Initial experience of Integra in the treatment of post-burn anterior cervical neck contracture

Use of Integra dermal regeneration template in burn patients: An Italian expert consensus Delphi study

INTRODUCTION

Burn injuries pose significant challenges in healthcare, with Integra dermal regeneration template (DRT) emerging as a prominent solution to enhance wound healing and recovery. Although there is no clear consensus on its technical use and application. We convened a panel of 14 burn specialists aiming to provide consensus regarding the application and usage of Integra in managing burn wounds.

METHODS

Panelists employed a modified Delphi technique to assess agreement and provide feedback on 81 initial statements covering various aspects of Integra DRT application in burn wound care over three subsequent rounds. This study was endorsed by the Italian Society of Burn Surgery (SIUST).

RESULTS

Fourteen heads of burn unit departments participated in the Delphi process. At the end of the third round and subsequent discussion on the final statement list, the panel achieved consensus on 24 statements shaping recommendations for Integra application across various aspects, including wound bed preparation, acellular dermal matrix application, definitive coverage, and complication management.

CONCLUSION

The resultant 24 finalized statements from this Italian consensus offer a comprehensive and practical framework for employing Integra DRT in burn patient care. Reflective of specific Italian expertise and practice, these recommendations supplement and refine existing literature, serving as a dynamic guide subject to periodic updates aligned with evolving evidence and experience in the field of burn surgery.

Integra® Dermal Regeneration Template: From Design to Clinical Use

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

Contemporary Aspects of Burn Care

The past one hundred years have seen tremendous improvements in burn care, allowing for decreased morbidity and mortality of this pathology. The more prominent advancements occurred in the period spanning 1930-1980; notably burn resuscitation, early tangential excision, and use of topical antibiotic dressings; and are well documented in burn literature. This article explores the advancements of the past 40 years and the areas of burn management that are presently topics of active discussion and research.

Dermal regenerative matrix use in burn patients: A systematic review

BACKGROUND

Dermal regenerative matrices (DRMs) have been used for several decades in the treatment of acute and reconstructive burn injury. The objective of this study was to perform a systematic review of the literature to assess clinical outcomes and safety profile of DRMs in full-thickness burn injury.

METHODS

Comprehensive searches of MEDLINE, EMBASE, CINAHL, and Cochrane Library were performed from 1988 to 2017. Two independent reviewers completed preliminary and full-text screening of all articles. English-language articles reporting on DRM use in patients with full-thickness burn injury were included.

RESULTS

Literature search generated 914 unique articles. Following screening, 203 articles were assessed for eligibility, and 72 met inclusion criteria for analysis. DRM was applied to1084 patients (74% acute burns, 26% burn reconstruction). Of the twelve studies that described changes in ROM, significant improvement was observed in 95% of reconstructive patients. The most frequently treated reconstructive sites were the neck, hand/wrist, lower extremity, and axilla. Vancouver scar scale was used in eight studies and indicated a significant improvement in the scar quality with DRM. The overall complication rate was 13%, most commonly infection, graft loss, hematoma formation, and contracture.

CONCLUSIONS

Although variability in functional and cosmetic outcomes was observed, DRM demonstrates improvements in ROM and scar appearance without objective regression. Essential demographic data were lacking in many studies, highlighting the need for future standardization of reporting outcomes in burns following application of dermal substitutes.

Aesthetic and Functional Rehabilitation of Postburn Maxillofacial Deformity

Postburn maxillofacial deformities, although rare, are a significant cause of morbidity. Since contracture scars have a potential role in deforming the maxillofacial skeleton, the focus of treatment should be on growing patients, where scar contractures can drastically influence growth and morphology of the maxillofacial units. There are certain aspects of severe facial burns and deformities, especially of the jaws, that deserve sincere attention to overcome aesthetic and functional disabilities such as inability to masticate and incompetent lips. The purpose of this article, therefore, is to discuss these injuries, the mechanism of development of deformities of the jaws and associated structures and their management for better aesthetic, functional, and psychological health of patient. An interpretive clinical report is presented.

Neodermis Formation in Full Thickness Wounds Using an Esterified Hyaluronic Acid Matrix

The role of the dermis is essential for the proper orchestration of all phases of the normal wound healing process. Wounds with seriously damaged or even absent dermis consistently show seriously impaired wound healing and/or long-term complications such as hypertrophic scarring. Replacing a damaged dermis requires a dermal matrix that is compatible with, or even stimulates, the process of wound healing. Hyaluronic acid (HA), in an esterified form, is among the many matrices that are available. HA has been used in a number of indications, such as ulcers (ie, diabetic foot ulcers and venous leg ulcers), trauma, including burns, and for the repair of contractures and hypertrophic scars. The shorter healing time and the decrease of recurring hypertrophy demonstrate the efficiency of HA-derived matrices. Biopsies, taken up to 12 months post-reconstruction show a neodermis that histologically is largely comparable to normal skin, which probably is a function of HA playing such a pivotal role in normal, unwounded skin, as well as in the process of healing.

Treatment of Large Scars in Children Using Artificial Dermis and Scalp Skin Grafting

BACKGROUND AND OBJECTIVES

Large scars formed after burns injury can seriously hamper appearance and function in children. Surgical resection of scars and secondary skin or flap grafting often brings severe damages to donor sites, which may lead to physiological and psychological development disorders in children. Here, we introduce the use of artificial dermis and skin grafts from scalps to treat large scars in children to minimize the donor site morbidity.

METHODS

A retrospective char review was performed including 7 children with large scars between January 2016 and December 2017. First, the scars were resected, and artificial dermis was applied to the secondary wounds. Twelve days later, outer silicone membrane was removed. Another 2 days later, scalp skin grafts of 0.3 mm were transplanted to the wounds. Manchester Scar Scale and Visual Analog Scale were used to evaluate scar appearance before and after the treatment respectively. One special patient with extensive scars was treated twice at an interval of 1 year. The first therapy was performed with both conventional method of resection and skin grafting and the new method described above. In the second therapy, 4 samples were taken from 4 different sites-the normal skin, scars, the skin where artificial dermis and scalp skin grafting were performed, and the skin where only scalp skin grafting was performed. H-E staining, Masson staining, Aldehyde fuchsin staining, and scanning electron microscopy were used for histological observation.

RESULTS

All skin grafts survived well. The Manchester Scar Scale score of the graft area was significantly reduced (P < 0.01) after the treatment. Histological examination showed obviously better dermis arrangement where artificial dermis and scalp grafting was performed.

CONCLUSION

The therapy achieves better appearances and minimizes donor site morbidity. It is beneficial to physical and psychological development of children and provides an alternative to treat children with large scars.

The Use of Dermal Skin Substitutes for the Treatment of the Burned Hand

The hand is commonly affected in burn injuries. Joints and extensor tendons are vulnerable given their superficial location. Durable coverage that permits relative frictionless tendon gliding and minimizes scar contracture is required to optimize functional outcomes. When soft tissue donor sites are limited, the use of dermal skin substitutes provides stable coverage with minimal scarring, good mobility, and acceptable appearance. A comprehensive review of dermal skin substitutes and their use with burn reconstruction of the hand is provided.

Postburn neck anterior contracture treatment in children with scar-fascial local trapezoid flaps: a new approach

One of the dramatic consequences of burns is scar contracture and deformities of the neck. Cervical contracture in children is especially dangerous, leading to face disfigurement and kyphosis; therefore, early reconstruction is indicated. Despite the existence of many various surgical techniques, the successful neck contracture treatment in pediatric patients remains a challenge for surgeons. Eleven children (aged 5 to 14 years) with postburn neck anterior contractures were studied to develop a new approach for reconstruction that would employ the use of local scar-fascial flaps. The new approach and technique for postburn pediatric contracture treatment was developed which is especially effective in the treatment of children who cannot undergo complex and long surgical procedures that are aimed at both contracture elimination and neck skin restoration. The technique consists of two trapezoid scar-fascial flaps mobilization which includes all the anterior neck surfaces and consists of scars, fat layer, platysma, and deep cervical fascia. Counter transposition of flaps with tension elongated neck anterior surface was 100 to 200%. The contracture was fully eliminated, and neck contours, mentocervical angle, and head movement were restored. In case of severe contracture, residual wound in submandibular region and above clavicles were skin-grafted. The full range of head motion (functional results) was achieved in all the 11 patients. The flaps continued to grow and the skin grafts shrinkage was moderate. Local trapeze-flap plasty allows neck contracture elimination in children in the cases when a more complex technique is impossible or undesirable to use. Early surgical intervention prevents secondary complications, allotting enough time for patients to mature and be ready for more complex procedures.

Tissue engineering in burn scar reconstruction

Nowadays, most patients with severe burns will survive their injury. This evolution is accompanied by the challenge to cover a large percentage of total body surface area burned. Consequently, more and more patients have to deal with the sequelae of burn scars and require (multiple) reconstructions. This review provides a gross overview of developments in the field of tissue engineering for permanent burn wound coverage and reconstructive burn surgery, focusing on usage and clinical effectiveness. Not only skin substitutes will be discussed but also the replacement of subcutaneous fat tissue and cartilage.

Integra® dermal regenerative template application on exposed tendon

BACKGROUND

Tendon without paratenon presents the reconstructive surgeon with a tissue coverage challenge. Integra® dermal regenerative template has been shown to initiate a stable, vascularized bed for skin grafting over tendon. However, histological processes that occur during incorporation have not been described. The purpose of this study is to characterize the pattern of changes that occur when Integra® is applied to an avascular tendon. We hypothesize that vascular incorporation will originate from the wound periphery and proceed toward the tendon center.

METHODS

A full-thickness defect was created over a denuded Achilles tendon in a single hind limb in eight New Zealand white rabbits. Integra was placed over the avascular tendon, and the limb was dressed and splinted. Two animals were euthanized at each timepoint (weeks 1, 2, 3, and 4), and hematoxylin and eosin (H&E)-stained tissue specimens were microscopically evaluated.

RESULTS

Week 1 specimens demonstrated limited adherence between Integra and the tendon, while myofibroblasts were found encircling the tendon. No cellularity was noted centrally. At week 2, the dermis-Integra junction had increasing vascularity and the central portion developed increasing cellularity. By week 3, Integra was completely revascularized. At week 4, Integra had the histological appearance of normal dermis.

CONCLUSION

Neovascularization of Integra® over exposed tendon occurs from the peripheral tissue. Ingrowth proceeds from the dermis-Integra interface toward the center of the graft. Four weeks after application to the denuded tendon, Integra has the histological appearance of native dermis.

Integra™ permits early durable coverage of improvised explosive device (IED) amputation stumps

INTRODUCTION

Improvised explosive device (IED) blasts cause serious injury. Survivors are left with multiple amputations, considerable soft tissue loss and open fractures with gross contamination. We present our early experience of Integra™ in the acute management of military wounds.

METHOD

The clinical records of all patients with IED injuries who underwent early reconstruction with Integra™ during the six month period between August and December 2009 in our unit were reviewed and data gathered prospectively.

RESULTS

There were 7 male soldiers, aged 21-31 years (mean=26). All sustained trunk and limb injuries, including multiple amputations. Number of procedures prior to application of Integra™ was 4-10 (mean=5). Application of Integra™ took place 6-24 days post-injury (mean=13). Size of wounds covered with Integra™ was 1-11.5% TBSA (mean=5%). Anatomical sites reconstructed included amputation stumps, and both upper and lower limbs. There was partial take of Integra in 3 wounds in 2 patients. All wounds were eventually treated with delayed split skin grafting and healed satisfactorily.

CONCLUSION

IEDs produce a large zone of injury with massive soft tissue damage, multiple discontinuous wounds which are significantly contaminated. The physiological insult is equivalent to a large cutaneous burn and there is a paucity of available donor sites. Multiple amputees also have a greater energy and power requirement(1-4) and cannot spare remaining functional muscles as donors. The literature suggests that microvascular flaps have a high failure rate in military patients.(5) Reconstruction began as soon as wounds were considered sufficiently clean. Integra™ was applied with the aim of providing higher quality coverage than that provided by split skin grafting alone (particularly for amputation stumps) whilst minimising operative time and morbidity. Integra™ allows timely closure of battlefield wounds with minimal operative time and morbidity. The procedure can begin whilst still in the acute phase and certainly before one would consider lengthy complex operations such as free flaps. Our experience suggests that Integra™ can allow early closure with robust tissue, promoting early rehabilitation and return to duties.

Burns: treatment and outcomes

Burns can cause extensive and devastating injuries of the head and neck. Prevention of the initial injury must always be a priority, but once an injury has occurred, then prevention of progression of the damage together with survival of the patient must be the immediate goals. The acute care will have a major influence on the subsequent scarring, reconstructive need, and long-term outcome. In the majority of cases, the reconstruction will involve restoration of form and function to the soft tissues, and the methods used will depend very much on the extent of scarring locally and elsewhere in the body. In nearly all cases, a significant improvement in functional and aesthetic outcomes can be achieved, which, in conjunction with intensive psychosocial rehabilitation, can lead to high-quality patient outcomes. With the prospect of facial transplantation being a clinical reality, the reconstructive spectrum has opened up even further, and, with appropriate reconstruction and support, no patient should be left economically deprived or socially isolated after a burn injury.

Two-stage reconstruction of head and neck defects after tumor resection with a dermal regeneration template

BACKGROUND

Large defects after tumor resection in the head and neck area can be reconstructed with local flaps or skin grafts or heal by secondary intention. Especially in elderly patients, a rapid procedure with an acceptable aesthetic and reliable functional outcome is required.

OBJECTIVE

We investigated an alternative strategy using the Integra Dermal Regeneration Template (IDRT) for the reconstruction of large defects.

METHODS

In 18 patients (75 ± 3 years), 19 extended head and neck defects were treated with IDRT to enhance healing.

RESULTS

The mean defect size was 32 ± 7 cm2. The defects were transplanted within a mean postoperative time of 25 ± 2 days and overall showed good cosmetic results and stable scars. The mean follow-up time was 11 ± 1 months. Minor complications were hyperpigmentation (n  =  1), small ulcus (n  =  1), one minor ectropion (n  =  1), and partial loss of the skin graft after immediate radiotherapy (n  =  1). In one patient, the silicon layer had to be removed after 8 days owing to partial destruction of the IDRT. We observed shrinkage of 50 ± 4% within 6 months.

CONCLUSION

IDRT is an alternative technique for the reconstruction of extended head and neck defects. It can be conducted without major complications and with a short healing time and acceptable cosmetic results in elderly patients.

The contribution of a dermal substitute in the three-layers reconstruction of a nose tip avulsion

Through and through defects of the nasal ala still remains debated challenge in plastic reconstructive surgery. We present a 36 y.o. woman who suffered by a through and through nose tip avulsion subsequently a dog bite. She refused the use of traditional auricular composite graft or the multiple stages midline forehead flap due to the secondary visible scars. We treated her with the combined use of mucoperichondrial septal flap, cartilage graft and dermal substitute Integra graft, followed by a secondary, full-thickness skin graft. We consider the Integra(®) as a useful option for the treatment of a complex trauma of the nose with through and through tip and alar avulsion when, due to scar or consent problem, it's not possible the use of other techniques.

An overview of war-related thermal injuries

Thermal injuries have always been a source of morbidity and mortality in times of war. Historically, they constitute 5% to 20% of all injuries and approximately 4% mortality. Although burn patients constitute a small number of casualties, they consume a disproportionate amount of resources and require specialized care. The current conflicts in the Middle East report similar numbers for thermal injuries despite improvement in predeployment education to reduce noncombat-related burns, flame retardant military clothing, and decline of war patterns usually associated with increased thermal injuries. However, the increased use of improvised explosive devices and vehicle-borne improvised explosive devices presents a new source of potential thermal injury. Indeed, the burden of explosion-related burns has increased as has its associated Injury Severity Score. As has been the case in previous conflicts, most burns are hand and head burns. Although usually not life threatening, burns to hands and face lead to significant physical and psychologic morbidities. In this paper, we will review the currently available literature on war-related thermal injuries in Operation Iraqi and Operation Enduring Freedom. We will describe the epidemiology of burn injuries, prewar preparation to prevent and treat thermal injuries, and the assessment, triage, and final treatment of burn patients. In addition, we will discuss the associated physical and psychologic morbidities and, finally, the role of plastic surgeon in burn rehabilitation and reconstruction.

Use of acellular dermal regeneration template in a complete finger degloving injury: case report

Finger degloving injury remains one of the most difficult challenges in hand reconstructive surgery. We report the use of an acellular dermal regeneration template to create a neodermis, followed by a secondary, full-thickness skin graft on a complete finger degloving injury, achieving a satisfactory recovery of range of motion and a cosmetically acceptable result.

Dentoalveolar development in beagle dogs after palatal repair with a dermal substitute

INTRODUCTION

Our aim was to compare the dentoalveolar development in beagle dogs after palatal repair according to the Von Langenbeck technique with and without implantation of a dermal substitute.

METHODS

Nineteen beagles (age, 12 weeks) were assigned to 2 experimental groups and an untreated control group. Palatal surgery was performed with the Von Langenbeck technique in the 2 experimental groups. The dermal substitute Integra (Plainsboro, NJ, USA) was implanted in 1 experimental group, and the other served as sham group. Dental casts were made before surgery and at several times in all groups to measure dentoalveolar development. Transversal distances, arch depth, tipping, and rotation were determined. Histologic evaluations were performed at 3, 7, and 15 weeks after surgery. The degrees of reepithelialization and tissue organization were evaluated microscopically.

RESULTS

All wounds healed without complications. Scar tissue attached to the bone was found in both experimental groups. Deposition of bone in the Integra occurred after implantation, indicating its osteoconductivity. Transversal dentoalveolar development was similar in both experimental groups, but it was significantly less than in the control group.

CONCLUSIONS

Implantation of Integra after the Von Langenbeck procedure for palatal repair does not improve dentoalveolar development.

Burn reconstruction: the problems, the techniques, and the applications

Many patients continue to experience problems long after burn wounds have closed. Contracture and deformity are frequent sequelae of the scar tissue that is formed secondary to thermal trauma. A variety of techniques are available to the burn reconstructive surgeon, ranging from simpler grafting methods to complex free-tissue transfers. In this article, the clinical applications of these procedures are discussed, with examples of management techniques for selected problems commonly encountered by the reconstructive surgeon.

Reanimation of thumb extension after upper extremity degloving injury treated with Integra

A case of severe degloving injury to the left hand with complete destruction of the extensor apparatus of the thumb and exposure of the IP joint is presented. The damaged area was resurfaced with the use of the Integra template and the abductor pollicis longus tendon, lengthened with a tendon graft provided by the extensor indicis, and used to restore thumb extension. The transfer was performed through a prefabricated sheath under the Integra resurfaced area in a two-staged procedure. The final result was functional and aesthetically satisfying.

Laser in the treatment of hypertrophic burn scars

This prospective study looked at the outcome of laser (light amplification by stimulated emission of radiation) treatment for hypertrophic scarring. Dermatrade mark K laser (a set of combined lasers erbium:yttrium aluminium garnet/carbon dioxide, qualified as a class IV laser) was used. Between 21 June 2000 and 19 November 2002, at the Siemianowice Burn Center, Poland, 592 interventions, using laser, were performed on N= 327 patients (220 women and 107 men, aged between 3 and 80 years). The majority of cases [N= 223 (68.9%)] were patients with post-burn hypertrophic scars, and 104 cases (31.8%) had various types of hypertrophic scars. Evaluation took place using an adapted Vancouver Scar Scale and digital photographs as well as the patient's opinion. It was noted that after laser treatment, satisfactory results were achieved in 72% of cases. The scars had become less red (192/327 scored no redness at the end of the study versus 92/327 upon initial), less raised (272/327 scored a flat scar versus 72/327 upon initial) and demonstrated an improved viscoelasticity (192/327 scored a soft skin versus 62/327 upon initial). Laser treatment did not improve contractures in post-burn hypertrophic scars. Results were not confirmed using objective measurement tools, as these were not available to us.

Evaluation of a Collagen-Glycosaminoglycan Dermal Substitute in the Dog Palate

Tissue shortage complicates surgery of cleft lip and palate. The healing of defects on the palate impairs growth of the dentoalveolar complex because of scar tissue formation. Implantation of a matrix into the wound might overcome this adverse effect. Integra with and without a silicone top layer was implanted into standardized full-thickness wounds (Ø 6 mm) in the palatal mucoperiosteum in beagle dogs. In some wounds, the silicone layer was removed after 14 days. Control wounds did not have an implant. At 2 and 4 weeks post-surgery, the wounds were assessed for epithelialization, inflammation (hematoxylin and eosin, leucocyte protein L1), number of myofibroblasts (alpha smooth muscle actin), and general histological characteristics. Wounds filled with Integra without the silicone layer showed fewer myofibroblasts and inflammatory cells than the sham wounds. Collagen fibers were more randomly orientated in these wounds than in the sham group. Wound closure was found to be retarded, and many inflammatory cells were present when Integra with silicone was implanted. The silicone layer was lost within 4 weeks in these wounds. We conclude that, in the moist oral environment, the silicone of Integra is not required. Re-epithelialization and tissue integration proceed more favorably without it. Further research in the dentoalveolar development with Integra will be conducted in a simulated cleft palate repair in the dog model.

Supraclavicular bilobed fasciocutaneous flap for postburn cervical contractures

Anterior cervical contractures after burn are a common problem in the treatment of sequelae in burnt patients. The contracture itself and the hypertrophic scarring can cause functional limitation and aesthetic disfigurement. As a consequence, the reconstruction of this area is a challenge to surgeons that must choose a procedure, which improves functionality and aesthetic appearance in addition to reversing the contracture, the surgical goal of avoiding a new scar band over time is added. We present three patients with moderate (grade II) cervical contractures caused by suicide attempt and reconstructed by means of a bilobed flap based on the supraclavicular axis with the purpose of avoiding grafts in the donor area and performing it in a single procedure. This flap is useful and reliable for reconstruction of defects caused by cervical scars in non-collaborative and psychologically unstable patients. The anatomy, surgical procedure and results in our series are presented in this article.

The Use of Artificial Dermis in the Reconstruction of Oncologic Surgical Defects

BACKGROUND

Integra dermal substitute has been used in burn reconstruction with great success. Its use in general reconstruction is currently being reported. The authors set out to evaluate the utility of Integra in the reconstruction and resurfacing of defects created by tumor excision.

METHODS

Since 2003, 17 patients with soft-tissue tumors involving the head and neck, lower extremity, and anterior chest wall underwent tumor resection and reconstruction with Integra dermal substitute. These patients were followed and clinical outcomes were assessed.

RESULTS

Seventeen patients with a mean age of 54 +/- 21 years underwent tumor resection and reconstruction with Integra dermal substitute. Twelve patients (71 percent) were male and five (29 percent) were female. Twelve cases (71 percent) involved recurrent tumor resection. The 17 cases involved 10 different tumor types at six different anatomical locations. The mean defect size was 172 +/- 260 cm (range, 20 to 1080 cm). The second stage of the reconstruction occurred on postoperative day 23 +/- 6. The mean follow-up was 12.3 +/- 7.2 months (range, 3 to 26 months). Clinically, 16 patients had 100 percent take of skin grafts and one patient had approximately 97 percent take of his graft. All patients experienced excellent defect contouring and cosmesis.

CONCLUSIONS

Artificial bilaminate acellular dermis is an excellent option for reconstructing defects created by tumor resection and can be used in a wide variety of locations. It is especially useful in large defects that usually require flaps for coverage. Patients experience minimal donor-site morbidity and have outstanding cosmetic and functional results.

Use of Integra in a paediatric upper extremity degloving injury

Dermal substitutes such as Integra have been used in surgery since 1981. This product was developed to cover large skin burns but it may have a role in reconstructive upper limb surgery. In upper extremity avulsion, the choice of skin cover depends on many variables. Dermal substitute is an alternative when split-thickness skin grafting is appropriate. We present a case of severe upper limb avulsion, or 'degloving', in a child of 9 years old which was treated successfully with Integra. Integra is particulary useful in growing children to cover large skin losses.

An algorithm for the release of burn contractures of the extremities

Burn contractures of the extremities present a clinical challenge. Flexion contractures are more common than extension contractures. The first component of treatment is adequate contracture release. A number of different methods are available for resurfacing the wound and these are reviewed. An algorithm is presented which permits a simple approach to managing burn scar contracture of the extremities.

Complex Wound Management Utilizing an Artificial Dermal Matrix

The benefits of the Integra Dermal Regeneration Template in the management of extensive burn injuries have been well documented. Integra can reduce donor- and graft-site scarring and has been reported to be capable of vascularizing over small areas of exposed bone and tendon. Given these potential advantages, we have used Integra for a variety of other reconstruction applications. We performed a retrospective review of patients with complex wounds treated with Integra at our burn center. Integra was used in the management of a variety of wounds, including necrotizing fasciitis, extremity degloving injury, meningococcemia, Marjolin ulcer, postburn lip reconstruction, and fourth-degree burns with exposed bone or tendon. Engraftment rates of Integra and autograft were 98% +/- 4% and 97% +/- 4%, respectively. All areas of graft loss healed without need for regrafting. The benefits of Integra in the management of acute burn wounds can be extended to other traumatic and complex wounds.

Model for human skin reconstructed in vitro composed of associated dermis and epidermis

CONTEXT AND OBJECTIVE

The technique of obtaining human skin with dermis and epidermis reconstructed from cells isolated from patients can enable autologous skin grafting on patients with few donor sites. It also enables in vitro trials on chemicals and drugs. The objective of this work was to demonstrate a method for obtaining human skin composed of associated dermis and epidermis, reconstructed in vitro.

DESIGN AND SETTING

Experimental laboratory study, in the Skin Cell Culture Laboratory of Faculdade de Ciências Médicas, Universidade Estadual de Campinas.

METHODS

Cells from human fibroblast cultures are injected into bovine collagen type I matrix and kept immersed in specific culturing medium for fibroblasts. This enables human dermis reconstruction in vitro. On this, by culturing human keratinocytes and melanocytes, differentiated epidermis is formed, leading to the creation of human skin composed of associated dermis and epidermis, reconstructed in vitro.

RESULTS

We showed that human skin composed of associated dermis and epidermis can be successfully reconstructed in vitro. It is histologically formed in the same way as human skin in vivo. Collagen tissue can be identified in the dermis, with cells and extracellular matrix organized in parallel to multilayer epidermis.

CONCLUSIONS

It is possible to obtain completely differentiated human skin composed of associated dermis and epidermis, reconstructed in vitro, from injection of human fibroblasts into bovine collagen type I matrix and culturing of human keratinocytes and melanocytes on this matrix.

Dermal regeneration template in the surgical management of diabetic foot ulcers: a series of five cases

Soft-tissue defects in the feet of patients with diabetes continue to pose a challenge because adequate debridement often leaves an extensive defect with exposed bone, tendon, and cartilage. The use of a dermal regeneration template followed by split-thickness skin grafts in the treatment of recalcitrant diabetic foot wounds was retrospectively reviewed. In a case series of 5 patients with diabetes and extensive tissue deficits of the foot, the use of a dermal regeneration template and split-thickness skin graft enabled closure of the lower-extremity defect. All patients completely healed and were able to resume ambulation with the aid of extradepth shoes and multidensity insoles. The take of the dermal regeneration template was excellent in all patients, and the grafts (dermal regeneration templates and split-thickness skin) were durable even when placed on difficult areas such as the plantar surface and heel. No infections occurred. Exposed bone, tendon, cartilage, and fascia were successfully covered. The experience in this case series suggests that the use of the dermal regeneration template followed by split-thickness skin graft offers an option for patients with diabetes with chronic wounds that have foot defects as a result of extensive tissue loss resulting from infection.

Stacking of a dermal regeneration template for reconstruction of a soft-tissue defect after tumor excision from the palm of the hand: a case report

Excision of tumors from the hand often leaves tissue defects with exposed tendons or neurovascular structures that require coverage. Various types of free and pedicled grafts have been described for use in these situations. We present a patient who had a tumor excision in the hand followed by wound coverage with a stacked dermal regeneration template. A 50-year-old man presented with a mass over the palm of the hand. He had an incisional biopsy procedure, the results of which suggested malignancy. He then had wide excision with planned temporary skin coverage with a dermal regeneration template. The dermal template incorporated nicely. With adequate skin coverage the palmar defect still was substantial in terms of depth. This was raised with layering or stacking of the template followed by a split-thickness skin graft. Excellent wound healing and coverage of the defect ultimately were achieved. Additionally the patient went on to obtain full range of motion. Stacking of a dermal regeneration template coupled with split-thickness skin grafting was used to fill a soft-tissue defect over the median and nerve and flexor tendons after wide tumor excision.

Treatment of second degree facial burns with allografts—preliminary results

Facial burns are very common and have significant clinical impact. However, the treatment regimen for superficial to deep facial burns is not well defined. The purpose of this study was to investigate the effects of cadaver skin grafting in deep partial thickness facial burns in comparison to standard care. In a prospective open study design severely injured patients with superficial and deep partial thickness burns were randomized into the group receiving open treatment with silversulfadiazine (standard n=5) or into the group receiving early superficial debridement followed by coverage with glycerolized cadaver skin (n=5). The outcome measures were time and quality of wound healing, and incidence of hypertrophic scarring at 3 and 6 months post burn. There were no significant differences in demographics between groups. In the group treated with the allogenic material time to reepithelialization was 10.5 days, while it was 12.4 days in the silversulfadiazine group (p<0.05). Scar quality was found to be significantly improved in the allogenic treatment group. Three and 6 months postburn there were no patients with significant hypertrophic scarring in the allogenic group while there were two patients who developed hypertrophic scars in the silversulfadiazine group (p<0.05). In this study, we demonstrated that glyzerolized cadaver allograft skin represents a superior biological dressing for shallow and deep partial thickness facial burns. This is in concordance with other reports on scalds. It would be worthwhile to perform more clinical studies with a larger number of patients to further evaluate the effect and function of allogenic skin for facial burns.

Artificial Dermis as an Alternative for Coverage of Complex Scalp Defects following Excision of Malignant Tumors

BACKGROUND

Artificial dermis has been used successfully for coverage of full-thickness wounds with a well-vascularized surgical bed. However, the use of artificial dermis in the reconstruction of partial- and full-thickness scalp defects has not been well documented.

METHODS

Seven patients (six men and one woman; mean age, 70 +/- 14 years) with partial-thickness (three patients) and full-thickness (four patients) soft-tissue defects of the scalp (mean defect area, 97 +/- 58 cm) following resection of recurrent malignant tumors and/or previous failed reconstructions underwent staged scalp reconstruction with a bilaminate skin substitute (Integra). After adequate debridement of scalp wounds, including burring the outer table of the calvaria down to bleeding bone for full-thickness defects, Integra was scored and applied unexpanded. A split-thickness skin graft (0.011 +/- 0.0 inch in thickness) was placed on the operative site at postoperative day 36 +/- 15 after removal of the silicone layer of the artificial dermis. Two patients required repeated applications of artificial dermis to compensate for contour deficits before skin grafting.

RESULTS

Clinically, all reconstructed areas showed well-vascularized neodermis before skin grafting. There was a 100 percent take of the skin grafts, with no infections or other complications noted. All reconstructive procedures were performed in less than 3 hours of combined operative time, with the last stage performed on an outpatient basis.

CONCLUSIONS

Artificial dermis can be used successfully for reconstruction of complex scalp defects following oncologic resection, offering minimal donor-site morbidity, expedient operative time, and when needed, temporary quality closure until final pathologic results are known. Integra skin may offer another option for definitive management of extensive full-thickness scalp defects.

The use of Integra® in an upper extremity avulsion injury

We present the case of a 22-year-old man who suffered an avulsion injury of the left upper extremity including the elbow region in an industrial accident. After debridement of the skin flap, the defect was primarily closed with Integra. On day 22 split thickness skin graft was performed. Functional and aesthetic outcome and skin quality are excellent.

Update on the use of collagen/glycosaminoglycate skin substitute-six years of experiences with artificial skin in 15 German burn centers

The clinical use of an artificial skin substitute (Integra) has been celebrated enthusiastically as an improvement in burn therapy over a period of more than 10 years. Many case-reports have shown the positive effects of the treatment with Integra as a skin substitute. In this study we examine the alterations of Integra-usage in Germany. Fifteen German burn centres have been interviewed respectively over a time period of 6 years with interviews in the years 1999, 2001, and 2003. The goal of this study is to focus on the problems associated with the use of artificial skin and to create a manual for Integra-therapy including indication, pre-, intra-, and postoperative treatment. Since the first Integra Users seminar in Germany in 1999 repeated interviews have been conducted with fifteen German burn centres. The collected results of the last 6 years were evaluated. These results show a change in the indication for the therapy with artificial skin towards extensive full thickness burned patients and as extended indication especially for posttraumatic reconstruction. This article gives our guidelines for the usage and handling of Integra and shows that Integra is an important reconstructive dermal substitute for the severely burned or posttraumatic patient if handled by a skilled surgeon in a correct way.

Acceleration of Integra incorporation in complex tissue defects with subatmospheric pressure

In an effort to accelerate vascularization and simplify the care of Integra (Ethicon, Inc., Somerville, N.J.), topical subatmospheric pressure was used for eight patients (age range, 2 to 60 years) with complex wounds. Bone was exposed in 62.5 percent of cases, joint in 50 percent, tendon in 37.5 percent, and bowel in 25 percent. The estimated Integra take rate was 96 percent. Split-thickness skin grafting was performed at 4 to 11 days (mean, 7.25 days), with a 93 percent take rate. No adverse side effects were observed with this technique. Application of subatmospheric pressure improved the take rate and time to vascularization of Integra, compared with previous published results, even with complicated wounds. This technique may be a practical alternative to flap closure.

Dermal regeneration template for deep hand burns: clinical utility for both early grafting and reconstructive surgery

Adequate acute treatment of the deeply burned hand and any subsequent reconstructive procedures may be hampered by the lack of sufficient suitable graft material and the risks of donor site morbidity and scarring. This investigation was designed to determine the feasibility of treating deep hand burns using a dermal regeneration template. Patients with deep hand burns underwent either acute treatment or reconstructive procedures with Integra dermal regeneration template. Wound sites were first grafted with the dermal regeneration template, and then 2-3 weeks later after neodermis formation the silicone layer of the Integra was removed and a very thin split-thickness epidermal autograft placed. Acute grafting was performed on 15 hands in 11 patients and reconstructive surgery on 14 hands in 11 patients. Median follow-up was 12 months. Integra take was 100% on all treated hands. After acute grafting the wound site skin was flexible and supple and did not adhere to the deeper layers, thus permitting free articular and functional movement. Cosmetic results of acute surgery were judged satisfactory by both patients and surgeons. After reconstructive procedures, significant improvements were achieved in cosmetic status, based on Vancouver Scar Scale (p=0.0002), and in three measures of function, namely, thumb opposition score (p=0.0005), fingertip-to-palm distance (p=0.0039) and prehensile score (p=0.0039). Favourable cosmetic and functional outcomes were consistently attained using a synthetic dermal regeneration template for treatment of deep hand burns either by acute grafting or reconstructive surgery.

Burned breast reconstructive surgery with Integra dermal regeneration template

Reconstruction of the burned breast poses several clinical challenges, since scarring can adversely affect the development, contour and positioning of the breast as well as the cosmetic appearance of the skin surface. Conventional management entails contracture release and thick split-thickness skin grafting. We investigated an alternative approach employing dermal regeneration template (Integra) for breast reconstruction in 12 consecutive patients who had suffered anterior chest wall burns in childhood. Integra is a bilayer material consisting of a collagen and chondroitin-6-sulfate dermal regeneration template and a temporary silicone epidermal layer. Portions of the scar contracture preventing the breast from assuming the desired shape and position were excised. Unmeshed Integra sheets were applied to the wound bed immediately following excision. Sufficient vascularization of the forming neodermis occurred within 28 days on average to enable removal of the silicone layer and placement of unmeshed 0.005in. epidermal autografts. Upon histological examination one month postoperatively, naturally-formed collagen fibres were observed in the dermal regeneration template. By one year, host collagen had typically completely replaced the Integra matrix, and elastic fibres were evident throughout the neodermis. Durable improvements in breast contour and shape were attained in all patients, and clinically-relevant recontracture of the graft site did not occur within the follow-up period. A statistically significant improvement of 6.0 (95% CI, 5.0-6.5) in Vancouver Scar Scale score was demonstrated at one year. A very high level of satisfaction in the outcome of reconstruction was expressed by 92% of the patients. Grafting with Integra provides an effective and well-tolerated alter-native to thick split-thickness grafting for breast reconstruction. Chief advantages are the availability of a biocompatible material in unlimited quantity that can be tailored to the particular wound site and the avoidance of a deep donor site wound with attendant potential for infection, scarring and permanent pigment changes.

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

The safety and effectiveness of Integra Dermal Regeneration Template was evaluated in a postapproval study involving 216 burn injury patients who were treated at 13 burn care facilities in the United States. The mean total body surface area burned was 36.5% (range, 1-95%). Integra was applied to fresh, clean, surgically excised burn wounds. Within 2 to 3 weeks, the dermal layer regenerated, and a thin epidermal autograft was placed. The incidence of invasive infection at Integra-treated sites was 3.1% (95% confidence interval, 2.0-4.5%) and that of superficial infection 13.2% (95% confidence interval, 11.0-15.7%). Mean take rate of Integra was 76.2%; the median take rate was 95%. The mean take rate of epidermal autograft was 87.7%; the median take rate was 98%. This postapproval study further supports the conclusion that Integra is a safe and effective treatment modality in the hands of properly trained clinicians under conditions of routine clinical use at burn centers.