Key Insights On Using Apligraf Successfully
There have been many technological advances in wound care over the past decade, ranging from research into the wound healing model to the role of growth factors and the use of living skin constructs in clinical practice. With this in mind, our expert panelists take a closer look at Apligraf and their experiences in using this product. Q: Do you use Apligraf much in your practice? If so, when do you use it in the course of treatment? A: Both Robert Snyder, DPM, and Sheldon Ross, DPM, use Apligraf frequently in their practices. David Armstrong, DPM, says he uses Apligraf if he does not see predictable healing following three to four weeks of conservative therapy, which consists of aggressive debridement and offloading. Dr. Ross concurs, noting that he usually uses the product to treat diabetic or venous stasis ulcerations that do not respond to conventional wound care within four to six weeks. He also uses Apligraf on several patients who have large wounds, which require more than one graft per site. “A construct such as Apligraf can also act as a ‘stimulatory packet,’ which may form a matrix that was previously lacking. It is, in essence, a ‘bag of growth factors,’” explains Dr. Snyder. Although the FDA has approved Apligraf for treating diabetic ulcerations and venous ulcers, Dr. Snyder believes the modality can also help treat problems including burns, status post-Mohs cancer surgery and pressure ulcers. Q: Some doctors do not feel comfortable working with Apligraf because it is cumbersome to handle and tears easily. What has been your experience and what techniques do you use? A: Although he doesn’t think working with Apligraf is difficult, Dr. Snyder says you may need practice to master the technique and offers the following advice. First, drizzle saline over the Apligraf before removing it from the container. Then grasp the graft with two atraumatic forceps at 10 o’clock and 2 o’clock. Gently lift the Apligraf from the container and place it epidermis down on the inside of the top cover. If you have a mesher, place the graft down on a carrier of 1.5:1 in the same fashion. Pie-crust with a #11 blade or mesh, if appropriate. Bring the top cover (or carrier) to the wound. Gently tease the graft off the cover and place it on the wound. If you place the graft on the cover or carrier with the epidermis down, you can easily place Apligraf on the wound, dermis side down, without repositioning the graft. There is almost no graft manipulation or excessive handling, according to Dr. Snyder. Dr. Armstrong recommends applying the product manually and then using cotton-tipped applicators to help spread the tissue over the wound site. He tends “to allow for a great deal of overlap of the graft over the margins of the wound.” Dr. Ross says he has had no problems with graft tearing and does not think working with Apligraf is cumbersome. “The worst problem I have experienced is the rolling of the graft edges, but if you maintain proper epidermal-dermal orientation, you won’t have a problem applying the graft,” points out Dr. Ross. “I work in a close sterile environment, transferring the graft from the transfer media container directly to a mesh plate.” Dr. Ross says he carefully teases the graft edge from the container with the blunt side of a scalpel handle, grasps it on two ends using sterile forceps in each hand and transfers it epidermal side down. If necessary, he trims the graft and then either meshes or incises it using a #11 blade. Then he brings the mesh plate directly to the wound site with the dermal side up and inverted and places the graft directly into the wound. Q: In your experience, does Apligraf actually “take” like an autograft? What would you expect to see on the first post-operative visit? A: In his experience, Dr. Ross says there have been many cases in which Apligraf took like an autograft. However, Dr. Armstrong disagrees, saying he believes many people made mistakes initially because of their expectations in terms of what to look for. “What was once considered by some to be ‘slough’ on the wound one to two weeks post-grafting is now known to be metabolically active graft,” explains Dr. Armstrong. “One should not disturb this until it dissipates. Other bioengineered products, such as Dermagraft, behave differently in the wound.