Close Relative Intermingled Skin Allograft and Autograft Use in the Treatment of Major Burns in Adults and Children

Availability, effectiveness and safety of cadaveric and fresh allogeneic skin grafts in pediatric burn care-a review

Burn injuries in children are a critical public health issue with significant mortality and morbidity. Allogeneic skin grafts, both cadaveric and freshly donated, have been utilized in pediatric burn care since many years, yet their efficacy and safety remain to be systematically assessed. This systematic review (PROSPERO number: CRD42024560654) analyzed studies from 01/2000 to 07/2024 sourced from PubMed. Inclusion criteria targeted RCTs and retrospective studies focused on the use of allogeneic skin grafts in pediatric burn patients. Extracted data were presented in a narrative synthesis and a comprehensive table. Established tools were used for risk of bias assessment. 13 studies were deemed suitable for analysis, with only two qualifying as RCTs. Allogeneic skin grafts have shown promise in managing pediatric burns, especially in resource-limited settings where autografts or skin substitutes are not available. Studies varied in their treatment approaches, with allogeneic grafts often used for more severe burns, suggesting that observed adverse effects may be due to injury severity rather than treatment type. The retrospective nature of the majority suggests a limited level of evidence. Moreover, the heterogeneity among study designs and patient populations makes it difficult to draw definitive conclusions. Allogeneic skin grafts represent a valuable treatment option in pediatric burn care. However, further well-designed RCTs are essential to establish a stronger evidence base for their use and to guide clinical decision-making. The current literature underscores the potential of allogeneic grafts but also the necessity for more nuanced research tailored to pediatric needs.

Outcome comparison of the most commonly employed wound coverage techniques in patients with massive burns ≥50% TBSA - A systematic review and meta-analysis

INTRODUCTION

Early wound coverage is one of the most essential factors influencing the survival of extensively burned patients, especially those with a total body surface area (TBSA) burned greater than 50 %. In patients with limited donor sites available for autografting, techniques such as the Meek micrograft procedure or cultured epidermal allografts (CEA) have proven to be viable alternatives. In this systematic review and meta-analysis, we analyzed the outcomes of different wound coverage techniques in patients with massive burn injuries ≥ 50 % TBSA in the past 17 years.

METHODS

The EMBASE, PUBMED, Google Scholar and MEDLINE databases were searched from inception to December 2022 for studies investigating major burn reconstruction (>50 % TBSA) with the use of one of: a) autografts, b) allografts, c) cell-based therapies, and d) Meek micrografting. The review was conducted in accordance with the PRISMA guidelines. The outcomes evaluated were mortality, length of hospital stay, graft take and number of operations performed.

RESULTS

Following a two-stage review process, 30 studies with 1369 patients were identified for analysis. Methods of coverage comprised the original autografting, and the newer Meek micrografting, CEA autografting, and allografting. Pooled mean age of the entire cohort was 32.5 years ( ± SE 3.6) with mean burn size of 66.1 % ( ± 2.5). After pooling the data, advantages in terms of mortality rate, length of stay, graft take and number of required surgeries were seen for the Meek and CEA groups. Mortality was highest in patients treated with autografts (50 %) and lowest with cell-based therapy (11 %). Length of stay was longest with cell-based therapy (91 ± 16 days) and shortest with Meek micrografting (50 ± 24 days). Graft take was highest with autografts (96 ± 2 %) and lowest with cell-based therapy (72 ± 9 %). Average number of operations was highest with cell-based therapy (9 ± 4) and lowest with Meek micrografting (4 ± 2).

CONCLUSIONS

Comparison of the four techniques highlighted differences in terms of all outcomes assessed, and each technique was associated with different advantages. Interestingly autografting, the option with the highest graft take rate, was also associated with the highest mortality. This study not only serves to provide the first comparison of the most commonly used techniques in major burn reconstruction, but also highlights the need for prospective studies that directly compare the efficacy of the different techniques to ultimately establish whether a true superior option exists.

Usage of intermingled skin allografts and autografts in a senior patient with major burn injury

Mortality rate in older adults following extensive burn injury is extremely high, and management of these patients is challenging. One of the main problems is that autologous split-thickness skin grafts are scarce and the wounds cannot be covered quickly and effectively. Intermingled skin grafting is a low-tech and economic method, which not only maximizes the use of precious autologous skin but also prevents the wounds from infection and consumption. Herein we present a case of extensive burn injury in a 68-year-old female successfully treated with intermingled skin grafting. The patient was accidentally burned by gas flame, resulting in a major burn injury covering 80% of her total body surface area. Early burn wound excision was performed and the wound was temporarily covered with irradiated porcine skin in the first week after injury. Autologous stamp-like skin grafts were applied to the wound bed 4 weeks after injury. In this operation, the results were not satisfactory. The take rate of the skin grafts is only about 50%. We covered the wounds with intermingled skin allografts and autografts 8 weeks after injury: autografts (0.5 cm × 0.5 cm) + fresh close relative’s allografts (1 cm × 1 cm) + cryopreserved allografts (2 cm × 2 cm).

Stromal vascular fraction improves deep partial thickness burn wound healing

OBJECTIVE

The practice of early burn wound excision and wound closure by immediate autologous skin or skin substitutes is the preferred treatment in extensive deep partial and full-thickness burns. To date there is no proven definite medical treatment to decrease burn wound size and accelerate burn wound healing in modern clinical practice. Stromal vascular fraction is an autologous mixture that has multiple proven beneficial effects on different kinds of wounds. In our study, we investigated the effects of stromal vascular fraction on deep partial-thickness burn wound healing.

METHODS

In this study, 20 Wistar albino rats were used. Inguinal adipose tissue of the rats was surgically removed and stromal vascular fraction was isolated. Thereafter, deep second-degree burns were performed on the back of the rats by hot water. The rats were divided into two groups in a randomized fashion. The therapy group received stromal vascular fraction, whereas the control group received only physiologic serum by intradermal injection. Assessment of the burn wound healing between the groups was carried out by histopathologic and immuno-histochemical data.

RESULTS

Stromal vascular fraction increased vascular endothelial growth factor, proliferating cell nuclear antigen index, and reduced inflammation of the burn wound. Furthermore, vascularization and fibroblastic activity were achieved earlier and observed to be at higher levels in the stromal vascular fraction group.

CONCLUSIONS

Stromal vascular fraction improves burn wound healing by increasing cell proliferation and vascularization, reducing inflammation, and increasing fibroblastic activity.

Porcine wound healing in full-thickness skin defects using Integra™ with and without fibrin glue with keratinocytes

BACKGROUND

An artificial dermal matrix such as Integra (Integra Life Sciences Corporation, USA) provides a wound bed template for vascular and fibrocyte ingrowth as well as collagen remodelling. Dermal repair leads to epidermal and basement membrane regeneration. Burn wounds in particular have been shown to benefit from Integra by enhanced wound healing.

OBJECTIVE

To evaluate the effect of fibrin glue to modify the integration of Integra in large excised cutaneous wounds. It was hypothesized that applying fibrin glue on a wound bed would reduce the time needed for matrix vascularization and incorporation of Integra and take of the cultured keratinocytes.

METHODS

Four separate full-thickness wounds were created on the dorsum of two swine. Wound beds were randomly assigned to either application of fibrin glue or no application of fibrin glue before application of Integra. Full-thickness biopsies were performed at days 7, 14, 21, 29 and 35. On day 21, keratinocytes were applied either as sheets or aerosolized fibrin glue suspension.

RESULTS

Histological analysis revealed a wave of inflammatory cells and early granulation tissue ingrowth into the Integra from the fascia below on day 7. Only this initial phase was augmented by application of fibrin glue to the wound bed. By day 14, most and by day 21, all of the Integra thickness was incorporated. Accelerated dermal repair proceeded from the base with new collagen deposition in Integra spaces. There was no evidence of keratinocyte engraftment, although re-epithelialization occurred at wound edges extending onto the incorporated Integra.

CONCLUSIONS

It appears there is an acceleration of early phase (day 7 to day 21) dermal incorporation with fibrin glue application to the wound bed, perhaps secondary to increased cellular migration. Day 21 appears to be too early to apply cultured keratinocytes either as sheets or aerosolized suspension.

Assessing the value of autologous and allogeneic cells for regenerative medicine

The advantages and disadvantages of autologous and allogeneic human cells for regenerative medicine are summarized. The comparison of relative advantages includes: ease and cost of treating large numbers of patients, the speed of availability of therapy and the differing complexity of the development pathways. The comparison of relative disadvantages deals with issues such as variability of source material, the risks of cell abnormality and of viral and prion contamination, and the sensitive issues surrounding use of embryo-derived cells. From the comparisons, several potentially decisive issues are drawn out, such as possible immune response and teratoma formation, the impact of patents and the virtues of hospital versus industry-centered development.

Cultured epithelial autograft (CEA) in burn treatment: three decades later

Methods for handling burn wounds have changed in recent decades and increasingly aggressive surgical approach with early tangential excision and wound closure is being applied. Split-thickness skin (STSG) autografts are the "gold standard" for burn wound closure and remain the mainstay of treatment to provide permanent wound coverage and achieve healing. In some massively burned patients, however, the burns are so extensive that donor site availability is limited. Fortunately, considerable progress has been made in the culture of human keratinocytes and it is now possible to obtain large amounts of cultured epithelium from a small skin biopsy within 3-4 weeks. Questions related to optimal cell type for culture, culture techniques, transplantation of confluent sheets or non-confluent cells, immediate and late final take, carrier and transfer modality, as well as final outcome, ability to generate an epithelium after transplantation, and scar quality are still not fully answered. Progress accomplished since Reinwald and Green first described their keratinocyte culture technique is reviewed.