Using a Biodegradable Bilayer Synthetic Matrix (BBSM) to Treat Pressor Injuries

Medical disclaimer: This content is for informational purposes only and is not a substitute for professional medical advice, diagnosis, or treatment. Always follow your local protocols and device IFUs.

Why vasopressor‑induced “pressor injuries” are so devastating

In the ICU, vasopressors can be life‑saving—and limb‑threatening at the same time. High‑dose agents that keep blood pressure up by intense vasoconstriction can choke off flow to the most distal vessels, especially in the toes and fingers, leading to patchy or circumferential necrosis once the dust settles from septic shock. [2]

A large cohort of vasopressor‑induced ischemia reported 30‑day amputation rates between 10–30% and mortality around 15%, underscoring that survival often comes with a heavy price in tissue loss and long‑term disability. [2,3]

Traditional management for these patients focuses on waiting for clear demarcation and then amputating non‑viable digits or limbs, followed by skin grafts or flaps if the patient can tolerate additional procedures. Even with aggressive reconstruction, functional outcomes are often limited when the entire forefoot or multiple toes are lost. [3,4]

The poster case “The use of Biodegradable Bilayer Synthetic Matrix (BBSM) in treatment of pressor injuries (CS‑057)” describes a different path: using a fully synthetic, bilayer dermal matrix to rebuild plantar soft tissue and toe stumps after vasopressor‑induced necrosis, avoiding skin grafting and preserving foot function. [1]

What exactly is vasopressor‑induced ischemia?

Vasopressor‑induced ischemia occurs when intense peripheral vasoconstriction from agents like norepinephrine, epinephrine, vasopressin, or combinations reduces distal perfusion below a critical threshold. It often presents as cool, mottled extremities that progress to dusky discoloration, blistering, and eventually dry gangrene of the toes, fingers, or entire distal foot. [2,3]

This pattern overlaps with acute limb ischemia, where sudden arterial inflow loss leads to pain, pallor, pulselessness and, without timely revascularization, high rates of limb loss and death. But in vasopressor injury, the problem is usually diffuse microvascular failure superimposed on shock rather than a single large‑artery occlusion—making surgical salvage more complex. [3]

Case series describe patients who survive septic shock only to wake with multi‑limb gangrene, facing serial amputations, prolonged rehabilitation, and major impact on quality of life. These experiences have driven interest in reconstructive strategies that preserve length and maximize function after demarcation. [2,4]

Meet the patient: ten necrotic toes and plantar foot damage

Patient depicting necrosis on foot and plantar foot damage

In CS‑057, the patient developed digital necrosis of all ten toes plus necrosis across the plantar aspect of both feet following high‑dose vasopressor therapy. Once the patient was stable and tissue demarcation had occurred, they required a combination of full and partial toe amputations, along with sharp debridement of necrotic plantar tissue. [1]

Because some toe wounds and plantar defects could not be closed primarily without excessive tension, the team chose a biodegradable bilayer synthetic matrix (BBSM) to resurface these areas rather than immediate skin grafting or more extensive soft‑tissue flaps. BBSM was applied to the plantar aspect of the right foot and to toe wounds that remained open after amputation. [1]

What is a Biodegradable Bilayer Synthetic Matrix (BBSM)?

BBSM is a fully synthetic, bilayer dermal substitute—most commonly represented clinically by NovoSorb® Biodegradable Temporising Matrix (BTM)—made from a porous polyurethane foam bonded to a non‑biodegradable sealing membrane. The foam provides a scaffold for vascular and fibroblast ingrowth, while the top membrane controls moisture loss and protects the wound surface. [5,11]

Over several weeks, host cells infiltrate the foam, laying down collagen and forming a vascularized “neodermis.” Once integration is complete, the sealing membrane is peeled away, leaving a robust dermal layer ready for either split‑thickness skin grafting or, in select cases, epithelialization and secondary intention healing. [5,6]

Compared with biologic dermal matrices, BBSM/BTM is entirely synthetic, lacks antigenic proteins, avoids disease transmission risk, and can be manufactured at scale. Clinical series across burns, trauma, and complex wounds report that it is versatile, durable, and capable of salvaging defects that once required free flaps or large local flaps. [5,6]

Importantly for critically ill and colonized patients, retrospective studies show BTM can integrate successfully even in wounds with heavy bacterial colonization and multiple comorbidities, as long as thorough debridement and sensible infection control are in place. [6,7]

A growing body of evidence also demonstrates that, in selected cases, secondary healing over BTM—without subsequent skin grafting—is possible, allowing prolonged temporization while patients are medically optimized or while amputation levels declare themselves. [7,8]

How BBSM was used in this pressor injury case

After demarcation and necessary toe amputations, the surgical team debrided necrotic plantar tissue down to healthy, bleeding margins. BBSM was then applied to the plantar aspect of the right foot and to toe amputation stumps that could not be closed primarily, creating a uniform synthetic dermal layer over previously non‑graftable wound beds. [1]

Pressor injury three weeks of BBSM post-placement

The matrix was secured and managed with simple dressings rather than negative pressure therapy. By three weeks post‑placement, the BBSM was fully integrated, with healthy granulation and neodermis apparent across the treated areas. [1]

Pressor injury nine weeks of BBSM post-placement

By nine weeks after BBSM application, the plantar wounds and toe stumps were nearly healed with a smooth contour. The patient achieved high functionality in both feet using orthotics and, crucially, healed by secondary intention without a skin graft—avoiding another trip to the OR and any donor‑site morbidity. [1]

These findings echo other reports where BTM has been used to resurface complex extremity wounds, including hands and feet with exposed bone or tendon, achieving durable coverage and good functional outcomes once the matrix had integrated. [9,10]

Why a synthetic bilayer matrix makes sense in pressor injuries

Patients with severe septic shock are often medically fragile for weeks to months—on dialysis, anticoagulation, or recovering from respiratory failure—making repeated anesthetics and donor‑site harvesting risky. BBSM provides a way to temporize the wound, letting dermis regenerate underneath a protective membrane while clinicians focus on stabilizing organ systems. [5,8]

Because it is fully synthetic and relatively tolerant of colonized wounds, BTM can stay in place longer than many biologic matrices, even in the face of bacterial load or delayed follow‑up, as demonstrated in multi‑center series and case reports of patients with significant comorbidities. [6,7]

Reconstructive literature on vasopressor‑induced limb ischemia now emphasizes limb salvage and function, not just amputation. Flaps, grafts, and dermal substitutes are all part of the toolkit; BBSM adds a flexible option that can bridge between life‑saving resuscitation and definitive closure, particularly when traditional flap options are limited by poor recipient vessels. [4,5]

Case reports of critical limb‑threatening ischemia (CLTI) with extensive tissue loss show BTM used successfully after revascularization to reconstruct dorsum‑of‑foot and calf defects, preserving limb length and ambulation—supporting its use in ischemic, not just traumatic, wounds. [9,12]

Practical tips for considering BBSM in vasopressor‑related foot necrosis

Before applying BBSM, ensure macrovascular inflow is adequate: evaluate pulses, duplex, or ankle‑brachial index as indicated, and coordinate with vascular surgery if large‑vessel occlusion is suspected; principles from acute limb ischemia management still apply. [2,3]

Perform meticulous debridement to a clean, bleeding wound bed, removing all non‑viable tissue and biofilm. Manufacturer guidance and clinical series stress that intimate contact between BTM and healthy tissue is critical for neovascularization and stable integration. [5,11]

Once placed, BBSM can usually be managed with simple dressings or, in some protocols, negative pressure therapy as a bolster; clinicians then monitor for progressive “take” over 2–6 weeks, watching for pink, supple neodermis beneath the sealing membrane. [6,8]

When integration is complete, the sealing layer can be delaminated. Some patients—like the case in CS‑057 and Semple’s unwell patient—may continue to epithelialize and contract until closure without a graft, while others will benefit from a thin split‑thickness skin graft to accelerate coverage. [1,8]

Early involvement of orthotics, physiatry, and physical therapy is essential. In the CS‑057 case, custom orthotics helped distribute plantar pressure over the reconstructed sole, supporting both wound durability and return to function. Similar collaborative approaches have been reported in BTM reconstructions of complex upper‑ and lower‑extremity wounds. [1,10]

What this single case can—and can’t—tell us

The BBSM pressor‑injury case is a single‑patient experience, so it cannot establish comparative effectiveness versus skin grafts, local flaps, or other dermal matrices. Still, the rapid integration, secondary healing, and preserved function align closely with broader BTM data from burns, trauma, and extremity reconstruction. [1,6]

Most published BTM evidence consists of retrospective series and case reports, often with heterogeneous wounds and comorbidities. While they consistently show high integration and acceptable complication rates, robust randomized trials against other reconstructive options are still lacking. [5,7]

Even so, current literature suggests that for complex, high‑risk patients—especially those with colonized wounds, multiple operations, or limited flap options—BBSM/BTM offers a reliable, limb‑sparing alternative that can be tailored to the patient’s trajectory and tolerance for further surgery. [6,9]

Bottom line

Vasopressor‑induced ischemia carries sobering amputation and mortality rates, and many survivors face extensive tissue loss in their feet and hands. Recognizing the pattern early, stabilizing the patient, and planning for staged reconstruction are critical steps toward preserving both life and limb. [2,4]

This case of pressor‑related foot necrosis shows how a biodegradable bilayer synthetic matrix can help salvage plantar tissue and toe stumps, achieving near‑complete healing by nine weeks without skin grafting and with good functional outcome—results that are consistent with a growing body of BTM experience in complex extremity wounds. [1,6]

For wound‑care clinicians and reconstructive teams, BBSM is not magic—but it is a powerful addition to the toolbox: a durable, fully synthetic dermal scaffold that can be placed once, left to integrate while the patient recovers, and then taken to graft or allowed to heal by secondary intention, all with the ultimate goal of maximizing limb preservation and function after catastrophic pressor injury. [5,11]

References

1. Kim P, Robertson T. (2025). The use of Biodegradable Bilayer Synthetic Matrix (BBSM) in treatment of pressor injuries (CS‑057). Symposium on Advanced Wound Care / Wound Healing Society Fall 2025 poster.

2. Livesey M, Jauregui JJ, Hamaker MC, Pensy RA, Langhammer CG, Eglseder WA. (2020). “Management of vasopressor induced ischemia.” Journal of Orthopaedics 22:497–502. PMC

3. Dormandy J, Heeck L, Vig S. (1999). “Acute limb ischemia.” Seminars in Vascular Surgery 12(2):148–153. PubMed

4. Deldar R, Abu El Hawa AA, Haffner ZK, et al. (2022). “Achieving functional outcomes after surgical management of catastrophic vasopressor‑induced limb ischemia.” Plastic and Reconstructive Surgery – Global Open 10:e4175. PMC

5. Rajaram R, et al. (2024). “Novosorb® BTM—history, production and application in challenging wounds.” Frontiers in Bioengineering and Biotechnology 12:1450973. Frontiers

6. Schlottmann F, et al. (2022). “Treatment of complex wounds with NovoSorb® Biodegradable Temporising Matrix (BTM)—a retrospective analysis of clinical outcomes.” Journal of Personalized Medicine 12(12):2002. MDPI

7. Struble SL, Patel NK, Graham EM, Tipps JA, Mendenhall SD. (2024). “Outcomes of Biodegradable Temporizing Matrix for soft tissue reconstruction of the hand and extremities.” Plastic and Reconstructive Surgery – Global Open 12(7):e5956. PMC

8. Semple HK, Young C, et al. (2022). “Secondary healing over NovoSorb® biodegradable temporising matrix (BTM) in the unwell patient: a case report.” Australasian Journal of Plastic Surgery 5(2):67969. AJOPS

9. Lane G, et al. (2024). “Biodegradable temporising matrix in the reconstruction of complex wounds.” European Journal of Trauma and Emergency Surgery / Journal of Plastic, Reconstructive & Aesthetic Surgery (case series of complex wounds reconstructed with BTM). PMC

10. Jou C, et al. (2024). “Use of biodegradable temporizing matrix dermal template for non‑ischaemic diabetic foot wounds and chronic wounds with exposed deep structures.” Plastic and Reconstructive Surgery – Global Open 12(1):e5560. Lippincott Journals

11. PolyNovo Ltd. (2023). “NovoSorb® BTM – Biodegradable Synthetic Dermal Matrix: product overview and instructions for use.” Company website. PolyNovo

12. Vascular News. (2024). “Utilisation of NovoSorb® Biodegradable Temporising Matrix in a patient with CLTI and extensive tissue loss.” Case report feature. Vascular News