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Reconstructivematerialsusedinsurgery:Classificationandhostresponse
OfficialreprintfromUpToDate
www.uptodate.com2016UpToDate

Reconstructivematerialsusedinsurgery:Classificationandhostresponse
Authors
EmanuelCTrabuco,MD,MS
JohnBGebhart,MD,MS

SectionEditors
DeputyEditor
LindaBrubaker,MD,FACS,FACOG KathrynACollins,MD,PhD,FACS
HilarySanfey,MD
CharlesEButler,MD,FACS

Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:Jun2016.|Thistopiclastupdated:Feb18,2016.
INTRODUCTIONThistopicreviewwilldiscusstheclassificationandhistologicbehaviorofreconstructive
materialsusedinsurgery.Prostheticmaterialsinthesurgicalmanagementofspecificconditionsarediscussedin
individualtopicreviews.
USEOFRECONSTRUCTIVEMATERIALS
HerniarepairTheuseofprostheticmaterialdramaticallyreducestheincidenceofrecurrenceassociatedwith
ventral,inguinal,andfemoralherniarepair.Polypropyleneisthemostcommonmaterialused.(See"Overviewof
treatmentforinguinalandfemoralherniainadults"and"Overviewofabdominalwallherniasinadults".)
PelvicorganprolapsePelvicorganprolapse(POP)andurinaryincontinencearecommon,comorbiddisordersin
women,andcangreatlyimpactqualityoflife[1].(See"Pelvicorganprolapseinwomen:Anoverviewofthe
epidemiology,riskfactors,clinicalmanifestations,andmanagement".)
TYPESOFRECONSTRUCTIVEMATERIALSThefourkindsofsurgicalreconstructivematerialsdifferbysource:
syntheticmesh,autografts,allografts,andxenografts.Advantagesanddisadvantagesofthedifferentmaterialtypes
arefoundinthetable(table1).
SyntheticmaterialsSyntheticmaterialsareavailableasbothabsorbable(eg,polygalactin910[Vicryl],polyglycolic
acid[Dexon])andnonabsorbablemesh(eg,polypropylene[Marlex,Prolene],andexpandedpolytetrafluoroethylene
[ePTFE,Goretex]).Comparedwithbiologicgrafts,advantagesofsyntheticmaterialsincludegreateravailability(does
notrequireharvesting)andlowercostofmaterial.However,infectiousanderosioncomplications,especiallywith
transvaginalsurgery,havepromptedasearchforalternativematerials[2](see'Hostresponse'below).
AutograftsAutograftmaterialsareharvestedfromthepatientwhoisundergoingtheprocedure.Tensorfascialata
andrectusfascia,themostcommonlyusedautografts,havebeenusedfordecadesandyieldpredicableresults[3].A
clearadvantageofautograftsisthatthehostresponseisrarelyproblematic.However,useofautograftsislimitedby
morbidityassociatedwithharvestingthetissue(eg,pain,bleeding,infection,herniaformation),aswellasinconsistent
size,quantity,andqualityoftissue[4](see'Hostresponse'below).
AllograftsAllograftsareprocessedcadavericfascialataoracellulardermalmatrices(ADM)ofhumandonors(table
2).Thematerialisdecellularizedandrenderednonimmunogenicbywashingprocesses,whicharedesignedtoremove
cellulardebriswithoutpermanentlydamagingtheconnectivetissuescaffold.
AlthoughtissuebanksinNorthAmericaareaccreditedthroughtheNationalAssociationofTissueBanks,evidence
basedcomparisonsamongallograftsdistributedbydifferentcompaniesaredifficultbecausetheharvesting,
processing,andpreservationofthesematerialsarevariedandproprietary.(See'Allograftprocessing'below.)
Humandonorsofallograftsarescreenedforbloodbornepathogensthosewithriskfactorsorwhotestpositivefor
HIV,syphilis,HTLV,orhepatitisBorCareexcluded.Therehavebeennoreportedcasesofdonorrelatedviral
infectionassociatedwiththeuseofallografts.
Useofthisclassofmaterialseliminatesthemorbidityassociatedwithautologousfasciaharvest.However,allografts
haveconsistentlyunderperformedcomparedwithautologousfasciaandsyntheticmaterials.
XenograftsXenograftsareacellularextractsofcollagenfromnonhumansources,harvestedwithorwithout
additionalextracellularmatrixcomponents(table3).Theydifferinthesourcespecies(bovineorporcine),siteof
harvest(pericardium,dermis,orsmallintestinesubmucosa),andbywhetherornotchemicalcrosslinkingisusedin
theprocessingofthematerial[5].
Itisnotclearwhetherarchitecturaldifferencesduetoharvestsite(eg,dermiswithhighelastincontentversus
intestinalsubmucosawithnoelastincontent)affectsinvivoperformance.
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Somepatientsmayobjecttouseofporcineorbovineimplantsduetoreligiousorculturalissues.
HOSTRESPONSEHistologicbehaviortoaclassofmaterialdependsuponthephysicalandstructuralproperties
oftheprosthesis.Thetypeofhostresponseisakeydeterminantofsyntheticmeshrelatedcomplications.Asan
example,amongpatientsundergoingasacrocolpopexy,theriskofmeshexposurewas4.2timesgreaterforthosewho
hadpolytetrafluoroethylene(PTFE)comparedtothosethatusednonPTFEmesh[6].
TerminologyHostresponsetoreconstructivematerialsisdescribedbyvaryingterminology[7],asanexample:
Incorporation:graftinfiltrationbyhostcells,allowingneovascularizationandcollagendepositionthroughoutthe
material
Encapsulation:collagenandconnectivetissuedepositattheperipheryofthematerial,ratherthaninfiltrationof
graftbyhostcells
Mixedresponse:incorporationoccursatgraftporesandencapsulationoccursaroundtheremainingmaterial
Resorption:materialisreplacedbyhostneoconnectivetissue
Theoretically,materialsthatundergoencapsulationormixedresponseareatincreasedriskofinfectionanderosion.
(See'Classification'below.)
Thekeyfactor(s)forhostresponsetoeachtypeofmaterialareasfollows:

Syntheticmesh:fiberdiameter,poresize,andweaveorknittype
Autografts:autologoustissue,hostresponseisrarelyproblematic
Allografts:keyfactor(s)havenotbeenelucidated
Xenografts:removalofhostcellularcomponentsandchemicallycrosslinking

TheInternationalUrogynecologicalAssociation(IUGA)andtheInternationalContinenceSociety(ICS)havepublished
aJointTerminologyandClassificationReportonmeshrelatedcomplicationsthatclassifiestheeventbasedupon
category(asymptomatic,symptomatic,infectionwithorwithoutabscess),location(vagina,urinarytract,bowel,skinor
patientcompromise),andtimingsinceimplantation(within48hoursofsurgery,until6monthsandbeyond6months
fromsurgery).Clinically,prostheticmaterialrelatedcomplicationsaremanifestedasexposures(meshfibersprotruding
intothelumenofthevaginalorsurroundingorgans),meshcontractionorprominence(thewrinklingorshrinkageofthe
materialprojectingbeyondthesurfaceoftheepithelium),infection(includingsinustractformationandabscess),bowel
orbladderinjury,orbleedingcomplicationsandsystemiccompromise.Itisraretohaveaninfected,unexposed
material.Insomelocations,suchasthevagina,itisdifficulttodifferentiatebetweeninfectionandcolonization,and
clinicalsignsofinfectionarenecessarytomakethediagnosis.Furthermore,itisunclearwhethertheseclinical
manifestationsareduetohostresponseortechnicalaspectsofmaterialuse(eg,thicknessofvaginalflaps).
SyntheticmaterialsHostresponsetosyntheticprostheticmaterialsdependsonseveralfactors:absorbability,pore
size(spacebetweenfibrils),weaveorknit(monoormultifilament),andweight(masspersurfaceareamesh).
AbsorbableversusnonabsorbableBothabsorbableandnonabsorbablematerialscauseinitialandchronic
inflammatorytissueresponsesaftertheyareimplanted[8].Thequantityandqualityoflocalinflammationdepend
directlyonthespecificmaterialused.
Theimplantationofabsorbablematerial(eg,polygalactin910[Vicryl]orpolyglycolicacid[Dexon])elicitsachronic
foreignbodyreactionandpromotesfibroblastactivity.Aftercompleteabsorption(30daysforpolygalactin91090days
forpolyglycolicacid),theprostheticmaterialisreplacedbyacollagenrichconnectivetissue[9].Absorbablematerials
arelesslikelytobecomeinfectedthannonabsorbablematerials,andarelessharmfultoviscera[10].One
disadvantagetoabsorbableimplants,basedonanimalstudies,isthattheresultantscartissueweakensafterthe
materialisabsorbed,andthereforemaynotprovidethenecessarylongtermrepairstrength[11].
Nonabsorbableprostheticmaterials(eg,polypropylene[Prolene,Marlex])areassociatedwithmoreconnectivetissue
reactionthanabsorbablematerials.Thus,repairstrengthisincreasedduetothecontinuingpresenceoftheimplantand
greaterscarformation.
Partiallyabsorbablematerialshavebeendeveloped,withtheaimofdecreasingtheamountofpermanentforeign
materialwhilemaintainingmechanicalresistance.Thesematerialsarecompositesofabsorbableandnonabsorbable
materials(eg,polypropylenewithpolygalactin[Vypro]orwithpoliglecaprone25[Ultrapro])andarelightweightfew
reportsareavailableregardingclinicalperformance[12,13](see'Weight'below).

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PoresizeandweavePoresizeinfluencescellularinfiltration,riskofinfection,tendencytoformadhesions,and
meshdensityandflexibility[14,15].Macropores(>75microns1mm=1000microns)allowforhostcellcolonization
withcollagendepositionandangiogenesis,althoughthishasonlybeenreportedinanimalstudies[16,17].Inaddition,
invivoevidencesuggeststhatthelargeporeallowsunrestrictedimmunecellaccessandminimizestheriskof
infection.
Micropores(<10microns)resultinrestrictionoffibroblastandimmunecellcolonizationtothematerialsurface(eg,
PTFE).Therefore,collagenandconnectivetissuedepositionoccursattheperiphery,ratherthaninfiltrationbyhost
cells,accordingtoanimaldata.Thisprocessiscalledencapsulation[5].
Inaddition,microporousmaterialsareatincreasedriskofbecominginfected,aslargeimmunecells(macrophagesand
naturalkillercells,meandiameter9to20microns)cannotinfiltratetheinterstices(spacebetweenfibers)to
phagocytosebacteria(<1micron)[14].
WeightMeshweight,ordensity,isanotherdescriptorforsyntheticmaterials(figure1).Generallyspeaking,the
weightisameasureofhowmuchmaterialispresentpersquaremeter.
Weightandelasticityaredeterminedbyporesize.Mesheswithlargerporesgenerallyhavealowerweightandare
moreelasticcomparedwiththosethathavesmallerpores.Thelargerthepores,thelessmaterialcontentandthemore
flexibletheelicitedscar[18].Ithasbeenpostulatedthatlightweightmaterialsmaybelesspronetoinfectionor
erosionthanheavyweightmaterials.
ClassificationNonabsorbablesyntheticmaterialsaregenerallydescribedbytype,aclassificationbasedon
poresizeandweave(figure1)[19].Therearefourtypes(figure1):
TypeIMacroporous(>75microns),monofilamentpolypropylene(eg,Prolene,Marlex).TypeImeshesare
furthersubdividedintoheavy,mid,andlightweightmaterials.
TypeIIMicroporous(<10microns),eg,expandedpolytetrafluoroethylene(eg,Goretex).
TypeIIIMacroporous(>75microns)graftswitheithermicroporouscomponentsormultifilamentfiberstructure,
eg,polyethylene[Mersilene].HistologicbehaviorissimilartoTypeIImaterials.Thiscategoryincludessome
polypropylenematerials,eg,ObTape(heatbonded,heatweldedpolypropylenewithmicroporouscomponents)
andIVSTunneler(multifilamentpolypropylene).Bothmaterialshavebeenassociatedwithincreasedratesof
infectionsanderosion[20]OBTapehasbeenremovedfromthemarketandIVSTunnelerisnotbeingmarketed.
TypeIVSubmicroscopicporesize(eg,polypropylenesheet[Cellgard]).Thesearenotcommonlyusedin
gynecologicsurgery.
AllograftprocessingAllograftprocessingisintendedtorenderagraftnonimmunogenic.Asmentionedabove,the
methodsusedbycompaniestoprocesshumantissuetoproduceallograftsvaryanddetailsarenotpubliclydisclosed
(table2),therebyinterferingwithevidencebasedcomparisonsamongallografts.
Thereareatleastfourmajorstepsinallograftprocessing:
HarvestingHarvestingoffascialataanddermisisdoneasepticallyfromcadavers.Fordermisproducts,the
epidermisismechanicallyorchemicallyseparatedfromtheunderlyingdermisthecollagenmatrixisthenextracted
fromthedermis.
HostcellremovalAfterharvesting,thematerialismadeacellularbywashingitinasolutiontoextractcellular
components.Theseprocessesrendertheallograftnonimmunogenicbyeliminatingcellsurfaceproteins(eg,human
histocompatibilityantigen,HLA)andsugarmoieties.Thesolventsmustremovecellulardebriswithoutpermanently
denaturingtheproteinscaffold.
Despiteassertionsbymanufacturers,itappearsthatthecellularextractionprocessisimperfect[21].Inonestudy,the
HLAtypeofallograftdonorscouldstillbeidentified(usingthepolymerasechainreaction)infreezedriedandTutoplast
processedgraftsRepliforminterferedwiththeassayinthestudyanditsantigenicitycouldnotbedetermined.These
datasuggestthatnotallcontaminatingDNAhadbeenextracted.However,thisfindingdoesnotsignifythatthegrafts
wereimmunogenic.Hostrejectionismediatedbyhostlymphocytedetectionofcellsurfaceproteinsandsugar
moieties,notbyDNAorotherintracellularcomponents.
PreservationandsterilizationThecollagenandextracellularmatrixarepreservedvialyophilization(freeze
driedundervacuum)orsolventdehydration.Insometissuebanks,thegraftisthenterminallysterilized(usuallywith
gammairradiation).
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Theprocessesemployedforthesestepsappeartoaffectthefinalgraftstrength.Asanexample,therateof
lyophilizationaltersthesizeoficecrystalformation(themoreicecrystalsformed,theweakerthefinalproduct)and
theterminalsterilizationtemperatureinfluencesthedegreeoffreeradicalformation.
Bothlyophilizationandsterilizationaffectthefinalintegrityofthematerialand,theoretically,graftperformance.
However,theeffectofpreimplantationbiomechanicalcharacteristicsofagraftoninvivobehavioriscontroversial
[7,2226].Nodataonpostimplantationbiomechanicaltestingexistforallograftsitappearsthatpreimplantation
mechanicaltestingdoesnotpredictinvivobehaviorofxenografts[7].
Infact,thefewstudieswhichhavecompareddifferentallograftsbypreimplantationstrengtharenotconsistentwith
reportsofclinicalperformance.Asanexample,onestudyreportedthatthepreimplantationmaximumloadtofailure
(minimumforceneededtotearthetissue)andstiffnessweresignificantlyhigherforsolventdehydratedcomparedwith
freezedriedfascialata[22].Nevertheless,solventdehydratedallograftshaveconsistentlybeenreportedtoresultin
earlyfailureafterpubovaginalsling[23,24],sacrocolpopexy[25],andvaginalreinforcedrepairs[26].Similarly,theonly
studywhichevaluatedvaginalrepairwithafreezedriedgraftreportedahighfailurerate[27].
XenograftprocessingSimilartoallografts,xenograftsprocessingincludesharvesting,hostcellremoval,
preservationandsterilization.Theseprocessesaregenerallyproprietary,andthuscomparisonsamongdifferentgrafts
aredifficult.Inourexperience,somepatientshavehadincreasedtissuereactionwithxenografts,raisingconcerns
abouthowwelltheprocessesremovecellulardebris.(See'Allograftprocessing'above.)
Inaddition,xenograftsundergochemicalcrosslinking,whichisoneofthekeydeterminantsofhostresponseto
xenografts(table3).
CrosslinkingNoncrosslinkedxenografts(eg,Surgisis,Xenform)arepurportedtoserveasbiologicscaffolding
forfibroblastandangioblastingrowththeyarereplacedbyhostconnectivetissueatvaryingrates,dependingon
materialthickness,methodoffreezing,andsiteofimplantation[5].
Conversely,materialswhicharecrosslinked(eg,Pelvicol)arefunctionallynonporous.Asaresult,hostcellular
infiltrationdoesnotoccurandthematerialissurroundedbyaconnectivetissueenvelop(ie,encapsulation,similarto
synthetictypeIImaterials)[5].(See'Classification'above.)
Ifcrosslinkedmaterialsareperforatedpriortoimplantation(eg,PelvisoftandFortagen),theyundergoamixed
responsewithincorporationattheperforationsandencapsulationintheremainderofthematerial(similartowhatis
observedfortypeIIIsyntheticmaterials)[5].(See'Classification'above.)
Althoughcrosslinkingisperformedtopermanentlystabilizethematerial,crosslinkedgraftresorptionovertimeisan
areaofconcern.Accordingtothemanufacturerreportonly,theprocessofresorptionwouldbedifferentforcrosslinked
andnoncrosslinkedgrafts.
Itisnotknownwhethereventualgraftlossaffectsthestructuralintegrityoftherepair.Furthermore,italsoremainsto
beelucidatedifresorptionoccursinallpatientsimplantedwithacrosslinkedgraft,oronlyinasubsetofpatientsthat
rejectthegraft.Thisisillustratedbythefollowingstudies:
Asmallhistopathologicstudyevaluatedwomenwhohadundergoneplacementofamidurethralslingusinga
crosslinkedporcinedermalcollagenimplant(Pelvicol)andwhorequiredslingrevisionduetorecurrentstress
urinaryincontinenceorurinaryretention[28].Timefromgraftplacementtobiopsyrangedfrom15to67months.
Althoughthegraftremainedencapsulatedintheearlybiopsyspecimens,therewasaprogressiveincreaseinthe
immunologicresponseatthegrafthostinterfaceat21weeks.Histiocyteandmultinucleatedgiantcellinfiltration
ofthegraftwasdetectedby42weeks[28].Noresidualgraftwasfoundinthe58and67weeksamples,
suggestingthatthematerialswereresorbedintheinterim[5,28].
Inanotherstudy,womenwhohadaPelvicolreinforcedposteriorrepairwereevaluateduponreoperationoneyear
postoperativelynoresidualPelvicolwasfound[29].
SUMMARYANDRECOMMENDATIONS
Surgicaltreatmentofavarietyofconditionsrequiringreconstruction(eg,hernia,prolapse)arefollowedbyhigh
recurrencerates.Theinterpositionofmanyreconstructivematerialsremainsinvestigational.(See'Introduction'
above.)
Therearefourcategoriesofreconstructivesurgicalmaterials:syntheticmaterial,autografts,allografts,xenografts
(table1).(See'Typesofreconstructivematerials'above.)
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Hostresponsetoaclassofmaterialdependsuponthephysicalandstructuralpropertiesoftheprosthesis.(See
'Hostresponse'above.)
Syntheticmaterialporesizedetermineshostresponse.Thetypeofresponsepredisposestoincreasedriskof
infectionandmeshexposure.(See'Hostresponse'above.)
Allograftprocessingisintendedtorenderaprosthesisnonimmunogenic.Processingtechniquesvaryby
manufacturerandinformationisnotpubliclydisclosed,thuslimitingevidencebasedcomparisonofallografts.
(See'Allograftprocessing'above.)
Chemicalcrosslinkingisakeydeterminantofhostresponsetoxenografts.(See'Xenograftprocessing'above.)
UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.
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11.BarboltTA.Biologyofpolypropylene/polyglactin910grafts.IntUrogynecolJPelvicFloorDysfunct200617
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Dysfunct200516:389.
14.IglesiaCB,FennerDE,BrubakerL.Theuseofmeshingynecologicsurgery.IntUrogynecolJPelvicFloor
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15.FalagasME,VelakoulisS,IavazzoC,AthanasiouS.Meshrelatedinfectionsafterpelvicorganprolapserepair
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16.White,RA.Theeffectofporosityandbiomaterialonthehealingandlongtermmechanicalpropertiesofvascular
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17.BobynJD,WilsonGJ,MacGregorDC,etal.Effectofporesizeonthepeelstrengthofattachmentoffibrous
tissuetoporoussurfacedimplants.JBiomedMaterRes198216:571.
18.CobbWS,BurnsJM,PeindlRD,etal.Textileanalysisofheavyweight,midweight,andlightweight
polypropylenemeshinaporcineventralherniamodel.JSurgRes2006136:1.
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20.BaesslerK,HewsonAD,TunnR,etal.Severemeshcomplicationsfollowingintravaginalslingplasty.Obstet
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21.FitzgeraldMP,MollenhauerJ,BrubakerL.Theantigenicityoffascialataallografts.BJUInt200086:826.
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22.LemerML,ChaikinDC,BlaivasJG.Tissuestrengthanalysisofautologousandcadavericallograftsforthe
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23.HuangYH,LinAT,ChenKK,etal.Highfailurerateusingallograftfascialatainpubovaginalslingsurgeryfor
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24.McBrideAW,EllerkmannRM,BentAE,MelickCF.Comparisonoflongtermoutcomesofautologousfascialata
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GRAPHICS
Comparisonofreconstructivematerials
Graft
type
Synthetic

Advantages
Accessible:easytomanufactureandobtain
Consistent:materialsarereproducible
Durable
Costeffective:lessexpensivetoproducethan
alloandxenografts

Autograft

Hostresponse:noriskofrejection
Noerosionrisk:althoughpermanentsutures
usedtosecuremayerode

Disadvantages
Infection:microporousand
multifilamentgraftsinparticular
Erosion:mayerodeintovaginaor
viscus

Limitedtissuequantityandquality
possible
Morbidity:tissueharvestrequired

Costeffective
Allograft

Accessible:largerquantitiesavailablethan
autografts,butdependsondonorsupply

Infection:theoreticalriskof
transmissionofhostpathogens

Noharvestmorbidity

Hostresponse:potentialforrejection

Lowerosionrisk

Inconsistentgraftstrength
Limiteddurability:processingmay
weakenmaterial
Limitedabilitytocompareamong
materials
Expensive

Xenograft

Accessible:largerquantitiesavailablethan
autografts

Infection:theoreticalriskof
transmissionofhostpathogens

Noharvestmorbidity

Hostresponse:potentialforrejection
givennonhumansource

Lowerosionrisk

Inconsistentgraftstrength
Limiteddurability:processingmay
weakenmaterial
Culturalissueswithporcineor
bovineproducts
Expensive
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Allografts
Tissue
source
Fascia
Lata

Dermis

Manufacturer

Product

Preservation

Crosslinking

Sterilization

Bard

FasLata

Lyophilized*

No

Irradiation

Mentor

Suspend

Solvent
dehydrated

No

Irradiation

Tutogen

Tutoplast

Solvent
dehydrated

No

Irradiation

Bard

RTIDermis

Lyophilized

No

Irradiation

LifeCell

AlloDerm

Freezedried

No

Irradiation

BostonScientific

Repliform

Lyophilized

No

EthyleneOxide

AMS

UroGen

Lyophilized

No

Irradiation

Mentor

Axis

Solvent
dehydrated

No

Irradiation

*Freezedriedundervacuum.
Gammaradiation.
TutoplastandSuspendarethesamematerial,soldandtrademarkedbyTutogenMedicalandMentor,
respectively.
AlloDermandRepliformarethesamematerial,soldbyLifeCellandBostonScientific,respectively.
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Xenografts
Source
animal
Porcine

Tissue
type

Host
response

Product

Manufacturer

Crosslinking

Sterilization

Dermis

DermMatrix

BrennanMedical

No

Irradiation

Replacement*

Small
intestine
submucosa

Surgisis

Cook

No

Ethyleneoxide

Replacement

Small
intestine

Fortagen

Organogenesis

EDC

Notavailable

Mixed

Dermis

Pelvicol

Bard

HDI

Irradiation

Encapsulation

Dermis

Pelvisoft

Bard

HDI

Irradiation

Mixed

Bladder

Matristem

ACell

No

Irradiation

Replacement

Dermis

Xenform

BostonScientific

No

Ethyleneoxide

Replacement*

Pericardium

PeriGuard

Synovis

GLUT

Propyleneoxide

Encapsulation*

Pericardium

Veritas

Synovis

No

Irradiation

Replacement*

Pericardium

UroPatch

YAMA

GLUT

Notavailable

Encapsulation

submucosa

Bovine

EDC:1ethyl3(3dimethylaminopropyl)carbodiimidehydrochlorideHDI:hexamethylenediisocyanate
GLUT:glutaraldehyde.
*Unpublishedcompanycommunication.
Hypothesizedbasedonchemicalcrosslinkingandmanufacturer'srecommendationofpreimplantation
perforations,butnohistologicstudiesavailabletoconfirminvivoresponse.
Gammaexternalbeamradiation.
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Reconstructivematerialsusedinsurgery:Classificationandhostresponse

Classificationofsyntheticmaterials

1.Davol,Inc.,Cranston,RI.
2.WLGore,Inc.,Flagstaff,AZ.
3.Dupont,Inc.,Wilmington,DE.
4.Ethicon,Inc.,Somerville,NJ.
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Reconstructivematerialsusedinsurgery:Classificationandhostresponse

ContributorDisclosures
EmanuelCTrabuco,MD,MSNothingtodisclose.JohnBGebhart,MD,MSAdvisoryBoard:Astora[Materials
(Slings,mesh)].LindaBrubaker,MD,FACS,FACOGNothingtodisclose.HilarySanfey,MDNothingtodisclose.
CharlesEButler,MD,FACSNothingtodisclose.KathrynACollins,MD,PhD,FACSNothingtodisclose.
Contributordisclosuresarereviewedforconflictsofinterestbytheeditorialgroup.Whenfound,theseareaddressed
byvettingthroughamultilevelreviewprocess,andthroughrequirementsforreferencestobeprovidedtosupportthe
content.AppropriatelyreferencedcontentisrequiredofallauthorsandmustconformtoUpToDatestandardsof
evidence.
Conflictofinterestpolicy

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