Versatile use of dermal substitutes: A retrospective survey of 127 consecutive cases

ABSTRACT

Background: Dermal substitutes are currently largely used for the treatment of huge skin loss in patients in critical general health conditions, for the treatment of severe burns and to promote the healing process in chronic wounds. Aims: The authors performed a retrospective assessment of their experience with bioengineered skin to possibly identify the most appropriate clinical indication and management for each substitute. Materials and Methods: The study involved 109 patients with 127 skin defects repaired with dermal substitutes over a 9 years period, from 2007 to 2016. Hyalomatrix^® was used in 63 defects, whereas Integra^® and Nevelia^® were used in 56 and 8 defects, respectively. Results: The statistical analysis failed to reveal a correlation between the choice of a specific dermal substitute and any possible clinical variable except in the soft-tissue defects of the scalp where Hyalomatrix^® was electively used. Conclusions: In the authors’ experience, the scalp defects followed a radical excision of skin tumours that included the periosteum. Here, the preliminary cover with a hyaluronan three-dimensional scaffold constantly allowed for the regeneration of a derma-like layer with a rich vascular network fit for supporting a split-thickness skin graft. Nevertheless, the authors still prefer Integra^® when the goal is a better cosmetic outcome and Hyalomatrix^® when a faster wound healing is required, especially in the management of deep wounds where the priority is a fast obliteration with a newly formed tissue with a rich blood supply. However, these clinical indications still are anecdotally based.

KEY WORDS

Clinical application - collagen - dermal substitutes - hyaluronan - skin reconstruction

• REFERENCES

• 1 Wolter TP, Noah EM, Pallua N. The use of integra in an upper extremity avulsion injury. Br J Plast Surg 2005; 58: 416-8
• 2 Weigert R, Choughri H, Casoli V. Management of severe hand wounds with integra^® dermal regeneration template. J Hand Surg Eur Vol 2011; 36: 185-93
• 3 Heimbach D, Luterman A, Burke J, Cram A, Herndon D, Hunt J. et al. Artificial dermis for major burns. A multi-center randomized clinical trial. Ann Surg 1988; 208: 313-20
• 4 Groos N, Guillot M, Zilliox R, Braye FM. Use of an artificial dermis (Integra) for the reconstruction of extensive burn scars in children. About 22 grafts. Eur J Pediatr Surg 2005; 15: 187-92
• 5 Gravante G, Delogu D, Giordan N, Morano G, Montone A, Esposito G. et al. The use of hyalomatrix PA in the treatment of deep partial-thickness burns. J Burn Care Res 2007; 28: 269-74
• 6 Motolese A, Vignati F, Brambilla R, Cerati M, Passi A. Interaction between a regenerative matrix and wound bed in nonhealing ulcers: Results with 16 cases. Biomed Res Int 2013; 2013: 849321
• 7 Nicoletti G, Scevola S, Faga A. Bioengineered skin for aesthetic reconstruction of the tip of the nose: A case report. Dermatol Surg 2008; 34: 1283-7
• 8 Faga A, Nicoletti G, Brenta F, Scevola S, Abatangelo G, Brun P. et al. Hyaluronic acid three-dimensional scaffold for surgical revision of retracting scars: A human experimental study. Int Wound J 2013; 10: 329-35
• 9 Nicoletti G, Brenta F, Bleve M, Pellegatta T, Malovini A, Faga A. et al. Long-term in vivo assessment of bioengineered skin substitutes: A clinical study. J Tissue Eng Regen Med 2015; 9: 460-8
• 10 Morozzo U, Villafañe JH, Ieropoli G, Zompi SC, Cleland JA, Navissano M. et al. Soft tissue reconstructions with dermal substitutes versus alternative approaches in patients with traumatic complex wounds. Indian J Surg 2015; 77: 1180-6
• 11 Brookes M, Revell WJ. Blood supply of flat bones. Bones of the skull. In: Brookes M, Revell WJ. editors. Blood Supply of Bone. Scientific Aspects. London: Springer Verlag; 1998: p. 66
• 12 Chen WY, Abatangelo G. Functions of hyaluronan in wound repair. Wound Repair Regen 1999; 7: 79-89
• 13 Presti D, Scott JE. Hyaluronan-mediated protective effect against cell damage caused by enzymatically produced hydroxyl (OH.) radicals is dependent on hyaluronan molecular mass. Cell Biochem Funct 1994; 12: 281-8
• 14 Kvam BJ, Fragonas E, Degrassi A, Kvam C, Matulova M, Pollesello P. et al. Oxygen-derived free radical (ODFR) action on hyaluronan (HA), on two HA ester derivatives, and on the metabolism of articular chondrocytes. Exp Cell Res 1995; 218: 79-86
• 15 Fukuda K, Takayama M, Ueno M, Oh M, Asada S, Kumano F. et al. Hyaluronic acid inhibits interleukin-1-induced superoxide anion in bovine chondrocytes. Inflamm Res 1997; 46: 114-7
• 16 Wang H, Pieper J, Péters F, van Blitterswijk CA, Lamme EN. Synthetic scaffold morphology controls human dermal connective tissue formation. J Biomed Mater Res A 2005; 74: 523-32
• 17 Michaeli D, McPherson M. Immunologic study of artificial skin used in the treatment of thermal injuries. J Burn Care Rehabil 1990; 11: 21-6
• 18 Philandrianos C, Andrac-Meyer L, Mordon S, Feuerstein JM, Sabatier F, Veran J. et al. Comparison of five dermal substitutes in full-thickness skin wound healing in a porcine model. Burns 2012; 38: 820-9
• 19 Janis JE, Kwon RK, Attinger CE. The new reconstructive ladder: Modifications to the traditional model. Plast Reconstr Surg 2011; 127 (Suppl. 01) 205S-12S