Can human amniotic membrane be used as an Ideal Suture or Filling Material? An Experimental study

Background: The use of the patient’s own tissues in surgery increases the morbidity rate, whereas the use of injected or implanted materials can cause allergic reactions in the body mostly via immunogenic pathways. In addition, absorbable suture materials and some fi llers used in almost all surgical applications can cause reactions in the body. Objective: The use of human amniotic membrane (HAM) as a suture and/or fi lling material has been successfully investigated in many areas to solve or minimize these problems. Material and Method: In this study, 40 rats were divided into four groups (10 rats per group). The HAM was removed with the surrounding tissue at the fi rst week from group 1, the second week from group 2, the fi rst month from group 3, and the third month from group 4, and underwent clinical and histopathological examination. Results: When the rats that had HAM placed under the skin and intramuscle were evaluated statistically using a points-based scoring system, there was a statistically signifi cant difference among all groups (p<0.001). Conclusion: In our study, we found that HAM progressively biodegraded by macrophages within 3 months could be used as an absorbable suture material; therefore, its use as a fi lling material was limited over time. In addition, it is also likely to be used as an absorbable suture material, as it can accelerate wound healing due to the growth factors secreted. However, further studies are needed to prevent adhesions of factors isolated from amniotic fl uid or the HAM and to investigate its use in wound healing. Research Article Can human amniotic membrane be used as an Ideal Suture or Filling Material? An Experimental study Fatma Bilgen1*, Alper Ural1, M Nuri Karatoprak2 and Mehmet Bekerecioğlu1 1Kahramanmaraş Sutcu Imam University School of Medicine. Plastic, Reconstructive and Aesthetic Surgery. Kahramanmaras, Turkey 2MNK Aesthetic Clinic, Turkey Received: 12 February, 2019 Accepted: 25 February, 2019 Published: 26 February, 2019 *Corresponding author: Fatma Bilgen, MD, Kahramanmaras Sutcu Imam, University, Tıp Fakültesi Hastanesi,Plastik, Rekonstrüktif ve Estetik Cerrahi Servisi. Kahramanmaras, Turkey, Tel: +90 5057280165, E-mail:


Introduction
Correction of congenital or acquired tissue defects and scars has been one of the most controversial issues since the beginning of plastic surgery. Despite advances in reconstructive and aesthetic surgery, the prevention of aging signs and the elimination of tissue defects continue to be major issues. Due to age, smoking, sun exposure, and gravity, collagen in the skin decreases and wrinkles become apparent. The history of soft tissue fi llings applied to correct these wrinkles is based on the fi rst use of Neuber's fat grafts in the face in the 1800s [1,2]. Since the use of the fi rst fi lling material, the search for the ideal material is ongoing.
Suture materials are one of the fundamental issues that concern every surgeon. The main goals of the use of suture are to complete the natural wound-healing process and to ensure that the wound edges are properly conjoined until the old tension is restored. Suture materials are foreign bodies implanted into the tissues and are likely to cause foreign body reactions 2 .
In the literature, it has been shown that human amniotic membrane (HAM) has several functions: it accelerates epithelization [2], prevents protein and fl uid loss of the wound surface [3], reduces adhesion formation [4], has antibacterial and non-immunological effects [5], contributes to collagen synthesis by increasing the fi broblastic activity [6], and reduces angiogenesis, scar formation, pain and infl ammation [7]. However, there is no study in the literature using HAM as a suture and/or fi lling material.
Based on these properties of the amnion membrane, in the present study we aimed to evaluate the usability of HAM as ideal suture and/or fi lling material considering the fact that it does not contain tissue antigens.

Preparation
The study was conducted on 40 male Wistar species, male albino rats (weighing 250-350 g and aged 105-120 d). The rats were randomly selected and divided into four groups of 10 rats in each group.
After receiving the consent forms, the HAMs were obtained following cesarean operations, when the patient was known to have been previously seronegative for infection. The blood was removed by washing with sterile 0.9% NaCl solution and washing with 0.025% sodium hypochlorite for sterilization. Strips 2 × 1 in size of HAM were prepared as 500,000 to 2,000,000 IU/L as described in the literature. Penicillin and 0.5 to 2 g streptomycin were used after soaking in sterile saline for 12 to 24 hours at +4°C.
After surgical site shaving, povidone-iodine (Betadin ® , Merkez İlaç, Turkey) was used for sterilization. The HAM was placed into the pouch opening in the left lumbar area and into the right quadriceps femoris muscle and fi xed with 5/0 non-absorbable suture to prevent prolapsing when placed in the muscle. Skin suturing was done with 5/0 non-absorbable sutures. The laboratory temperature was set between 25°C and 30°C. The wound location of each rat was dressed daily with povidone-iodine (Betadine ® ). All groups received a single dose of subcutaneous ampicillin 150 mg/kg daily for 5 days for infection prophylaxis.
The HAM was removed with the surrounding tissue at the fi rst week from group 1, the second week from group 2, the fi rst month from group 3, and the third month from group 4, and underwent clinical and histopathological examination.

Measurements
In the clinical and histopathological examinations, muscle and subcutaneous tissue samples were initially taken from all groups. These tissue samples were then fi xed in 10% formalin and embedded in paraffi n blocks. The sections were stained with hematoxylin and eosin (H&E) and examined under the light microscope. In the pathological examination of the tissue specimens, parameters such as polymorphonuclear neutrophil leukocytes (PMNL), lymphocytes, fi broblast proliferation, eosinophil density, and foreign body granulation tissue were examined as was the presence of HAM and indica-tors of an infl ammatory response in the specimens. The pathological degree of infl ammation was scored for the numerical transfer of the means of the data (Table 1).
HAM was fi rst used by Davis in 1910 as a graft material in the closure of skin defects [11][12][13][14]. In the following years, it was used successfully in several cases as follows: the repair of symblepharon, the treatment of acute ocular burns, for accelerating wound healing, the repair of abdominal defects, unhealed skin ulcers, urinary bladder reconstruction, artifi cial vaginal reconstruction, the prevention of abdominal chirurgical adhesions, the treatment of corneal surface defects and ulcers, repair of urethral defects, myelomeningoceles repair in vestibuloplasty cases, prevention of tendon adhesions, peripheral nerve anastomosis, and complicated scleritis [12][13][14][15].
HAM, a rapidly growing biological cover with increasing value, is an easy and convenient way to accelerate epithelialization, to prevent protein and fl uid loss from the wound surface, to reduce adhesion formation, to have antibacterial and non-immunological effects, to contribute to collagen synthesis by increasing fi broblastic activity, and to reduce angiogenesis, scar formation, pain, and infl ammation [3,4,16].
The features, graft excretion is not a concern. In addition, it has a reducing effect on wound contracture for moderate defects [17][18][19]. Epithelial cells in the stromal matrix of HAM exhibit anti-infl ammatory effects by depressing interleukin-1  and , which play a role in infl ammation by transforming lipopolysaccharides. Again, due to the presence of progesterone and other factors, it shows bacteriostatic effect against grampositive microorganisms [18,19].
It was reported that HAM acquires the feature of the body region in which it is applied over time; thus, a new surgical procedure is not required [18,19]. Studies have shown that in the tendon incision model, HAM completely disappeared over time and that it transformed into connective tissue composed of cells originating from the epitenon [19,20]. In an effort to identify the incidence and characterization of infection after HAM transplantation, Marangon [20], suggested that infection occurred in 3.4% of 326 (11 cases) transplantations.
In addition, the most isolated microorganisms in cultures were gram-positive ones.
In the present study, we found that the highest level of infl ammatory reactions in the early postoperative period, particularly in the second week, may be due to infl ammatory response after surgical trauma, due to the absence of Human Leucoyte Antigene in HAM. The fact that the statistically signifi cant difference in this study can be attributed to the reduced reaction after the fi rst month and to the fact that that these reactions completely disappeared in the third month also showed once again that HAM had no allergenic potential.
In conclusion, in our study, we found that HAM progressively underwent biodegradation by macrophages over a period of 3 months. Therefore, it was concluded that the use of HAM as a fi lling material was limited over time. However, it can be used as an absorbable suture material, as it accelerates wound healing due to the growth factors secreted and does not have allergic potential. Furthermore, to prevent adhesions of the factors to be isolated from the amniotic fl uid or HAM and to enhance their potential for the use in wound healing, further immunohistochemical studies are required.

Acknowledgement
All of the authors declare that they have all participated in the design, execution, and analysis of the paper, and that they have approved the fi nal version. Additionally, there are no confl icts of interest in connection with this paper, and the material described is not under publication or consideration for publication elsewhere.