Acellular Fetal Bovine Dermal Matrix in Pediatric Skull Base Reconstruction: Initial Report

The use of human cadaveric acellular dermal allograft (Alloderm) has become standard practice in many forms of endoscopic skull base reconstruction. Advantages described include product availability, ease of endoscopic tissue manipulation, and avoidance of donor site morbidity (relative to autologous tissue). Recently a new biological product, acellular fetal bovine dermal matrix (Surgimend), was approved by the Food and Drug Administration as a medical device. Acellular fetal bovine dermal matrix is comprised of tissue that has been terminally sterilized, with theoretical disease transmission risk that is favorable compared with human cadaveric dermis. Within this report, we describe our initial experience with acellular fetal bovine dermal matrix for the repair of skull base defects in the pediatric population; the authors have no commercial affiliation whatsoever with either allograft product.

A total of three cases are presented, including two defects of the anterior cranial base and one lateral skull base defect. The two anterior cranial base defects presented with intracranial abscess following head trauma; and with meningitis as a complication of sinusitis. One of these cases involved a sphenoid region encephalocele and the other an anterior ethmoid encephalocele. These defects were repaired utilizing an endoscopic endonasal approach. In each case, acellular fetal bovine dermal matrix was used as an underlay graft in a similar manner as that described previously for human cadaveric dermal allograft. A multilayered repair with autologous tissues and free mucosal grafts were utilized and a lumbar drain was left in place postoperatively. The lateral skull base defect was related to prior mastoid surgery and occurred in the context of postoperative radiation for temporal bone rhabdomyosarcoma. Acellular fetal bovine dermal matrix was used as an underlay graft as part of a multilayered repair with autologous tissues; a lumbar drain was not utilized. Cerebrospinal fluid leak was stopped and the skull base successfully repaired in all cases at 6 month follow up.

There are several reasons why acellular fetal bovine dermal matrix may be superior to human cadaveric tissue for skull base reconstruction. First, acellular fetal bovine dermal matrix is more pliable than human cadaveric tissue and, in our experience, easier to work with endoscopically. Second, acellular fetal bovine dermal matrix is available at a lower cost when compared with human tissue products. Finally, the product is classified as a medical device rather than a tissue product. While cadaveric allografts are sterilized and irradiated to eradicate communicable disease, some patients are uncomfortable with the use of a human tissue product from an anonymous donor. This difference is particularly significant in the pediatric population, where parents are often uncomfortable with implantation of cadaveric tissue into their children.

Acellular fetal bovine dermal matrix (Surgimend) may be a comparable material to human cadaveric acellular dermis for skull base reconstruction. Increased pliability, lower cost, and classification as a medical device rather than a tissue are potential advantages of this product, as compared with human cadaveric tissue. Further comparison studies are warranted.