Dermal substitution with Matriderm in burns on the dorsum of the hand

Background

Dermal substitutes are used increasingly in deep partial and full-thickness burn wounds in order to enhance elasticity and pliability. In particular, the dorsum of the hand is an area requiring extraordinary mobility for full range of motion. The aim of this comparative study was to evaluate intra-individual outcomes among patients with full-thickness burns of the dorsum of both hands. One hand was treated with split-thickness skin grafts (STSG) alone, and the other with the dermal substitute Matriderm^® and split-thickness skin grafts.

Material and Methods

In this study 36 burn wounds of the complete dorsum of both hands in 18 patients with severe burns (age 45.1 ± 17.4 years, 43.8 ± 11.8% TBSA) were treated with the simultaneous application of Matriderm^®, a bovine based collagen I, III, V and elastin-hydrolysate based dermal substitute, and split-thickness skin grafting (STSG) in the form of sheets on one hand, and STSG in the form of sheets alone on the other hand. The study was designed as a prospective comparative study. Using both objective and subjective assessments, data were collected at one week and 6 months after surgery. The following parameters were included: After one week all wounds were assessed for autograft survival. Skin quality was measured 6 months postoperatively using the Vancouver Burn Skin Score (VBSS). Range of motion was measured by Finger-Tip-Palmar-Crease-Distance (FPD) and Finger-Nail-Table-Distance (FNTD).

Results

Autograft survival was not altered by simultaneous application of the dermal matrix (p > 0.05). The VBSS demonstrated a significant increase in skin quality in the group with dermal substitutes (p = 0.02) compared to the control group with non-substituted wounds. Range of motion was significantly improved in the group treated with the dermal substitute (p = 0.04).

Conclusion

From our results it can be concluded that simultaneous use of Matriderm^® and STSG is safe and feasible, leading to significantly better results in respect to skin quality of the dorsum of the hand and range of motion of the fingers. Skin elasticity was significantly improved by the collagen/elastin dermal substitute in combination with sheet-autografts.     

Skin wound repair: Results of a pre-clinical study to evaluate electropsun collagen–elastin–PCL scaffolds as dermal substitutes.

The gold standard treatment for severe burn injuries is autologous skin grafting and the use of commercial dermal substitutes. However, resulting skin tissue following treatment usually displays abnormal morphology and functionality including scarring, skin contracture due to the poor elasticity and strength of existing dermal substitutes. In this study, we have developed a triple-polymer scaffold made of collagen–elastin–polycaprolactone (CEP) composite, aiming to enhance the mechanical properties of the scaffold while retaining its biological properties in promoting cell attachment, proliferation and tissue regeneration. The inclusion of elastin was revealed to decrease the stiffness of the scaffold, while also decreasing hysteresis and increasing elasticity. In mice, electrospun collagen–elastin–PCL scaffolds promoted keratinocyte and fibroblast proliferation, tissue integration and accelerated early-stage angiogenesis. Only a mild inflammatory response was observed in the first 2 weeks post-subcutaneous implantation. Our data indicates that the electrospun collagen–elastin–PCL scaffolds could potentially serve as a skin substitute to promote skin cell growth and tissue regeneration after severe burn injury.     

Benefits of cryopreserved human amniotic membranes in association with conventional treatments in the management of full‐thickness burns

The use of split‐thickness skin autografts (STSA) with dermal substitutes is the gold standard treatment for third‐degree burn patients. In this article, we tested whether cryopreserved amniotic membranes could be beneficial to the current treatments for full‐thickness burns. Swines were subjected to standardised full‐thickness burn injuries, and then were randomly assigned to treatments: (a) STSA alone; (b) STSA associated with the dermal substitute, Matriderm; (c) STSA plus human amniotic membrane (HAM); and (d) STSA associated with Matriderm plus HAM. Clinical and histological assessments were performed over time. We also reported the clinical use of HAM in one patient. The addition of HAM to classic treatments reduced scar contraction. In the presence of HAM, skin wound healing displayed high elasticity and histological examination showed a dense network of long elastic fibres. The presence of HAM increased dermal neovascularization, but no effect was observed on the recruitment of inflammatory cells to the wound. Moreover, the use of HAM with classical treatments in one human patient revealed a clear benefit in terms of elasticity. These results give initial evidence to consider the clinical application of HAM to avoid post‐burn contractures and therefore facilitate functional recovery after deep burn injury.     

Allogeneic skin substitutes applied to burns patients

Early re-surfacing of burn wounds remains the ideal but is limited by the availability of skin graft donor sites. Cultured grafts overcome these problems and autologous keratinocytes can be grown in culture and placed on a dermal substitute, but this results in delay and requires two operations. We developed an organotypic skin substitute, which achieves cover in one procedure, and have previously found allogeneic cell survival up to 2.5 years after grafting onto clean elective wounds (tattoo removal). Here, we report a short series using the same model applied to burns patients with less than 20% total body surface area affected. The skin substitutes consisted of allogeneic dermal fibroblasts embedded in a collagen gel overlain with allogeneic epidermal keratinocytes, and were grafted to patients with tangentially excised burns. A side-by-side comparison with meshed split-thickness autografts was performed. No grafts became infected. The allogeneic skin substitute showed little effective take at 1 week, and by 2 weeks only small islands of keratinocytes survived. These sites were subsequently covered with meshed split-thickness autograft, which took well. It is concluded that further development of this model is needed to overcome the hostile wound bed seen in burns patients.     

First experiences with the collagen-elastin matrix Matriderm as a dermal substitute in severe burn injuries of the hand

Restoring function after hand burns plays a major role in the restitution of a quality of life. Thereby the reconstructed pliability of the grafted areas is of utmost importance for good hand function. The collagen elastin matrix Matriderm was evaluated as a dermal substitute for the treatment of severe hand burns. In a series of 10 patients, mean age 43 years, TBSA 22.8%, an early debridement and immediate grafting with the matrix and unmeshed skin graft was carried out in a one-stage procedure. In the early postoperative follow up an overall take rate of 97% was observed. In contrast to conventional skin grafts, the color of the skin grafts over the matrix appeared pale in the first few days, but after 2 weeks no difference was observed. After three months, pliability of the grafted area was excellent, (mean VSS 3.2+/-1.2). Full range of motion was achieved in all hands, no blisters and no unstable or hypertrophic scars occurred. Matriderm has proved to be a dermal substitute suitable for the treatment of hand burns. We therefore consider Matriderm as a promising dermal substitute for the treatment of severe hand burns.     

Long-term results of a clinical trial on dermal substitution. A light microscopy and Fourier analysis based evaluation

Although dermal substitution is a main topic of current wound healing research, there is a paucity of clinical trials with a long-term clinical and histopathological evaluation. A clinical trial was conducted to perform an intra-individual comparison of conventional treatment (split-thickness autograft) to a collagen/elastin dermal substitute in combination with an autograft. Promising results with this substitute were obtained with respect to dermal organisation and scar elasticity in animal studies and clinical trials with a short-term follow-up. Twenty-nine of the 42 pairs of the burn wounds and 28 of the 44 pairs of the scar reconstructions enrolled in the study were biopsied after 1 year. Promising but not statistically significant differences were found between substituted groups and control groups for epidermal thickness, basement membrane maturation, rete ridges (P=0.055), fibroblasts, myofibroblasts, inflammatory cells, vessels and extracellular matrix maturation. An objective and accurate technique, Fourier analysis, was used to evaluate collagen bundle orientation and packing. However, no statistically significant differences were obtained for these parameters. This microscopic evaluation provided no convincing evidence for a long-term effectiveness of a dermal substitute despite promising data over a short-term in in vitro and in vivo studies with the same material.     

Clinical effectiveness of dermal substitution in burns by topical negative pressure: A multicenter randomized controlled trial

Previous research has shown clinical effectiveness of dermal substitution; however, in burn wounds, only limited effect has been shown. A problem in burn wounds is the reduced take of the autograft, when the substitute and graft are applied in one procedure. Recently, application of topical negative pressure (TNP) was shown to improve graft take. The aim of this study was to investigate if application of a dermal substitute in combination with TNP improves scar quality after burns. In a four‐armed multicenter randomized controlled trial, a split‐skin graft with or without a dermal substitute and with or without TNP was compared in patients with deep dermal or full‐thickness burns requiring skin transplantation. Graft take and rate of wound epithelialization were evaluated. Three and 12 months postoperatively, scar parameters were measured. The results of 86 patients showed that graft take and epithelialization did not reveal significant differences. Significantly fewer wounds in the TNP group showed postoperative contamination, compared to other groups. Highest elasticity was measured in scars treated with the substitute and TNP, which was significantly better compared to scars treated with the substitute alone. Concluding, this randomized controlled trial shows the effectiveness of dermal substitution combined with TNP in burns, based on extensive wound and scar measurements.     

Contracture of skin graft in human burns: Effect of artificial dermis

BackgroundSkin grafts with an artificial dermis have been widely used as a part of the efforts to minimize contractures and reduce donor-site scars. We conducted a prospective randomized clinical trial to study the effect of a dermal substitute by measuring the size of the graft after surgery for months.MethodThe artificial dermis (Matriderm, Dr. Suwelack Skin and Health Care AG, Billerbeck, Germany) was applied in combination with a split-thickness autograft in 40 patients with acute burn wounds or scar reconstruction. Demographic and medical data were collected on each patient. We directly measured the graft size by using a transparent two-ply film (Visitrak Grid, Smith & Nephew Wound Management, Inc, Largo, FL, USA) intraoperatively and 1, 2, 3, and 6 months postoperatively. For effective data comparison, the size of the graft at the time of surgery was taken to be “100%.” Then, the size in each phase was estimated in percentage (%).ResultDuring the 1st month, the average size was 89%. The figure decreased to 86% and 82% in the 2nd and 3rd months, respectively. In the 6th month, it slightly rebounded to 85% but failed to return to the original state. The size of patients with acute burns was smaller than the size of scar patients as follows: 85–91% in the 2nd month, 81–87% in the 3rd month, and 85–96% in the 6th month.ConclusionThis study examined the progress of skin grafts through the measurement of graft size in the human body. The grafted skin underwent contracture and remodeling for 3–6 months. In terms of skin contraction, an acute burn was more serious than scar reconstruction. The use of an artificial dermis that contains elastin is very effective from the functional and esthetic perspective by minimizing contractures and enhancing skin elasticity.     

Effect of artificial dermal substitute, cultured keratinocytes and split thickness skin graft on wound contraction

In this study, the effect of different wound treatments on contraction was evaluated in an established porcine model. In two separately conducted experiments full thickness wounds treated with artificial dermal substitute, split thickness skin graft (STSG), meshed STSG applied in combination with cultured keratinocytes or meshed STSG alone were compared with untreated wounds. The surface area of all wounds was quantified at regular time intervals. After 20 days wounds from some groups were subjected to histological analysis to establish the degree of epithelialization. Wounds treated with STSG contracted more than with artificial dermal substitute until day 21. From day 21 to day 35 wounds treated with STSG showed the least contraction. Wounds sprayed with cultured keratinocytes demonstrated a slower rate of contraction than those with meshed STSG alone after 20 days. The untreated control wounds showed a greater rate of contraction and had almost closed by day 20. This study demonstrates that there is a significant difference in contraction between wounds treated with artificial dermal substitute and control wounds and between wounds treated with STSG with cultured keratinocytes and meshed STSG alone. STSG with cultured keratinocytes, unmeshed STSG, and artificial dermal substitute all reduced wound contraction significantly.     

Integra as a dermal replacement in a meshed composite skin graft in a rat model: a one-step operative procedure.

BACKGROUND: Current use of Integra, the collagen-based dermal analogue, requires a two-step grafting procedure to achieve wound closure with an "ultrathin" autograft. METHODS: A one-step operative procedure of meshed composite skin graft (MCSG) using Integra as a dermal template for a meshed split thickness autograft was developed in rats. The silicon layer of Integra was removed, the resulting dermal analogue was meshed (1:1.5), expanded, and placed on excised full thickness wound and covered with a meshed (1:1.5 or 1:6) split thickness autograft. Grafted wounds were dressed with BioBrane, Vaseline gauze, silver-impregnated nylon, or silver-nylon and direct current (SNDC). At scheduled intervals up to 3 months postgrafting, wounds were examined for epithelialization, collagen deposition and fibrosis, hair growth, and contraction. The results of wound closure and healing following the one-step procedure were compared with the outcome of the two-step grafting procedure where application of meshed Integra (step one) was followed in 14 days by removal of the silicon layer and application of the meshed autograft (step two). RESULTS: The one-step procedure applied to meshed autograft/Integra (1:1.5/1:1.5) composite graft accelerated wound closure by 6-19 days when compared with the two-step procedure. At 3 months postgrafting, the contraction of the healed wound dressed with SNDC, BioBrane, or Vaseline gauze was reduced by 13-16% following the one-step procedure compared with the two-step procedure (p < 0.05). The one-step procedure allowed the expansion of the autograft layer to 1:6 while achieving wound healing results similar to grafting with 1:1.5 meshed autograft layer using the two-step grafting procedure. CONCLUSION: Single-step application of meshed, thin, split thickness autograft over meshed Integra-derived dermal substitute allows more rapid wound closure with less contraction and more efficient use of graft donor skin than can be obtained with the commonly used two-step grafting procedure.     

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.     

A long-term follow-up study of acellular dermal matrix with thin autograft in burns patients

We report long-term follow-up results of acellular dermal matrix (ADM) allograft combined with thin split-thickness skin autograft (STSG) for burn treatment. Between March 2001 and May 2007, we treated 19 cases of burn wounds or scar wounds at 34 different body sites with ADM allograft combined with STSG. All patients were monitored, with the mean follow-up period being 3.3 ± 1.4 years. Transplant skin was assessed by using a modified Manchester Scar Scale. The control sites that were treated with STSG at the same time were also monitored. There were significant differences in contour, contracture, and texture between the treatment and control sites (P < 0.05), but not in color, sensation, and complications (P > 0.05). All composite-grafted joints showed recovery and improvement in function postoperatively. The aesthetic contour of the skin donor site was satisfactory. Composite graft with ADM produces a supple texture without contractures, approaching the normal skin contour, and leading to adequate improvement in function.     

Skin substitute‐assisted repair shows reduced dermal fibrosis in acute human wounds validated simultaneously by histology and optical coherence tomography

Skin substitutes are heterogeneous biomaterials designed to accelerate wound healing through provision of replacement extracellular matrix. Despite growing evidence for their use in chronic wounds, the role of skin substitutes in acute wound management and their influence on fibrogenesis remains unclear. Skin substitute characteristics including biocompatibility, porosity, and elasticity strongly influence cellular behavior during wound healing. Thus, we hypothesize that structural and biomechanical variation between biomaterials may induce differential scar formation after cutaneous injury. The following human prospective cohort study was designed to investigate this premise. Four 5‐mm full thickness punch biopsies were harvested from 50 volunteers. In all cases, site 1 healed by secondary intention, site 2 was treated with collagen‐GAG scaffold (CG), and decellularised dermis (DCD) was applied to site 3 while tissue extracted from site 4 was replaced (autograft). Healing tissue was assessed weekly with optical coherence tomography (OCT), before being excised on days 7, 14, 21, or 28 depending on study group allocation for later histological and immunohistochemical evaluation. Extracted RNA was used in microarray analysis and polymerase chain reaction of highlighted genes. Autograft treatment resulted in minimal fibrosis confirmed immunohistochemically and with OCT through significantly lower collagen I levels (p = 0.047 and 0.03) and reduced mean grayscale values (p = 0.038 and 0.015), respectively. DCD developed intermediate scar formation with partial rete ridge reformation and reduced fasiculonodular fibrosis. It was uniquely associated with late up‐regulation of matrix metalloproteinases 1 and 3, oncostatin M, and interleukin‐10 (p = 0.007, 0.04, 0.019, 0.019). Regenerated dermis was significantly thicker in DCD and autografts 28 days post‐injury compared with control and CG samples (p = 0.003 and <0.0001). In conclusion, variable fibrotic outcomes were observed in skin substitute‐treated wounds with reduced scarring in autograft and DCD samples compared with controls. OCT enabled concurrent assessment of wound morphology and quantification of dermal fibrosis.     

Persistent Ischemia Impairs Myofibroblast Development in Wound Granulation Tissue a New Model of Delayed Wound Healing

Skin substitutes are slowly finding a position in the treatment of burns, scar reconstructions and chronic wounds. Some of the substitutes consist of extracellular matrix replacement material only, such as Integra and Alloderm; some include allogeneic cells (Dermagraft, Appligraf). The ideal skin substitute has not been developed yet, since none of the presently available products can ultimately prevent scar formation.
Study of the role of autologous fibroblasts in the healing process might give further insight into the scarring process and eventually lead to improved skin substitutes.
We compared wound reepithelialization of experimental wounds treated with proliferating keratinocytes and a dermal substitute with either dermal fibroblasts, adipose tissue derived fibroblasts or no fibroblasts. We also investigated the rate of keratinocyte migration of human skin equivalents cultured in vitro in the presence of dermal or adipose tissue derived fibroblasts.
We reached successful wound closure in 8 days with transfer of proliferating keratinocytes on a dermal substitute seeded with dermal fibroblasts. However, the wounds treated with substitutes which contained adipose tissue derived fibroblasts or no fibroblasts at all were not closed even after 21 days.
Keratinocytes seeded onto collagen lattices populated with either dermal or fat‐derived fibroblasts showed similar findings: a retarded migration and/or proliferation of keratinocytes on the collagen lattices with fat‐derived fibroblasts. The collagen lattices populated with fat‐derived fibroblasts also showed a marked contraction, up till 50% of the original area.
In both models, more alpha‐smooth muscle actin positive cells were found in the fibroblast population from adipose origin.
We conclude that epidermal regeneration is negatively influenced by the presence of fat‐derived fibroblasts in a dermal matrix; possibly, myofibroblasts play a role in this.     

Hyalomatrix PA(®) in skin substitutes. About 10 cases

During the surgical treatment of burns and reconstructive surgery, we can use autografts, allografts, xenografts or dermal substitutes. Acellular dermal substitutes, implantable medical devices of class III are composed mostly of collagen but also, more recently, derivatives of hyaluronic acid (Hyalomatrix PA(?)). Their mechanism of action is based on revascularization and colonization by fibroblasts of the patient. They are then used to screen for delayed epidermal grafting (2-stage procedure for Integra(?), Matriderm(?) 2mm, Renoskin(?), Hyalomatrix PA(?)) or simultaneous (1-time procedure for IntegraSL(?), Matriderm(?) 1mm). We report 10 cases of clinical use of Hyalomatrix PA(?) in the service of burns and plastic surgery of Nantes.     

无细胞真皮基质与自体皮片复合移植的临床应用

目的：改善烧伤创面移植皮片愈合后皮肤的外形和功能,并减轻供皮区瘢痕增生。方法：应用自制的无细胞真皮基质与自体刃厚皮片复合移植于4例切（或削）痂后的烧伤创面。结果：未发现对复合移植皮片的排异反应。创面愈合后,大体观察发现移植自体网状皮片及自体小皮片的轮廓界面变得不明显或基本消失,自体大张皮片与真皮基质复合移植区出现较厚而特殊的脱屑,均反映了愈合过程的特殊性。光镜和电镜观察发现复合皮片移植区棘细胞间桥粒清晰,基底膜连续而完整等。与对照部位相比,复合皮片移植区瘢痕增生减轻,未见明显挛缩,皮肤弹性较好。结论：在3－4个月的观察期内,自体刃厚皮片与无细胞真皮基质复合移植后,功能和形态等同或优于单纯自体刃厚皮片移植。     

Vertical (two-layer) skin grafting: new reserves for autologic skin

The main, permanent source of burn coverage continues to be autologic skin. In patients with major burns, the amount of available autologic skin may be insufficient. Consequently, severe wounds are covered after debridement with other biological or synthetic skin substitutes. Another source of skin reserves for wound coverage is the use of cultured keratinocyte sheet graft alone or with any dermal substitute. Some of these materials provide only temporal coverage and are often costly and time-consuming in preparation. These factors can be critical in burned patients. To expand the effective means of wound coverage, the authors sought a new source of autologic skin. The dermal grafts that were the marginal product of skin harvesting were meshed and grafted on the debrided third-degree burn, granulated wound, or muscle. The authors observed good dermal grafts "take" with rapid or slow epithelialization. They saw no the delay in donor site healing where the skin grafts overlapped. The histological difference in usual skin grafts and dermal grafts was studied after their harvesting and "taking."     

028 Clinical Trials of Allogenic Cultured Dermal Substitute for the Treatment of Burn Wounds

Aim: Recently, various types of cultured skin substitutes have been developed and some of them are used clinically. This study was designed to evaluate the efficacy of allogenic cultured dermal substitute which was applied to burn injuries in clinical trials such as deep dermal burns and dermal burns. Methods: Allogenic cultured dermal substitute (CDS) was simply applied to the burn wound, over which covering materials were applied to protect CDS. Results: The application of CDS to deep dermal burns was proved to facilitate healthy granulation tissue formation at early stage and epithelialization from the outer margins. When CDS applied to the debrided wound surface of dermal burns, an excellent wound bed was generated which was suitable for the graft take of an autologous patch. Conclusion: CDS provides an excellent epithelialization and granulation for burn wounds.     

Conservative surgical debridement as a burn treatment: Supporting evidence from a porcine burn model

In thermal deep‐dermal burns, surgical debridement is normally used in conjunction with skin grafting or skin substitutes and debridement alone as a burn treatment is not usually practiced. The current study addresses whether or not debridement alone would enhance burn wound healing on small deep‐dermal‐partial thickness burns. This was a prospective and blinded experimental trial using a porcine deep‐dermal‐partial thickness burn model. Four burns, approximately 50 cm² in size, were created on each of eight pigs. Two burns from each pig were immediately surgically debrided and the other two were not debrided as the internal control. Hydrate gel together with paraffin gauze were used to cover the burns for four pigs and silver dressings for the other four. Clinical assessment of wound healing was conducted over a 6‐week period. Skin samples were collected at the end of the experiment and histopathological evaluation was performed. The results show thinner scar formation and lower scar height in the debrided compared with nondebrided wounds in the hydrate gel/paraffin gauze groups. There were no statistically significant differences in wound healing assessment between the debrided and nondebrided wounds dressed with silver dressings. This study provides supporting evidence that immediate debridement with an appropriate dressing and without skin grafting may promote wound healing, suggesting its potential benefit for clinical patients.     

Principles and practices for treatment of cutaneous wounds with cultured skin substitutes

BACKGROUND: Skin substitutes prepared from cultured skin cells and biopolymers may reduce requirements for donor skin autograft, and have been shown to be effective in treatment of excised burns, burn scars, and congenital skin lesions. DATA SOURCES: Cultured skin substitutes (CSS) generate skin phenotypes (epidermal barrier, basement membrane) in the laboratory, and restore tissue function and systemic homeostasis. Healed skin is smooth, soft and strong, but develops irregular degrees of pigmentation. Quantitative analysis demonstrates that CSS closes 67 times the area of the donor skin, compared to less than 4 times for split-thickness skin autograft. CONCLUSIONS: CSS reduce requirements for donor skin autograft for closure of excised, full-thickness cutaneous wounds, and demonstrate qualitative outcome that is not different from meshed, split-thickness autograft. These results offer reductions in morbidity and mortality for the treatment of burns and chronic wounds, and for cutaneous reconstruction.