chondroitin-sulfates and Burns

Over the past two decades the treatment of hypertrophic scars and keloids has seen substantial changes due to the evolution of current and establishment of new conservative and surgical methods. This review gives an overview of the current research with respect to the multifactorial etiology and pathophysiology of keloids and hypertrophic scars, discusses conservative surgical treatment options and provides an outlook on novel treatment strategies.

Topics: Adult; Burns; Cell Proliferation; Child; Chondroitin Sulfates; Cicatrix, Hypertrophic; Collagen; Combined Modality Therapy; Diagnosis, Differential; Facial Injuries; Female; Free Tissue Flaps; Granulation Tissue; Humans; Keloid; Male; Microsurgery; Middle Aged; Plastic Surgery Procedures; Reoperation; Tissue Expansion Devices

The therapeutic management of the sequelae of deep burns always relies in principle on dermal-epidermal grafts. The latter, the price of which to pay is heavy scarring, cannot always be performed because the surface of skin available may not be sufficient. Research pathways have turned towards the creation of skin substitutes to minimise the scarring and improve the cosmetic quality of the grafts. We review the technical characteristics of collagen matrixes (Intégra(®) - Matriderm(®)) and their method of use.

Topics: Burns; Chondroitin Sulfates; Cicatrix; Collagen; Elastin; Humans; Skin, Artificial; Treatment Outcome; Wound Healing

Several skin substitutes are available that can be used in the management of hand burns; some are intended as temporary covers to expedite healing of shallow burns and others are intended to be used in the surgical management of deep burns. An understanding of skin biology and the relative benefits of each product are needed to determine the optimal role of these products in hand burn management.

Topics: Bioengineering; Burns; Chondroitin Sulfates; Coated Materials, Biocompatible; Collagen; Hand Injuries; Humans; Occlusive Dressings; Skin, Artificial; Transplantation, Homologous; Treatment Outcome

Topics: Burns; Chondroitin Sulfates; Collagen; Forecasting; Humans; Skin Care; Skin Transplantation; Skin, Artificial; Treatment Outcome; Wound Healing

Topics: Biocompatible Materials; Burns; Chondroitin Sulfates; Collagen; Humans; Severity of Illness Index; Skin Transplantation; Skin, Artificial; Transplantation, Autologous; Transplantation, Homologous

The role of artificial skin substitutes in burn surgery and the treatment of chronic wounds is constantly evolving. New products are regularly being produced and approved for clinical use. Studies on existing products clarify their efficacy and effectiveness in different clinical scenarios. This review is aimed at busy clinicians in order to bring them up to date with the latest developments in the field of artificial skin substitutes. It examines the components, structure, performance and comparative costs of the main commercial skin substitutes, and reviews briefly technologies under development that have not yet become widely available.

Topics: Biocompatible Materials; Biological Dressings; Burns; Chondroitin Sulfates; Collagen; Costs and Cost Analysis; Humans; Skin Physiological Phenomena; Skin, Artificial; Wounds and Injuries

The loss of skin has been one of the oldest, yet most frequent and costly problems in our health care system. To restore functional and esthetic integrity in patients with unstable or hypertrophic scars, in burn patients and after skin loss for hereditary, traumatic or oncological reasons, an armamentarium of reconstructive surgical procedures including autogenous, allogenous and xenogenous tissue transfer as well as implantation of alloplastic materials has been favored. For several decades there has been increasing interest focused on 'tissue engineering' of dermal, epidermal and full thickness skin substitutes by both biological and synthetic matrices. At our institution (Hannover Medical School), a collagen/glycosaminoglycan dermal regeneration matrix has been used for immediate dermal coverage after escharectomy in burn injuries as well as for dermal replacement in chronically unstable scars. This article gives an overview on the current state of the art in bioartificial skin as well as our personal experience with the collagen/glycosaminoglycan matrix for dermal replacement in different clinical situations.

Topics: Adolescent; Adult; Biocompatible Materials; Burns; Chondroitin Sulfates; Cicatrix; Collagen; Dermis; Epidermis; Extracellular Matrix; Female; Follow-Up Studies; Glycosaminoglycans; Humans; Middle Aged; Silicones; Skin Diseases; Skin Transplantation; Skin, Artificial

The aim of this study was to compare three different methods to cover excised burn wounds in a randomized controlled trial.. Fascially excised burn wounds, measuring 10 cm × 5 cm, were covered with Integra(®), split thickness skin graft (STSG), and a viscose cellulose sponge Cellonex™ in each of ten adult patients. Integra(®) and Cellonex™ treated areas were covered with thin STSG on day 14. Biopsies were taken 3, 7, 14, and 21 days, 3 months, and 12 months after surgery, and samples were subjected to a range of immunohistochemical stains, in addition to hematoxylin and eosin (HE). Scar assessment was performed 3 and 12 months post-operatively with the Vancouver Scar Scale (VSS).. Inflammation was not substantial in any of the study areas, but Cellonex™ had the most neutrophils, histiocytes, and lymphocytes with significant differences on days 7 and 14. Complete vascularization of Integra(®) seemed to occur later compared to the other materials. STSG had the most myofibroblasts on day 14 (p = 0.012). In VSS the quality of the scar improved in all materials from 3 to 12 months.. The final results for all treatments after 12 months demonstrate equal clinical appearance, as well as histological and immunohistochemical findings.

Topics: Adult; Biocompatible Materials; Burns; Cellulose; Chondroitin Sulfates; Collagen; Female; Humans; Male; Middle Aged; Neovascularization, Physiologic; Prospective Studies; Skin Transplantation; Surgical Sponges; Young Adult

Early excision with autograft-allograft closure is standard in severe burn management. Cadaver skin is associated with risks such as antigenicity, infection, and limited availability and shelf life. Previous studies have shown that Integra is safe to use in burns of <20% total body surface area. However, the suitability of its use in large burns (>50% total body surface area), its effects on postburn hypermetabolism, and the long-term cosmetic and functional results have not yet been evaluated.. Twenty children with an average burn size of 73 +/- 15% total body surface area (71 +/- 15% full-thickness burn) were randomized to be treated with either Integra or with autograft-allograft technique. Outcome measures such as length of hospital stay, mortality, incidence of infection and sepsis, acute phase protein levels, and muscle fractional synthetic rate were compared between and within groups during the acute stay (admission to discharge). Outcome measures such as resting energy expenditure, body composition data (measured by dual-energy radiograph absorptiometry), cardiac function indexes, and number of reconstructive procedures were compared during acute hospital stay and at long-term follow-up (up to 2 yrs postinjury). Scar evaluation was performed at long-term follow-up.. There were no significant differences between Integra and controls in burn size (70 +/- 5% vs. 74 +/- 4% total body surface area), mortality (40% vs. 30%), and length of stay (41 +/- 4 vs. 39 +/- 4 days). In the short term, resting energy expenditure significantly decreased (p < .01), and serum levels of constitutive proteins significantly increased (p < .03) in the Integra group compared with controls. Long-term follow-up revealed a significant increase in bone mineral content and density (24 months postburn, p < .05), as well as improved scarring in terms of height, thickness, vascularity, and pigmentation (12 months and 18-24 months, p < .01) in the Integra group.. Integra can be used for immediate wound coverage in children with severe burns without the associated risks of cadaver skin.

Topics: Burns; Child; Chondroitin Sulfates; Collagen; Female; Humans; Injury Severity Score; Longitudinal Studies; Male; Skin, Artificial

Development of scaffold from biopolymers can ease the requirements for donor skin autograft and plays an effective role in the treatment of burn wounds. In the current study, a porous foam based, bilayered hydrogel scaffold was developed using gelatin, hyaluronic acid and chondroitin sulfate (G-HA-CS). The fabricated scaffold was characterized physicochemically for pre- and post-sterilization efficacy by scanning electron microscopy (SEM), Fourier transform infrared (FTIR) spectroscopy, differential scanning calorimetry (DSC) and thermal gravimetric analysis (TGA).

Topics: Animals; Biocompatible Materials; Burns; Chondroitin Sulfates; Disease Models, Animal; Gamma Rays; Gelatin; Hyaluronic Acid; Hydrogels; Male; Porosity; Swine; Tissue Scaffolds; Wound Healing

The advent of dermal regeneration templates has fostered major advances in the treatment of acute burns and their sequelae, in the last three decades. Both data on morphological aspects of the newly-formed tissue, and clinical trials comparing different templates, are few. The goal of this study was to prospectively analyze the outcome of randomized patients treated with two of the existing templates, followed by thin skin autograft. They are both 2 mm-thick bovine collagen templates (Matriderm® and Integra®), the latter includes a superficial silicone layer. Surgery was performed on patients with impaired mobility resulting from burn sequelae (n = 12 per template) in a two-step procedure. Negative pressure therapy was applied after surgery; patients were monitored for 12 months. No intra or postoperative complications were observed. Data on scar skin quality (Vancouver scar scale), rate of mobility recovery, and graft contraction were recorded; as well as morphological analyses at light microscopical level. Improvement in mobility and skin quality were demonstrated along with graft contraction, in all patients. The double layer template showed the best performance in retraction rate, skin quality and mobility recovery. The subepidermal newly-formed connective tissue showed no histoarchitectural differences between the templates. The double layer template was not absorbed up to 12 months after placement.

Topics: Adolescent; Adult; Burns; Chondroitin Sulfates; Cicatrix; Collagen; Contracture; Elastin; Female; Guided Tissue Regeneration; Humans; Longitudinal Studies; Male; Middle Aged; Negative-Pressure Wound Therapy; Plastic Surgery Procedures; Postoperative Complications; Skin; Skin Transplantation; Transplantation, Autologous; Young Adult

The development of antimicrobial nanofibre dressings that can protect the injured tissues from commensal pathogens while promoting tissue regeneration finds enormous potential in plastic and reconstructive surgery practices. To achieve this goal, we investigated the effect of chondroitin sulphate on the morphology, mechanical properties, wettability and biocompatibility of polydopamine crosslinked electrospun gelatin nanofibres containing mineralized magnesium. To extend the durability of dressings, we prepared composite dressings containing polycaprolactone (PCL) and gelatin as blend or core-shell nanofibres. Nanofibre blends presented greater tensile strength and stretchability, while core-shell nanofibres displayed superior photoluminescent properties. In a porcine model of cutaneous burn injury, both the blend and core-shell nanofibre dressings displayed improved re-epithelialization, wound closure and clinical outcome in comparison to untreated burns. Histology of the biopsied tissues indicated smooth regeneration and collagen organization of the burns treated with core-shell nanostructures than untreated burns. This study compared the physico-chemical and biological properties of composite nanofibres that are capable of accelerating burn wound healing and possess antimicrobial properties, highlighting their potential as wound dressings and skin substitutes.

Topics: Animals; Anti-Bacterial Agents; Bandages; Burns; Cell Line; Cell Proliferation; Cell Survival; Chondroitin Sulfates; Female; Gelatin; Gram-Positive Bacteria; Humans; Magnesium; Nanofibers; Polyesters; Swine; Wound Healing

Rapid wound closure in extensively burned patients has remained one of the major unresolved issues of medicine. Integra® is the most widely established artificial skin, which is composed of a porous matrix of cross-linked bovine collagen and chondroitin 6-sulphate covered by a semi-permeable silicone layer. We present here a (immuno)histological study of a severely burned patient with a full-thickness burn treated with a tissue-engineered dermal template (Integra®) and split-thickness skin graft-based protocol. Immunohistochemical investigation of the artificial dermis revealed that immune cell infiltration reached its peak on day 10. Tissue immunophenotyping found an increase in CD3+ cells over the course of the study as well as CD4 and CD8 positivity on day 40, indicating remaining T-cell subpopulations. We observed weak/no infiltration of NK cells (CD56+). In conclusion, the use of bi-layer Integra® represents a feasible and safe procedure resulting in formation of non-irritating dermal substitutes.

Topics: Animals; Burns; Cattle; Chondroitin Sulfates; Humans; Skin Transplantation; Skin, Artificial; Wound Healing

Burns and chronic wounds, often related to chronic diseases (as diabetes and cancer), are challenging lesions, difficult to heal. The prompt and full reconstitution of a functional skin is at the basis of the development of biopolymer-based scaffolds, representing a 3D substrate mimicking the dermal extracellular matrix. Aim of the work was to develop scaffolds intended for skin regeneration, according to: fabrication by electrospinning from aqueous polysaccharide solutions; prompt and easy treatment to obtain scaffolds insoluble in aqueous fluids; best performance in supporting wound healing. Three formulations were tested, based on chitosan (CH) and pullulan (P), associated with glycosaminoglycans (chondroitin sulfate - CS or hyaluronic acid - HA). A multidisciplinary approach has been used: chemico-physical characterization and preclinical evaluation allowed to obtain integrated information. This supports that CS gives distinctive properties and optimal features to the scaffold structure for promoting cell proliferation leading tissue reparation towards a complete skin restore.

Topics: Biocompatible Materials; Burns; Chitosan; Chondroitin Sulfates; Glucans; Humans; Hyaluronic Acid; Skin, Artificial; Tissue Engineering; Tissue Scaffolds; Wound Healing

Artificial skin has become the treatment of choice in extensive, full-thickness thermal injuries. The longest follow-up of the healing process in burn sites covered with the Integra Bilayer Matrix Wound Dressing onto the wound published to date was at around five years after application. In our case report, we describe the clinical and histological analysis of an extensive, full-thickness thermal injury 14 years on from treatment with the bilayer matrix wound dressing.. A nine-year-old boy suffered a full-thickness skin loss over 85% of his body surface area following a fire accident. The bilayer matrix wound dressing was used on both legs and covered almost 30% of his body surface area. Cosmetic and functional results were satisfactory. Histological analysis performed nine years after the application of the bilayer matrix wound dressing onto the wound showed a double-layered skin composition with changes in the fibrous component of the dermis.. Despite satisfactory short- and long-term clinical results from applications of the bilayer matrix wound dressing, we found important differences in microstructure when compared with the physiological condition.

Topics: Burns; Child; Chondroitin Sulfates; Collagen; Humans; Male; Plastic Surgery Procedures; Skin, Artificial; Wound Healing

In the present work, a hydrogel platform composed of biopolymer gelatin, and glycosaminoglycan's (Hyaluronic acid and Chondroitin sulfate) incorporated with Asiatic acid (a triterpenoid) and nanoparticles (Zinc oxide and Copper oxide) has been designed and developed to find out the efficacy of healing in second degree burn wounds in Wistar rats. The developed hydrogel composite has been characterized by physico-chemical methods such as; SEM, swelling, mechanical strength, degradation and drug release kinetics. Results showed that the morphology of composite scaffolds are porous with maximum water uptake capacity of 1068% and possessed tensile strength of ~0.196 MPa. Anti-microbial evaluation depicted increase in zone of inhibition with hydrogel containing gelatin + ZnO (5.3 ± 0.2 mm in E. coli and 4.9 ± 0.6 mm in S. aureus) and gelatin + CuO (4.8 ± 0.7 mm in E. coli, 3.8 ± 0.3 mm in S. aureus) in comparison to hydrogel composite scaffold. In-vitro cytocompatibility of developed hydrogel composite was assessed in terms of MTT and DNA quantification on L929 fibroblast cells. In-vivo studies for the composite scaffolds were evaluated on Wistar rats after second degree burn wounds were induced and studied for 28 days which showed the significant wound healing activity in comparison to the control (NeuSkin™ and Cotton guaze) in terms of DNA, total protein, hexosamine and hydroxyproline content. Histopathology studies showed the significant progress in re-epithelization, collagen fibers arrangement and angiogenesis in comparison to control. Additionally, a decrease of TNF-α and increase of MMP-2 expression on day 7 of animal experiment support healing. Furthermore, no toxicity was seen with the developed scaffolds suggesting their suitability to use as a wound dressing in second degree burns.

Topics: Animals; Biocompatible Materials; Burns; Cell Line; Chondroitin Sulfates; Copper; Gelatin; Hyaluronic Acid; Hydrogels; Matrix Metalloproteinase 2; Metal Nanoparticles; Mice; Pentacyclic Triterpenes; Rats; Rats, Wistar; Skin; Tensile Strength; Tumor Necrosis Factor-alpha; Wound Healing; Zinc Oxide

Various kinds of synthetic dermal substitutes are produced and used in clinical application and contribute to wound bed preparation for subsequent skin grafting. Although their appearance and outcomes are different, the criteria for the selection of proper synthetic dermal substitutes is not well defined yet. In this study, we focused on the contraction of dermal substitutes and compared the morphological differences in scaffolds. A marked contraction was observed with Pelnac

Topics: Burns; Chondroitin Sulfates; Collagen; Fibroblasts; Humans; In Vitro Techniques; Skin, Artificial

Long-term function following severe burns to the hand may be poor secondary to scar adhesions to the underlying tendons, webspaces, and joints. In this pilot study, we report the feasibility of applying a pasty dermal matrix combined with percutaneous cannula teno- and adhesiolysis.. In this 6 month follow-up pilot study, we included eight hands in five patients with hand burns undergoing minimal-invasive, percutaneous cannula adhesiolysis and injection of INTEGRA™ Flowable Wound Matrix for a pilot study of this new concept. The flowable collagen-glycosaminoglycan wound matrix (FCGWM) was applied with a buttoned 2mm cannula to induce formation of a neo-gliding plane. Post treatment follow-up was performed to assess active range of motion (AROM), grip strength, Disabilities of the Arm, Shoulder and Hand (DASH) score, Vancouver Scar Scale (VSS) and quality of life Short-Form (SF)-36 questionnaire.. No complications were detected associated with the treatment of FCGWM injection. The mean improvement (AROM) at 6 months was 30.6° for digits 2-5. The improvement in the DASH score was a mean of 9 points out of 100. The VSS improved by a mean of 2 points out of 14.. The study demonstrates the feasibility and safety of percutaneous FCGWM for dermal augmentation after burn. Results from this pilot study show improvements in AROM for digits 2-5, functional scores from the patient's perspective (DASH) and scar quality (VSS). The flowable form of established INTEGRA™ wound matrix offers the advantage of minimal-invasive injection after scar release in the post-burned hand with a reduction in the risk of postsurgical re-scarring.

Topics: Adult; Burns; Catheterization; Catheters; Chondroitin Sulfates; Cicatrix; Collagen; Feasibility Studies; Female; Hand Injuries; Hand Joints; Hand Strength; Humans; Male; Middle Aged; Minimally Invasive Surgical Procedures; Pilot Projects; Plastic Surgery Procedures; Range of Motion, Articular; Tissue Adhesions; Treatment Outcome

Artificial dermal templates play an important role in physiologic wound closure after injury. In addition to contributing to stable, durable and flexible wound closure, they provide a scaffold for tissue repair. Several dermal templates are commercially available, with animal-derived Integra(®) dermal regeneration template perhaps the most widely used. NovoSorb™ Biodegradable Temporising Matrix (BTM) is a fully synthetic alternative that eliminates any risk of cross-species residual antigenicity. In this study, we aimed to compare early response after application of NovoSorb™ BTM with Integra(®) in terms of temporary wound closure, host cell infiltration, neovascularisation and collagen deposition in a mouse model.. Twenty athymic nude mice received full-thickness skin excision followed by grafting of the dermal template (n=10 NovoSorb™ BTM, n=10 Integra(®)), with the grafts excised and assessed after two weeks.. All twenty mice achieved temporary wound closure with no evidence of wound contracture. Microscopically, all twenty grafts became infiltrated with host cells along the entire length of the template, with NovoSorb™ BTM demonstrating a particular abundance of host inflammatory cells. Evidence of new collagen deposition and neovascularisation was observed in both templates, with NovoSorb™ BTM demonstrating a more extensive vascular network at this time point. However, a greater inflammatory response was also observed in the NovoSorb™ BTM grafts at this time point.. In this study, NovoSorb™ BTM demonstrates favourable properties as a dermal template, but further investigation is required to assess the significance of the differing inflammatory and vascular response to its implantation compared with Integra(®).

Topics: Animals; Burns; Chondroitin Sulfates; Collagen; Disease Models, Animal; Male; Mice; Mice, Nude; Skin Transplantation; Skin, Artificial; Tissue Scaffolds; Wound Healing

Head and neck wounds can present a reconstructive challenge for the plastic surgeon. Whether from skin cancer, trauma, or burns, there are many different treatment modalities used to dress and manage complex head and neck wounds. Vacuum-assisted closure (VAC) therapy has been used on wounds of nearly every aspect of the body but not routinely in the head and neck area. This study was conducted to demonstrate our results using the VAC in the treatment of complex head and neck wounds.. This is an IRB-approved, retrospective review of 69 patients with 73 head and neck wounds that were managed using the VAC between 1999 and 2008. The wound mechanism, location, and size, length of VAC therapy, patient comorbidities, use of radiation, complications, and ultimate outcome were assessed. In this patient population, the VAC was utilized because the standard reconstructive ladder was not a good option or had previously failed.. Sixty-nine patients with complex head and neck wounds were treated with the wound VAC. The mean age of the patients was 66 years, with a range of 5-96 years. Males outnumbered females in this study nearly 2:1. Eighty-six percent of patients had wounds secondary to cancer, 8% secondary to trauma, 3% secondary to infection, and 3% secondary to burns. The VAC was used as a dressing over skin grafts in 50%, over Integra in 21%, and over open debrided wounds in 29%. Wounds healed without complication in 44% of the skin grafts, 67% of Integra-covered wounds, and 71% of debrided wounds. Minor complications included failure of complete graft take, failure of granulation tissue formation in open debrided wounds, infection, and hematoma formation under skin grafts. Major complications included positive cancer margins requiring reexcision and death secondary to pulmonary embolism, sepsis, and metastatic cancer. Most complications resolved with dressing changes, repeat grafting, or the administration of antibiotics.. Our results demonstrate that the wound VAC provides a reliable, effective, and durable dressing for a multitude of complex head and neck wounds. Additionally, it is a valuable tool when traditional surgical procedures are not a viable option.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Burns; Child; Child, Preschool; Chondroitin Sulfates; Collagen; Craniocerebral Trauma; Debridement; Female; Follow-Up Studies; Head and Neck Neoplasms; Humans; Male; Middle Aged; Neck Injuries; Negative-Pressure Wound Therapy; Plastic Surgery Procedures; Postoperative Complications; Retrospective Studies; Skin Transplantation; Skin, Artificial; Treatment Outcome; Wound Healing; Young Adult

Topics: Accidents, Traffic; Adult; Aged, 80 and over; Burns; Cellulitis; Chondroitin Sulfates; Collagen; Debridement; Diabetic Foot; Elastin; Female; Foot Injuries; Humans; Leg Injuries; Male; Middle Aged; Necrosis; Skin, Artificial

The application of cultured epidermal autograft (CEA) over bilayer artificial dermis theoretically should minimize surgical stress and donor site morbidity in severe burn patients. However, CEA over regenerated dermis is very fragile and easily detaches soon after application, because the very weak attachment. We performed chronological histological studies of the wounds of a 29 year-old patient, which was reconstructed using CEA (JACE(®)) and bilayer artificial dermis (Integra™). These studies included immunohistochemistry of anti-collagen (types III, IV, and VII) and anti-laminin, in addition to H&E and EVG staining. Reconstructed epidermis and dermis showed almost normal histological appearance with time, but formation of basement membrane proteins was delayed. Absent or immature basement membrane protein in the early phase after the CEA application was considered to be an important problem. In the late phase after the CEA application over the bilayer artificial dermis, the reconstructed skin was very durable and demonstrated no sign of skin stripping (although there was still a lack of basement membrane proteins).

Topics: Adult; Burns; Chondroitin Sulfates; Collagen; Epithelial Cells; Humans; Immunohistochemistry; Laminin; Male; Skin Transplantation; Skin, Artificial; Transplantation, Autologous

Dermal substitutes, such as Integra(®) introduced as a new alternative to our surgical arsenal and its use in burn treatment, in both acute and chronic phases, have gained great importance.. The aim of the experiment is to describe the results of the functional evaluation of patients with burned hands treated with Integra(®) in both acute and chronic phases.. A retrospective review of a transversal cohort. Patient characteristics evaluated were sociodemographic characteristics, burn mechanism, burn extension and depth, treatments received previous to Integra(®) and complications related to its use. Clinical and photographic evaluations were performed evaluating skin elasticity, range of articular movement, prehensile strength, pain and functional evaluation using the validated 400 Point Evaluation Test.. A total of 17 burned hands in 14 right-handed patients, were treated with Integra(®), three being bilateral hand burns. Eleven were treated in the acute phase and in nine in the scar reconstruction phase. Range of articular motion was complete in 15 of 17 hands. In 88% of the hands, flexible skin coverage was achieved. No statistically significant difference was observed in prehension strength of the burned hand versus the contralateral non-burned hand. Sixteen hands had a painless evolution. The 400 Point Evaluation score was 92.8 ± 6.3% (80 - 100%). Nearly four-fifths (79%) of the patients returned to normal active working activities.

Topics: Adult; Aged; Burns; Chondroitin Sulfates; Collagen; Female; Follow-Up Studies; Hand; Hand Injuries; Humans; Male; Middle Aged; Plastic Surgery Procedures; Recovery of Function; Retrospective Studies; Skin, Artificial; Treatment Outcome; Wound Healing; Young Adult

Topics: Aged; Burns; Chondroitin Sulfates; Collagen; Female; Humans; Plastic Surgery Procedures; Scalp; Skin Transplantation; Treatment Outcome

Hand injuries have major psychological, social and professional repercussions. Treatment of burned hands is suggested to be early and optimal to avoid catastrophic consequences and allow social and professional rehabilitation. Our study analyses the long-term results obtained with Integra(®), a dermal substitute used for the treatment of deep burns of the hands.. A total of 29 hands were treated with Integra(®). Long-term monitoring was performed on 12 hands with a clinical, ultrasonographic and elastometric study. The results were compared with those from a series of healthy hands. This study, with a low number of subjects, is a pilot report.. This study showed a low complication rate, with a high percentage of engraftment of thin skin, and good cosmetic and functional quality. The thickness and viscoelasticity of the skin treated with Integra(®) in our series appeared to be similar to those of healthy skin.. Integra(®) artificial skin is an attractive alternative in the treatment of deep burns of the hand and can achieve results with aesthetic and functional characteristics that are close to those of healthy skin.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Burns; Chondroitin Sulfates; Collagen; Elasticity; Female; Follow-Up Studies; Hand Injuries; Humans; Male; Middle Aged; Pilot Projects; Plastic Surgery Procedures; Retrospective Studies; Skin; Treatment Outcome; Ultrasonography

Topics: Aged; Burns; Chondroitin Sulfates; Collagen; Debridement; Fasciitis, Necrotizing; Female; Humans; Hypnotics and Sedatives; Midazolam; Skin, Artificial; Wound Healing

Loss of sensory function in scar after burn is common, although the basis for this loss is not clear. Additionally, little is known about the effects of different treatment modalities on sensory function and neuroanatomical outcomes in burn patients. Here, we investigated the effects of the use of the INTEGRA(®) dermal scaffold on neuroanatomy and sensory function in acute burn patients.. We hypothesized that the use of artificial dermal templates would inhibit or reduce reinnervation after excision, since regrowth of nerves requires complex molecular interactions. Therefore the primary objective of this study was to identify whether there is regrowth of nerve fibres in the INTEGRA(®) dermal scaffold. The secondary objective was to identify whether the INTEGRA(®) dermal scaffold reduced nerve regrowth or limited sensory function outcomes in acute burn patients.. Five patients treated with INTEGRA(®), cultured epithelial autograft spray (prepared using ReCell(®) (CEA)) and split skin graft (SSG) were assessed for sensory function in scar and uninjured contralateral control skin. Neuroanatomy of scar and control sites was assessed using immunohistochemistry for PGP9.5, CGRP and substance P neuronal markers. Nerve density and sensory function was also assessed in a comparative group (n=8) treated with CEA and SSG only.. Neuroanatomy was not significantly different in the INTEGRA(®) patients when compared to the CEA/SSG group only. The patients treated with INTEGRA(®) had worse sensory function than those with CEA/SSG only.. Peripheral nerves do reinnervate the INTEGRA(®) dermal scaffold. There is no statistically significant reduction in reinnervation observed when compared to a control group. It is possible that the use of artificial dermal constructs, while permissive for nerve regrowth, limit functionality when compared to nerves that regrow through dermal tissue. Further research to understand the causes of this, and into enhancing reinnervation in dermal scaffolds may improve sensory outcome in the most severely burned patients.

Topics: Adult; Burns; Cells, Cultured; Chondroitin Sulfates; Cicatrix; Collagen; Epithelium; Humans; Immunohistochemistry; Nerve Regeneration; Peripheral Nerves; Recovery of Function; Sensory Thresholds; Skin; Skin Transplantation; Touch Perception; Wound Healing

Topics: Amputation, Surgical; Burns; Chondroitin Sulfates; Collagen; Dermatologic Surgical Procedures; Diabetic Foot; Female; Humans; Limb Salvage; Male; Plastic Surgery Procedures; Skin; Skin, Artificial

Integra Artificial Skin, a biosynthetic dermal template, is well established in acute burn surgery. The aim of the study was to determine the role of Integra in the surgical treatment of postburn scars in a younger population. Between March 1998 and November 2004, 17 patients (n=17; mean age=13.15 years) underwent complete excision of hypertrophic scars or keloids (1-4% TBSA; extremities=47%, head/neck=35%, trunk=18%) with subsequent implantation of Integra for defect closure. Split thickness skin grafting (STSG) of the Integra-derived neodermis was performed 3 weeks after the first operation. Scar excision and primary Integra implantation was successful in all but one patient (94%) who (6%) needed reimplantation once. Integra's mean take rate was 99.7% for all primarily successful patients. Complications occurred in three patients (18%), including minor problems without long-term consequences in 12% (seroma formation), and major problems in 6% (hematoma formation). Take rate of STSG ranged from 50% to 100% (mean 94%). Functional and cosmetic long-term outcome showed results scored "excellent" in 53%, "good" in 36%, and "fair" in 11%. Comparison of pre- and postoperative findings revealed a significant functional improvement in all and a considerable cosmetic improvement in all but two patients. These results suggest that Integra is a valid new treatment modality for extensive burn scar revision in younger patients.

Topics: Adolescent; Burns; Child; Chondroitin Sulfates; Cicatrix, Hypertrophic; Collagen; Esthetics; Female; Humans; Keloid; Male; Plastic Surgery Procedures; Reoperation; Skin, Artificial; Treatment Outcome

The artificial dermis Integra (Ethicon, Johnson & Johnson Medical, Norderstedt, Germany) is widely used in the treatment of excessive burn injuries. It is also used in reconstructive surgery when large soft-tissue defects could not be covered with local or free flaps. In this article a 25-year old patient who presented with an early childhood burn of the trunk and lower extremity was treated with Integra in combination with the vacuum assisted closure (V.A.C., KCI, Texas, U.S.A.) and split thickness skin grafting. The combination of the artificial dermal substitute with negative pressure therapy has lead to a complete healing of Integra and the skin graft. During the whole treatment sterile wound conditions were present and time-consuming dressing changes could be prevented. Hospital stay was shortened because the patient could be treated as an outpatient with an ambulant vacuum assisted closure device.

Topics: Adult; Burns; Buttocks; Chondroitin Sulfates; Cicatrix; Collagen; Humans; Leg; Male; Plastic Surgery Procedures; Skin Transplantation; Thorax; Vacuum

The field of wound healing and tissue repair has advanced rapidly in the last decade, with this there is an increasing emphasis on the importance of the functional and cosmetic outcomes following injury. Integra artificial skin is the most widely used synthetic skin substitute and is reported to have better outcomes in relation to the appearance and elasticity when compared to split thickness skin grafting (SSG). A review of the literature reveals very few trials that are based on an objective evaluation of Integra treated scars as compared to SSGs. This research aimed to provide objective data on the long-term outcome of Integra.. All adult patients from the Welsh Burns Centre who had been successfully treated with Integra+/-SSG were invited to attend a clinic for a follow up provided they had been healed for greater than one year. The hypothesis that Integra scars are more pliable than skin grafts was tested objectively using the Cutometer, a suction device which measures skin elasticity.. Of the 13 patients eligible, six were available for assessment. The results of this study suggest that Integra treated sites correlate well with normal skin as measured by the Cutometer. This was statistically significant for the parameters Ur/Ue (elastic function) and Ur/Uf (gross elasticity). On the other hand there was no correlation seen between the patients SSG sites and the patient's normal skin.. With advances in medicine we are increasingly able to modulate wound healing and the resultant scars. In order to assess new and often costly treatments the need for objective scar measurement tools have become apparent. Integra has been advocated to improve scarring from injury. However, there have been few studies to evaluate the long-term outcome of Integra as compared to traditional methods such as SSG. In the past scar evaluation has been based on subjective scores by patients and clinicians. Now the mechanical properties of the skin can be evaluated using simple bioengineering methods such as the Cutometer Suction Device. Using this device our study has objectively demonstrated that the elastic properties of areas treated with Integra is comparable to normal skin.

Topics: Adult; Burns; Chondroitin Sulfates; Collagen; Elasticity; Female; Follow-Up Studies; Humans; Male; Middle Aged; Skin; Skin Transplantation; Skin, Artificial; Treatment Outcome; Wound Healing; Young Adult

Topics: Adult; Burns; Chondroitin Sulfates; Collagen; Fatal Outcome; Female; Humans; Methicillin-Resistant Staphylococcus aureus; Shock, Septic; Staphylococcal Infections; Wound Infection

Tissue expansion is a valuable technique in soft tissue reconstruction. Osmotic expanders are self-inflating and obviate the need for repeated injections. In doing so, they eliminate port site problems and may reduce the potential to introduce infection. The use of such expanders has become more common in recent years. We report on our experience with the Osmed™ osmotic expanders over the last 5-years.

Topics: Adolescent; Adult; Alopecia; Burns; Child; Child, Preschool; Chondroitin Sulfates; Cicatrix; Collagen; Female; Humans; Male; Mefenamic Acid; Middle Aged; Osmosis; Prosthesis Design; Skin, Artificial; Surgical Wound Infection; Tissue Expansion Devices; Young Adult

The use of topical negative pressure (TNP) dressings with dermal regeneration template (DRT), Integra, has improved outcomes and simplified aftercare. Previous clinical studies have suggested accelerated vascularisation; with a reduction in the duration of the 1st stage after the application of Integra, from 2 to 4 weeks to as little as 4 days, but with no histological evidence. However, histological studies, without TNP, have shown that vascularisation occurs between the second and the fourth week. This study set out to examine histologically the rate of DRT neovascularisation when combined with TNP.. Eight patients with nine reconstruction sites were enlisted. Unmeshed Integra and fibrin sealant to promote adherence were used. TNP was applied for the duration between the 1st and the 2nd stages. Patients underwent serial biopsies on days 7, 14, 21 and 28 post-application. The biopsies were stained with H&E and endothelial markers CD31 and CD34. Template vascularisation was assessed as a percentage of the template depth in which patent, canalised vascular channels could be demonstrated.. The median percentage of the template depth which demonstrated canalised channels was 0%, 20%, 61% and 80% for days, 7, 14, 21 and 28, respectively.. The application of TNP dressings to dermal templates can reduce shearing forces, restrict seroma and haematoma formation, simplify wound care and improve patient tolerance. However, this study could not demonstrate that TNP accelerates neovascularisation as verified by the presence of histologically patent vascular channels.

Topics: Adult; Biocompatible Materials; Biopsy; Burns; Chondroitin Sulfates; Collagen; Female; Fibrin Tissue Adhesive; Humans; Male; Middle Aged; Negative-Pressure Wound Therapy; Neovascularization, Physiologic; Prospective Studies; Skin; Skin Transplantation; Wound Healing; Young Adult

Integra (Integra Lifesciences Corporation, Plainsboro, NJ) has been used in a variety of reconstructive surgical procedures. The application of Integra using subatmospheric pressure (V.A.C., Kinetic Concepts, Inc, San Antonio, TX) has been suggested to be easier, faster, and more consistent than previous dressings, allowing grafting as soon as 1 week after Integra placement. Ten patients were chosen for outpatient reconstructive surgery with Integra and subatmospheric pressure with skin grafting 7-10 days (mean = 8 days) post-Integra. Skin graft take was 75% to 100% (mean = 91.5%). No patients required additional grafting or reconstruction. Integra may be successfully used for reconstruction of difficult areas as an outpatient in combination with subatmospheric pressure (V.A.C.). This allows for expedited treatment, decreased morbidity, and lower cost versus standard Integra application.

Topics: Adult; Ambulatory Surgical Procedures; Atmospheric Pressure; Burns; Child; Child, Preschool; Chondroitin Sulfates; Collagen; Female; Humans; Keloid; Male; Middle Aged; Plastic Surgery Procedures; Soft Tissue Injuries

Integra dermal substitute is used as biomaterial after thermal injury. This artificial skin allows temporary coverage after burns excision, transformation of matrix in neo dermis and definitive engraftment. Infections are the most common complication of this technique. The objectives were to evaluate incidence of sepsis, to analyse microbiology and risk factors of developing Integra infections. Patients with acute burns and indications of Integra during five years were retrospectively enrolled. Demographic data, surgical procedures and microbiologic biopsies were collected. Fifty patients (40 + or - 15 years) were studied and 71 surgical procedures using Integra were performed. Burns were extended 45 + or - 21% total body surface area. Placement of Integra was made 15 + or - 11 days after burns and autografts 31 + or - 9 days after placement of Integra. Twenty-one patients had infected Integra (42% of population). A total of 23 Integra infected sites were observed (15 local and eight invasive). Diagnosis of infection was made after 13 + or - 5 days using quantitative cultures. Other sites of infection were respiratory tract (46 pneumonias) and others burned wounds (17 infections outside of Integra. Any risk factor was identified between burns who developed Integra infections and the others. Incidence of infected Integra was higher than in previous studies. Delayed application of Integra after burns could explain higher incidence of infection. Pseudomonas aeruginosa and Staphylococcus aureus were more frequently isolated than other pathogens. Standardized technique for wounds coverage with Integra is necessary to reduce incidence of infections and improve functional results in burns patients.

Topics: Adolescent; Adult; Burns; Child; Child, Preschool; Chondroitin Sulfates; Collagen; Emergency Service, Hospital; France; Humans; Incidence; Infant; Plastic Surgery Procedures; Pneumonia, Bacterial; Pseudomonas aeruginosa; Retrospective Studies; Risk Factors; Staphylococcus aureus; Surgical Wound Infection

Facial burns present significant acute and reconstructive challenges. It has long been our practice to excise facial burns unlikely to heal in a timely manner in order to reduce the risk of aesthetic and functionally debilitating scar contractures. We present our approach to the acute surgical management of facial burns.

Topics: Bandages; Burns; Chondroitin Sulfates; Cicatrix; Collagen; Eye; Face; Humans; Postoperative Care; Skin Transplantation; Tissue and Organ Harvesting; Transplantation, Homologous

Topics: Animals; Burns; Cell Survival; Chondroitin Sulfates; Collagen; Melanocytes; Stem Cells; Swine

Topics: Burns; Chondroitin Sulfates; Collagen; Humans; Surgical Flaps; Tissue Engineering

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.

Topics: Amputation, Surgical; Burns; Chondroitin Sulfates; Collagen; Hand Injuries; Humans; Male; Middle Aged; Skin Transplantation; Thumb

We present our two year experience with a dermal regeneration template (INTEGRA) in burn reconstructive surgery for contracture release as well as a reconstructive tool for management of soft tissue loss.

Topics: Adult; Burns; Child, Preschool; Chondroitin Sulfates; Collagen; Female; Humans; Plastic Surgery Procedures; Skin Transplantation

The treatment of major burn injuries are a formidable challenge to the burn surgeon. Early aggressive surgery for deep to full thickness burn injuries is vital in the prevention of infection. The ultimate goal in major burn injuries is to prevent the onset of multi-resistant organisms and achieve early wound cover. The field of tissue engineering can help to expedite the healing of these burn wounds. The development of keratinocyte culture delivery system can be used clinically to fasten the healing process and save many lives.

Topics: Adolescent; Adult; Burns; Cells, Cultured; Child; Child, Preschool; Chondroitin Sulfates; Collagen; Epidermis; Female; Humans; Infant; Keratinocytes; Male; Retrospective Studies; Skin Transplantation; Tissue Engineering; Transplantation, Autologous; Wound Healing; Wound Infection; Young Adult

Topics: Adult; Burns; Burns, Inhalation; Chondroitin Sulfates; Collagen; Hand Injuries; Humans; Male; Plastic Surgery Procedures; Treatment Outcome

Standard care for lower extremity injuries with exposed bone or tendon is vascularized tissue transfer. In patients with deep and extensive burn injuries, these options are often not available or for various reasons are technically difficult. The advent of Integra, a permanent dermal replacement matrix, provides an important alternative to the traditional reconstructive choices.. The authors report seven patients, with a total of nine lower extremity injuries, from the Los Angeles County and University of Southern California Hospital Burn Unit treated from September of 2001 to January of 2003 who presented with complex burn injuries involving their lower extremities with tendon, open joints, and/or bone exposure.. All seven patients were treated initially with tangential excision of the burn eschar and placement of Integra. After engraftment, epidermal coverage was restored with a thin split-thickness skin graft. This treatment provided stable wound coverage, and none of the patients have required further surgical procedures to maintain wound closure.. The use of a bioengineered, cell-free dermal matrix expands reconstructive options and allows salvage of extremities that might otherwise have been amputated or required prolonged, staged procedures. The authors' experience shows that Integra provides a sound alternative option for providing durable coverage of vital lower extremity structures. It should be considered as part of the lower extremity wound coverage algorithm.

Topics: Adult; Burns; Child; Chondroitin Sulfates; Collagen; Dermatologic Surgical Procedures; Female; Humans; Male; Plastic Surgery Procedures; Skin; Skin, Artificial

Integra is a skin substitute used for dermal reconstruction. Current clinical practice consists of two procedures, first applying Integra to the wound and then replacing the silicone pseudo-epidermis with an epidermal autograft 3 weeks later. This two-step repair limits the clinical use of the product. An effective one-step procedure could reduce the time taken to repair and decrease the number of procedures for use of Integra. This study examined the effects of simultaneous application of a non-cultured autologous suspension of cells, isolated using the ReCell autologous cell harvesting device, in combination with Integra, to achieve a one-step skin repair. In two female Yorkshire swine, 10 full-thickness wounds were created. Wounds were treated with Integra seeded with cell suspension and compared to controls of Integra alone and cell suspension alone. Weekly macroscopic and histological assessment demonstrated that the wounds treated simultaneously with Integra and non-cultured autologous cells had enhanced epithelialization at an early time-point compared to controls. Wounds treated simultaneously with Integra and cell suspension demonstrate that cells remain viable, migrate through the Integra template and self-organize into differentiated epidermis. The results indicate that combining Integra with autologous cells facilitates one-step skin reconstruction of a full-thickness skin wound.

Topics: Animals; Burns; Chondroitin Sulfates; Collagen; Female; Skin; Swine; Tissue and Organ Harvesting; Transplantation, Autologous; Wound Healing

Topics: Adult; Burns; Chondroitin Sulfates; Collagen; Contracture; Humans; Male; Microsurgery; Plastic Surgery Procedures; Skin, Artificial; Surgical Flaps; Tissue Engineering

Topics: Burns; Chondroitin Sulfates; Collagen; Data Interpretation, Statistical; Humans; Injury Severity Score; Sample Size; Skin, Artificial; Survival Rate

The incidence of extensive full thickness scalp burn involving the calvaria is rare and can be very difficult to reconstruct, as the application of local or free tissue transfer is limited. Although wound closure can be achieved with bone debridement and immediate or delayed split-thickness autografting, the result may be problematic due to unstable skin graft surface. The use of artificial dermis that may provide stable thick coverage in the treatment scalp and skull burn has rarely been reported in literature. We encountered two patients who suffered from severe head burns involving the calvarium. Following debridement including the necrotic bone, the artificial dermis (Integra) was used for immediate wound coverage which was 15 cmx10 cm in one case and 5 cmx6 cm in another. Three weeks later, ultra-thin skin grafting was placed on the neodermis. Compared to split-thickness skin graft, this technique provides a thicker coverage for wound closure. Neither skin breakdown nor ulceration was noted in the 1-year follow-up. This paper reports the successful use of artificial dermis for reconstruction of severe scalp burn with calvarial bone involvement.

Topics: Adolescent; Adult; Biocompatible Materials; Burns; Chondroitin Sulfates; Collagen; Female; Graft Survival; Humans; Plastic Surgery Procedures; Scalp; Skin Transplantation; Treatment Outcome

Integra, a dermal replacement template consisting of bovine collagen, chondroitin-6-sulfate, and a silastic sheet is a postexcisional treatment for deep partial to full thickness burns where autograft is limited. This study correlates Integra histology and quantitative microbiology cultures with clinical outcomes after autografting.. Charts of 29 burn patients who underwent Integra treatment and neodermis biopsy at the time of ultra thin autografting were reviewed. We analyzed microbial contamination, inflammatory reaction, and autograft take.. The mean burn size and age were 43% total body surface area and 39 years old, respectively. In quantitative neodermis cultures, 90% of samples had bacterial growth; nine samples (31%) had > 10(5) colony forming units per gram. The most common organism was Staphylococcus aureus (31%). Patients with quantitative bacterial counts >10(5) CFU/g received targeted systemic antibiotics. Integra take (83%) and autograft take (92%) were acceptable even in patients with high bacterial counts (78% Integra take; 86% autograft take). More than 50% of biopsies had dermal regeneration similar to normal dermis; foreign body reactions were unusual. Histologic evidence of inflammation, especially polymorphonuclear cells, was increased in biopsies with high bacterial counts.. Integra and autograft take can be acceptable even with high bacterial counts if wounds are treated with appropriate targeted topical and systemic antibiotics in the presence of microbial contamination. Neodermis biopsies showed fibrous in-growth congruent with existing Integra fibers with minimal foreign body reaction. These data support Integra use as a safe and effective treatment modality in patients with major burns.

Topics: Administration, Topical; Adult; Bacitracin; Biocompatible Materials; Burns; Chondroitin Sulfates; Collagen; Colony Count, Microbial; Drug Combinations; Female; Humans; Male; Neomycin; Polymyxin B; Retrospective Studies; Skin Transplantation; Skin, Artificial; Surgical Wound Infection; Treatment Outcome

Topics: Anti-Infective Agents, Local; Bandages; Biocompatible Materials; Burns; Chondroitin Sulfates; Collagen; Debridement; Facial Injuries; Fluid Therapy; Humans; Skin Transplantation; Skin, Artificial

Management of deep facial burns remains one of the greatest challenges in burn care. We have developed a protocol over the past 20 years for management of facial burns that includes excision and coverage with thick autograft. However, the results were not perfect. Deformities of the eyelids, nose and mouth as well as the prominence of skin graft junctures demonstrated the need to explore novel approaches. Integra has been used with success in the management of burns of the trunk and extremities. The purpose of this study was to prospectively evaluate the aesthetic outcome of the use of Integra for deep facial burns. Twelve consecutive patients underwent excision of large, deep facial burns and placement of Integra. Integra provides excellent color and minimally visible skin graft junctures. The texture is good but not as supple as thick autograft. Integra is not well suited for use in the coverage of eyelid burns due to the need to wait 2 weeks for adequate vascularization. In summary, thick autograft remains the gold standard for deep facial burns. However, for patients with extensive burns and limited donor sites, Integra provides an acceptable alternative.

Topics: Adult; Biocompatible Materials; Burns; Chondroitin Sulfates; Collagen; Esthetics; Eyelids; Facial Injuries; Female; Humans; Male; Middle Aged; Plastic Surgery Procedures; Prospective Studies; Skin Pigmentation; Skin Transplantation; Skin, Artificial; Treatment Outcome

The advantages of Integra have lead to an increase in its use after extensive burn injuries, in reconstructive surgery after burns, and abroad in general reconstructive surgery as well. At the Burn Center of FNsP Hospital in Ostrava Integra was used for the first time in March 2003. Since then, seven patients have undergone operations, involving the use of Integra in 14 body areas. In four of the patients scars after burns were corrected--on the neck, axilla, two on the trunk, two in the popliteal area and one between the toes. In three patients the artificial skin was applied after necronectomy. In a 7-month-old baby and in a 2-year-old child with burn injuries exceeding 25% of the body surface it was applied twice on the trunk, once on the upper extremity and once on the lower extremity. In an adult female Integra was applied on her neck and axilla after burns to a lesser extent. We have evaluated the scars one year after surgery in two patients. Cosmetic appearance was good in both of them. We have noted good functional result after the reconstruction of axilla. After reconstruction in the neck area and reconstruction of the necrectomy in the neck area and axilla, the functional results were average. The average functional results in both patients are probably due to poor compliance with the immobilization and following rehabilitation program.

Topics: Adult; Biocompatible Materials; Burns; Child, Preschool; Chondroitin Sulfates; Collagen; Female; Humans; Infant; Male; Skin, Artificial

We used an artificial dermis (Integra) for the reconstruction of extensive burn scars in children. Integra was initially developed for the primary coverage of acute burns, but several authors report good experiences with Integra for reconstructive surgery. We present a group of 10 children who underwent Integra grafting at 22 different operational sites. Five children received several grafts with Integra. On average, 260 cm(2) per session were grafted. We compared the surface of Integra on the day of grafting and then again on the evaluation day to measure the secondary retraction of the grafts. Complications (infection of Integra, failure of the epidermal graft) were observed in 5 cases. At the final evaluation, 20 grafts were visible. The surface of the Integra graft represented less than 50% of the initial surface in 7 cases, 51-75% in 5 cases and more than 76% in 8 cases. The disadvantages of Integra in reconstructive surgery are that two operative procedures are necessary and the recurrence of contraction seems to be more significant than with full thickness auto grafts. However, Integra has many advantages: the immediate availability of large quantities, the simplicity and reliability of the technique, the pliability and the cosmetic aspect of the resulting coverage. In light of these preliminary results, Integra appears to offer a new alternative for the reconstruction of extensive burn scars in children.

Topics: Biocompatible Materials; Burns; Child; Child, Preschool; Chondroitin Sulfates; Collagen; Female; Follow-Up Studies; Humans; Infant; Male; Skin, Artificial; Treatment Outcome

Full thickness burns usually lead to a great loss of skin and physiological instability because human skin is not only the biggest organ of our body it is the most important protection barrier as well. As natural skin has only limited options to recover, there is a great need for the development of synthetic skin in order to save patients with these high total body surface area full-thickness burns. Many artificial skin substitutes have been developed for this purpose so far. The benefits and harms of one substitute--Integra artificial skin--are discussed in a critical literature review.

Topics: Burns; Chondroitin Sulfates; Collagen; Humans; Treatment Outcome

One of the problems with the dermal substitute Integra has been securing the material to the wound bed to prevent shearing and loss. Techniques to achieve stability include staples and elastic netting with an over layer of absorbent dressings that can be changed regularly. We report an effective technique using suction dressings to immobilise Integra. This technique led to firm application underlying tissue, and appeared to decrease fluid collection under the Integra. Earlier mobilisation and discharge from hospital were facilitated.

Topics: Bandages; Biocompatible Materials; Burns; Child; Chondroitin Sulfates; Collagen; Humans; Length of Stay; Prospective Studies; Suction

We report a head and neck full-thickness burn injury that was reconstructed with a tissue-engineered dermal template and then early implantation of microdissected hair follicles through the silicone epidermis 12 days after the burn injury. The treatment resulted in complete reepithelialization and a hair-bearing scalp without the need for a split-thickness skin graft. Restoration of the stem cell population, hair growth, and earlier reepithelialization were achieved using this novel micrografting technique, and histologic examination confirmed maturation of a normal skin type over the subsequent 2 years.

Topics: Adult; Biocompatible Materials; Burns; Chondroitin Sulfates; Collagen; Epithelium; Hair Follicle; Humans; Male; Microsurgery; Scalp; Skin, Artificial; Stem Cell Transplantation; Tissue Engineering

Topics: Adult; Biocompatible Materials; Burns; Chondroitin Sulfates; Collagen; Elasticity; Follow-Up Studies; Humans; Male; Skin; Skin Transplantation; Skin, Artificial; Treatment Outcome

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.

Topics: Anti-Infective Agents, Local; Biocompatible Materials; Burn Units; Burns; Chondroitin Sulfates; Collagen; Cost-Benefit Analysis; Germany; Glycosaminoglycans; Humans; Patient Selection; Perioperative Care; Retrospective Studies; Skin, Artificial

Integra, a dermal replacement, is used as an immediate and temporary coverage for acute wounds, after which, autograft is used to reconstitute permanently the epidermal coverage. The fibrin sheet-cultured epithelium autograft (FS-CEA) could provide an effective alternative to the surgical procedure. To evaluate this hypothesis, we compared the association of Integra/FS-CE to Integra/control-cultured epithelium (control-CE). Their respective abilities: (1) to produce dermal-epidermal construct in vitro; (2) to generate skin replacement when grafted onto athymic mice were studied. We have shown that: (1) 83% of the FS-CE attached to the artificial dermis in vitro compared to only 33% for control-CE; (2) retraction of the grafted area was significantly lower 2 weeks after grafted with FS-CE than with the control-CE (P < 0.05); (3) 83% of the mice grafted with FS-CE showed the presence of a differentiated human epidermis 21 days after grafting, while such an epidermis was absent in all the animals of the control-CE group. We found that the use of FS-CE greatly improved adhesion, development of the epithelium and graft take onto the artificial dermis. We believe this technology should significantly improve the performance of dermal-epidermal skin replacement for acute wounds.

Topics: Animals; Biocompatible Materials; Burns; Cells, Cultured; Chondroitin Sulfates; Collagen; Epidermis; Epithelium; Fibrin; Graft Survival; Keratinocytes; Mice; Mice, Nude; Skin, Artificial

The aim of this study was to assess the functional outcome in children who had undergone release of upper limb burn contractures at the axilla, elbow and wrist.. We studied a series of 10 patients reconstructed with local flaps (n = 5), Integra artificial skin (n = 10) and micro-vascular free tissue transfer (n = 5) to release contracted axillae (n = 8), elbows (n = 5) and wrists (n = 7). Follow-up ranged from 6 months to 6 years and outcome was assessed by functional improvement.. Full functional release was achieved in all cases at the time of the surgery. Local flaps resulted in good or excellent outcomes in all five cases. Six patients reconstructed with Integra were assessed as having an excellent outcome whereas four had a poor outcome. Free tissue transfer with excellent result was achieved in five children.. This series assessed the three treatment options that we have used for the release of upper limb post-burn contractures. We have shown that local flaps fashioned from burnt skin survive, Integra requires extended post-operative care to prevent recontraction and free tissue transfer is safe in young children. Each method when used appropriately has produced excellent results which have been maintained over the follow-up period.

Topics: Adolescent; Arm Injuries; Biocompatible Materials; Burns; Child; Child, Preschool; Chondroitin Sulfates; Collagen; Contracture; Female; Follow-Up Studies; Humans; Male; Plastic Surgery Procedures; Skin Transplantation; Skin, Artificial; Surgical Flaps; Treatment Outcome

Topics: Adolescent; Adult; Biocompatible Materials; Burns; Chondroitin Sulfates; Collagen; Humans; Male; Reoperation; Skin Transplantation; Skin, Artificial; Surgical Wound Infection; Treatment Outcome

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.

Topics: Adolescent; Adult; Biocompatible Materials; Breast; Burns; Chondroitin Sulfates; Collagen; Female; Humans; Postoperative Care; Skin Transplantation; Skin, Artificial; Treatment Outcome; Wound Healing

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.

Topics: Adolescent; Adult; Aged; Biocompatible Materials; Burns; Child; Chondroitin Sulfates; Collagen; Female; Graft Survival; Hand Injuries; Humans; Male; Middle Aged; Plastic Surgery Procedures; Skin Transplantation; Skin, Artificial; Treatment Outcome; Wound Healing

The recent release of artificial dermis for general use, has open wide a new field in pediatric reconstructive surgery. The aim of this paper is to analyze the results of Integra artificial dermis in our Plastic Surgery Department.. The records of the patients treated with Integra between february 1999 and january 2001 were analyzed, focusing on the indications, the complications and the final results.. Fourteen Integra implantation procedures in 11 patients aged 16 months to 12 years (mean +/- SD: 80.9 +/- 48.5 months) were performed. Indications were: acute burns in 5 cases, burns sequelae in 5, and partial extirpation of a congenital giant nevus in the last one. Integra was used to replace between 2 and 30% of total body surface area. The percentage of "take" of skin grafts was 85%. The most frequent early complication was the development of infection under the Integra; it occurred in 2 cases and artificial dermis had to be partially removed. Hypertrophic scars developed in 2 patients; both had refused pressure garments. Cosmetic results in the remaining 9 patients are considered excellent.. The use of artificial dermis has settled as a new procedure in plastic pediatric surgery. In spite of possible complications, the easy manipulation and the good results make Integra a perfect skin substitute in several cutaneous disorders.

Topics: Biocompatible Materials; Burns; Child; Child, Preschool; Chondroitin Sulfates; Collagen; Dermis; Female; Humans; Infant; Male; Pediatrics; Plastic Surgery Procedures

Topics: Biocompatible Materials; Burns; Chondroitin Sulfates; Collagen; Humans; Regeneration; Skin Physiological Phenomena

Integra artificial skin provides immediate full-thickness reconstruction for cutaneous burns. The clinical outcome appears to be superior in terms of final function and cosmesis. Consequently the use of such a skin substitute is being heralded as the future treatment of choice, particularly for massive burns where autologous donor skin is limited. The three cases reported here describe the senior author's early experience with Integra and highlight some of the difficulties and successes encountered. A high rate of dermal graft loss and slow epidermal engraftment have tempered the original enthusiasm, but with growing experience the final outcome justifies the continued use of Integra in our unit.

Topics: Accidents, Occupational; Arm; Biocompatible Materials; Burns; Child; Child, Preschool; Chondroitin Sulfates; Collagen; Contracture; Follow-Up Studies; Humans; Male; Middle Aged; Reoperation; Skin, Artificial; Thorax; Transplantation, Autologous; Treatment Failure

Early excision and prompt coverage in severely burned patients are the best way to lessen morbidity and improve survival. Repair of full-thickness burns requires replacement of both dermal and epidermal components of skin and treatment with split thickness autografts replaces both of them. But healthy skin is not sufficient in extensive burns. Alternative to split thickness skin grafts have been studied by several groups including epidermis, dermis or a complete replacement comprising epidermis and dermis. Because of the difficulties in homografts supplying, a new way was use to replace the dermis. In 1981, Yannas and Burke were the first to develop such a matrix. Intégra is available in France since 1997 and was used in our service for the treatment of both acute and reconstructive surgery for burned patients. Twenty patients were treated for acute surgery. Nineteen patients were treated for reconstructive surgery of burn scar contractures. Fifty-one grafts of Intégra were performed. Long-term final results seem to show that Intégra improve cosmetical and functional results and is a new surgical alternative for the treatment of burns in the acute phase as well as in late surgery of deformities.

Topics: Activities of Daily Living; Acute Disease; Adolescent; Adult; Aged; Aged, 80 and over; Biocompatible Materials; Biopsy; Burns; Child; Chondroitin Sulfates; Collagen; Contracture; Female; Follow-Up Studies; France; Humans; Injury Severity Score; Male; Middle Aged; Plastic Surgery Procedures; Porosity; Skin Transplantation; Transplantation, Autologous; Transplantation, Homologous; Treatment Outcome; Wound Healing

We report on our experience with Integra application in 22 patients treated from February 1996 through April 1999. Nine patients suffered a primary burn injury and 13 patients had secondary unstable scars. Integra is artificial skin that consists of a collagen/glycosaminoglycane matrix and a silicon layer. It was first used by Burke and Yannas in 1980 in the USA. The mechanical and biological features of Integra protect the tissue from fluid loss and bacterial invasion in the acutely burned patient. The integra-induced formation of a neodermis leads to functionally and aesthetically highly acceptable scar formation. We present our clinical experience with Integra in long-term follow-up.

Topics: Adult; Burns; Chondroitin Sulfates; Cicatrix; Collagen; Female; Humans; Male; Middle Aged; Silicones; Skin Transplantation; Skin, Artificial; Wound Healing

1. Samples of normal skin from four patients, post-burn hypertrophic scar from five patients and post-burn mature scar from six patients were analysed for hydroxyproline, water and uronic acid and extracted with guanidinium chloride to yield the proteoglycan pool. A large chondroitin sulphate proteoglycan and biglycan were purified from one hypertrophic scar biopsy and decorin from a normal skin biopsy, by ion-exchange chromatography, gel-filtration and hydrophobic interaction chromatography. These purified proteoglycans were used in an inhibition ELISA assay to estimate the quantities of each in the tissue samples. 2. Samples of post-burn hypertrophic scar had on average 30% less hydroxyproline, 12% more water and 2.4 times as much uronic acid as normal skin. These differences were all statistically significant, whereas the small differences between mature scars and normal skin were not. The content of decorin in hypertrophic scars was only 25% of that in normal skin whereas the large chondroitin sulphate proteoglycan and biglycan were each about 6-fold higher. The mature scars had slightly elevated levels of large chondroitin sulphate proteoglycan and biglycan and a reduced content of decorin compared with normal skin but these differences were not statistically significant. 3. The results suggest that aberrant proteoglycan metabolism is a significant factor contributing to the altered physical properties of hypertrophic scars and that maturation of post-burn scars is dependent on a return of the relative proportions and concentrations of proteoglycans to those characteristic of normal dermis.

Topics: Burns; Chondroitin Sulfates; Chromatography, Gel; Chromatography, High Pressure Liquid; Chromatography, Ion Exchange; Cicatrix, Hypertrophic; Decorin; Enzyme-Linked Immunosorbent Assay; Extracellular Matrix Proteins; Humans; Hydroxyproline; Proteoglycans; Skin; Uronic Acids; Water

A collagen and chondroitins 4-, 6-sulphate biomaterial designed for the coverage of severe burns was optimized in terms of mechanical strength by addition of 20% (wt/vol) of chitosan to the starting material. Chitosan should create ionic bonds with collagen and thus increase the tensile strength and Young's modulus of the sponge. On the other hand, sterilization by h-irradiation of the biomaterial induced a decrease in its mechanical properties that could be avoided by sterilization using beta-irradiation. The thickness, pore size and morphology of the biomaterial were optimized before freeze-drying by freezing the mixture at -60 degrees C at a weight/volume concentration of 1.25% and a volume of 270 mul/cm2. The biomaterial obtained under these conditions may further the vascularization and cellular colonization of the porous structure by the host cells of the wound bed and therefore may accelerate the regeneration of a new dermis.

Topics: Burns; Chitin; Chondroitin Sulfates; Collagen; Freezing; Humans; Materials Testing; Microscopy, Electron, Scanning; Porosity; Skin, Artificial; Sterilization; Tensile Strength; Wound Healing

Repair of full-thickness burns requires replacement of both the dermal and the epidermal components of the skin. Use of tissue culture methods allows very large expansions of surface area to be covered by cultured normal human epidermal keratinocytes (HK). Porous and resorbable materials, such as collagen and chondroitin-6-sulfate membranes, may be expected to adhere to wounds and promote fibrovascular ingrowth better than grafts of cultured epidermal keratinocytes alone. This article demonstrates the in vitro formation of biologic attachments between HK and a collagen and chondroitin-6-sulfate dermal skin replacement. Dermal membranes are prepared as generic acellular sheets and stored in the dry state for extended periods. Subconfluent HK cultures in logarithmic phase growth can attach quickly to dermal membranes in vitro, form a confluent epithelial sheet on the surface of each membrane, and exhibit mitotic cells for at least 1 week in vitro. Transmission electron microscopy demonstrates the formation of hemidesmosomes, extracellular matrix, and banded collagen at the interface of the epidermal cells and the dermal membrane. By comparison, HK cultures as confluent sheets released enzymatically with Dispase do not attach to the dermal membranes in vitro, under the conditions tested, although complete coverage of the membrane by the cell sheets is obtained. Growth assays show that subconfluent HK cells retain sufficient growth potential to maintain logarithmic phase growth, but that HK cells disaggregated from confluent sheets become growth arrested in comparison. The composite material has discrete dermal and epidermal compartments, has total thickness comparable to split-thickness skin graft, and can be applied to full-thickness skin defects in a single procedure.

Topics: Burns; Chondroitin; Chondroitin Sulfates; Collagen; Culture Techniques; Desmosomes; Epidermal Cells; Humans; Keratins; Mitosis; Skin Transplantation

Topics: Animals; Burns; Chondroitin; Chondroitin Sulfates; Collagen; Female; Inflammation; Injections, Intradermal; Male; Rats; Rats, Inbred Strains; Time Factors; Wound Healing

A bilayer artificial skin composed of a temporary Silastic epidermis and a porous collagen-chondroitn 6-sulfate fibrillar dermis, which is not removed, has been used to physiologically close up to 60% of the body surface following prompt excision of burn wounds in ten patients whose total burn size covered 50--95% body surface area (BSA). Following grafting, the dermal portion is populated with fibroblasts and vessels from the wound bed. The anatomic structure of the artificial dermis resembles normal dermis and serves as a template for the synthesis of new connective tissue and the formation of a "neodermis," while it is slowly biodegraded. This artificial skin has physiologically closed excised burn wounds for periods of time up to 46 days before the Silastic epidermis was removed. At the time of election when donor sites are ready for reharvesting, the Silastic epidermis is removed from the vascularized artificial dermis and replaced with 0.004 autoepidermal graft in sheet or meshed form. Clinical and histologic experience in a relatively short follow-up period (2--16 months) indicates that "neodermis" retains some of the anatomic characteristics and behavior of normal dermis, thus promising improvement in the functional and cosmetic results, as well as providing physiologic function as a skin substitute. The artificial skin is easily sterilized and stored at room temperature, capable of large scale production, and immediately available for grafting, indicating its potential for easy and relatively economic use in the burn patient.

Topics: Adolescent; Adult; Artificial Organs; Burns; Child; Child, Preschool; Chondroitin Sulfates; Collagen; Humans; Middle Aged; Postoperative Complications; Silicone Elastomers; Skin; Wound Healing