The Use of Acellular Fish Skin Grafts in Burn Wound Management-A Systematic Review

A Randomized, Controlled Trial Comparing PermeaDerm to Mepilex Ag for the Treatment of Adult and Pediatric Partial-Thickness Burns

A next-generation transparent biosynthetic wound matrix (PermeaDerm) was developed for the treatment of burn injuries. Improvements include slits in an outer 2D silicone epidermal analog allowing for customizable moisture control, and an updated biocoating of the nylon knitted fabric to optimize wound adherence. The purpose of this randomized, single-blinded, multicenter trial was to compare PermeaDerm to a commonly used silver-containing foam dressing (Mepilex Ag) for the treatment of partial-thickness burns. Patients with partial-thickness burns <30% TBSA treated within 72 hours were included. Primary outcomes included incidence of 100% re-epithelialization at 14 days and time to conversion to alternative therapy. Secondary outcomes included incidence of healing at 7 and 21 days, pain, number of product changes, and adverse events. Sixty-seven patients (42 pediatric, 25 adult) were analyzed, 32 with Mepilex Ag and 35 with PermeaDerm. Though not statistically significant, more patients achieved healing with PermeaDerm at day 14 (P = 0.36), particularly those with superficial partial-thickness injuries (OR 5.87, P = 0.203, 95% CI = 0.385, 89.580). This trend continued to day 21 (P = 0.25). At day 7, nonsignificant increased incidence of healing of Mepilex Ag-treated wounds was observed (P = 0.25), in addition, PermeaDerm was associated with lower needs for product changes (OR 0.15, P = 0.034, 95% CI = 0.027, 0.872); both observations likely attributable to the adherent nature of PermeaDerm. No significant differences in time to conversion to alternate therapies were noted. Overall pain scores, aesthetics, and adverse events, including infection, were similar between groups. PermeaDerm is a safe and effective treatment for partial-thickness burns. PermeaDerm offers the clinical advantages of being transparent to continuously monitor the wound and adherent, reducing the need for a product change and allowing for bathing after 72 hours.

Real-world outcomes of acellular fish skin grafts for chronic wounds: A retrospective analysis of effectiveness and costs

Chronic wounds (CW) are a major public health problem. Acellular fish skin grafts (AFSG) are increasingly used in advanced wound care, but data on their effectiveness and costs in real-world settings are scarce. We therefore retrospectively analysed the wound surface area (WSA), pain scores, and AFSG-related costs in patients with CW over a 12-week follow-up period. In this single-centre observational study, we analysed two datasets of 34 (full dataset) and 22 (WSA-dataset) CW patients treated with AFSG in a university hospital. Of 34 AFSG-treated patients (mean age 75.9 ± 11.4 years, 44.0% females) with 50 CW of various aetiologies (median ulcer duration 32 weeks), 66.6% experienced pain improvement at 12 weeks. Of 22 patients, 19 (86.4%) showed a mean reduction in WSA of -60.7% ± 143.8% (p = 0.0025); 36.4% of CW were healed. AFSG-related costs were 1232.3 EUR/patient and 130.4 EUR/reduced cm2 (n = 22), which was 6.5 times more cost-effective compared to previous study results using living cellular skin substitutes. During 12 weeks of follow-up in a real-world setting, AFSG resulted in reduced WSA in most patients, improved pain in two-thirds, and healed CW in one-third. AFSG may be more cost-effective than other products, but prospective head-to-head comparisons are needed.

Accelerated wound healing of enzymatically debrided deep dermal burn wounds after the use of fish skin (Kerecis Omega3 Wound®) in comparison to Suprathel®

Recent studies have shown that long-term scarring from burns is significantly reduced through the use of enzymatic debridement. Following enzymatic debridement of deep dermal burns, numerous wound dressings are available that provide an adequate wound environment and ideal conditions for rapid wound healing. In German burn centres, Suprathel® has mostly been used for this purpose. Since 2019, the alternative Kerecis Omega3 Wound®, which is derived from fish skin, has been used as an alternative in burn medicine. Therefore, we conducted a single-centre prospective, open, comparative, and intra-individual clinical study to gain initial experience in the use of Kerecis Omega3 Wound®, establish a treatment algorithm and compare Suprathel® and Kerecis Omega3 Wound® in the treatment of deep dermal burns after enzymatic debridement with respect to wound healing, exudation and pain. After enzymatic debridement of deep dermal burns of the hand and foot, wounds were divided into two areas: one was treated with Suprathel® and the other with Kerecis Omega3 Wound®. Dressing changes and wound checks were carried out on days 2, 4, 8, 12, 16, 24, and 48, after application. With this, initial experience concerning the handling of Kerecis Omega3 Wound® was gained and wound healing, infection, exudation, and pain were documented. In the period from January 1, 2022, to October 1, 2023, 22 patients between the ages of 18 and 83 years with deep dermal burns were treated. Satisfactory results were obtained in all cases; no patients had to undergo a second debridement followed by skin grafting. Mean healing time after the use of Kerecis Omega3 Wound was 17 days (min 8 days, max 25 days) whereas it was 23 days (min 12 days, max 42 days) in the Suprathel-Areas. No infections were observed in both groups. Exudation throughout the wound healing process was significantly higher in the Kerecis Omega3 Wound group than in the Suprathel group, whereas no significant differences in pain levels were documented. The management of dressing changes, the assessment of the progress of wound healing and adjusting the level of moisture in the dressings were obstacles, which could only be overcome by appropriate experience of the burn surgeon. In particular, adjusting the degree of moisture had a major influence on the progress of wound healing. Depending on these parameters, very different healing processes of the fish skin, from early dissolution into the so-called "active slough", to the drying out of the wound dressing to form a crust and remaining there for several weeks. In all 22 patients, however, the treatment led to spontaneous wound healing and satisfactory results without the need of skin grafting or other surgical procedures. Kerecis Omega3 Wound® is safe to use and suitable for the treatment of deep dermal burn wounds following enzymatic debridement. Its application leads to accelerated wound healing compared to the use of Suprathel®, however, owing to the different courses of the external appearance of the wound during wound healing, a high degree of user experience is necessary. Kerecis Omega3 Wound® might be useful to improve scarring after enzymatically debrided deep dermal burn wounds. Thus, a comparison between Kerecis Omega3 Wound® and Suprathel® concerning their long-term results is still pending.

Bioactivity, Efficacy, and Safety of a Wound Healing Ointment With Medicinal Plant Bioactives: In Vitro and In Vivo Preclinical Evaluations

Chronic wounds have a significant impact on patients' quality of life, necessitating the management of pain, infection, bleeding, and emotional challenges. Debridement, which involves the removal of nonviable tissue, is crucial for promoting wound healing. In addition to surgical methods, cost-effective alternatives such as local solutions and ointments with biological properties have been explored. The use of natural compounds with anti-inflammatory, antibacterial, and collagen-synthesizing abilities holds promise for wound healing. This in vitro and in vivo preclinical study aimed to assess the safety and effectiveness of a wound healing ointment containing bioactive ingredients derived from medicinal plants (extracts, essential oils, and vegetable oils). The chemical composition of the ointment was characterized using Fourier transform infrared (FTIR) spectroscopy to gain insights into its synergistic action. Preclinical tests were conducted following standardized protocols. FTIR analysis revealed similarities between the product's spectrum and that of bioactive compounds. The in vitro tests demonstrated that all formulations of the ointment induced no cell death, DNA damage, or acute toxicity in cell cultures (p < 0.05). No lethal dose was observed, indicating the safety of the ointment at all concentrations. The ointment also stimulated a notably more organized, significantly higher collagen production compared to control groups (p < 0.05). In vivo preclinical analyses also demonstrated no adverse responses being effective in the healing process compared to the control group (silver sulfadiazine) in terms of wound contraction and ulcer re-epithelization (p < 0.05). Significantly higher means of wound contraction were observed in the groups treated with the bioactive-containing ointment when compared to both the positive control group (sulfadiazine) and the control untreated groups (p < 0.05). The regenerative ointment exhibited excellent biocompatibility and bioactivity in in vitro and in vivo studies, contributing to the development of innovative and sustainable wound management therapies.

Advanced Secondary Intention Healing for Complex Soft-Tissue Defects Using Reprocessed Micronized Acellular Dermal Matrix

Secondary intention healing offers an alternative when surgical options are infeasible. This study analyzed the effect of micronized acellular dermal matrices (mADMs; CGderm Matrix®, CG Bio, Seoul, Republic of Korea) on secondary intention healing in patients with complex soft-tissue defects and assessed mADMs' efficacy in promoting secondary healing and improving clinical outcomes in these challenging cases. This retrospective study included 26 patients treated with sheet-type reprocessed mADMs between August 2022 and December 2022 at Soonchunhyang University Cheonan Hospital. Patients with full-thickness skin defects classified as complex wounds were included. Data on demographics, wound characteristics, and treatment outcomes were collected and analyzed. Wound area was measured using ImageJ software, and statistical analyses were conducted using SPSS. The application of mADMs resulted in a median wound area reduction of 81.35%, demonstrating its significant efficacy in wound healing. Most patients presented with compromised vascular supply, significant tissue loss, or infections that precluded conventional surgical interventions. No significant correlations were observed between patient variables and wound-healing outcomes, indicating the complex nature of wound healing. mADMs effectively promote secondary intention healing by providing a supportive extracellular matrix scaffold that enhances epithelialization and angiogenesis. Their rapid absorption, ease of handling, and ability to improve wound tensile strength make them particularly suitable for complex wounds.

Acellular Fish Skin Grafts for Treatment of Periocular Skin Defects

PURPOSE

To describe the outcomes of acellular fish skin grafts for repair of periocular anterior lamella skin defects after Mohs surgery for skin cancers.

METHODS

Following the institutional review board approval, the authors conducted a retrospective chart review of patients treated with acellular fish skin grafts between January 2022 and December 2023. Indication was to repair defects after Mohs excision of basal cell carcinoma and squamous cell carcinoma. Demographics, smoking and diabetes status, diagnosis, defect location, graft size, and complications were evaluated. Outcomes were analyzed using the scar cosmesis assessment and rating scale.

RESULTS

Six patients (3 females and 3 males) with a mean age of 60.8 (range 44-80) had Mohs surgery for basal cell carcinoma (4) and squamous cell carcinoma (2). Location of defects included eyebrow (3 cases), lateral nasal wall (1 case), lower eyelid (1 case), and medial lower eyelid/nasal wall (1 case). Defect size ranged from 8 × 10 mm to 30 × 40 mm. Two patients had more than 1 application of xenograft. One patient developed a mild cicatricial ectropion. No other postoperative complications were seen, and all had good wound healing and cosmetically acceptable results.

CONCLUSIONS

In this pilot study, acellular fish skin xenografts are shown to be promising skin graft substitutes in patients with Mohs defects and decrease the need for autologous skin harvesting or allogenic skin donation.

Poison Turned Panacea: Arsenic Trioxide Loaded Hydrogel for Inhibiting Scar Formation in Wound Healing

Without intervention, the natural wound healing process can often result in scarring, which can have detrimental effects on both the physical and mental well-being of patients. Therefore, it is crucial to develop biomaterials that can promote healing without scarring. Regulating the Yes-associated protein-1/PDZ-binding motif (YAP/TAZ) signaling pathway is possible to reduce excessive fibrosis of fibroblasts and proliferation of vascular endothelial cells, ultimately impacting scar formation. Arsenic trioxide (ATO), an ancient drug with medicinal and toxic properties, has shown promise in regulating this pathway. An ATO-loaded hydrogel dressing (ATO@CS/SA) was created to facilitate scarless wound healing, utilizing chitosan (CS) and sodium alginate (SA) to prevent direct contact of ATO with the wound tissue and minimize potential side effects. In vitro studies demonstrated that low concentrations of ATO did not impact cell viability and even promoted proliferation and migration. Co-culturing the hydrogel with fibroblasts and vascular endothelial cells led to decreased expression levels of YAP and TAZ. Animal studies over a 90-day period revealed significant inhibition of scar formation with this system. Histological experiments further confirmed that the decreased expression of YAP and TAZ was responsible for this outcome. In conclusion, when administered at the appropriate dose, ATO can be repurposed from a traditional poison to a therapeutic agent, effectively suppressing excessive cell fibrosis and blood vessel proliferation and offering a novel approach to scar-free treatment.

Management of Large Full-Thickness Burns Using Kerecis™ Acellular Fish Skin Graft and ReCell™ Autologous Skin Cell Suspension: A Case Report of Two Patients with Large Surface Area Burns

Novel treatments for extensive full-thickness burns revolve around fluid control, addressing systemic inflammatory derangements, and achieving early skin coverage with acceptable cosmetic and functional results. Recent advances in the management of extensive burns include fish skin xenografts, such as Kerecis Omega-3 acellular dermal substitute. Reported to be non-allergenic and antimicrobial, this Atlantic Cod skin derivative has the potential to supplement the management of patients with large surface area burns. A chart review was performed on two complex patients. Patient 1 suffered 65% partial and full-thickness burns after lighting herself on fire with gasoline, and patient 2 suffered 86% partial and full-thickness burns following a methamphetamine explosion. The patients were both treated with a multi-step process using cadaveric allografts, Kerecis acellular fish skin placement, and autologous split-thickness skin grafts (STSG). Case 2 utilized ReCell autologous skin cell suspension and Novosorb bilaminate dermal substitute (BTMTM) due to limited donor sites. Complete coverage and epithelization were achieved on both patients but required multiple reapplications of autograft and Kerecis. Contractures of the neck, elbows, and hand were present in Case 1. Kerecis xenografting may have an expanding role in burn management due to standalone capabilities for deep partial-thickness burns and ease of use. Further evaluation is needed to establish the most optimal timing of use and best zones of application to improve take and reduce contractures.

NOVEL USE OF NILE TILAPIA FISH (OREOCHROMIS NILOTICUS) SKIN AS XENOGRAFT IN ZOOLOGICAL SPECIES

Nile tilapia fish skin (Oreochromis niloticus) has been increasingly used in human and veterinary medicine in xenografts for treatment of burn wounds. The objective of this study was to self-prepare the graft using a Brazilian patent (WO2017/035615 A1) as a guide and apply it to full-thickness wounds in zoological species (n = 4). The wounds, which were all characterized as contaminated wounds in which the entire dermal layer was missing, had all previously been surgically debrided and treated with traditional wound-healing techniques without success. This graft technique was developed in response to the poor treatment success. The graft was prepared and sutured to the affected area, leading to complete contraction and epithelialization in all cases. The patients were concurrently placed on one course of systemic antibiotics because of the severity of wound contamination. The frequency of dressing changes varied between species and no adverse effects were apparent. This method of processing Nile tilapia fish skin proves promising for use in contaminated wounds, as it is inexpensive and easy to acquire and develop, mitigates stress in wildlife patients because of a decreased frequency of dressing changes and therefore handling, and can be utilized in clinical environments.

Resolution of a chronic occipital wound with exposed skull bone with a fish skin graft: a successful treatment approach

Chronic skin defects in the head, face and neck pose challenges for closure, especially after multiple surgeries or radiation therapy. We report the case of a woman in her 70s with a chronic occipital wound following squamous cell carcinoma resections, resulting in exposed skull bone. Despite various options, we successfully treated the 4 cm x 5 cm wound with a Kerecis fish skin graft (FSG), observing significant improvement within a week. The FSG promoted granulation tissue formation, enabling subsequent full-thickness skin grafting from the patient's groin. Complete wound closure was achieved within 2 weeks, indicating FSG's efficacy in complex wound management. Our experience highlights FSG's potential as a valuable tool in wound healing and reconstruction, particularly in challenging cases involving the head and neck.

Preclinical evaluation of mucogingival defect treatment using piscine membranes: An in vivo assessment of wound healing

Periodontitis is a bacteria-induced chronic inflammatory disease characterized by degradation of the supporting tissue and bone in the oral cavity. Treatment modalities seek to facilitate periodontal rehabilitation while simultaneously preventing further gingival tissue recession and potentially bone atrophy. The aim of this study was to compare two differently sourced membranes, a resorbable piscine collagen membrane and a porcine-derived collagen membrane, in the repair of soft tissue defects utilizing a preclinical canine model. This in vivo component consisted of 10 beagles which were subjected to bilateral maxillary canine mucogingival flap defects, as well as bilateral soft tissue defects (or pouches) with no periodontal ligament damage in the mandibular canines. Defects received either a piscine-derived dermal membrane, (Kerecis® Oral, Ísafjörður, Iceland) or porcine-derived dermal membrane (Geistlich Mucograft®, Wolhusen, Switzerland) in a randomized fashion (to avoid site bias) and were allowed to heal for 30, 60, or 90 days. Statistical evaluation of tissue thickness was performed using general linear mixed model analysis of variance and least significant difference (LSD) post hoc analyses with fixed factors of time and membrane. Semi-quantitative analysis employed for inflammation assessment was evaluated using a chi-squared test along with a heteroscedastic t-test and values were reported as mean and corresponding 95% confidence intervals. In both the mucogingival flap defects and soft tissue gingival pouches, no appreciable qualitative differences were observed in tissue healing between the membranes. Furthermore, no statistical differences were observed in the thickness measurements between piscine- and porcine-derived membranes in the mucogingival flap defects (1.05 mm [±0.17] and 1.29 mm [±0.17], respectively [p = .06]) or soft tissue pouches (1.36 mm [±0.14] and 1.47 mm [±0.14], respectively [p = .27]), collapsed over time. Independent of membrane source (i.e., piscine or porcine), similar inflammatory responses were observed in both the maxilla and mandible at the three time points (p = .88 and p = .79, respectively). Histologic and histomorphometric evaluation results indicated that both membranes yielded equivalent tissue responses, remodeling dynamics and healing patterns for the mucogingival flap as well as the soft tissue gingival pouch defect models.

Multidisciplinary Management and Autologous Skin Grafting in a Patient with Severe Burns: A Case Study

Background: Heat burns are a prevalent type of trauma. Rapid and effective treatment is crucial for deep burns to minimize complications. Autologous skin grafting is a highly effective treatment for full-thickness burns. A multidisciplinary team plays a vital role in managing burn patients undergoing skin grafting, from initial contact to outpatient follow-up. Case Summary: This case study involves a 56-year-old patient who suffered burns on 60% of his body following an alcohol explosion on an open flame. The patient underwent autologous skin grafting at a Major Burn Center. Initial symptoms included severe pain and immobility, but the patient remained alert and breathed spontaneously. The diagnosis was a loss of epidermis and dermis with burns covering 60-69% of the total body surface area (TBSA) and third-degree burns covering 10% TBSA. Post-discharge, the patient showed significant improvement, with complete healing of the grafts and partial resolution of other lesions. Six months after the intervention, the patient significantly improved his autonomy and mobility. Conclusions: This case highlights the importance of burn prevention and the critical role of multidisciplinary teams in the entire care pathway of burn patients. Appropriate diagnosis, complete treatment, and continuous multidisciplinary support are essential to prevent complications and ensure recovery.

Fish skin grafts versus standard of care on wound healing of chronic diabetic foot ulcers: A systematic review and meta-analysis

INTRODUCTION

This study will explore the effectiveness of fish skin grafts (FSG) in ulcer healing in diabetic foot disease compared to standard of care (SOC).

METHODS

The systematic review and meta-analysis were performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standard. The electronic databases of PubMed, EMBASE, and Web of Science (WoS) internet were searched for the outcome rate of complete ulcer healing. The risk of bias assessment was conducted using the tool recommended by the Cochrane Collaboration. Statistical analysis included the individual and combined result of the studies, heterogeneity test, the effect size, sensitivity analysis, and publication bias tests.

RESULTS

Five randomised controlled trials (RCTs) with a total of 411 patients were included in this study. This meta-analysis showed a higher rate of complete ulcer healing in groups receiving fish skin grafts (OR = 3.34, 95% CI 2.14-5.20, p < 0.01, I2 = 0%) compared to control groups.

CONCLUSION

Fish skin grafts have been shown to be more effective for achieving complete ulcer healing compared to current conventional treatments in diabetic foot disease.

Acellular fish skin grafts in the treatment of diabetic wounds: Advantages and clinical translation

Diabetic wounds cannot undergo normal wound healing due to changes in the concentration of hyperglycemia in the body and soon evolve into chronic wounds causing amputation or even death of patients. Diabetic wounds directly affect the quality of patients and social medical management; thus researchers started to focus on skin transplantation technology. The acellular fish skin grafts (AFSGs) are derived from wild fish, which avoids the influence of human immune function and the spread of the virus through low-cost decellularization. AFSGs contain a large amount of collagen and omega-3 polyunsaturated fatty acids and they have an amazing effect on wound regeneration. However, after our search in major databases, we found that there were few research trials in this field, and only one was clinically approved. Therefore, we summarized the advantages of AFSGs and listed the problems faced in clinical use. The purpose of this paper is to enable researchers to better carry out original experiments at various stages.

Recent progress of electrospun nanofibers as burning dressings

Burns are a global public health problem, which brings great challenges to public health and the economy. Severe burns often lead to systemic infection, shock, multiple organ failure, and even death. With the increasing demand for the therapeutic effect of burn wounds, traditional dressings have been unable to meet people's needs due to their single function and many side effects. In this context, electrospinning shows a great prospect on the way to open up advanced wound dressings that promote wound repairing and prevent infection. With its large specific surface area, high porosity, and similar to natural extracellular matrix (ECM), electrospun nanofibers can load drugs and accelerate wound healing. It provides a promising solution for the treatment and management of burn wounds. This review article introduces the concept of burn and the types of electrospun nanofibers, then summarizes the polymers used in electrospun nanofiber dressings. Finally, the drugs (plant extracts, small molecule drugs and nanoparticles) loaded with electrospun burn dressings are summarized. Some promising aspects for developing commercial electrospun burn dressings are proposed.

The Use of Fish Skin Grafts in Children as a New Treatment of Deep Dermal Burns-Case Series with Follow-Up after 2 Years and Measurement of Elasticity as an Objective Scar Evaluation

Background: Wound healing in deep dermal burn injuries continues to be a challenge in paediatrics. In the absence quick and spontaneous wound closure, split-thickness skin grafting is often necessary. Since the development of a new type of acellular fish matrix, which is very similar to the human skin matrix, skin closure and wound conditioning can be achieved without split-thickness skin grafting. Methods: The following study shows a case series of 20 children in whom a fish skin graft was used. The aim was to develop an algorithm for selecting and using fish skin and its long-term results after one and two years. Acellular fish skin worked as a granulation base for wound healing and also as a substitute for split-thickness skin grafts. Results: There was no evidence of infection. Skin transplants and, thus, additional operations could be avoided. The follow-up examinations showed an excellent result, both objectively by means of elasticity measurements (DermalabCombo®) and in the subjective assessment of the skin as part of the Patient and Observer Scar Assessment Scale (POSAS). Conclusion: Fish skin grafts are a good alternative to split-thickness skin grafts for deep dermal wounds. These results should be further analysed with a larger number of patients in future publications.

Platelet-derived extracellular vesicles: a new-generation nanostructured tool for chronic wound healing

Chronic nonhealing wounds pose a serious challenge to regaining skin function and integrity. Platelet-derived extracellular vesicles (PEVs) are nanostructured particles with the potential to promote wound healing since they can enhance neovascularization and cell migration and reduce inflammation and scarring. This work provides an innovative overview of the technical laboratory issues in PEV production, PEVs' role in chronic wound healing and the benefits and challenges in its clinical translation. The article also explores the challenges of proper sourcing, extraction techniques and storage conditions, and discusses the necessity of further evaluations and combinational therapeutics, including dressing biomaterials, M2-derived exosomes, mesenchymal stem cells-derived extracellular vesicles and microneedle technology, to boost their therapeutic efficacy as advanced strategies for wound healing.

Skin Substitutes and Autograft Techniques: Temporary and Permanent Coverage Solutions

Coverage of burn wounds is crucial to prevent sequalae including dehydration, wound infection, sepsis, shock, scarring, and contracture. To this end, numerous temporary and permanent options for coverage of burn wounds have been described. Temporary options for burn coverage include synthetic dressings, allografts, and xenografts. Permanent burn coverage can be achieved through skin substitutes, cultured epithelial autograft, ReCell, amnion, and autografting. Here, we aim to summarize the available options for burn coverage, as well as important considerations that must be made when choosing the best reconstructive option for a particular patient.

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.

Enhancement of Wound Healing and Angiogenesis Using Mouse Embryo Fibroblasts Loaded in Decellularized Skin Scaffold

Background

Synthetic and natural polymer scaffolds can be used to design wound dressing for repairing the damaged skin tissue. This study investigated acute wound healing process using a decellularized skin scaffold and mouse embryo fibroblast (MEF).

Methods

Mouse skin fragments were decellularized and evaluated by DNA content, toxicity, H&E staining, Raman confocal microscopy, Masson’s trichrome staining, SEM, and biodegradation assays. The fragments were recellularized by the MEFs, and cell attachment and penetration were studied. De- and decellularized scaffolds were used wound dressings in mouse acute wound models as two experimental groups. Using morphological and immunohistochemical assessments, wound healing was evaluated and compared among the experimental and control groups.

Results

DNA content of the decellularized tissue significantly reduced compared to the native control group (7% vs. 100%; p < 0.05). extracellular matrix components, e.g. collagen types I, III, and IV, elastin, and glycosaminoglycan, were well preserved in the decellularized group. The porosity and fiber arrangement in the stroma had a structure similar to normal skin tissue. A significant reduction in healing time was observed in the group treated with a decellularized scaffold. A thicker epidermis layer was observed in the recovered tissue in both experimental groups compared to the control group. Immunostaining showed a positive reaction for CD31 as an endothelial marker in both experimental groups, confirming new vascularization in these groups.

Conclusion

Using MEFs with decellularized skin as a wound dressing increases the rate of wound healing and also the formation of new capillaries. This system could be beneficial for clinical applications in the field of tissue engineering.

Age-related morphological and ultrastructural changes in the palate and pharyngeal masticatory apparatus of grass carp (Ctenopharyngodon idella) juveniles

Grass carp (Ctenopharyngodon idella or C. idella) is a Cyprinid fish frequently utilized for aquaculture, medical, and research purposes. In C. idella, the palate is followed by a well-developed pharyngeal masticatory apparatus. The latter consists of an upper chewing pad superimposing a paired set of teeth. The present study investigated morphological, morphometric, histochemical, and surface ultrastructural changes involving these structures in C. idella juveniles at three different timepoints namely 35 mm total length (TL; 59 days posthatching (dph); fry-fingerling transition), 70 mm TL (90 dph; fingerling), and 210 mm TL ( 365 dph: yearling). The palatal epithelium revealed a constant number of taste buds. However, the height and width of these buds revealed an age-dependent increase. The number of palatal acidic goblet cells increased gradually with age. Enhanced keratinization of pad epithelium, and increased teeth dimensions were age-associated characteristics. Ultrastructurally, the palatal surface of C. idella was slightly papillated at 35 mm TL after which it formed brick-like structural units that tended to cluster into longitudinally paralleled rows toward the palate-pad junction. Goblet cell openings appeared oval at 35 mm TL and became club-shaped by 210 mm TL at which the epithelium appeared compact and heavily coated in mucus. Indentations of pad surface and signs of dental wear and tear were evident ultrastructurally at 70 mm TL and onwards. The current study reports for the first time age-related developmental features of the palate and pharyngeal masticatory apparatus of grass carp. Results of the present work will help to understand aging-associated factors involving the studied fish and other related aquatic species.

Management of Severe Burn Wounds Colonized With Multi-resistant Pseudomonas aeruginosa and Fusarium Using Marine Omega3 Wound Matrix in a Female Victim of War

War-related burns are common injuries, also among the civilian population. Additional trauma such as fractures or shrapnel wounds may add significant morbidity. Burn injuries in war zones are furthermore frequently undertreated and hence prone to complications. We report a case of a young female victim of war, whose severely infected burn wounds could be successfully healed using a combination of targeted antimicrobial therapy, wound conditioning using decellularized fish skin, and subsequent skin grafting.

An Overview of Recent Developments in the Management of Burn Injuries

According to the World Health Organization (WHO), around 11 million people suffer from burns every year, and 180,000 die from them. A burn is a condition in which heat, chemical substances, an electrical current or other factors cause tissue damage. Burns mainly affect the skin, but can also affect deeper tissues such as bones or muscles. When burned, the skin loses its main functions, such as protection from the external environment, pathogens, evaporation and heat loss. Depending on the stage of the burn, the patient's condition and the cause of the burn, we need to choose the most appropriate treatment. Personalization and multidisciplinary collaboration are key to the successful management of burn patients. In this comprehensive review, we have collected and discussed the available treatment options, focusing on recent advances in topical treatments, wound cleansing, dressings, skin grafting, nutrition, pain and scar tissue management.

Subjective and objective observation of Tilapia skin as auto skin graft dressing in cats

Background

The recovery of auto skin graft is a dynamic and complex process that requires a suitable environment for vascularization as nutrition delivery to cells and donor skin reception.

Aims

This research aimed to determine the effect of Tilapia skin dressing on the recovery of auto skin graft treatment on domestic cats through subjective and objective observation.

Methods

Six male Indonesian local cats aged 1-2 years old weighing 3-4 kg were separated into two groups. The surgical procedure was performed in a sterile and aseptic environment. The first surgery created wound defects on the forelimb area 2 × 2 cm in size to whole groups. The wounds were left for 4 days and then treated with the following treatments; Group I (G-I) was treated with Tilapia skin dressing, and Group II (G-II) was treated with moist dressing Sofra-tulle®. The dressing of the two groups was replaced every 3 days and evaluated subjectively and objectively.

Results

Subjective observation showed that skin was reddish (day 3), the bleeding test showed bleeding immediately occurred after incision, and pain response was observed on day 6 post-surgery on both treatment groups showed significantly differences with 95% confidence level (p < 0.05). Objective observation in the form of NaCl 0.9% absorption and medicine effect on auto skin graft did not show a significant difference between the two treatment groups (p > 0.05).

Conclusion

Auto skin graft treatment by moist dressing showed better healing, but Tilapia skin dressing can be an alternative choice during auto skin graft treatment.

Cutaneous Cell Therapy Manufacturing Timeframe Rationalization: Allogeneic Off-the-Freezer Fibroblasts for Dermo-Epidermal Combined Preparations (DE-FE002-SK2) in Burn Care

Autologous cell therapy manufacturing timeframes constitute bottlenecks in clinical management pathways of severe burn patients. While effective temporary wound coverings exist for high-TBSA burns, any means to shorten the time-to-treatment with cytotherapeutic skin grafts could provide substantial therapeutic benefits. This study aimed to establish proofs-of-concept for a novel combinational cytotherapeutic construct (autologous/allogeneic DE-FE002-SK2 full dermo-epidermal graft) designed for significant cutaneous cell therapy manufacturing timeframe rationalization. Process development was based on several decades (four for autologous protocols, three for allogeneic protocols) of in-house clinical experience in cutaneous cytotherapies. Clinical grade dermal progenitor fibroblasts (standardized FE002-SK2 cell source) were used as off-the-freezer substrates in novel autologous/allogeneic dermo-epidermal bilayer sheets. Under vitamin C stimulation, FE002-SK2 primary progenitor fibroblasts rapidly produced robust allogeneic dermal templates, allowing patient keratinocyte attachment in co-culture. Notably, FE002-SK2 primary progenitor fibroblasts significantly outperformed patient fibroblasts for collagen deposition. An ex vivo de-epidermalized dermis model was used to demonstrate the efficient DE-FE002-SK2 construct bio-adhesion properties. Importantly, the presented DE-FE002-SK2 manufacturing process decreased clinical lot production timeframes from 6-8 weeks (standard autologous combined cytotherapies) to 2-3 weeks. Overall, these findings bear the potential to significantly optimize burn patient clinical pathways (for rapid wound closure and enhanced tissue healing quality) by combining extensively clinically proven cutaneous cell-based technologies.

The Use of Intact Fish Skin Grafts in the Treatment of Necrotizing Fasciitis of the Leg: Early Clinical Experience and Literature Review on Indications for Intact Fish Skin Grafts

BACKGROUND

Necrotizing fasciitis (NF) is a serious infectious disease that can initially place the patient's life in danger and, after successful surgical and antibiotic treatment, leaves extensive wounds with sometimes even exposed bones and tendons. Autologous skin grafts are not always possible or require adequate wound bed preparation. Novel intact fish skin grafts (iFSGs; Kerecis® Omega3 Wound, Kerecis hf, Isafjördur, Iceland) have already shown their potential to promote granulation in many other wound situations. Faster wound healing rates and better functional and cosmetic outcomes were observed due to their additionally postulated anti-inflammatory and analgesic properties. Therefore, iFSGs may also be essential in treating NF. We present our initial experience with iFSGs in treating leg wounds after NF and review the literature for the current spectrum of clinical use of iFSGs.

CASE PRESENTATIONS

We present two male patients (aged 60 and 69 years) with chronic or acute postsurgical extensive leg ulcers six weeks and six days after necrotizing fasciitis, respectively. Both suffered from diabetes mellitus without vascular pathologies of the lower limbs. A single application of one pre-meshed (Kerecis® Graftguide) and one self-meshed 300 cm2 iFSG (Kerecis® Surgiclose) was performed in our operation room after extensive surgical debridement and single circles of negative wound pressure therapy. Application and handling were easy. An excellent wound granulation was observed, even in uncovered tibia bone and tendons, accompanied by pain relief in both patients. Neither complications nor allergic reactions occurred. The patients received autologous skin grafting with excellent functional and cosmetic outcomes.

CONCLUSIONS

iFSGs have the potential to play a significant role in the future treatment of NF due to the fast promotion of wound granulation and pain relief. Our experience may encourage surgeons to use iFSGs in NF patients, although high-quality, large-sized studies are still required to confirm these results. The observed effects of iFSGs on wounds associated with NF may be transferred to other wound etiologies as well.

Acellular fish skin for wound healing

Fish skin grafting as a new skin substitute is currently being used in clinical applications. Acceleration of the wound healing, lack of disease transmission, and low cost of the production process can introduce fish skin as a potential alternative to other grafts. An appropriate decellularization process allows the design of 3D acellular scaffolds for skin regeneration without damaging the morphology and extracellular matrix content. Therefore, the role of decellularization processes is very important to maintain the properties of fish skin. In this review article, recent studies on various decellularization processes as well as biological, physical, and mechanical properties of fish skin and its applications with therapeutic effects in wound healing were investigated.

Fish Skin Graft: Narrative Review and First Application for Abdominal Wall Dehiscence in Children

Acellular fish skin grafts (FSGs) are tissue-based products created by minimally processing the skin of the Atlantic cod (Gadus morhua). The FSG is rich in omega-3 and facilitates tissue regeneration by supporting revascularization and ingrowth in the proliferation and remodeling phases of wound healing. FSG is structurally more similar to human skin than antiviral-processed skin substitutes such as amniotic membrane, and there are no known prion, bacterial, or viral diseases that can be transmitted from North-Atlantic cod to humans. The FSG is processed using a proprietary method that preserves the structure and lipid composition of the skin. FSG is CE marked, and US Food and Drug Administration cleared for multiple clinical applications in partial and full-thickness wounds. FSG is currently the only acellular dermal matrix product that does not originate from mammalian tissues. For this narrative review, Medline and UpToDate were used to include a total of 21 articles published from 2015 to 2022 about fish skin graft use. We also reported a case of a 7-year-old boy who underwent treatment with FSG for abdominal wall dehiscence at our department of pediatric surgery, IRCCS Sant'Orsola-Malpighi, Alma Mater Studiorum, University of Bologna, University Hospital of Bologna. FSG provides a valuable and sustainable treatment that improves wound healing in both adult and pediatric populations. We described the first application of an FSG for wound dehiscence of the abdominal wall in a pediatric patient, reporting how FSG was completely reabsorbed and improved the skin's repair.

How to Select an Extracellular Matrix for Wound Repair: A Comprehensive Review

Background

An extracellular matrix (ECM) is a network of proteins and other molecules that provide support and structure to cells and tissues in the body. Since its discovery in 1930, researchers have reproduced the ECM through an array of evolving technologies, developing products that accelerate healing times, minimize scarring, and reduce pain. When selecting which ECM product to use, physicians rely on personal experience while considering wound location, type of tissue lost, exposed structures, chronicity, and even the patient's religious preferences. While comparison trials between a few different types of ECMs exist, there lacks a thorough investigation that assesses a majority of ECMs against each other.

Methods

Herein, we conducted a literature review using the PubMed database and utilized 71 articles to identify the best ECM for wound healing and positive patient outcomes. The primary search terms included extracellular matrix, xenograft, porcine, bovine, allograft, bioengineered matrix, acellularized fish skin, wounds, wound healing, and wound care. We did not exclude any specific type of research, but predominantly reviewed clinical trials, case series, and other review articles. We focused on the most popular and commonly used ECMs and constructed our results into the Table.

Results

We compared the indications, advantages, and disadvantages of each ECM and concisely illustrated these findings to provide a guide on how to select an ECM (Table). Allografts, whether they are glycerol or cryopreserved, suffice as a treatment choice and are superior to exposure healing. However, they do not produce healing at the same rate or quality as bioengineered matrices, porcine and bovine xenografts, or acellularized fish skin (AFS). Bioengineered matrices and porcine and bovine xenografts offer antimicrobial properties, low immunogenicity, cost effectiveness, and availability. The compromise with these ECMs is with healing times and cosmesis. Acellularized fish skin (AFS) provides diverse utility, antimicrobial activity, low immunogenicity, faster healing times, and cosmetic superiority. However, AFS yields a potential cost burden and is not plentiful or easily accessible in some parts of the world.

Conclusions

Our findings assist in removing the subjectivity component of selecting an ECM and suggest further comparison or head-to-head trials would yield a more algorithmic approach to wound healing. We suggest to consider implementing the Disabilities of the Arm, Shoulder, and Hand (DASH) score as an additional objective comparison method in these future trials.

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.

Current state of clinical trials on xenograft

BACKGROUND

Xenotransplantation is a worth investing branch of science, since it aims to fulfil the demand on human cells, tissues and organs. Despite decades of consistent work in preclinical assessments, clinical trials on xenotransplantation are far from reaching the targeted goal. Our study aims to track the characteristics, assess the content and summarize the plan of each trial on skin, beta-island, bone marrow, aortic valve and kidney xenografts, leading to a clear sorting of efforts made in this field.

METHODS

In December 2022, we searched clinicaltrial.gov for interventional clinical trials related to xenograft of skin, pancreas, bone marrow, aortic valve and kidney. A total of 14 clinical trials are included in this study. Characteristics on each trial were gathered. Linked publications were searched using Medline/PubMed and Embase/Scopus. Content of trials was reviewed and summarized.

RESULTS

Only 14 clinical trials met our study's criteria. The majority were completed, and most of the trials' enrolment was between 11 and 50 participants. Nine trials used a xenograft of porcine origin. Six trials targeted skin xenotransplantation, four targeted β-cells, two targeted bone marrow and one trial targeted each of the kidney and aortic valve. The average length of trials was 3.38 years. Four trials were conducted in the United States and two trials in each of Brazil, Argentina and Sweden. Of all the included trials, none had any results provided and only three had published work. Phases I, III, and IV had only one trial each. A total of 501 participants were enrolled in these trials.

CONCLUSION

This study sheds the light on the current state of clinical trials on xenograft. Characteristically, trials on this field are of low number, low enrolment, short duration, few related publications and no published results. Porcine organs are the most used in these trials, and skin is the most studied organ. An extension of the literature is highly needed due to the variety of conflicts mentioned. Overall, this study sheds the light on the necessity of managing research efforts, leading to the initiation of more trials targeting the field of xenotransplantation.

Fish Skin Grafts Versus Alternative Wound Dressings in Wound Care: A Systematic Review of the Literature

Wound healing poses a variety of challenges making it a vital subject in medicine. With the advancement of science, we have seen the use of a new xenograft known as acellular fish skin (AFS) grafts that are derived from either Atlantic cod or Nile Tilapia. Fish skin has shown anti-inflammatory and anti-bacterial properties that support and improve wound healing in a variety of wounds including burns and diabetic foot ulcers (DFU). There is ongoing research that evaluates the efficacy of fish skin grafts in comparison to alternative wound healing techniques. A literature search was conducted through the National Library of Medicine with search terms fish skin graft, AFS, xenograft, dehydrated human amnion/chorion, ulcer, burns, and wounds. A total of ten studies that investigate the efficacy of fish skin grafts either in comparison to a different wound healing technique or by simply observing wound healing with fish skin grafts and recording the results were chosen. AFS showed superior healing in comparison to collagen alginate dressings, silver sulfadiazine cream 1%, and allografts. Although there is no one specific gold standard technique for wound healing, fish skin grafts demonstrated overall improved and quicker wound healing, fewer dressing changes, less pain, and lower costs.

The Importance of Psychometric and Physical Scales for the Evaluation of the Consequences of Scars-A Literature Review

BACKGROUND

Scars affect patients after trauma, burns, or surgical procedures and can generate both physical and psychosocial changes. The aesthetic damage represents the modification of a person's physical appearance, in its bodily integrity, causing numerous sufferings and determining social or economic consequences. The aim of this research is to evaluate the advantages and disadvantages offered by the available psychosocial and physical scar scales in assessing the physical, aesthetic, psychosocial, and juridical consequences of scars. This will aid to inform medical examiners about the most valued existing scales to allow them to select the most appropriate instrument to manage their patient.

METHODS

A broad search of relevant scientific studies on the psychosocial determinants of post-traumatic and surgical scars was conducted by using the following international database tools: PsycINFO, MedLine Social Science Index, Scopus, Web of Science, published from 1960 until 2022.

RESULTS

We analyzed 63 scientific studies to assess the advantages and limits of several psychometric and physical scar evaluation scales.

CONCLUSIONS

The researchers analyzed in this review highlight the advantages and limitation of existing instruments, evidencing the demand for future scar evaluation instruments and a scar-assessing algorithm that takes into account the physical, aesthetic, psychosocial, and legal consequences of scars.