The role of alternative wound substitutes in major burn wounds and burn scar resurfacing

Chapter 17 The role of alternative wound substitutes in major burn wounds and burn scar resurfacing



Juan P. Barret


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Introduction


The loss of the cutaneous barrier creates an important problem for the injured organism. The skin barrier is damaged, homeostasis altered, and part, if not all, of the immunological function of the skin is lost. Following a burn injury many issues must be addressed. Trauma guidelines, resuscitation, maintenance of the internal milieu by critical care techniques, and protection of the victim against infection, among others, are therapies directed towards a common goal: survival and complete functional rehabilitation.


However, the main focus of the reconstructive surgeon is the complete and permanent closure of the burn wound. Two main factors are involved in this scenario. A clean, vital, graftable wound bed has to be obtained in order to be ready for the engraftment and survival of any skin coverage that has been selected. Following this process, a permanent wound cover has to be obtained that protects the recipient, provides all skin properties and functions, and allows for complete recovery and rehabilitation of the victim.


The treatment of severe burn sequelae follows similar sound surgical principles. Alternative wound coverings are reserved for those situations encountered in burn reconstruction as well as in acute setting: either a paucity of skin donor site availability or a failure of previous surgeries to provide good, pliable skin coverage.



The ideal wound coverage


A permanent, durable, nature-like wound coverage is the gold standard for any disease process that requires the replacement of damaged and destroyed skin. The provision of large and infinite quantities of such wound coverage is also desirable. The wound cover that most resembles normal skin is autologous skin graft. However, even though it is durable and permanent, it relies on wound healing cascades to produce the desired vitality, vascularization and maturation. This is accomplished by connective tissue deposition, leaving permanent sequelae ranging from minimal scarring to florid hypertrophic scarring and keloid formation.1


Current attempts to obtain a better quality of skin graft and a more profound control of scar formation between the interface of the wound bed and the transplanted autologous skin include single-layer dermal substitutes: Integra single-layer dermal template (Integra life Sciences) and Matriderm (Dr Sawelacs Skin). These are similar but differ in their composition and width. Capillary ingrowth in these templates precedes final ingrowth into super-thin applied skin grafts (18/1000 inch); therefore careful wound manipulation is necessary. These templates are applied on the wound bed with similar goals as delineated for Integra double-layer. Optimization of graft take can be obtained by using a negative-pressure dressing, but in general, guidelines for wound care as applied in all burn centers worldwide render excellent graft take. The use of both dermal templates follows the same philosophy as that involved in the application of Alloderm and super-thin skin grafts. Future clinical research focusing on similar biologic dermal templates, such as glycerol-preserved dermis, Strattice and Veritas, will determine their role in this type of surgery.



Alternative wound covers


This broad definition refers to any materials used as an alternative to the gold standard: the autologous skin graft. Ideally, they should carry the same characteristics (durability, permanency, good vascularization, defense against infection, and provision of excellent quality of life). Their relevant role in the improvement of the quality of wound cover in major burns and other large wounds should not be underestimated, although their final outcomes are still far from perfect. The emergence in the clinical scenario of alternative wound coverage allowed swift burn reconstruction in either the acute or the rehabilitation phase. The possibility to obtain large amounts of tissue (dermal templates, etc.) off the shelf has made possible immediate coverage of large open wounds in one operation. It has allowed the development of controlled surgical protocols for critical burns and for the resection of large areas of hypertrophic scar.


The health industry is constantly providing burn surgeons with new alternative wound covers (either temporary or permanent).2

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Mar 14, 2016 | Posted by in General Surgery | Comments Off on The role of alternative wound substitutes in major burn wounds and burn scar resurfacing

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