The use of MatriDerm in early excision and simultaneous autologous skin grafting in burns--a pilot study

The application of dermal substitutes in deep partial and full-thickness burn wounds in a two-stage procedure prior to skin grafting has become increasingly popular. Synchronous application of dermal substitutes and skin graft has not yet been established as a standard procedure. In a consecutive study 20 wounds in 10 patients with severe burns (age 49.5+/-16.2 years; TBSA 45.6+/-14.5%) were treated with either simultaneous transplantation of Matriderm, a bovine based collagen I, III, V and elastin hydrolysate based dermal substitute and split-thickness skin grafting (STSG), or STSG alone after appropriate excision of the burn wound. The study was designed as a prospective intra-individual comparative study. After 1 week all wounds were assessed for the percentage of autograft survival. Autograft survival was not altered by simultaneous application of a dermal matrix (p=0.015). Skin elasticity was measured after 3-4 months with the Vancouver Burn Skin Score (VBSS). The VBSS demonstrated a significant increase of elasticity in the group with dermal substitutes (p=0.04) as compared with non-substituted wounds for sheet autograft, but not for meshed autograft (p=0.24). From this pilot study it can be concluded that simultaneous application of a dermal matrix is safe and feasible, yielding significantly better results with respect to skin elasticity. Skin elasticity was considerably improved by the collagen/elastin dermal substitute Matriderm in combination with sheet autograft.     

Use of dermal substitute Matriderm® in severe injuries of the hand: about one case

Restoring function after hand burns is still a great surgical challenge. Reconstitution of elasticity and pliability are of utmost importance for hand function and aesthetics results. Dermal substitutes have been developed and have been used for many years. The dermal substitute Matriderm^® is an acellular three-dimensional matrix composed of native structurally intact collagen fibrils coated with elastin obtained from bovine dermis. The possibility of a one-stage procedure is profitable in treatment of hand burns. The authors report the case of a 43-year-old man admitted for severe burn by flames to 18% of his total body surface area with complete full thickness injury of left hand. After debridement incisions in emergency, early excision and skin graft using Matriderm^® were performed. Physical therapy was established at Day 10. At six weeks follow-up, full range of motion was achieved and the patient was able to use his hand in daily activities.     

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."     

Grafting of deeply burned problem zones in the lower extremity with a dermal substitute

Functional results after deep excision and split thickness skin grafts are often limited as a consequence of unstable grafted areas and contractures. In two patients with a full-thickness thermal injury to the lower extremities and one patient with a chronic unstable skin area over the knee, the Integra^TM bilayered membrane dermal substitute was applied. After uneventful dressing changes graft take was complete without infection or other complications. Complete wound closure was achieved in all three patients within 3–4 weeks after the initial operation. The functional range of motion of the involved joints and the skin quality and contour was superior to conventional grafted skin after excision down to fascia and rather more comparable to skin grafts over a tangentially excised eschar. After wound healing, the neodermis was histologically similar to normal dermis. Considering the high incidence of unstable skin and contractures after regular grafting of deeply excised burns, this concept may present a significant improvement not only for the primary but also for secondary reconstructive procedures, with respect to the long-term quality of life for burn patients. Received: 1 December 1997 / Accepted: 13 June 1998     

The treatment of deep dermal hand burns: How do we achieve better results?: Should we use allogeneic keratinocytes or skin grafts?

The treatment of deep dermal burns has a broad spectrum and has been subject to discussion over the past years. The treatment of hand burns is challenging due to the high requirements to aesthetic and functional outcome. 27 patients, 7 women and 20 men with deep dermal hand burns with a mean age of 41.3 ± 16.5 and a mean TBSA of 15% ± 19.6% were treated either with allogeneic cryopreserved keratinocytes or with split skin grafts. Long-term follow-up revealed no statistical significant differences between the two groups concerning Vancouver Scar Scale as well as hand function judged by the DASH score; however there was a tendency to higher VSS scores and impaired aesthetic results in the keratinocyte group. Allogeneic keratinocytes are a suitable armentarium for the treatment of deep dermal hand burns; and, if used correctly, they can produce a timely healing comparable to split-thickness skin grafts. Limited availability, high costs as well as the need for special skills are key factors, which render application of this technique outside specialist burn centres virtually impossible. In our opinion, the cultivation and use of keratinocytes should be reserved to these centres in order to facilitate a sensible application for a full range of indications. We recommend usage of allogeneic keratinocytes for deep dermal hand burns only in severely burned patients with a lack of donor sites. Patients with unrestricted availability of donor sites seem to profit from the application of split-thickness skin grafts according to our results.     

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.     

促进真皮替代物血管化进程的因素

对于严重大面积烧伤患者,自体皮肤组织移植常难以实施。尽管真皮替代物以其优良的理化特性,在烧伤重建外科领域发挥了重大作用,但与传统皮片移植相比,仍存在着血管延迟长入真皮层的缺陷。本文就真皮替代物的特性,以及移植后血管化进程的促进因素进行综述。     

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.     

The use of a polylactide‐based copolymer as a temporary skin substitute in deep dermal burns: 1‐year follow‐up results of a prospective clinical noninferiority trial

Deep dermal burns can be covered with different kind of materials and techniques; one of them is a polylactide‐based temporary skin substitute. The aim of this study was to intraindividually compare its 1‐year outcome with the results obtained by use of autologous skin grafts in patients suffering from deep dermal burns. A prospective noninferiority trial was designed in order to assess skin quality and scar formation by use of subjective (Vancouver Scar Scale; Patient and Observer Scar Assessment Scale) and objective (noninvasive cutometry) burn scar assessment tools. All items of the Patient and Observer Scar Assessment Scale, except vascularity, were found to be noninferior in the areas covered with the temporary skin substitute vs. autologous skin. Results of objective scar evaluation showed comparable viscoelastic parameters without reaching noninferiority. Overall, the outcome of deep dermal burns covered with a polylactide‐based temporary skin substitute revealed satisfactory results in terms of scar formation and skin quality as compared with autologous skin. This paper supports its use in deep dermal burns, where autologous skin donor sites require either to be reserved for coverage of full‐thickness skin defects in severe burns or to be saved for reduction of additional morbidity in selected patient collectives.     

The deeply burned upper extremity: functional graft distribution concept with selective use of a synthetic dermal substitute (Integra) and split-thickness skin grafts

A 15-year-old boy sustained a severe inhalation injury and second/third degree burns following a flame burn involving the face, neck, upper thoracic regions, and upper extremities measuring 25% of his total body surface area. The right arm had a full-thickness burn, the left arm deep partial-thickness burns. Tangential excision and split-thickness skin grafting (STSG) were performed. Because of the full-thickness burns on the right arm, an epifascial excision was necessary on the left arm, sparing the venous tributaries. To reconstruct the epifascially excised extremity, a new concept was used. Split-thickness skin graftings were selectively distributed over the digits, and the remaining zones were covered with a synthetic dermal substitute (Integra). Unfortunately, the dressing changes and the definitive grafting of the synthetic dermal substitute had to be delayed until day 62 because of severe lung failure, acute respiratory distress syndrome (ARDS), the necessity for extracorporeal membrane oxygenation, multiple organ failure, and prolonged intensive care stay. Despite circulatory and ischemic complications, all grafts taken on both extremities after incorporation of the dermal substitute, both immediate and delayed, were complete. There was no infection or other complication. The functional range of motion of all involved joints and the skin surface quality and contour were remarkably good. It is emphasized that the considerations in this report should be considered as preliminary and that further investigations are required.     

Aesthetic Improvements of Skin Grafts in Nasal Tip Reconstruction

Defect closure on the nasal tip subunit still remains challenging. Full-thickness skin transplantation still is used despite its poor outcome in terms of the nasal tip contour caused by lack of dermal tissue. To avoid subsidence deformities associated with nasal tip reconstruction with skin transplants, this study analyzed methods using combined epidermal and dermal replacement. For 30 consecutive patients with a nasal tip defect, a retrospective comparison was made between conventional full-thickness skin transplantation, retroauricular perichondrodermal composite grafts, and skin transplantation supplemented with the collagen-elastin matrix, Matriderm, used as a dermal substitute (n = 10 per study group).The postoperative results were evaluated in a randomized and blind manner by external facial surgeons using the Manchester Scar Scale. The findings showed a marked improvement in nasal tip contour with combined epidermal/dermal replacement without any deterioration in other graft qualities, justifying the additional effort involved in this procedure. Two patients developed fistulae after Matriderm-aided skin transplantation. Therefore, the authors do not consider this a suitable method for nasal tip reconstruction.     

异体脱细胞真皮基质与自体皮片复合移植的临床应用

目的:探讨异体脱细胞真皮基质与自体皮片复合移植修复大面积深度烧伤及瘢痕切除后皮肤缺损创面及其愈合后皮肤的外形和功能。方法:应用异体脱细胞真皮基质与自体刃厚皮片组成复合皮移植,以自体刃厚皮片移植作为对照,采用一步移植法治疗切痂后大面积深度烧伤创面及瘢痕切除后皮肤缺损共56例患者60处创面,观察术后皮片的成活情况、外形及功能恢复情况并随访。结果:60处创面全部愈合,移植皮片生长良好,瘢痕增生不明显,未见明显挛缩,皮肤弹性较好。在6～12个月的观察期内,自体刃厚皮片与异体脱细胞真皮基质复合移植后,功能和形态优于单纯自体刃厚皮片移植;随访2年复合移植未发现明显的排异反应。结论:异体脱细胞真皮基质与自体皮片复合移植修复大面积深度烧伤及瘢痕切除后皮肤缺损创面愈合良好,无瘢痕增生,皮肤外观功能满意,无排异反应。     

真皮替代物移植后的血管化过程及组织学变化的实验研究

目的了解不同种类真皮替代物移植后的血管化过程及组织学变化。方法将21只SD大鼠根据其皮下埋植不同的真皮替代物分为猪脱细胞真皮基质(sADM)组、人脱细胞真皮基质(hADM)组及人工真皮(Integra)组。于埋植后2、3、4、7、10、14、21、30、60、90、120、150、180d行移植物大体观察,采用免疫组织化学法观察移植物的血管化过程及组织学变化。结果大体观察术后各组大鼠创口周围皮肤无明显红肿及炎性反应,切口愈合良好,移植物与创面接触紧密。90d后各组移植物不易从体表触及。180d时,部分移植物面积缩小、厚度变薄甚至难以辨认。组织学观察移植术后2d起可见成纤维细胞、中性粒细胞、淋巴细胞等侵入移植物内,3d时与受床组织连接处可见长入的新生毛细血管芽。30—60d,移植物内形成丰富的血管网。150d后近似正常真皮结构。180d后部分移植物有不同程度吸收退化。结论3种真皮替代物移植后均能很快建立与受床组织的血液循环,并长时间存留于创面,但有一定程度的吸收退化。     

复合皮混合移植治疗深Ⅱ度烧伤患者创面疗效观察

目的观察深Ⅱ度烧伤患者创面削痂术后应用复合皮混合移植治疗的效果。方法对23例烧伤患者的30个深Ⅱ度烧伤肢体在伤后3d内分次行削痂术,削至浅筋膜后移植大张异体脱细胞真皮基质,然后切取大张自体刃厚皮(0.10～0.25mm)覆盖于其上。术后10—12d计算移植皮片的存活率,记录创面愈合时间。观察随访3—6个月时患者的肢体外观及功能恢复情况。取1例患者随访3个月时的愈合创面皮肤标本,行病理学观察。结果本组患者复合皮片成活率为93%,7%的皮片因术中固定较差,移植后自体刃厚皮与异体脱细胞真皮基质分离致皮片坏死,或因感染致皮片溶解。随访3—6个月,移植部位皮肤外观、弹性及功能恢复良好。病理学观察显示,成活皮片表皮、真皮结构正常。结论烧伤后早期削痂立即移植复合皮是治疗深Ⅱ度创面的有效方法。     

New grafts for old? A review of alternatives to autologous skin.

Immediate resurfacing of skin defects is a challenging prospect, especially in patients with extensive full-thickness burns. Currently, split-thickness autografts offer the best form of wound coverage, but limited donor sites and their associated morbidity have prompted the search for alternatives. The application of allogeneic skin is restricted by availability and the risk of transmission of infection, whilst synthetic skin substitutes are simply expensive dressings. The problems of limited expansion may be overcome by culturing keratinocytes in vitro. Unlike autologous cells, allogeneic keratinocytes are available immediately, although they survive for less than a week when applied to full-thickness skin defects. Moreover, the absence of a dermal component in these grafts predisposes to instability and contracture. A cross-linked collagen and glycosaminoglycan dermal substitute, covered with thin split-skin grafts or cultured autologous keratinocytes, shows promise in burns patients. An alternative is a collagen matrix populated by allogeneic fibroblasts and overlaid with cultured autologous or allogeneic keratinocytes. The clinical application of cultured grafts remains imperfect but offers the prospect of immediate coverage and massive expansion.     

Acellular allograft dermal matrix: immediate or delayed epidermal coverage?

In a prospective, randomized study seventeen patients received skin grafts to a freshly excised burn wound. One group was grafted with a deantigenized dermal matrix and immediately overgrafted with thin autograft. The second group was grafted with dermal matrix, which was then covered with bank allograft for protection, and autografted 1 week later. Each group also received a standard split thickness control graft. Assessment was carried out for up to 1 year. There were no statistically significant differences of graft take between any of the groups, or in the Vancouver scar score at follow-up. Thin donor sites used for dermal matrix coverage healed faster than standard control graft sites, P<0.001. Immediate grafting of acellular dermal matrix with thin autograft works well and leads to an acceptable late result, with faster donor site healing than standard split thickness grafts.     

Hautersatzverfahren in der Verbrennungschirurgie

Patients with extensive deep partial or full thickness burns require early excision of necrotic tissue, however, in many of these cases simultaneous autografting is not possible due to the general condition of the patient. In this instance temporary dressings like allogeneic or xenogeneic skin or foam dressings can be applied to minimize fluid and protein loss. In Europe glycerolized preserved allogeneic skin remains the treatment standard. Dermal replacements are considered to optimize the long-term outcome of split thickness skin grafting. Reduced contracture rates and increased pliability have been reported after additional dermal enhancement with either collagen-glycosaminoglycan matrix, acellular allogeneic dermis or collagen/elastin matrix. True regeneration of the dermis has not yet been observed. However, these materials are suitable for improvement of the wound bed and also the final result after split thickness skin transplantation.     

Denatured acellular dermal matrix seeded with bone marrow mesenchymal stem cells for wound healing in mice

It is the basic task of burn therapy to cover the wound with self-healthy skin timely and effectively. However, for patients with extensive burns, autologous skin is usually insufficient, and allogenic or heterogeneous skin leads to strong immune response. It is vital to choose an appropriate treatment for deep extensive burns. Nowadays, the dermal substitute combined with bone marrow mesenchymal stem cells (BM-MSCs) is a prospective strategy for burn wound healing. Denatured acellular dermal matrix (DADM), as one of dermal substitutes, which prepared by burn skin discarded in escharotomy, not only maintains a certain degree of 3D structure of collagen, but also has good biocompatibility. In this study, the preparation method of DADM was improved and DADM was seeded with BM-MSCs. Then BM-MSCs-seeded DADM (DADM/MSCs) was implanted into mice cutaneous wound, and the effect of DADM/MSCs dermal substitute was assessed on skin regeneration. As a result, BM-MSCs survived well and DADM/MSCs scaffolds significantly promoted wound healing in terms of angiogenesis, re-epithelialization and skin appendage regeneration. DADM/MSCs scaffold may represent an alternative promising therapy for wound healing in deep extensive burns.     

异体去细胞真皮基质重建真皮的实验研究

目的　通过不同形式去细胞真皮 (acellulardermalmatrix ,ADM )与单纯自体刃厚皮片移植的比较研究 ,探讨异体ADM作为真皮替代物的机制及效果。方法　猪全层皮肤缺损创面分别行颗粒状 (实验组 1)及网状异体ADM (实验组 2 )结合自体刃厚皮移植 ,以单纯自体刃厚皮移植作对照 ,观察各组移植术后皮片存活率、创面收缩率、组织学变化及血管化程度等。结果　移植术后 ,各组皮片均全部存活 ;与对照组相比 :两实验组创面收缩较小 ,弹性较好 ,创面充血程度轻 (P <0 .0 1) ,瘢痕增生程度也明显小于对照组。结论　网状及颗粒状异体ADM结合自体刃厚皮移植较好地封闭了全层皮肤缺损创面 ;其愈后功能优于单纯自体刃厚皮移植 ;颗粒状ADM制作简单 ,使用方便 ,值得进一步探索研究。