In this reviewer-blinded trial, 82 subjects with venous stasis leg ulcers were randomized to receive either standard care (n=20) or one of 3 groups that received standard treatment combined with different treatment frequencies with talymed: 1) applied only once, 2) once every other week, or 3) once every third week.  Seven subjects were lost to follow-up, 5 from the one application group and 2 from the every three weeks group.  Additionally, another 4 subjects were withdrawn from the study, 3 from the one application group and 1 from the every three weeks group.  This left 62 subjects in the experimental group and 20 in the control group.  At 20 weeks, the authors report that 45.0% (n=9 of 20) of subjects receiving standard care alone had complete healing, while 45.0% (n=9 of 20), 86.4% (n=19 of 22), and 65.0% (n=13 of 20) of subjects receiving Talymed only once, every other week, and every 3 weeks, respectively, had complete healing.  This single study is insufficient to allow proper evaluation of the safety and efficacy of Talymed.

Theraskin

The use of Theraskin cryopreserved human skin allograft has only been described in two peer reviewed publications.  In the first, DiDomenico (2011) and colleagues describe a small randomized controlled study investigating the use of Theraskin (n=12) compared to Apligraf (n=17) for the treatment of diabetic foot ulcers.  Subjects were followed for 20 weeks, with total wound closure or evaluation of unclosed wounds as the study endpoints.  A problem occurred with randomization resulting in more subjects randomized to receive Apligraf.  The authors reported that at 12 weeks 41.3% of the Apligraf subjects and 66.7% of the Theraskin subjects had achieved wound closure.  These numbers changed only slightly at 20 weeks, to 47.14% and 66.7% respectively. The average number of applications was 1.53 for Alpigraf and 1.38 for Theraskin and average time to closure was 6.86 weeks in the Apligraf group and 5.00 weeks on in the Theraskin group.  No comparative statistical analysis was provided for this study, making conclusions about these results difficult. However, the authors conclude that Theraskin was more efficacious in healing diabetic foot ulcers.  In an accompanying commentary, Treadwell notes that the healing rates for the Apligraf group reported by DiDomenico are surprisingly low, with previously published rates ranging from 51-72%.  He speculates that this may be due to inappropriate use of the product.  In the DiDomenico study Apligraft dressings were initially changed after one week and then every 1-2 days subsequently. However, the application protocol for Apligraf indicates that the initial dressing change should occur at 5-10 days and then the non-adherent dressing should be left undisturbed for 14-21 days.  An excursion from the standard treatment protocol was also noted for the Theraskin group, with the initial dressing change at one week and then every 1-2 days.  Standard protocol for this product calls for the initial dressing change at 5-7 days and with subsequent changes only as necessary.  It is highly likely that these deviations from standard protocol significantly altered expected outcomes for both these products.  Additionally, a close look at the DiDomenico study leaves some uncertainty as to who was responsible for dressing changes; given the rate at which subjects were seen. Treadwell suspects that some changes were done either by the patient or a family member which is a significant variation for standard treatment.   Overall, the results of this study are not generalizable to a wider population.  This is due to the studies methodological issues, including its small sample size and lack of proper statistical analysis, combined with significant variations from standard care protocols.

In the second study, Landsman (2011) and colleagues conducted a single-center, retrospective, uncontrolled case series study of 188 subjects with venous leg ulcers and diabetic foot ulcers treated with Theraskin. Standard treatment protocol for this product, as discussed above, was adhered to.  The follow-up time was 20 weeks, with the primary outcome measure being the proportion of healed wounds by 12 weeks.  Subjects were considered treatment failures when wounds were not completely healed by this time point.  The authors report that at the 12 week follow-up, 60.4% of diabetic ulcers and 60.7% of venous ulcers were completely closed.  At 20 weeks those numbers increased to 74.1% and 74.6%, respectively.  The average number of grafts required to achieve closure at 12 weeks was 2.03 (range 1-8).  Five subjects (3%) were lost to follow-up at 12 weeks, and 12 (6%) at 20 weeks. Overall loss to follow-up was 17 subjects (9%).  Three serious adverse events were reported requiring hospitalization for IV antibiotic treatment (n=2) or incision and draining (n=1).  The authors briefly compare these results to historical controls from Apligraf and Dermagraft studies, but no statistical analysis is provided. Additionally, a multivariate logistical regression model was used to evaluate the impact of wound size on healing times.  Unsurprisingly, the model showed that larger wounds require longer healing times.   While this study does provides some data regarding the use of Theraskin for the treatment of diabetic foot ulcers, its retrospective, case series methodology does not allow a rigorous comparison to other treatment methods. 

The results of these studies, while informative, leave many questions unanswered.  Much better quality data from well-done large scale controlled trials is needed in order to properly assess the safety and efficacy of Theraskin.

Veritas

The available evidence addressing Veritas is currently limited to a single RCT of 94 subjects assigned to treatment with either anterior colporrhaphy alone vs. colporrhaphy reinforced with Veritas bovine pericardium graft (Guerette, 2009).  This study had significant loss to follow-up, with only 72 of 94 (76.6%) subjects at the 1 year time point and 59 of 92 (64.1%) at the completion of the study at 2 years.  The authors report so significant differences between groups.

Skin Wound Care

The skin is the largest organ of the body. It is composed of two layers, the epidermis and the dermis, and provides functions critical to survival. The skin acts as a protective barrier to fluid losses and dehydration and it protects against infection and injury by providing a barrier to repel bacteria and other organisms. The skin provides sensory contact with our environment that tells us whether we are feeling light touch, pressure, pain, heat, or cold.  Damage to the skin that is extensive or prolonged may interfere with these functions or with those of other body systems and may become life-threatening in some circumstances. 

The treatment of burns and other wounds that have failed to heal despite conservative measures, referred to as chronic wounds, pose a significant burden on the population in terms of pain, disability, and decreased quality of life.  Chronic wounds may be due to the effects of diabetes, venous insufficiency to the extremities, pressure due to prolonged periods in the same body position, and other types of skin injuries.  They can be difficult to treat and may require treatment with various coverings, such as skin graft or other materials to prevent infection, maintain an environment conducive to healing, or provide a medium for re-growth of new skin.  Such coverings come in a wide array of types, from synthetic materials, tissues from the individuals themselves (autologous), human donors (allogeneic), or from animals such as cows and pigs (xenographic), or any combination of these materials (composites).

Surgical Reinforcement Procedures

In a wide variety of surgical procedures, there may be a need for additional reinforcement of soft tissues to strengthen the structures being repaired, such as in hernia repair or orthopedic reconstruction procedures.  Traditionally this task is undertaken with the use of allogeneic cadaver-derived grafts or synthetic materials such as polypropylene and Gore-Tex^®_.  However, in some cases such materials may not be appropriate, and other materials have been sought.

In other circumstances, the use of grafting materials has been suggested as substitute for surgery.

Product types:

Synthetic Products

Synthetic treatments include various forms of skin-like coverings, barriers, and devices to augment cartilage and other connective tissues.  This category includes wound dressings, silicone/nylon membranes and material to augment or replace cartilage, tendons and ligaments. 

Completely synthetic wound dressings (e.g., Biobrane) are composed of man-made materials to form a complex multilayer covering for wounds. This type of product may consist of a wide array of materials including silicone, nylon, and others, as well as collagen or other biologic materials.

Allogeneic Products

There are currently several different types of allogeneic (human derived) wound care products available.  One type involves the use of donated human cadaver skin which is then treated with various methods to remove the cellular material and deactivate or kill pathogens (e.g., Alloderm, GraftJacket, and Neoform Dermis).  This process leaves only the collagen protein scaffold, which has been proposed as an acceptable medium for which new skin cells from the individual can populate and grow into when placed over a wound site. 

Another type of allogeneic product is composite products that may contain human skin cells, keratinocytes and/or fibroblasts (depending upon the product), which are imbedded into a decellularized collagen protein scaffold derived from a xenographic source (e.g., Apligraf, OrCel).  Some of these products may also consist of layers of synthetic materials like silicone, nylon, or polyglactin (e.g., Dermagraft, TransCyte).

Xenographic and Xenographic-Related or Derived Products

Many wound care and reconstructive products are made from materials derived from various animal sources including cow, horse and pig tissues.  Most of these products are created by harvesting living tissues (e.g., skin, intestines, tendons, etc) from a donor animal that is then processed to remove the cellular content to leave only the collagen protein scaffold.  As with such allogeneic products, this scaffold is intended to act as a welcoming environment into which new autologous cells (e.g., skin, tendon, and cartilage) may grow.  Most xenographic products are composed of only the decellularized collagen scaffold alone (e.g., Collamend, Cuffpatch,  Oasis, OrthoADAPT, Pelvicol, Pelvisoft, PriMatrix, Surgisis, Unite). Other products may only be minimally processed and contain most of the structures and compounds found in whole skin (e.g., Mediskin, E-Z Derm).

Xenographic materials have been proposed for many such applications including reconstruction procedures of the breast, pelvic floor, abdominal wall, tendons and others.  These products are sewn onto the soft tissues where they are needed to provide support and strengthen the underlying structures.  This occurs by the xenograft acting as a bed for new growth of autologous tissue.

Another type of product involves the use of substance made by or derived from xenographic sources.  One such product is honey, which has been proposed as a topical treatment for a wide variety of skin conditions.

Composite Autologous / Allogeneic / Xenographic Products

The development of advanced in vitro culturing techniques has allowed the development of new products which combine human dermal cellular materials with those derived from animals (e.g., Epicel®).  These products involve the harvesting of human epidermal cells (either from the individual being treated or from donor tissue) which are then cultured with animal cells to produce sheets of biosynthetic skin which have been proposed for use in treating human skin conditions. 

Xenographic products may be combined with synthetic materials to create a composite product (e.g. Avaulta Plus, Integra matrix, Integra Bilayer Matrix).

Epidermolysis bullosa (EB): A disease characterized by the presence of extremely fragile skin and recurrent blister formation, resulting from minor mechanical friction or trauma.

Equine-derived decellularized collagen products (e.g., OrthADAPTÔ and UniteÔ): This is a type of product derived from purified tissues derived from horses.  It has been proposed that this type of technology may be used for the repair and reinforcement of soft tissues such as tendons and ligaments, as well as the treatment of skin wounds.

Frey's Syndrome: A condition occurring in some individuals after removal of the parotid salivary gland, in which nerve damage results in flushing and sweating on one side of the face when certain foods are consumed.

Wound infection: A wound with at least some clinical signs and symptoms of infections such as increased exudates, odor, redness, swelling, heat, pain, tenderness to touch, and purulent discharge; quantitative culture is not required.

The following codes for treatments and procedures applicable to this document are included below for informational purposes.  A draft of future ICD-10 Coding (effective 10/01/2014) related to this document, as it might look today, is included below for your reference.  Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy.  Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

Application of skin substitutes and soft tissue grafts: 

When services may be Medically Necessary when criteria are met:

When services are Investigational and Not Medically Necessary:
For the procedure codes listed above when criteria are not met, or when the code describes application of a product indicated in the Position Statement section as investigational and not medically necessary

When Services are also Investigational and Not Medically Necessary: 

Products
When services may be Medically Necessary when criteria are met [for Apligraf, OrCel, and Dermagraft]:

When services may be Medically Necessary when criteria are met [for Alloderm]:

When services may be Medically Necessary when criteria are met [for TransCyte and Integra Bilayer Matrix Wound Dressing]:

When services are Investigational and Not Medically Necessary
For the product codes listed above when criteria are not met or for all other diagnoses not listed, or when the code describes a procedure indicated in the Position Statement section as investigational and not medically necessary

When Services are also Investigational and Not Medically Necessary: 

Peer Reviewed Publications:

Allograft (unspecified)

1. Buchberger B, Follmann M, Freyer D, et al. The evidence for the use of growth factors and active skin substitutes for the treatment of non-infected diabetic foot ulcers (DFU): a health technology assessment (HTA). Exp Clin Endocrinol Diabetes. 2011; 119(8):472-479.

Government Agency, Medical Society, and Other Authoritative Publications:

AlloDerm

1. Becker S, Saint-Cyr M, Wong C, et al.  AlloDerm versus DermaMatrix in immediate expander-based breast reconstruction: a preliminary comparison of complication profiles and material compliance. Plast Reconstr Surg. 2009; 123(1):1-6.
2. Bindingnavele V, Gaon M, Ota KS, et al. Use of acellular cadaveric dermis and tissue expansion in postmastectomy breast reconstruction. J Plast Reconstr Aesthet Surg. 2007; 60(11):1214-1218.
3. Breuing KH, Colwell AS. Inferolateral AlloDerm hammock for implant coverage in breast reconstruction. Ann Plast Surg. 2007; 59(3):250-255.
4. Breuing KH, Warren SM.  Immediate bilateral breast reconstruction with implants and inferolateral AlloDerm slings. Ann Plast Surg. 2005; 55(3):232-239.
5. Diaz JJ Jr, Conquest AM, Ferzoco SJ, et al. Multi-institutional experience using human acellular dermal matrix for ventral hernia repair in a compromised surgical field. Arch Surg. 2009; 144(3):209-215.
6. Diaz JJ Jr, Guy J, Berkes MB, et al. Acellular dermal allograft for ventral hernia repair in the compromised surgical field. Am Surg. 2006; 72(12):1181-1187. 
7. Espinosa-de-los-Monteros A, de la Torre JI, Marrero I, et al. Utilization of human cadaveric acellular dermis for abdominal hernia reconstruction. Ann Plast Surg. 2007; 58(3):264-267.
8. Gamboa-Bobadilla GM. Implant breast reconstruction using acellular dermal matrix. Ann Plast Surg. 2006; 56(1):22-25. 
9. Glasberg SB, D'Amico RA. Use of regenerative human acellular tissue (AlloDerm) to reconstruct the abdominal wall following pedicle TRAM flap breast reconstruction surgery. Plast Reconstr Surg. 2006; 118(1):8-15. 
10. Govindaraj S, Cohen M, Genden EM, et al. The use of acellular dermis in the prevention of Frey's syndrome. Laryngoscope. 2001; 111(11 Pt 1):1993-1998.
11. Helling ER, Dev VR, Garza J, et al. Low fistula rate in palatal clefts closed with the Furlow technique using decellularized dermis. Plast Reconstr Surg. 2006; 117(7):2361-2365.
12. Lee EI, Chike-Obi CJ, Gonzalez P, et al. Abdominal wall repair using human acellular dermal matrix: a follow-up study. Am J Surg. 2009; 198(5):650-657.
13. Lin HJ, Spoerke N, Deveney C, Martindale R. Reconstruction of complex abdominal wall hernias using acellular human dermal matrix: a single institution experience. Am J Surg. 2009; 197(5):599-603.
14. Maurice SM, Skeete DA. Use of human acellular dermal matrix for abdominal wall reconstructions. Am J Surg. 2009; 197(1):35-42.
15. Milstein CF, Akst LM, Hicks MD, et al. Long-term effects of micronized Alloderm injection for unilateral vocal fold paralysis. Laryngoscope. 2005; 115(9):1691-1696.
16. Misra S, Raj PK, Tarr SM, Treat RC. Results of AlloDerm use in abdominal hernia repair. Hernia. 2008; 12(3):247-250.
17. Nahabedian MY. Secondary nipple reconstruction using local flaps and AlloDerm. Plast Reconstr Surg. 2005; 115(7):2056-2061.
18. Patton JH Jr, Berry S, Kralovich KA. Use of human acellular dermal matrix in complex and contaminated abdominal wall reconstructions. Am J Surg. 2007; 193(3):360-363.
19. Preminger BA, McCarthy CM, Hu QY, et al. The influence of AlloDerm on expander dynamics and complications in the setting of immediate tissue expander/implant reconstruction: a matched-cohort study. Ann Plast Surg. 2008; 60(5):510-513.
20. Salzberg CA.  Nonexpansive immediate breast reconstruction using human acellular tissue matrix graft (AlloDerm). Ann Plast Surg. 2006; 57(1):1-5.
21. Sclafani AP, Jacono AA, Dolitsky JN. Grafting of the peritonsillar fossa with an acellular dermal graft to reduce posttonsillectomy pain. Am J Otolaryngol. 2001; 22(6):409-414.
22. Sclafani AP, Romo T 3rd, Jacono AA, et al. Evaluation of acellular dermal graft in sheet (AlloDerm) and injectable (micronized AlloDerm) forms for soft tissue augmentation. Clinical observations and histological analysis. Arch Facial Plast Surg. 2000; 2(2):130-136.
23. Sinha UK, Saadat D, Doherty CM, Rice DH. Use of AlloDerm implant to prevent frey syndrome after parotidectomy. Arch Facial Plast Surg. 2003; 5(1):109-112.
24. Sinha UK, Shih C, Chang K, Rice DH. Use of AlloDerm for coverage of radial forearm free flap donor site. Laryngoscope. 2002; 112(2):230-234.
25. Spear SL, Parikh PM, Reisin E, Menon NG. Acellular dermis-assisted breast reconstruction. Aesthetic Plast Surg. 2008; 32(3):418-425.
26. Steele M, Seagle M. Palatal fistula repair using acellular dermal matrix: the University of Florida experience. Ann Plast Surg. 2006; 56(1):50-53.
27. Sullivan SA, Dailey RA. Graft contraction: a comparison of acellular dermis versus hard palate mucosa in lower eyelid surgery. Ophthal Plast Reconstr Surg. 2003; 19(1):14-24.
28. Treadwell T. A prospective comparison of diabetic foot ulcers treated with either cryopreserved skin allograft or bioengineered skin substitute. Wounds. 2011; 23(7):190-191.
29. Vertrees A, Greer L, Pickett C, et al. Modern management of complex open abdominal wounds of war: a 5-year experience. J Am Coll Surg. 2008; 207(6):801-809.

Apligraf

1. Steinberg JS, Edmonds M, Hurley DP Jr, King WN. Confirmatory data from EU study supports Apligraf for the treatment of neuropathic diabetic foot ulcers. J Am Podiatr Med Assoc. 2010; 100(1):73-77.
2. Waymack P, Duff RG, Sabolinski M. The effect of a tissue engineered bilayered living skin analog, over meshed split-thickness autografts on the healing of excised burn wounds. The Apligraf Burn Study Group. Burns. 2000; 26(7):609-619. 
3. Veves A, Falanga V, Armstrong DG, et al. Graftskin, a human skin equivalent, is effective in the management of noninfected neuropathic diabetic foot ulcers: a prospective randomized multicenter clinical trial. Diabetes Care. 2001; 24(2):290-295.

Biobrane

1. Barret JP, Dziewulski P, Ramzy PI, et al. Biobrane versus 1% silver sulfadiazine in second-degree pediatric burns. Plast Reconstr Surg. 2000; 105(1):62-65.
2. Feldman DL, Rogers A, Karpinski RH. A prospective trial comparing Biobrane, Duoderm and xeroform for skin graft donor sites. Surg Gynecol Obstet. 1991; 173(1):1-5.
3. Gerding RL, Emerman CL, Effron D, et al. Outpatient management of partial-thickness burns: Biobrane versus 1% silver sulfadiazine. Ann Emerg Med. 1990; 19(2):121-124.
4. Lal S, Barrow RE, Wolf SE, et al. Biobrane improves wound healing in burned children without increased risk of infection. Shock. 2000; 14(3):314-318.
5. Prasad JK, Feller I, Thomson PD. A prospective controlled trial of Biobrane versus scarlet red on skin graft donor areas. J Burn Care Rehabil. 1987; 8(5):384-386.

CorMatrix

1. Boyd W, Johnson WE 3rd, Sultan PK, et al.  Pericardial reconstruction using an extracellular matrix implant correlates with reduced risk of postoperative atrial fibrillation in coronary artery bypass surgery patients. Heart Surg Forum. 2010; 13(5):E311-E316.
2. Quarti A, Nardone S, Colaneri M, et al. Preliminary experience in the use of an extracellular matrix to repair congenital heart disases. Interact Cardiovasc Thorac Surg. 2011; 13(6):569-572.

Cymetra

1. Karpenko AN, Dworkin JP, Meleca RJ, Stachler RJ. Cymetra injection for unilateral vocal fold paralysis. Ann Otol Rhinol Laryngol. 2003; 112(11):927-934.
2. Milstein CF, Akst LM, Hicks MD, et al. Long-term effects of micronized Alloderm injection for unilateral vocal fold paralysis. Laryngoscope. 2005; 115(9):1691-1696.
3. Morgan JE, Zraick RI, Griffin AW, et al. Injection versus medialization laryngoplasty for the treatment of unilateral vocal fold paralysis. Laryngoscope. 2007; 117(11):2068-2074.

Dermagraft 

1. Gentzkow GD, Iwasaki SD, Hershon KS, et al. Use of dermagraft, a cultured human dermis, to treat diabetic foot ulcers. Diabetes Care. 1996; 19(4):350-354.
2. Marston WA, Hanft J, Norwood P, et al. The efficacy and safety of Dermagraft in improving the healing of chronic diabetic foot ulcers: results of a prospective randomized trial. Diabetes Care. 2003; 26(6):1701-1705.
3. Warriner RA 3rd, Cardinal M; TIDE Investigators. Human fibroblast-derived dermal substitute: results from a treatment investigational device exemption (TIDE) study in diabetic foot ulcers. Adv Skin Wound Care. 2011; 24(7):306-311.

DermaMatrix  

1. Athavale SM, Phillips S, Mangus B, et al. Complications of alloderm and dermamatrix for parotidectomy reconstruction. Head Neck. 2012; 34(1):88-93.
2. Becker S, Saint-Cyr M, Wong C, et al.  Alloderm versus DermaMatrix in immediate expander-based breast reconstruction: a preliminary comparison of complication profiles and material compliance. Plast Reconstr Surg. 2009; 123(1):1-6.  

Enduragen

1. McCord C, Nahai FR, Codner MA, et al. Use of porcine acellular dermal matrix (Enduragen) grafts in eyelids: a review of 69 patients and 129 eyelids. Plast Reconstr Surg. 2008; 122(4):1206-1213.

Epifix

1. Adly OA, Moghazy AM, Abbas AH, et al. Assessment of amniotic and polyurethane membrane dressings in the treatment of burns. Burns. 2010 Aug;36(5):703-10.
2. Amer MI, Abd-El-Maeboud KH, Abdelfatah I, et al. Human amnion as a temporary biologic barrier after hysteroscopic lysis of severe intrauterine adhesions: pilot study. J Minim Invasive Gynecol. 2010; 17(5):605-611.
3. Branski LK, Herndon DN, Celis MM, et al.  Amnion in the treatment of pediatric partial-thickness facial burns. Burns. 2008; 34(3):393-399.
4. Mostaque AK, Rahman KB. Comparisons of the effects of biological membrane (amnion) and silver sulfadiazine in the management of burn wounds in children. J Burn Care Res. 2011; 32(2):200-209.

E-Z Derm

1. Healy CM, Boorman JG. Comparison of E-Z Derm and Jelonet dressings for partial skin thickness burns. Burns Incl Therm Inj. 1989; 15(1):52-54.
2. Vanstraelen P. Comparison of calcium sodium alginate (KALTOSTAT) and porcine xenograft (E-Z DERM) in the healing of split-thickness skin graft donor sites. Burns. 1992; 18(2):145-148.

Flex HD

1. Cahan AC, Palaia DA, Rosenberg M, Bonanno PC. The aesthetic mastectomy utilizing a non-nipple-sparing portal approach. Ann Plast Surg. 2011; 66(5):424-428.
2. Rawlani V, Buck DW 2nd, Johnson SA, et al. Tissue expander breast reconstruction using prehydrated human acellular dermis. Ann Plast Surg. 2011; 66(6):593-597.

Graftjacket

1. Barber FA, Burns JP, Deutsch A, et al. A prospective, randomized evaluation of acellular human dermal matrix augmentation for arthroscopic rotator cuff repair. Arthroscopy. 2012; 28(1):8-15.
2. Brigido SA, Boc SF, Lopez RC. Effective management of major lower extremity wounds using an acellular regenerative tissue matrix: a pilot study. Orthopedics. 2004; 27(1 Suppl):s145-149.
3. Brigido SA. The use of an acellular dermal regenerative tissue matrix in the treatment of lower extremity wounds: a prospective 16-week pilot study. Int Wound J. 2006; 3(3):181-187.
4. Gupta AK, Hug K, Berkoff DJ, et al. Dermal tissue allograft for the repair of massive irreparable rotator cuff tears. Am J Sports Med. 2012; 40(1):141-147.
5. Martin BR, Sangalang M, Wu S, Armstrong DG. Outcomes of allogenic acellular matrix therapy in treatment of diabetic foot wounds: an initial experience. Int Wound J. 2005; 2(2):161-165.
6. Reyzelman A, Crews RT, Moore JC, et al. Clinical effectiveness of an acellular dermal regenerative tissue matrix compared to standard wound management in healing diabetic foot ulcers: a prospective, randomised, multicentre study. Int Wound J. 2009; 6(3):196-208.

Integra

1. Branski LK, Herndon DN, Pereira C, et al. Longitudinal assessment of Integra in primary burn management: a randomized pediatric clinical trial. Crit Care Med. 2007; 35(11):2615-2623.
2. Dantzer E, Braye FM. Reconstructive surgery using an artificial dermis (Integra): results with 39 grafts. Br J Plast Surg. 2001; 54(8):659-664.

Matriderm

1. Haslik W, Kamolz LP, Manna F, et al. Management of full-thickness skin defects in the hand and wrist region: first long-term experiences with the dermal matrix Matriderm. J Plast Reconstr Aesthet Surg. 2010; 63(2):360-364.
2. Riml S, Wallner H, Larcher L, et al. Aesthetic improvements of skin grafts in nasal tip reconstruction. Aesthetic Plast Surg. 2011; 35(4):475-479.

Medihoney

1. Gethin G, Cowman S. Manuka honey vs. hydrogel--a prospective, open label, multicentre, randomised controlled trial to compare desloughing efficacy and healing outcomes in venous ulcers. J Clin Nurs. 2009; 18(3):466-474.
2. Jull A, Walker N, Parag V, et al. Randomized clinical trial of honey-impregnated dressings for venous leg ulcers. Br J Surg. 2008; 95(2):175-182. 
3. Lund-Nielsen B, Adamsen L, Gottrup F, et al. Qualitative bacteriology in malignant wounds--a prospective, randomized, clinical study to compare the effect of honey and silver dressings. Ostomy Wound Manage. 2011; 57(7):28-36.
4. Malik K, Malik MA, Aslam A. Honey compared with silver sulphadiazine in the treatment of superficial partial-thickness burns. Int Wound J. 2010; 7(5):413-417. 

Menaflex

1. Rodkey, WG, DeHaven KE, Montgomery WH 3rd, et al. Comparison of the collagen meniscus implant with partial meniscectomy.  A prospective randomized trial. J Bone Joint Surg Am. 2008; 90(7):1413-1426.
2. Monllau JC, Gelber PE, Abat F, et al. Outcome after partial medial meniscus substitution with the collagen meniscal implant at a minimum of 10 years' follow-up. Arthroscopy. 2011; 27(7):933-943.
3. Zaffagnini S, Marcheggiani Muccioli GM, Lopomo N, et al. Prospective long-term outcomes of the medial collagen meniscus implant versus partial medial meniscectomy: a minimum 10-year follow-up Study. Am J Sports Med. 2011; 39(5):977-985.

Neuragen

1. Farole A, Jamal BT. A bioabsorbable collagen nerve cuff (NeuraGen) for repair of lingual and inferior alveolar nerve injuries: a case series. J Oral Maxillofac Surg. 2008; 66(10):2058-2062.
2. Wangensteen KJ, Kalliainen LK. Collagen Tube conduits in peripheral nerve repair: a retrospective analysis. Hand (N Y). 2010; 5:273–277.

OASIS

1. Mostow EN, Haraway GD, Dalsing M, et al. Effectiveness of an extracellular matrix graft (OASIS Wound Matrix) in the treatment of chronic leg ulcers: a randomized clinical trial. J Vasc Surg. 2005; 41(5):837-843.
2. Niezgoda JA, Van Gils CC, Frykberg RG, Hodde JP.  Randomized clinical trial comparing OASIS Wound Matrix to Regranex Gel for diabetic ulcers. Adv Skin Wound Care. 2005; 18(5 Pt 1):258-266.
3. Romanelli M, Dini V; Bertone M. Randomized comparison of OASIS wound matrix versus moist wound dressing in the treatment of difficult-to-heal wounds of mixed arterial/venous etiology. Adv Skin Wound Care. 2010; 23(1):34-38.
4. Romanelli M, Dini V, Bertone M, et al. OASIS wound matrix versus Hyaloskin in the treatment of difficult-to-heal wounds of mixed arterial/venous aetiology. Int Wound J. 2007; 4(1):3-7.

Pelvicol

1. Dahlgren E, Kjølhede P; RPOP-PELVICOL Study Group. Long-term outcome of porcine skin graft in surgical treatment of recurrent pelvic organ prolapse. An open randomized controlled multicenter study. Acta Obstet Gynecol Scand. 2011; 90(12):1393-1401.

Permacol

1. Mitchell IC, Garcia NM, Barber R, et al. Permacol: a potential biologic patch alternative in congenital diaphragmatic hernia repair. J Pediatr Surg. 2008; 43(12):2161-2164. 

Promogran

1. Veves A, Sheehan P, Pham HT. A randomized, controlled trial of Promogran (a collagen/oxidized regenerated cellulose dressing) vs. standard treatment in the management of diabetic foot ulcers. Arch Surg. 2002; 137(7):822-827.
2. Vin F, Teot L, Meaume S. The healing properties of Promogran in venous leg ulcers. J Wound Care. 2002; 11(9):335-341.

Surgisis

1. Champagne BJ, O'Connor LM, Ferguson M, et al. Efficacy of anal fistula plug in closure of cryptoglandular fistulas: long-term follow-up. Dis Colon Rectum. 2006; 49(12):1817-1821.
2. Christoforidis D, Pieh MC, Madoff RD, Mellgren AF. Treatment of transsphincteric anal fistulas by endorectal advancement flap or collagen fistula plug: a comparative study. Dis Colon Rectum. 2009; 52(1):18-22.
3. Chung W, Kazemi P, Ko D, et al. Anal fistula plug and fibrin glue versus conventional treatment in repair of complex anal fistulas. Am J Surg. 2009; 197(5):604-608.
4. Ellis CN. Bioprosthetic plugs for complex anal fistulas: an early experience. J Surg Educ. 2007; 64(1):36-40.
5. Ellis CN, Rostas JW, Greiner FG. Long term outcomes with the use of bioprosthetic plugs for the management of complex anal fistulas. Dis Colon Rectum. 2010; 53(5):798-802. 
6. Franklin ME Jr, Treviño JM, Portillo G, et al. The use of porcine small intestinal submucosa as a prosthetic material for laparoscopic hernia repair in infected and potentially contaminated fields: long-term follow-up. Surg Endosc. 2008; 22(9):1941-1946.
7. Hyman N, O'Brien S, Osler T. Outcomes after fistulotomy: results of a prospective, multicenter regional study. Dis Colon Rectum. 2009; 52(12):2022-2027.
8. Johnson EK, Gaw JU, Armstrong DN.  Efficacy of anal fistula plug vs. fibrin glue in closure of anorectal fistulas. Dis Colon Rectum. 2006; 49(3):371-376.
9. Ky AJ, Sylla P, Steinhagen R, et al. Collagen fistula plug for the treatment of anal fistulas. Dis Colon Rectum. 2008; 51(6):838-843.
10. O'Connor L, Champagne BJ, Ferguson MA, et al.  Efficacy of anal fistula plug in closure of Crohn's anorectal fistulas. Dis Colon Rectum. 2006; 49(10):1569-1573.
11. Oelschlager BK, Pellegrini, CA, Hunter JG, et al. Biologic prosthesis reduces recurrence after laparoscopic paraesophageal hernia repair: a multicenter, prospective, randomized trial. Ann Surg. 2006; 244(4):481-490.
12. Ortiz H, Marzo J, Ciga MA, et al.  Randomized clinical trial of anal fistula plug versus endorectal advancement flap for the treatment of high cryptoglandular fistula in ano. Br J Surg. 2009; 96(6):608-612.
13. Thekkinkattil DK, Botterill I, Ambrose NS, et al. Efficacy of anal fistula plug in complex anorectal fistulae. Colorectal Dis. 2009; 11(6):584-587.
14. van Koperen PJ, Bemelman WA, Gerhards MF, et al. The anal fistula plug treatment compared with the mucosal advancement flap for cryptoglandular high transsphincteric perianal fistula: a double-blinded multicenter randomized trial. Dis Colon Rectum. 2011; 54(4):387-393. 

Talymed

1. Kelechi TJ, Mueller M, Hankin CS, et al. A randomized, investigator-blinded, controlled pilot study to evaluate the safety and efficacy of a poly-N-acetyl glucosamine-derived membrane material in patients with venous leg ulcers. J Am Acad Dermatol. 2011; May 25. [Epub ahead of print]

Theraskin

1. DiDomenico L, Emch KJ, Landsman AR, Landsman A.  A prospective comparison of diabetic foot ulcers treated with either a cryopreserved skin allograft or a bioengineered skin substitute. Wounds. 2011; 23(7):184-189.
2. Landsman AS, Cook J, Cook E, et al. A retrospective clinical study of 188 consecutive patients to examine the effectiveness of a biologically active cryopreserved human skin allograft (TheraSkin®) on the treatment of diabetic foot ulcers and venous leg ulcers. Foot Ankle Spec. 2011; 4(1):29-41.

TransCyte

1. Demling RH, DeSanti L. Management of partial thickness facial burns (comparison of topical antibiotics and bio-engineered skin substitutes). Burns. 1999; 25(3):256-261.
2. Kumar RJ, Kimble RM, Boots R, Pegg SP. Treatment of partial-thickness burns: a prospective, randomized trial using Transcyte. ANZ J Surg. 2004; 74(8):622-626.
3. Noordenbos J, Doré C, Hansbrough JF. Safety and efficacy of TransCyte for the treatment of partial-thickness burns. J Burn Care Rehabil. 1999; 20(4):275-281.

Veritas

1. Guerette NL, Peterson TV, Aguirre OA, et al. Anterior repair with or without collagen matrix reinforcement: a randomized controlled trial. Obstet Gynecol. 2009; 114(1):59-65. 

XenoGrafts (unspecified) for Burns

1. Moserová J, Bĕhounková-Housková E. Temporary skin substitutes and evaporative water loss. Scand J Plast Reconstr Surg. 1979; 13(1):143-145.
2. Broz L, Vogtová D, Königová R. Experience with banked skin in the Prague burn center. Acta Chir Plast. 1999; 41(2):54-58.
3. Ding YL, Pu SS, Wu DZ, et al. Clinical and histological observations on the application of intermingled auto- and porcine-skin heterografts in third degree burns. Burns Incl Therm Inj. 1983; 9(6):381-386.

Government Agency, Medical Society, and Other Authoritative Publications:

1. American Diabetes Association. Standards of Medical Care in Diabetes—2012. Diabetes Care. 2012; 35(Suppl 1):S11-S63. Available at: http://care.diabetesjournals.org/content/33/Supplement_1. Accessed on amniotic membrane-derived.
2. Bergin SM, Wraight P. Silver based wound dressings and topical agents for treating diabetic foot ulcers. Cochrane Database Syst Rev. 2006;(1):CD005082
3. Centers for Medicare and Medicaid Services. Available at: http://www.cms.hhs.gov/mcd/index_list.asp?list_type=ncd. Accessed on amniotic membrane-derived.
   • National Coverage Determination for Blood-Derived Products for Chronic Non-Healing Wounds. NCD #270.3. Effective July 23, 2004.
   • National Coverage Determination for Porcine Skin and Gradient Pressure Dressings. NCD #270.5. Effective date not posted.
   • National Coverage Determination for Services provided for the Diagnosis and Treatment of Diabetic Sensory Neuropathy with Loss of Protective Sensation (Diabetic Peripheral Neuropathy). NCD #70.2.1. Effective July 1, 2002
   • National Coverage Determination for Treatment of Decubitus Ulcers. NCD #270.4. Effective date not posted.
   • National Coverage Determination for Collagen Meniscus Implant. NCD #150.12. Effective July 6, 2010.
4. Jones JE, Nelson EA. Skin grafting for venous leg ulcers. Cochrane Database Syst Rev. 2007;(2):CD001737.
5. Storm-Versloot MN, Vos CG, Ubbink DT, Vermeulen H. Topical silver for preventing wound infection. Cochrane Database Syst Rev. 2010;(3):CD006478.

1. National Library of Medicine (NIH). Burns. Available at: http://www.nlm.nih.gov/medlineplus/burns.html. Accessed on amniotic membrane-derived.
2. National Library of Medicine (NIH). Diabetic Foot. Available at:  http://www.nlm.nih.gov/medlineplus/diabeticfoot.html. Accessed on October 29, 2012.

Bilaminate Skin Substitute
Culture-Derived Human Skin Equivalent
Frey's Syndrome
Graftskin
Grave's Disease
Human Skin Equivalent
Wound Healing
XenMatrix^™
Xenograft

The use of specific product names is illustrative only.  It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.