Multicenter postapproval clinical trial of Integra dermal regeneration template for burn treatment

Reconstructing Nasal Defects With Acellular Dermal Matrix After Mohs Micrographic Surgery: A 12-year Experience

BACKGROUND AND OBJECTIVE

Large defects of the nose after Mohs surgery pose a significant reconstructive challenge to both dermatologic and reconstructive surgeons. The authors present their 12-year experience utilizing acellular dermal matrices for nasal reconstruction.

METHODS

A retrospective review of patients undergoing Mohs surgery and alloplastic nasal reconstruction with acellular dermal matrices between 2010 and 2022 was performed. Patients who underwent single-stage reconstruction and dual-stage reconstruction with skin graft with at least 90 days of follow-up were included.

RESULTS

Fifty-one patients met criteria with a median age of 77 years. Fifty-three lesions were reconstructed with acellular dermal matrices. The most common lesion location was nasal sidewall (50%) with a mean defect size of 10.8 cm 2 . 30.8% underwent same-day acellular dermal matrix reconstruction, with 69.2% undergoing two-stage reconstruction. Acellular dermal matrices successfully reconstructed acquired defects in 94.2% of lesions. Average time to re-epithelialization was 27.6 + 6.2 days. Average time to repigmentation was 145.35 + 86 days. No recurrences were recorded. Total complication rate was 9.62%. Average size for successful healing was 10.8 cm 2 . Average defect size for complication or failure was 14.7 cm 2 . Seven sites (13.46%) underwent aesthetic improvement procedures.

CONCLUSION

Acellular bilayer wound matrix is an adequate reconstructive option for single or dual-stage reconstruction of the nose with low complication and revision rates.

Comparative Analysis of Animal-Derived vs Fully Synthetic Acellular Dermal Matrices in Reconstructive Surgery: An Examination of Clinical, Aesthetic, and Economic Measures

INTRODUCTION

The fully synthetic skin substitute, NovoSorb Biodegradable Temporizing Matrix (BTM), may be a cost-effective alternative to the animal-derived Integra Dermal Regeneration Template (IDRT). However, the current literature insufficiently compares the two. Therefore, our study compared clinical, aesthetic, and economic outcomes in treating soft tissue wounds with IDRT, an animal-derived template, vs BTM, a fully synthetic template.

METHODS

Our single-center retrospective study compared outcomes of 26 patient cases treated with BTM (57.7%) or IDRT (42.3%) during 2011-2022.

RESULTS

The mean surgery time was significantly shorter in BTM cases (1.632 ± 0.571 hours) compared with IDRT cases (5.282 ± 5.102 hours, P = 0.011). Median postoperative hospital stay was notably shorter for BTM placement than IDRT placement (0.95 vs 6.60 days, P = 0.003). The median postoperative follow-up length approached a shorter duration in the BTM group (P = 0.054); however, median follow-up visits were significantly lower in the BTM group compared with the IDRT group (5 vs 14, P = 0.012). The median duration for complete wound closure was shorter for BTM (46.96 vs 118.91 days, P = 0.011). Biodegradable Temporizing Matrix demonstrated a notably lower infection rate (0.0%) compared with IDRT (36.4%, P = 0.022). Integra Dermal Regeneration Template exhibited higher wound hypertrophy rates (81.8%) than BTM (26.7%, P = 0.015). Revisionary surgeries were significantly more frequent in the BTM group (P < 0.001). Failed closure, defined as requiring one or more attempts, exhibited a significant difference, with a higher risk in the IDRT group (26.7%) compared with BTM (6.7%, P = 0.003). Biodegradable Temporizing Matrix showed a lower mean Vancouver Scar Scale adjusted fraction (0.279) compared with IDRT (0.639, P < 0.001). Biodegradable Temporizing Matrix incurred lower costs compared with IDRT but displayed a lower mean profit per square centimeter ($10.63 vs $22.53, P < 0.001).

CONCLUSION

Economically, although the net profit per square centimeter of dermal template may favor IDRT, the ancillary benefits associated with BTM in terms of reduced hospital stay, shorter surgery times, fewer follow-up visits, and lower revisionary surgery rates contribute substantially to overall cost-effectiveness. Biodegradable Temporizing Matrix use reflects more efficient resource use and potential cost savings, aligning with broader trends in healthcare emphasizing value-based and patient-centered care.

Current Approaches to Wound Repair in Burns: How far Have we Come From Cover to Close? A Narrative Review

Burn injuries are a significant global health concern, with more than 11 million people requiring medical intervention each year and approximately 180,000 deaths annually. Despite progress in health and social care, burn injuries continue to result in socioeconomic burdens for victims and their families. The management of severe burn injuries involves preventing and treating burn shock and promoting skin repair through a two-step procedure of covering and closing the wound. Currently, split-thickness/full-thickness skin autografts are the gold standard for permanent skin substitution. However, deep burns treated with split-thickness skin autografts may contract, leading to functional and appearance issues. Conversely, defects treated with full-thickness skin autografts often result in more satisfactory function and appearance. The development of tissue-engineered dermal templates has further expanded the scope of wound repair, providing scar reductive and regenerative properties that have extended their use to reconstructive surgical interventions. Although their interactions with the wound microenvironment are not fully understood, these templates have shown potential in local infection control. This narrative review discusses the current state of wound repair in burn injuries, focusing on the progress made from wound cover to wound closure and local infection control. Advancements in technology and therapies hold promise for improving the outcomes for burn injury patients. Understanding the underlying mechanisms of wound repair and tissue regeneration may provide new insights for developing more effective treatments in the future.

Immediate Results of the Use of Split-Thickness Skin Autografts With and Without Acellular Dermal Matrix in Patients with Burns: A Comparative Study in a Colombian Population

Dermal substitutes have become fundamental tools for covering skin defects, most recently with biological subtypes such as glycerolized acellular dermal matrix (GADM). However, literature regarding this matter is scarce in Latin America and Colombia. In this descriptive observational study, we compared the use of partial skin autografts (PSA) combined with GADM and autografts without GADM. Patients were selected from the burn unit of a hospital in northeastern Colombia between 2021 and 2022. Two study groups were defined: one receiving GADM plus PSA and the other control receiving only a partial split-thickness autograft. A total of 29 patients with 68 body areas were included, with an average age of 20 years. Most cases involved third-degree burns caused by flame. Hospitalization time was the same for both groups (41 days). The percentage of grafts taken was similar in both groups; in the GADM with autografts group, it was 94.7% compared with 96% in the control group. The presence of complications was similar in both groups. GADM produced in local tissue banks is a cost-effective alternative. It can be used in a single surgical procedure without increasing complications, providing a postsurgical course similar to autografts alone. Granting the potential long-term benefits that dermal matrices give for healing in these patients, which should be evaluated in subsequent studies.

Sweet but Challenging: Tackling the Complexity of GAGs with Engineered Tailor-Made Biomaterials

Glycosaminoglycans (GAGs) play a crucial role in tissue homeostasis by regulating the activity and diffusion of bioactive molecules. Incorporating GAGs into biomaterials has emerged as a widely adopted strategy in medical applications, owing to their biocompatibility and ability to control the release of bioactive molecules. Nevertheless, immobilized GAGs on biomaterials can elicit distinct cellular responses compared to their soluble forms, underscoring the need to understand the interactions between GAG and bioactive molecules within engineered functional biomaterials. By controlling critical parameters such as GAG type, density, and sulfation, it becomes possible to precisely delineate GAG functions within a biomaterial context and to better mimic specific tissue properties, enabling tailored design of GAG-based biomaterials for specific medical applications. However, this requires access to pure and well-characterized GAG compounds, which remains challenging. This review focuses on different strategies for producing well-defined GAGs and explores high-throughput approaches employed to investigate GAG-growth factor interactions and to quantify cellular responses on GAG-based biomaterials. These automated methods hold considerable promise for improving the understanding of the diverse functions of GAGs. In perspective, the scientific community is encouraged to adopt a rational approach in designing GAG-based biomaterials, taking into account the in vivo properties of the targeted tissue for medical applications.

An Introduction to Burn Care: The Sequel

GENERAL PURPOSE

To review burn care, with an emphasis on burn-specific issues and treatment.

TARGET AUDIENCE

This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care.

LEARNING OBJECTIVES/OUTCOMES

After participating in this educational activity, the participant will:1. Select the appropriate treatment guidelines for patients who have burn injuries.2. Identify common complications of major burns.3. Choose the recommended pharmacologic approaches to burn care.

Artificial dermis combined with split-thickness skin autograft in the treatment of hand thermal compression wounds: a single center case-control study

Objective

To explore the clinical effect of artificial dermis combined with split-thickness skin autograft in treating hand thermal compression wounds.

Methods

Forty-two patients in our hospital from January 2016 to October 2022 with thermal compression wounds were divided into two groups. The survival rate of autologous skin grafts seven days after skin grafting, the number of operations, total hospital stay, total hospitalization cost, and bacterial culture results of secretions were recorded. The visual analog scale was used to evaluate the wound pain. The condition of skin graft rupture was recorded and the scar status of the donor site was evaluated by the Vancouver Scar Scale.

Results

It showed combination of artificial dermis, split-thickness skin autograft, and vacuum sealing drainage improves the treatment of hand thermal compression wounds by enhancing the survival rate of skin grafting (95.24% > 66.67%), reducing the number of operations (P < 0.001), relieving wound pain (P < 0.001), effectively controlling wound infection (4.76% < 9.52%), and reducing the skin graft rupture rate after surgery (4.8% < 28.6%). There was no evident scar hyperplasia in the donor (P = 0.003) and skin graft areas (P < 0.001), which had a good recovery of hand function (P = 0.037); however, this treatment strategy may prolong the hospital stay (P = 0.030) and increase the total hospitalization cost (P = 0.030).

Conclusion

The composite transplantation of artificial dermis and split-thickness skin combined with the VSD significantly improves treatment and aesthetic outcomes in patients with thermal compression wounds to the hand, which is worth promoting and applying in clinical practice.

Upper Extremity Wounds Treated with Biodegradable Temporizing Matrix versus Collagen-Chondroitin Silicone Bilayer

Objective  This study aims to compare outcomes between Novosorb Biodegradable Temporizing Matrix (BTM) and Integra collagen-chondroitin silicone for upper-extremity wound reconstruction. Methods  This retrospective study analyzed adult patients who underwent wound reconstruction with either BTM or Integra at our institution between 2015 and 2020. Results  Forty-eight patients were included: 31 (64.6%) BTM and 17 (35.4%) Integra. Mean age was 44.0 (range: 18-68) years. Age, race, sex, smoking, comorbidities, and defect size were similar between groups. Wound etiologies included 12 (25.0%) burn, 22 (45.8%) trauma, and others. Median template size was 133 cm 2 for BTM and 104 cm 2 for Integra ( p  = 0.526). Skin grafting was performed after 14 (45.2%) and 14 (82.4%) wounds treated with BTM and Integra, respectively ( p  = 0.028). Template complications of infection and dehiscence were comparable. Skin-graft complications occurred in five (35.7%) and three (21.4%) wounds in BTM and Integra, respectively ( p  = 0.031). Skin-graft failure rates were comparable ( p  = 0.121). Mean number of secondary procedures required after template placement was higher in the Integra group (BTM, 1.0; Integra, 1.9; p  = 0.090). Final healing was achieved in 17 (54.8%) BTM and 11 (64.7%) Integra wounds ( p  = 0.694). Median time to healing was 4.1 months after BTM and 2.6 months after Integra placement ( p  = 0.014). Conclusion  Compared with Integra, BTM achieved comparable wound healing and complication rates. Fewer secondary procedures and skin grafts were observed in BTM wounds, likely as a result of the coronavirus disease 2019 pandemic. At our institution, 100 cm 2 of product costs $850 for BTM and $3,150 for Integra, suggesting BTM as an economical alternative to fulfill the high functional and aesthetic requirements of upper-extremity wounds.

Clinical outcomes and resource utilisation in patients with major burns treated with NovoSorb® BTM

INTRODUCTION

Patients with major burns can undergo temporary coverage while skin graft donor sites heal, where dermal templates have an emerging role. The aim of this study was to evaluate the clinical outcomes and resource utilisation in patients with major burns treated with a bilayer biodegradable synthetic matrix (NovoSorb BTM).

METHOD

This retrospective cohort study included patients admitted to the Royal Brisbane and Women's Hospital Adult Burn Unit with burns to at least 40 % TBSA who survived their acute admission. Patients treated from July 2017 to June 2022 with BTM were compared with patients with similar injuries treated using cadaveric allograft as temporising full thickness wound coverage between January 2013 and June 2017. Outcomes measures included number of operations, total operative time, hospital and intensive care unit (ICU) length of stay (LOS), cadaveric allograft and BTM use, and blood product use. Unadjusted comparisons were made with Wilcoxon Rank-Sum tests and Fisher's exact tests. Multivariate linear regression was used to adjust for the effect of TBSA on each outcome.

RESULTS

Fifty-five patients were included (78 % male), 22 of whom were treated with BTM. We found no significant differences in age, sex, or TBSA between groups. One patient had half of the BTM removed due to infection and replaced with allograft. Patients treated with BTM had significantly less operative theatre time (median 1361.5 min [BTM] vs 1768 min [no BTM], P = 0.044). Number of operations, allograft use, hospital and ICU LOS, and blood product use were similar between groups. Adjusted models accounting for TBSA supported unadjusted models.

CONCLUSION

Resource utilisation and clinical outcomes were similar in patients with at least 40 % TBSA treated with BTM and those who were treated with allograft before the introduction of BTM. Patients treated with BTM had significantly less total operative time and no difference in number of operations, allograft use and ICU LOS.

Meshed dermal regeneration template for traumatic periocular tissue loss in the young population

The IntegraⓇ Dermal Regeneration Template (DRT) is a bioengineered dermal substitute that is becoming increasingly popular in the field of reconstruction. Its unique properties allow for immediate wound closure while providing a scaffold for tissue regeneration. Currently, it is commonly used to treat burns, ulcers, and complex wounds. In the setting of traumatic periocular tissue loss, only two prior reports have been published on its use for primary reconstruction. We present our institution's experience with a series of four young patients who received primary reconstruction with IntegraⓇ DRT as a full-thickness skin substitute for their large traumatic periorbital skin defects.

Design matters: A comparison of natural versus synthetic skin substitutes across benchtop and porcine wound healing metrics: An experimental study

Background and Aims

Skin substitutes, essential tools for helping close full thickness wounds with minimal scarring, are available in both collagen-based and synthetic polyurethane constructions. Here we explore fundamental differences between two frequently used skin substitutes and discuss how these differences may impact in vivo performance.

Methods

Polyurethane- and collagen-based matrices were characterized in vitro for pore size via scanning electron microscopy, hydrophobicity via liquid contact angle, conformability via bending angle, and biocompatibility via fibroblast and keratinocyte adhesion and proliferation. These matrices were then evaluated in a full-thickness excisional pig wound study followed by histological analysis. Statistical analysis was performed using t-tests or one-way analysis of variances with Tukey's multiple post hoc comparisons, where appropriate.

Results

Average pore diameter in the tested polyurethane matrix was over four times larger than that of the collagen matrix (589 ± 297 µm vs. 132 ± 91 µm). Through liquid contact angle measurement, the collagen matrix (not measurable) was found to be hydrophilic compared to the hydrophobic polyurethane matrix (>90°). The collagen matrix was significantly more conformable than the polyurethane matrix (9 ± 2° vs. 84 ± 5° bending angle, respectively). Fibroblast and keratinocyte adhesion and proliferation assays elucidated a significantly greater ability of both cell types to attach and proliferate on collagen versus polyurethane. While the porcine study showed minimal contraction of either matrix material, histological findings between the two treatments were markedly different. Collagen matrices were associated with early fibroblast infiltration and fibroplasia, whereas polyurethane matrices elicited a strong multinucleated giant cell response and produced a network of comparatively aligned collagen fibrils.

Conclusions

The more favorable in vitro properties of the collagen matrix led to less inflammation and better overall tissue response in vivo. Overall, our findings demonstrate how the choice of biomaterial and its design directly translate to differing in vivo mechanisms of action and overall tissue quality.

Biomaterials and tissue engineering approaches using glycosaminoglycans for tissue repair: Lessons learned from the native extracellular matrix

Glycosaminoglycans (GAGs) are an important component of the extracellular matrix as they influence cell behavior and have been sought for tissue regeneration, biomaterials, and drug delivery applications. GAGs are known to interact with growth factors and other bioactive molecules and impact tissue mechanics. This review provides an overview of native GAGs, their structure, and properties, specifically their interaction with proteins, their effect on cell behavior, and their mechanical role in the ECM. GAGs' function in the extracellular environment is still being understood however, promising studies have led to the development of medical devices and therapies. Native GAGs, including hyaluronic acid, chondroitin sulfate, and heparin, have been widely explored in tissue engineering and biomaterial approaches for tissue repair or replacement. This review focuses on orthopaedic and wound healing applications. The use of GAGs in these applications have had significant advances leading to clinical use. Promising studies using GAG mimetics and future directions are also discussed. STATEMENT OF SIGNIFICANCE: Glycosaminoglycans (GAGs) are an important component of the native extracellular matrix and have shown promise in medical devices and therapies. This review emphasizes the structure and properties of native GAGs, their role in the ECM providing biochemical and mechanical cues that influence cell behavior, and their use in tissue regeneration and biomaterial approaches for orthopaedic and wound healing applications.

The Burn Wound

Skin serves as a protective barrier against infection, prevents excessive fluid and electrolyte losses, performs crucial thermoregulation, and provides tactile feedback of surroundings. The skin also plays an essential role in human perception of body image, personal appearance, and self-confidence. With these many diverse functions, understanding normal anatomic composition of skin is pivotal to evaluating the extent of its disruption from burn injury. This article discusses the pathophysiology, initial evaluation, subsequent progression, and healing of burn wounds. By delineating the various microcellular and macrocellular alterations of burn injury, this review also augments providers' capacity to deliver patient-centered, evidence-based burn care.

Delayed Reconstruction after Major Head and Neck Cancer Resection: An Interdisciplinary Feasibility Study

A single immediate reconstruction with free tissue transfer is the method of choice after major head and neck cancer (HNC) resection, but this is frequently associated with long operating hours. Considering regulatory working hour constraints, we investigated whether a two-staged reconstructive approach with temporary defect coverage by an artificial tissue substitute would be feasible. HNC patients underwent either immediate or delayed reconstruction after tumor resection. Patients with delayed reconstruction received preliminary reconstruction with an artificial tissue substitute followed by definitive microvascular reconstruction in a separate, second procedure. Of the 33 HNC patients, 13 received delayed reconstruction and 20 received immediate reconstruction. Total anesthesia time (714 vs. 1011 min; p < 0.002) and the total duration of hospital stay (34 ± 13 vs. 25 ± 6 days; p = 0.03) were longer in the delayed reconstruction group. Perioperative morbidity (p = 0.58), functional outcome (p > 0.1) and 5-year postoperative survival rank (p = 0.28) were comparable in both groups. Delayed reconstruction after HNC resection was feasible. Perioperative morbidity, functional outcome and overall survival were comparable to immediate reconstruction.

Integra® Dermal Regeneration Template: From Design to Clinical Use

Integra^® Dermal Regeneration Template (IDRT, Integra LifeSciences, Princeton, NJ, USA) is a bilayer membrane developed, by Yannas and Burke in the 1980s, to fulfill the unmet need of surgeons having a readily available off-the-shelf dermal regeneration method. IDRT is composed of a sheet of porous cross-linked type I collagen and glycosaminoglycans, with a semi-permeable silicone sheet cover. IDRT is bio-engineered, from adult bovine Achilles tendons and chondroitin-6-sulfate derived from shark cartilage, in a multi-step process involving cross-linking using glutaraldehyde. By design, the composition, porosity, and biodegradation rate of IDRT guides the mechanism of wound repair towards a regenerative pathway. Its mechanism of action involves four distinct phases: imbibition, fibroblast migration, neovascularization, and remodeling/maturation. Originally developed for the post-excisional treatment of deep-partial to full-thickness burns where autograft is limited, over the years its use has expanded to reconstructive surgery.

Biodegradable temporising matrix: use of negative pressure wound therapy shows a significantly higher success rate

OBJECTIVE

The purpose of this case series was to evaluate the efficacy of a synthetic biodegradable temporising matrix (BTM; PolyNovo Biomaterials Pty Ltd, Australia) and compare the outcome of BTM patients with and without negative pressure wound therapy (NPWT).

METHOD

A retrospective chart review was conducted on patients admitted with deep full-thickness burns, traumatic or complex wound injuries treated with BTM. Electronic medical records and images were evaluated by a team of clinical professionals. Endpoints included: the measure of successful BTM integration; and comparison between patients treated with and without NPWT. Additional measures were BTM total surface area, BTM sites, timeliness of BTM application and any complications.

RESULTS

A total of 28 patients were evaluated and 23 (82.1%) demonstrated overall successful BTM integration. Patients treated with BTM in conjunction with NPWT (n=16) demonstrated a significantly higher (p=0.046) integration rate compared to patients treated without NPWT (n=12) (93.8% versus 58.3%, respectively). Patients treated with BTM with NPWT continued to successfully integrate and sustain favourable outcomes despite the presence of severe infection or the development of haematomas.

CONCLUSION

A significantly higher integration rate was demonstrated when BTM was used in conjunction with NPWT. The results of this study further support the efficacy of successful integration of BTM as a replacement for tissue loss in the treatment of deep, full-thickness burns, traumatic and complex wound injuries, and particularly favourable outcomes with the use of NPWT. To the best of our knowledge, this is the first reported case series comparing the clinical outcomes of BTM with and without the use of NPWT.

Recent progress in the manipulation of biochemical and biophysical cues for engineering functional tissues

Tissue engineering (TE) is currently considered a cutting-edge discipline that offers the potential for developing treatments for health conditions that negatively affect the quality of life. This interdisciplinary field typically involves the combination of cells, scaffolds, and appropriate induction factors for the regeneration and repair of damaged tissue. Cell fate decisions, such as survival, proliferation, or differentiation, critically depend on various biochemical and biophysical factors provided by the extracellular environment during developmental, physiological, and pathological processes. Therefore, understanding the mechanisms of action of these factors is critical to accurately mimic the complex architecture of the extracellular environment of living tissues and improve the efficiency of TE approaches. In this review, we recapitulate the effects that biochemical and biophysical induction factors have on various aspects of cell fate. While the role of biochemical factors, such as growth factors, small molecules, extracellular matrix (ECM) components, and cytokines, has been extensively studied in the context of TE applications, it is only recently that we have begun to understand the effects of biophysical signals such as surface topography, mechanical, and electrical signals. These biophysical cues could provide a more robust set of stimuli to manipulate cell signaling pathways during the formation of the engineered tissue. Furthermore, the simultaneous application of different types of signals appears to elicit synergistic responses that are likely to improve functional outcomes, which could help translate results into successful clinical therapies in the future.

Optical coherence tomography for in vivo longitudinal monitoring of artificial dermal scaffold

OBJECTIVES

Artificial dermal scaffold (ADS) has undergone rapid development and been increasingly used for treating skin wound in clinics due to its good biocompatibility, controllable degradation, and low risk of disease infection. To obtain good treatment efficacy, ADS needs to be monitored longitudinally during the treatment process. For example, scaffold-tissue fit, cell in-growth, vascular regeneration, and scaffold degradation are the key properties to be inspected. However, to date, there are no effective, real-time, and noninvasive techniques to meet the requirement of the scaffold monitoring above.

MATERIALS AND METHODS

In this study, we propose to use optical coherence tomography (OCT) to monitor ADS in vivo through three-dimensional imaging. A swept source OCT system with a handheld probe was developed for in vivo skin imaging. Moreover, a cell in-growth, vascular regeneration, and scaffold degradation rate (IRDR) was defined with the volume reduction rate of the scaffold's collagen sponge layer. To measure the IRDR, a semiautomatic image segmentation algorithm was designed based on U-Net to segment the collagen sponge layer of the scaffold from OCT images.

RESULTS

The results show that the scaffold-tissue fit can be clearly visualized under OCT imaging. The IRDR can be computed based on the volume of the segmented collagen sponge layer. It is observed that the IRDR appeared to a linear function of the time and in addition, the IRDR varied among different skin parts.

CONCLUSION

Overall, it can be concluded that OCT has a good potential to monitor ADS in vivo. This can help guide the clinicians to control the treatment with ADS to improve the therapy.

The Bridging Effect of Artificial Dermis on Reconstruction of Skin Avulsion Injury

Skin avulsion wounds are expected to be swollen and tense after trauma, and skin perfusion can be compromised after primary closure, resulting in wound dehiscence and poor healing. The artificial dermis (AD) serves as a dermal regeneration template that is used to heal skin defects with secondary intention. Therefore, the aim of this study is to evaluate the effect of AD application on traumatic skin avulsion injuries compared to conventional primary closure. A retrospective cohort of 20 patients with skin avulsion injuries were included the study: ten patients were treated with AD and ten patients were managed with primary closure. When compared to the primary closure group, AD group had a shorter average healing time (58.40 ± 26.94 days V 65.50 ± 46.45 days) and significantly higher flap viability (92.00 ± 13.17% V 78.00 ± 13.98%; p = .03). In conclusion, AD is a promising material for the treatment of skin avulsion injury and produces better clinical results.

A Risk-Benefit Review of Currently Used Dermal Substitutes for Burn Wounds

While split-thickness autologous skin grafts remain the most common method of definitive burn wound closure, dermal substitutes have emerged as an attractive option. There are many advantages of utilizing a dermal substitute, notably reducing the need for donor tissue and subsequent iatrogenic creation of a secondary wound. However, there are disadvantages with each that most be weighed and factored into the decision. And most come at a high initial financial cost. There is little comparative literature of the various available and emerging products. This analysis was performed to objectively present risks and benefits of each option.

Use of Dermal Regenerative Templates for Burns

Autologous skin grafting has permitted survival and restoration of function in burn injuries of ever larger total body surface area (TBSA) sizes. However, the goal of replacing "like with like" skin structures is often impossible because full-thickness donor harvesting requires primary closure at the donor site for it to heal. Split-thickness skin grafting (STSG), on the other hand, only harvests part of the dermis at the donor site, allowing it to re-epithelialize on its own. The development of the first dermal regenerative template (DRT) in the late 1970s represented a major advance in tissue engineering that addresses the issue of insufficient dermal replacement when STSGs are applied to the full-thickness defect. This review aims to provide an overview of currently available DRTs in burn management from a clinician's perspective. It focuses on the main strengths and pitfalls of each product and provides clinical pearls based on clinical experience and evidence.

Basic fibroblast growth factor-impregnated collagen gelatin sponge completes formation of dermis-like tissue within 2 weeks: A prospective cohort study

Introduction

Methods

Results

Conclusion

•

This study examined the usefulness of bFGF-CGS for skin defects.

•

bFGF-CGS completes dermis-like tissue within 2 weeks.

•

bFGF-CGS rapidly achieved wound closure of acute full-thickness skin defects.

Two-stage skin grafting using a basic fibroblast growth factor-impregnated artificial dermis

For traditional artificial dermises, a waiting period of approximately three weeks is required after the first implantation before they are adequately vascularized. The objective of this retrospective case series was to investigate whether full-thickness skin defects, requiring surgical reconstruction, could be successfully treated by implantation of a basic fibroblast growth factor (bFGF)-impregnated artificial dermis and secondary skin grafting with a shorter waiting period. Between January 2019 and January 2021, 19 skin defects in 14 patients (7 male and 7 female) were treated with two-stage skin grafting using bFGF-impregnated collagen-gelatin sponge (CGS). All of them were included in this case series, and the waiting period for skin grafting, success rate of skin grafting, infection during the waiting period, and scar quality 6–12 months postoperatively were retrospectively investigated. As a result, all skin grafting surgeries were successfully performed with a waiting period of 13.3 ± 4.3 days. Infection during the waiting period was observed in three lesions (15.8%); however, all infections were controllable. Postoperative scar quality was acceptable (Vancouver Scar Scale score range, 1–8). In conclusion, compared to traditional artificial dermises, bFGF-impregnated CGSs have the potential to shorten the waiting period without decreasing the success rate of skin grafting. Further studies are required to confirm this finding.

•

We previously developed a novel artificial dermis which is capable of sustained release of bFGF.

•

Skin defects were successfully treated by two-stage skin grafting using bFGF-impregnated CGS.

•

The use of bFGF-impregnated CGS allowed for a short waiting period for secondary skin grafting.

Combined negative pressure wound therapy with irrigation and dwell time and artificial dermis prevents infection and promotes granulation formation in a ruptured giant omphalocele: a case report

Background

Omphalocele is a congenital abdominal wall defect of the umbilical cord insertion site. A giant omphalocele, with a fascial defect > 5 cm in diameter and/or containing > 50% of the liver within the hernia sac, can be challenging for pediatric surgeons. Recently, negative pressure wound therapy has been reported as an effective management for giant omphaloceles; however, it is not recommended for an infected wound with necrotic tissue as it may exacerbate infection. We adopted negative pressure wound therapy with irrigation and dwell time (NPWTi-d) for a case of a ruptured giant omphalocele. Artificial membranes, followed by artificial dermis, were used to promote fibrous capsule formation, and then NPWTi-d was used to promote granulation while controlling infection. However, studies have not been conducted regarding NPWTi-d for ruptured giant omphaloceles; hence, we present our treatment experience with NPWTi-d for a giant omphalocele.

Case presentation

The patient was a boy born at 38 weeks and 3 days of gestation, weighing 1896 g. He was diagnosed with a ruptured giant omphalocele with a total liver and intestine defect hole of 10 cm × 10 cm. The patient underwent silo placement using an artificial mesh, followed by plicating the artificial mesh at 4 days of age. The herniated viscera were gradually reduced into the abdominal cavity; however, the defect size was still large. Hence, a collagen-based artificial dermis was patched on the defect hole. After creating a fresh and smooth granulated tissue, NPWTi-d was applied at 33 days of age to promote granulation and control infection. We used the 3 M™ V.A.C.® Ulta Therapy Unit with 3 M™ VeraFlo™ therapy. NPWTi-d was stopped at 60 days of age when the granulation tissue was well formed including at the artificial dermis site. The wound was managed with prostandin ointment and appropriate debridement, resulting in complete epithelialization at 5 months of age.

Conclusions

Artificial membranes followed by artificial dermis were used to promote a fibrous capsule and artificial dermis granulation, which protects against organ damage. NPWTi-d achieved better control of infection and promoted wound healing. NPWTi-d combined with artificial dermis can effectively treat ruptured giant omphaloceles.

Skin grafting treatment of adolescent lower limb avulsion injury

Background

Under the influence of various factors, the number of lower extremity avulsion injuries in adolescents is increasing year by year. The main modality of treatment is skin grafting. There are many types of skin grafting. Although many studies on skin grafting after avulsion injuries have been published in the past few decades, there are differences in the treatment options for adolescents with post avulsion injuries.

Main body

Thorough debridement and appropriate skin grafts are essential for the surgical management of avulsion injuries for optimal prognosis. In the acquisition of grafts, progress has been made in equipment for how to obtain different depths of skin. The severity of the avulsion injury varies among patients on admission, and therefore the manner and type of skin grafting will vary. Especially in adolescents, graft survival and functional recovery are of great concern to both patients and physicians. Therefore, many efforts have been made to improve survival rate and activity.

Conclusion

This review summarizes the principles of treatment of avulsion injuries, the historical development of skin grafts, and the selection of skin grafts, hoping to be helpful for future research.

Designing a Biomaterial Approach to Control the Adaptive Response to a Skin Injury

The goal of this review is to explain how to design a biomaterial approach to control the adaptive response to injury, with an emphasis on skin wounds. The strategies will be selected based on whether they have a reasonable probability of meeting the desired clinical outcome vs. just comparing the pros and cons of different strategies. To do this, the review will look at the normal adaptive response in adults and why it does not meet the desired clinical outcome in most cases. In addition, the adaptive response will be looked at in cases where it does meet the clinical performance requirements including animals that regenerate and for fetal wound healing. This will lead to how biomaterials can be used to alter the overall adaptive response to allow it to meet the desired clinical outcome. The important message of the review is that you need to use the engineering design process, not the scientific method, to design a clinical treatment. Also, the clinical performance requirements are functional, not structural. The last section will give some specific examples of controlling the adaptive response for two skin injuries: burns and pressure ulcers. For burns, it will cover some preclinical studies used to justify a clinical study as well as discuss the results of a clinical study using this system. For pressure ulcers, it will cover some preclinical studies for two different approaches: electrical stimulation and degradable/regenerative scaffolds. For electrical stimulation, the results of a clinical study will be presented.

Head and Neck Wound Reconstruction Using Biodegradable Temporizing Matrix Versus Collagen-Chondroitin Silicone Bilayer

BACKGROUND

Head and neck reconstruction is challenging because of the functional requirements of movement, sensation, and cosmesis of this highly visible region. This study is the first to compare Novosorb biodegradable temporizing matrix (BTM) and Integra collagen-chondroitin silicone (CCS) skin substitutes for reconstruction of soft tissue head and neck wounds.

METHODS

This retrospective review included adults who underwent wound reconstruction of the head/neck with either BTM or CCS between 2015 and 2020. Patient-level data, complications, and closure rates were compared.

RESULTS

The review identified 15 patients: 5 who received BTM and 10 who received CCS. Mean age at dermal template placement was 55 (range, 28-79) years. Race, sex, smoking status, medical comorbidities, defect size, radiation history, prior surgeries, and follow-up time were not significantly different between groups. Wound etiologies for BTM and CCS included burn (40% vs 60%), trauma (20% vs 20%), surgical wounds (20% vs 20%), and skin cancer (20% vs 0%), respectively (P = .026). Skin grafts were placed in 8 (80%) wounds after CCS placement, compared with 3 (60%) after BTM (P = .670). Template reapplication was required in 2 (40%) BTM wounds and 3 (30%) CCS wounds (P = 1.0). Infection, hematoma, and seroma were comparable between groups, although skin graft failure was higher in the CCS group at 3 (37.5%) compared with 0 for BTM (P = .506). More secondary procedures were required after CCS placement (CCS, 1.9 ± 2.2; BTM, 0.9 ± 0.8; P = .090). Definitive closure in patients not lost to follow-up occurred in 4 (100%) BTM and 6 (75%) CCS cases (P = 1.0).

CONCLUSIONS

Head and neck wounds treated with BTM had comparable closure and complication rates as CCS bilayer and required fewer secondary procedures and skin grafts. These findings suggest that BTM is safe and efficacious for application in head and neck wounds and may be considered as an economical alternative.

Wound healing and dermal regeneration in severe burn patients treated with NovoSorb® Biodegradable Temporising Matrix: A prospective clinical study

INTRODUCTION

For extensive burns, autologous donor skin may be insufficient for early debridement and grafting in a single stage. A novel, synthetic polyurethane dermal template (NovoSorb® Biodegradable Temporising Matrix, BTM) was developed to address this need. The aim of this study was to evaluate use of BTM for primary dermal repair after deep burn injury.

METHODS

A multicentre, prospective, clinical study was conducted from September 2015 to May 2018. The primary endpoint was % split skin graft take over applied BTM at 7-10 days after grafting. Secondary endpoints included % BTM take, incidence of infection and adverse events, and scar quality to 12 months after BTM application.

RESULTS

Thirty patients were treated with BTM and delayed split skin grafting. The % graft take had a mean of 81.9% and % BTM take had a mean of 88.6%, demonstrating effective integration of BTM. When managed appropriately, it was possible for BTM to integrate successfully despite findings suggestive of infection. Scar quality improved over time.

DISCUSSION

These results provide additional clinical evidence on the safety and performance of BTM as an effective dermal substitute in the treatment of patients with deep burn injuries.

The Role of Skin Substitutes in Acute Burn and Reconstructive Burn Surgery: An Updated Comprehensive Review

Burns disrupt the protective skin barrier with consequent loss of cutaneous temperature regulation, infection prevention, evaporative losses, and other vital functions. Chronically, burns lead to scarring, contractures, pain, and impaired psychosocial well-being. Several skin substitutes are available and replace the skin and partially restore functional outcomes and improve cosmesis. We performed a literature review to update readers on biologic and synthetic skin substitutes to date applied in acute and reconstructive burn surgery. Improvement has been rapid in the development of skin substitutes in the last decade; however, no available skin substitute fulfills criteria as a perfect replacement for damaged skin.

Assessment of Two Commonly used Dermal Regeneration Templates in a Swine Model without Skin Grafting

In the medical care of partial and full-thickness wounds, autologous skin grafting is still the gold standard of dermal replacement. In contrast to spontaneous reepithelializing of superficial wounds, deep dermal wounds often lead to disturbing scarring, with cosmetically or functionally unsatisfactory results. However, modern wound dressings offer promising approaches to surface reconstruction. Against the background of our future aim to develop an innovative skin substitute, we investigated the behavior of two established dermal substitutes, a crosslinked and a non-crosslinked collagen biomatrix. The products were applied topically on a total of 18 full-thickness skin defects paravertebrally on the back of female Göttingen Minipigs—six control wounds remained untreated. The evaluation was carried out planimetrically (wound closure time) and histologically (neoepidermal cell number and epidermis thickness). Both treatment groups demonstrated significantly faster reepithelialization than the controls. The histologic examination verified the highest epidermal thickness in the crosslinked biomatrix-treated wounds, whereas the non-crosslinked biomatrix-treated wounds showed a higher cell density. Our data presented a positive influence on epidermal regeneration with the chosen dermis substitutes even without additional skin transplantation and, thus, without additional donor site morbidity. Therefore, it can be stated that the single biomatrix application might be used in a clinical routine with small wounds, which needs to be investigated further in a clinical setting to determine the size and depths of a suitable wound bed. Nevertheless, currently available products cannot solely achieve wound healing that is equal to or superior to autologous tissue. Thus, the overarching aim still is the development of an innovative skin substitute to manage surface reconstruction without additional skin grafting.

Review of History of Basic Principles of Burn Wound Management

Thermal energy is an essential and useful resource to humans in modern society. However, a consequence of using heat carelessly is burns. Burn injuries have various causes, such as exposure to flame, radiation, electrical, and chemical sources. In this study, we reviewed the history of burn wound care while focusing on the basic principles of burn management. Through this review, we highlight the need for careful monitoring and customization when treating burn victims at each step of wound care, as their individual needs may differ. We also propose that future research should focus on nanotechnology-based skin grafts, as this is a promising area for further improvement in wound care.

Clinical applications of acellular dermal matrices: A review

INTRODUCTION

The extracellular matrix (ECM) plays an integral role in wound healing. It provides both structure and growth factors that allow for the organised cell proliferation. Large or complex tissue defects may compromise host ECM, creating an environment that is unfavourable for the recovery of anatomical function and appearance. Acellular dermal matrices (ADMs) have been developed from a variety of sources, including human (HADM), porcine (PADM) and bovine (BADM), with multiple different processing protocols. The objective of this report is to provide an overview of current literature assessing the clinical utility of ADMs across a broad spectrum of applications.

METHODS

PubMed, MEDLINE, EMBASE, Scopus, Cochrane and Web of Science were searched using keywords 'acellular dermal matrix', 'acellular dermal matrices' and brand names for commercially available ADMs. Our search was limited to English language articles published from 1999 to 2020 and focused on clinical data.

RESULTS

A total of 2443 records underwent screening. After removing non-clinical studies and correspondence, 222 were assessed for eligibility. Of these, 170 were included in our synthesis of the literature. While the earliest ADMs were used in severe burn injuries, usage has expanded to a number of surgical subspecialties and procedures, including orthopaedic surgery (e.g. tendon and ligament reconstructions), otolaryngology, oral surgery (e.g. treating gingival recession), abdominal wall surgery (e.g. hernia repair), plastic surgery (e.g. breast reconstruction and penile augmentation), and chronic wounds (e.g. diabetic ulcers).

CONCLUSION

Our understanding of ADM's clinical utility continues to evolve. More research is needed to determine which ADM has the best outcomes for each clinical scenario.

LAY SUMMARY

Large or complex wounds present unique reconstructive and healing challenges. In normal healing, the extracellular matrix (ECM) provides both structural and growth factors that allow tissue to regenerate in an organised fashion to close the wound. In difficult or large soft-tissue defects, however, the ECM is often compromised. Acellular dermal matrix (ADM) products have been developed to mimic the benefits of host ECM, allowing for improved outcomes in a variety of clinical scenarios. This review summarises the current clinical evidence regarding commercially available ADMs in a wide variety of clinical contexts.

Advances in Skin Wound and Scar Repair by Polymer Scaffolds

Scars, as the result of abnormal wound-healing response after skin injury, may lead to loss of aesthetics and physical dysfunction. Current clinical strategies, such as surgical excision, laser treatment, and drug application, provide late remedies for scarring, yet it is difficult to eliminate scars. In this review, the functions, roles of multiple polymer scaffolds in wound healing and scar inhibition are explored. Polysaccharide and protein scaffolds, an analog of extracellular matrix, act as templates for cell adhesion and migration, differentiation to facilitate wound reconstruction and limit scarring. Stem cell-seeded scaffolds and growth factors-loaded scaffolds offer significant bioactive substances to improve the wound healing process. Special emphasis is placed on scaffolds that continuously release oxygen, which greatly accelerates the vascularization process and ensures graft survival, providing convincing theoretical support and great promise for scarless healing.

Comparison of Skin Substitutes for Acute and Chronic Wound Management

Chronic and acute wounds, such as diabetic foot ulcers and burns, respectively, can be difficult to treat, especially when autologous skin transplantations are unavailable. Skin substitutes can be used as a treatment alternative by providing the structural elements and growth factors necessary for reepithelialization and revascularization from a nonautologous source. As of 2020, there are 76 commercially available skin substitute products; this article provides a review of the relevant literature related to the major categories of skin substitutes available.

Hard-to-heal wound treated with Integra Flowable Wound Matrix: analysis and clinical observations

Skin healing defects severely impair the quality of life of millions of people and burden healthcare systems globally. The therapeutic approach to these pathologies still represents a challenge. Novel scaffolds, used as dermal substitutes, possibly represent a promising strategy in complex wound management. Integra Flowable Wound Matrix (IFWM) is composed of a lyophilised, micronised form of collagen/chondroitin sulphate matrix, already used in regenerative medicine and endorsed in the therapy of diabetic foot lesions. In this paper, IFWM was applied to a tunnelling hard-to-heal skin lesion in order to restore tissue integrity. Although the different phases of skin wound healing are well established, the molecular mechanism underpinning IFWM-induced tissue repair are almost unknown. Here, we report, for the first time, the comparative analysis of molecular, histological and clinical observations of the healing process of a hard-to-heal tunnelling skin wound. The therapeutic success of this clinical case allowed us to recommend the use of IFWM as a tissue substitute in this rare type of hard-to-heal wound in which the high inflammatory status hampered the natural healing process.

Reconstruction of Chronic Wounds Secondary to Injectable Drug Use with a Biodegradable Temporizing Matrix

Injectable drug use in the upper extremity often leads to chronic wounds complicated by osteomyelitis. Conventional reconstructive options are often not feasible and/or are contraindicated in this patient population. We have started using a synthetic, biodegradable temporizing matrix (BTM) for the treatment of these patients. We hypothesize that BTM is a safe, low-risk, and low-morbidity alternative reconstructive option. We report outcomes after staged debridement and BTM application followed by split-thickness skin grafting for two patients with large, chronic bilateral forearm wounds with concomitant osteomyelitis confirmed by MRI and biopsy. No acute surgical complications were encountered and at a mean follow-up of 13 months, both patients had maintained stable soft-tissue coverage. Reconstruction using BTM is a novel treatment option that can simplify the reconstruction, reduce donor-site morbidity, and optimize success for patients with chronic wounds resulting from injectable drug use. Initial outcomes are promising; however, further comparative studies are needed to better evaluate long-term outcomes of this technique.

Impact of dermal matrix thickness on split-thickness skin graft survival and wound contraction in a single-stage procedure

Optimal treatment of full‐thickness skin injuries requires dermal and epidermal replacement. To spare donor dermis, dermal substitutes can be used ahead of split‐thickness skin graft (STSG) application. However, this two‐stage procedure requires an additional general anaesthetic, often prolongs hospitalisation, and increases outpatient services. Although a few case series have described successful single‐stage reconstructions, with application of both STSG and dermal substitute at the index operation, we have little understanding of how the physical characteristics of dermal substitutes affects the success of a single‐stage procedure. Here, we evaluated several dermal substitutes to optimise single‐stage skin replacement in a preclinical porcine model. A porcine full‐thickness excisional wound model was used to evaluate the following dermal substitutes: autologous dermal graft (ADG; thicknesses 0.15‐0.60 mm), Integra (0.4‐0.8 mm), Alloderm (0.9‐1.6 mm), and chitosan‐based hydrogel (0.1‐0.2 mm). After excision, each wound was treated with either a dermal substitute followed by STSG or STSG alone (control). Endpoints included graft take at postoperative days (PODs) 7 and 14, wound closure at POD 28, and wound contracture from POD 28‐120. Graft take was highest in the STSG alone and hydrogel groups at POD 14 (86.9% ± 19.5% and 81.3% ± 12.3%, respectively; P < .001). There were no differences in graft take at POD 7 or in wound closure at POD 28, though highest rates of wound closure were seen in the STSG alone and hydrogel groups (93.6% ± 9.1% and 99.8% ± 0.5%, respectively). ADG‐treated wounds demonstrated the least amount of wound contracture at each time point. Increase dermal substitute thickness was associated with worse percent graft take at PODs 14 and 28 (Spearman ρ of −0.50 and −0.45, respectively; P < .001). In this preclinical single‐stage skin reconstruction model, thinner ADG and hydrogel dermal substitutes outperformed thicker dermal substitutes. Both substitute thickness and composition affect treatment success. Further preclinical and clinical studies to optimise this treatment modality are warranted.

Extracellular matrix graft for reconstruction over exposed structures: a pilot case series

OBJECTIVE

Soft tissue defects, especially those involving exposed vital structures, present a reconstructive challenge because poor vascularity of such defects typically makes immediate skin grafting unviable. Where flap procedures are inappropriate or not possible, dermal matrices represent an alternative reconstructive option for defects with denuded vital structures. With dermal matrices becoming increasingly available and technologically advanced, we evaluated an ovine-derived extracellular matrix graft in the reconstruction of complex soft tissue defects involving exposed vital structures.

METHOD

Six cases of soft tissue defects exhibiting denuded vital structures underwent reconstruction using an ovine forestomach matrix graft as a dermal matrix. Grafts were fixed directly into defects for immediate coverage and subsequently temporised defects via granulation tissue formation for later skin graft or secondary closure. Defect granulation and epithelialisation were monitored until closure and the final aesthetic and functional outcomes were evaluated.

RESULTS

Complete healing was achieved in all cases, with defect granulation becoming observable within one to two weeks and complete granulation occurring within one to six weeks. Granulation tissue resulting from the graft was suitable for skin grafting, with 100% take of skin grafts after one week and complete re-epithelialisation in two to three weeks in the four cases that received a skin graft. Good cosmetic, functional and patient satisfaction outcomes were achieved in all cases.

CONCLUSION

The present series demonstrates our initial use of an extracellular matrix-based dermal matrix in reconstructing defects with exposed vital structures. While such dermal matrices do not supersede or replace flap procedures, they represent an alternative option on the reconstructive ladder in cases where flap procedures are not appropriate or possible.

Clinical Factors Influencing the Outcomes of an Acellular Dermal Matrix for Skin Cancer Treatment: A Retrospective Study

OBJECTIVE

To evaluate the efficacy and safety of a biologically engineered dermal matrix used in reconstructive surgery after skin tumor resection, focusing on the frequency of successful grafting and identifying potential factors influencing treatment outcomes.

DESIGN AND PARTICIPANTS

This retrospective analysis involved consecutive patients diagnosed with skin cancer in any area of the body and for which treatment with a dermal skin template was recommended as alternative to traditional surgery.

MAIN OUTCOME MEASURES

Percentage of successful grafting and the patient and tumor characteristics influencing treatment outcome via univariate analysis.

MAIN RESULTS

A total of 302 patients were included. Surgical reconstruction with the matrix was effective in 88.9% of the patients within 21 days of surgery. Notably, the matrix was successful regardless of tumor location, type, or size. Infection was the only variable significantly associated with graft failure (P < .001).

CONCLUSIONS

The studied dermal matrix provides an efficient alternative to traditional reconstructive surgery in patients who present specific comorbidities or risk factors. The only variable significantly associated with graft failure was infection, which should be properly controlled through appropriate treatment.

A phase 3, open-label, controlled, randomized, multicenter trial evaluating the efficacy and safety of StrataGraft® construct in patients with deep partial-thickness thermal burns

OBJECTIVE

This phase 3 study evaluated StrataGraft construct as a donor-site sparing alternative to autograft in patients with deep partial-thickness (DPT) burns.

METHODS

Patients aged ≥18 years with 3-49% total body surface area (TBSA) thermal burns were enrolled. In each patient, 2 DPT areas (≤2000cm² total) of comparable depth after excision were randomized to either cryopreserved StrataGraft or autograft. Coprimary endpoints were: the difference in percent area of StrataGraft treatment site and autograft treatment site autografted at Month 3 (M3), and the proportion of patients achieving durable wound closure of the StrataGraft site without autograft at M3. Safety assessments were performed in all patients. Efficacy and safety follow-up continued to 1 year.

RESULTS

Seventy-one patients were enrolled. By M3, there was a 96% reduction in mean percent area of StrataGraft treatment sites that required autografting, compared with autograft treatment sites (4.3% vs 102.1%, respectively; P<.0001). StrataGraft treatment resulted in durable wound closure at M3 without autografting in 92% (95% CI: 85.6, 98.8; n/n 59/64) of patients for whom data were available. The most common StrataGraft-related adverse event was pruritus (15%).

CONCLUSIONS

Both coprimary endpoints were achieved. StrataGraft may offer a new treatment for DPT burns to reduce the need for autografting.

CLINICAL TRIAL IDENTIFIER

NCT03005106.

Negative-pressure wound therapy combined with artificial dermis (Terudermis) followed by split-thickness skin graft might be an effective treatment option for wounds exposing tendon and bone: A retrospective observation study

Skin grafts are not suitable for closing tendon- or bone-exposing wounds, which require flap surgery. Dermal regeneration templates have value for closing such wounds, but the disadvantages of the technique include implantation failures because of infection, hematoma formation, or inappropriate immobilization. Negative-pressure wound therapy was reported to increase graft acceptance in difficult wounds.This retrospective case series of 65 patients evaluated negative-pressure therapy combined with artificial dermis for the treatment of acute or chronic tendon- or bone-exposing wounds. The artificial dermis was placed after adequate wound-bed preparation, with simultaneous application of a vacuum-assisted closure system. Split-thickness skin grafting was performed after the implanted artificial dermis had become established.The overall success rate was 88.1% (59/67): 88.6% (39/44) in the chronic wounds group and 87% (20/23) in the acute-trauma group separately. The overall mean survival time of artificial dermis in success cases was 13.24 ± 7.14 days. In separately, the survival time of artificial dermis had no statistically difference in chronic wound group (13.64 ± 7.53 vs 12.60 ± 5.86. P = .943), but had significant statistical difference in acute trauma group (12.45 ± 6.44 days vs 23.33 ± 4.04 days, P = .018). Also, comorbidity of PAOD was found a strong risk factor of failure in chronic wound group (100% vs 23.1%, P < 0.001).We concluded that artificial dermis combined with negative-pressure therapy followed by split-thickness skin grafting might be a reliable and effective option for surgical reconstruction of tendon- or bone-exposing wounds, and could decreasing waiting periods of autologous skin graft.

Historical Evolution of Skin Grafting-A Journey through Time

Autologous skin grafting was developed more than 3500 years ago. Several approaches and techniques have been discovered and established in burn care since then. Great achievements were made during the 19th and 20th century. Many of these techniques are still part of the surgical burn care. Today, autologous skin grafting is still considered to be the gold standard for burn wound coverage. The present paper gives an overview about the evolution of skin grafting and its usage in burn care nowadays.

Matriderm dermal substitute in the treatment of post traumatic hand's fingertip tissue loss

INTRODUCTION

Treatment of fingers tissue loss is particularly challenging as it often necessitates advanced reconstructive techniques such as flaps or grafts, with esthetic and functional results that are not always as good as hoped for, with long healing times. Recently, along with tissue engineering development, numerous types of dermal substitute have been commercialized, with promising possibilities of treatment in finger tissue loss. In the author's unit, Matriderm^® is the most commonly used dermal substitute. As described by the manufacturer, this scaffold is designed to be covered with a split-thickness skin graft. In using a two-step procedure, the authors realized that in most cases of fingertips injuries, at three weeks follow-up, the wound appeared in an advanced state of healing, which permitted to avoid grafting.

MATERIAL AND METHODS

Between October 2017 and October 2018, 27 fingers have been included in this study. Patients have been divided in two groups: those treated with Matriderm^® alone (15 fingers) and those who had a skin graft three weeks after the first surgery (12 fingers). At the 6-month follow-up, authors evaluated the esthetic results with the Vancouver Scar Scale (VSS), the functional results with Quick Disability of the Arm, Shoulder and Hand (qDASH) score, and sensibility by the mean of two-point discrimination test (2-PD).

RESULTS

All outcomes were overlapping in patients treated with or without skin graft: mean VSS was 2.3, mean qDASH was 13.3, and mean 2-PD was 7.7 mm.

CONCLUSIONS

The results obtained allow to consider Matriderm^® , used also without skin graft coverage, as a valid solution for treatment of fingertip tissue loss.

Translational stem cell therapy: vascularized skin grafts in skin repair and regeneration

The skin is made up of a plethora of cells arranged in multiple layers with complex and intricate vascular networks, creating a dynamic microenvironment of cells-to-matrix interactions. With limited donor sites, engineered skin substitute has been in high demand for many therapeutic purposes. Over the years, remarkable progress has occurred in the skin tissue-engineering field to develop skin grafts highly similar to native tissue. However, the major hurdle to successful engraftment is the incorporation of functional vasculature to provide essential nutrients and oxygen supply to the embedded cells. Limitations of traditional tissue engineering have driven the rapid development of vascularized skin tissue production, leading to new technologies such as 3D bioprinting, nano-fabrication and micro-patterning using hydrogel based-scaffold. In particular, the key hope to bioprinting would be the generation of interconnected functional vessels, coupled with the addition of specific cell types to mimic the biological and architectural complexity of the native skin environment. Additionally, stem cells have been gaining interest due to their highly regenerative potential and participation in wound healing. This review briefly summarizes the current cell therapies used in skin regeneration with a focus on the importance of vascularization and recent progress in 3D fabrication approaches to generate vascularized network in the skin tissue graft.

Dermal Regeneration Template and Staged Skin Grafting for Extirpative Scalp Wound Reconstruction: A 14-Year Experience

OBJECTIVE

Dermal regeneration template and staged split-thickness skin grafting may mitigate the need for flap coverage of postoncologic scalp defects. This technique has been studied previously in small case series. We examine the effect of risk factors, surgical technique, irradiation, and dressing modalities on reconstructive outcomes in a highly comorbid patient cohort.

STUDY DESIGN

Retrospective review.

SETTING

Academic medical center.

METHODS

Full- and partial-thickness extirpative scalp wounds reconstructed with dermal regeneration template and staged skin grafting were reviewed over a 14-year period. Stage 1 consisted of template application following burr craniectomy in cases lacking periosteum. Stage 2 consisted of skin grafting. Negative pressure wound therapy (NPWT) was variably used to support adherence.

RESULTS

In total, 102 patients were analyzed (average age 74, mean follow-up 18 months). Eighty-one percent were American Society of Anesthesiologists class 3 or 4. Defect size averaged 56 cm². Average skin graft take was 94.5% in full-thickness wounds. Seven patients failed this method. Preoperative scalp irradiation was associated with major complication and delayed graft healing. Comorbidities, wound size, and burring were not associated with complication. Patients were more likely to heal with NPWT compared to bolster (hazard ratio, 1.67; 95% CI 1.01-2.77; P = .046). Time between stages was 6.6 days shorter when NPWT was applied (P < .001).

CONCLUSION

Dermal template and staged skin grafting is a reliable option for postcancer scalp reconstruction in poor flap candidates. Radiotherapy is associated with adverse outcomes. Negative pressure wound therapy simplifies postoperative wound care regimens and may accelerate healing.

Evaluation of a cross-linked versus non-cross-linked collagen matrix in full-thickness skin defects

Autologous skin transplantation is the gold standard for treatment of full-thickness skin defects such as deep burn injuries, but has the disadvantages of limited donor sites and donor site morbidities. Alternative skin replacement products, such as xenografts and allografts, are not a permanent solution. Numerous manufactured skin substitutes already show promising approaches, but have limited efficacy. Therefore, wound dressings adaptable to the physiology of wound healing are still needed. In a randomized controlled in vivo study, a newly designed biocompatible collagen nonwoven matrix was compared to the Integra® bilayer dermal substitute and untreated controls in 48 full-thickness skin defects in a swine model. The take of all templates was complete, and all the tissue-engineered products accelerated dermal wound healing compared to the untreated controls, as identified by planimetric measurements. The higher collagen dose treatments and Integra®-covered wounds developed the thickest, cell-rich neoepidermal tissue in histological examination. The innovative biocompatible collagen matrix is flexibly applicable and modifiable, and offers potential as a carrier membrane for therapeutic supplemental products such as growth factors to further develop effective wound dressings.

Indications and functional outcome of the use of integra® dermal regeneration template for the management of traumatic soft tissue defects on dorsal hand, fingers and thumb

INTRODUCTION

Few studies have been conducted to explore the utility of the Integra^® dermal regeneration template (IDRT) combined with a delayed split-thickness skin graft (STSG) for reconstructing complex dorsal hand, digit, and thumb injuries. This study reports the indications and outcomes for 14 patients treated with this technique via a two-stage process.

MATERIALS AND METHODS

We retrospectively reviewed all patients treated by IDRT combined with STSG from May 2015 to October 2018. The inclusion criterion was traumatic or post-infectious soft tissue defects (STDs) of the dorsal hand, fingers, and thumb, not suitable for direct wound closure and requiring local, pedicle, or free flap reconstruction. After debridement, a two-stage procedure was applied, namely IDRT followed by STSG. Indications, functional outcomes, aesthetic results, complications, patient satisfaction, and the STSG take rate were evaluated over a 36-month follow-up using standardised instruments.

RESULTS

A total of 14 patients with 15 reconstructions (average age = 48 years) were included. The dominant hand was involved in 50% of cases. Dorsal STDs involved the hand, fingers, thumb, and hand and thumb in 7, 3, 2 and 2 cases, respectively. The mean STD size was 35 cm² (range: 3-150 cm²). The wound was associated with exposed tendons (without peritenon), bone (without periosteum), and joints (without a capsule) in eight cases (57%). The IDRT/STSG take rate was 97%. The average Vancouver Scar Scale score was 2 (1-4).

CONCLUSION

The 36-month follow-up demonstrated that IDRT is a safe and reliable technique that can be considered a viable alternative to flap reconstruction for the management of traumatic STDs in selected patients. The aesthetic outcomes are acceptable, functional recovery of the fingers is excellent, patient satisfaction is very high and the rate of complications is very low.