Bioartificial dermal substitute: a preliminary report on its use for the management of complex combat-related soft tissue wounds

OBJECTIVE: To report our institutional experience with the use of a bioartificial dermal substitute (Integra) combined with subatmospheric pressure vacuum-assisted closure (VAC)] dressings followed by delayed split-thickness skin grafting for management of complex combat-related soft tissue wounds secondary to blast injuries. DESIGN: Retrospective review of patients treated December 2004 through November 2005. SETTING: Military treatment facility. PATIENTS/PARTICIPANTS: Integra grafting was performed 18 times in 16 wounds at our institution. Indications for Integra placement were wounds not amenable to simple split-thickness skin grafting, specifically those with substantial exposed bone and/or tendon. INTERVENTION: Patients underwent an average of 8.5 irrigation and debridement procedures and concurrent VAC dressings prior to placement of the Integra. Following Integra grafting, all patients were managed with VAC dressings, changed every 3 to 4 days at the bedside or in clinic, with subsequent split-thickness skin grafting an average of 19 days later. MAIN OUTCOME MEASUREMENTS: The mechanism and date of injury, size of residual soft tissue deficit, indication for Integra placement, number of irrigation and debridement procedures prior to Integra placement, days from injury to Integra placement, days from Integra placement to split-thickness skin grafting, and clinical outcome were recorded. RESULTS: Integra placement and subsequent skin grafting was successful in achieving durable and cosmetic definitive coverage in 15 of 16 wounds with two of these patients requiring repeat Integra application. Two patients with difficult VAC dressing placement had early Integra graft failure but successfully healed following repeated Integra application and skin grafting. CONCLUSIONS: Bioartificial dermal substitute grafting, when coupled with subatmospheric dressing management and delayed split-thickness skin grafting, is an effective technique for managing complex combat-related soft tissue wounds with exposed tendon. This can potentially lessen the need for local rotational or free flap coverage.