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Summary Background Scalp wounds pose reconstructive challenges due to the lack of skin elasticity, potential for compromised adjacent tissue, and desire for the restoration of esthetic contour. Bilayer Wound Matrix (BWM) has been successfully employed as a treatment modality for complex, full-thickness wounds of the scalp. We aimed to highlight risk factors for BWM success and failure in complex wounds of the scalp. Methods A retrospective case-control study was performed from 2012 to 2019 of adult subjects who presented to plastic or dermatological surgery with complex scalp defects with or without exposed calvarium, who underwent staged reconstruction with BWM and split-thickness skin grafting or secondary intention. Success was defined as complete wound re-epithelialization within 90-day follow-up without additional operative procedures for wound coverage. Demographics, comorbidities, treatment history, wound characteristics, and clinical course were analyzed and correlated with reconstructive outcomes. Results In total, 127 subjects were identified for inclusion, with mean age 74.6 ± 12.2 years, defect area 80.2 ± 89.4 cm2, and wound age 10.0 ± 65.4 days. Successful wound reconstruction occurred in 107 (84%) subjects. Postoperative wound infections were an independent predictor of BWM failure at 90 days (Odds Ratio: 6.4, 95% Confidence Interval: 1.5 – 26.7, and p Conclusion BWM represents a reliable and efficacious modality in the treatment of complex scalp wounds. Patient comorbidities may not heavily influence the success of BWM to establish adequate wound coverage; however, preoperative radiation and postoperative wound infection may often lead to reconstructive failure.

Large defects in plantar surface secondary to acral melanoma excision can be difficult to repair with local flaps, and skin grafts in weight-bearing surfaces often suffer necrosis causing prolonged disability. Acellular dermal matrices represent an easy alternative to cover deep wounds or those with bone or tendon exposure. Despite their high cost and the requirement of two surgical procedures, this alternative may offer excellent functional and aesthetic results in acral defects.

Optimal treatment of full‐thickness skin injuries requires dermal and epidermal replacement. To spare donor dermis, dermal substitutes can be used ahead of split‐thickness skin graft (STSG) application. However, this two‐stage procedure requires an additional general anaesthetic, often prolongs hospitalisation, and increases outpatient services. Although a few case series have described successful single‐stage reconstructions, with application of both STSG and dermal substitute at the index operation, we have little understanding of how the physical characteristics of dermal substitutes affects the success of a single‐stage procedure. Here, we evaluated several dermal substitutes to optimise single‐stage skin replacement in a preclinical porcine model. A porcine full‐thickness excisional wound model was used to evaluate the following dermal substitutes: autologous dermal graft (ADG; thicknesses 0.15‐0.60 mm), Integra (0.4‐0.8 mm), Alloderm (0.9‐1.6 mm), and chitosan‐based hydrogel (0.1‐0.2 mm). After excision, each wound was treated with either a dermal substitute followed by STSG or STSG alone (control). Endpoints included graft take at postoperative days (PODs) 7 and 14, wound closure at POD 28, and wound contracture from POD 28‐120. Graft take was highest in the STSG alone and hydrogel groups at POD 14 (86.9% ± 19.5% and 81.3% ± 12.3%, respectively; P

Objective: To evaluate large propensity-matched cohorts to assess outcomes in patients receiving advanced treatment (AT) with skin substitutes for lower extremity diabetic ulcers (LEDUs) versus no AT (NAT) for the management of LEDUs. Method: The Medicare Limited Dataset (1 October 2015 through 2 October 2018) were used to retrospectively analyse people receiving care for a LEDU treated with AT or NAT (propensity-matched Group 1). Analysis included major and minor amputations, emergency department (ED) visits and hospital readmissions. In addition, AT following parameters for use (FPFU) was compared with AT not FPFU (propensity-matched Group 2). A paired t-test was used for comparisons of the two groups. For comparisons of three groups, the Kruskal–Wallis test was used. A Bonferroni correction was performed when multiple comparisons were calculated. Results: There were 9,738,760 patients with a diagnosis of diabetes, of whom 909,813 had a LEDU. In propensity-matched Group 1 (12,676 episodes per cohort), AT patients had statistically fewer minor amputations (p=0.0367), major amputations (pConclusion: AT for the management of LEDUs was associated with significant reductions in major and minor amputation, ED use, and hospital readmission compared with LEDUs managed with NAT. Clinics should implement AT in accordance with the highlighted parameters for use to improve outcomes and reduce costs.

Pleomorphic dermal sarcoma is a rare neoplasm of mesenchymal origin that most commonly affects the head. We describe the presentation of a 61-year-old man with a 10-week history of an exophytic lesion affecting the occipital scalp, demonstrating rapid growth. The final histopathology revealed a completely excised 9cm pleomorphic dermal sarcoma (pT2aN0M0, Stage 3), one of the largest such lesions reported in the literature to date. This patient’s management involved a wide local subperiosteal excision onto the cranium, with a reconstruction with an Integra dermal regeneration template (Integra LifeSciences, Princeton, NJ, USA) and healing with secondary intention. This was mainly due to poorly defined clinical margins on primary excision, the potential for further excision of involved margins (later confirmed as not needed) and the patient’s comorbidities, making a return to theatre for definitive reconstruction undesirable.

Currently, many dressings are commercially available for the treatment of burn wounds. Some of these wound dressings remain on the wound, prevent painful dressing changes, and reduce tissue scarring. Nevertheless, still a wound dressing that is cost‐effective, produces good wound healing properties, and has a high patient satisfaction is needed. Standard care of superficial burn wounds differs between burn centres. This study aimed to determine a dressing with easy appliance, accurate pain control, favourable outcome, and cost‐effectiveness. Therefore, we compared the widely used but expensive Suprathel with the rather new but much cheaper Dressilk in the clinical setting. In a prospective clinical study, the healing of partial thickness burn wounds after simultaneous treatment with Suprathel and Dressilk was examined in 20 patients intra‐individually. During wound healing, pain, infection, exudation, and bleeding were evaluated. A subjective scar evaluation was performed using the Patient and Observer Scar Scale. Both dressings were easy to apply, remained on the wound in place, and were gradually cut back as reepithelisation proceeded and showed similar times to wound closure. Dressing changes were not necessary, and neither infections nor bleeding was detected. Overall exudation and pain were highest in the beginning but declined during the wound‐healing phase without significant differences. In the follow‐up scar evaluation after 12 months, patients reported overall high satisfaction. Overall, the modern dressings Suprathel and Dressilk (solely made out of pure silk) led to safe wound healing without infection and rapidly reduced pain. There was no need for dressing changes, and they had similar clinical outcomes in scar evaluation. Therefore, both dressings seem to be ideal for the treatment of superficial burns. Because acquisition costs remain one of the main factors in the treatment of burns, Dressilk, which is ~20 times cheaper than Suprathel, remains a good option for the treatment of partial thickness burns.

Introduction Proper wound care along with the use of skin grafts over deep burn wounds has been the standard treatment. However, the goal in burn wound care has shifted from achieving a satisfactory survival rate to improving long-term form and function of the healed wound, which is sometimes hindered by scar contracture. This has prompted surgeons to find alternative ways to treat burn wounds without compromising function. Among burn cases, hand injuries are the most problematic when it comes to delicate function recovery. Methods This study presents the results of conjunctive use of a bilayer artificial dermis, negative pressure wound therapy, and split-thickness skin grafts for grafting over acute burn wounds and scar-releasing defects after severe hand burns. Results Three months after the operation, the scar was soft and pliable, the aesthetic outcome was good, and the patients gained much improvement in hand function and quality oflife. Conclusions The combined technique achieved a good scar quality and aesthetic effect on burned hands as well as excellent functional outcome, which resulted in major improvements and an independent life for the patient.

Summary Background Artificial dermal skin substitutes (ADSS) in combination with split thickness skin grafts (STSG) are a valuable option for reconstruction of skin- and soft tissue defects. However, successful incorporation of ADSS can be limited by various factors. We investigated the anticipated benefits of negative pressure wound therapy (NPWT) as an adjunct to support integration of ADSS in a retrospective, comparative cohort study. Patients and Methods We performed a retrospective, non-blinded, non-randomized comparative study including 86 Patients with various soft-tissue defects, managed by application of either ADSS with or without NPWT based on the surgeon´s preference. Outcome measurements comprised ADSS and skin graft take rates as well as analysis of treatment duration and time to wound healing. Additionally, patients were analyzed for the occurrence of hematoma, seroma, wound infection and lack of substitute or skin graft adhesion. Results Demographic data and individual risk factors did not differ statistically significant between both groups. The combination of ADSS with NPWT lead to significantly improved rates of ADSS integration (89 vs. 70.1 %; p = 0.035) and skin graft take (91 vs. 76 %; p = 0.049) compared to standard wound dressings without NPWT. In addition, while differences in the incidence of seroma were neglectable, NPWT application lead to significantly reduced rates of infection of ADSS (2.2 vs. 7.3 %; p = 0.043). Moreover, STSG could be performed on average 4 days earlier with the application of NPWT (p = 0.031). Conclusions The addition of NPWT to ADSS is a helpful adjunct that reduces time of incorporation and vascularization and improves clinical success rates.

Background Management of skin and soft-tissue defects of the fingertips is functionally and aesthetically important, but controversial, especially when bones are exposed. Recent advances in wound healing technology allow the use of cells or biological dermis. The authors studied the clinical efficacy of tissue-engineered dermis grafts and artificial dermis grafts versus immediate reconstructive procedures, such as the reverse digital artery island flap, in treating bone-exposed fingertip defects. Methods One hundred eighty-two patients with bone-exposed fingertip defects treated with tissue-engineered dermis grafts (n = 71), artificial dermis grafts (n = 23), or reverse digital artery island flaps (n = 88) were included in this retrospective cohort study. Surgical time, duration of hospitalization, total cost, success rate, healing time, sensory recovery, range of motion, scar quality, and patient satisfaction were compared. Results No tissue-engineered or artificial dermis graft exhibited graft rejection or failure, whereas there was one partial loss and one total loss after reverse digital artery island flap surgery. Tissue-engineered dermis grafts were superior in scar quality, and artificial dermis grafts had shorter surgical times and lower surgical costs; both groups demonstrated superior results in postoperative range of motion and sensory recovery in two-point discrimination tests and shorter hospitalization, compared with the reverse digital artery island flap group. The reverse digital artery island flap had shorter complete closure time and less postoperative tingling sensation. There were no differences in overall patient satisfaction among the groups. Conclusions Tissue-engineered and artificial dermis grafts may be promising alternatives for fingertip reconstruction. In particular, tissue-engineered dermis grafts may deliver superior functional results, including recovery of sensory discomfort and aesthetic results in terms of scar quality over artificial dermis grafts. Clinical question/level of evidence Therapeutic, III.

Introduction. Acellular dermal matrix (ADM) products are adopted in the management of injuries to soft tissues. ADMs have been increasingly employed for their clinical advantages, and they are acquiring relevance in the future of plastic surgery. The aim of our study is to evaluate the application of ADMs in our patients who could not undergo fast reconstruction. Materials and Methods. We performed a retrospective study on 12 patients who underwent ADM placement for scalp and limb surgical reconstructions at the Humanitas Research Hospital, Rozzano (Milano), Italy. Wounds resulted from 9 tumor resections and 3 chronic ulcers. The ADM substrate used to treat these lesions was PELNAC™ (Gunze, Japan), a double-layered matrix composed of atelocollagen porcine tendon and silicon reinforcement. All patients underwent a second surgical operation to complete the treatment with a full-thickness skin graft to cover the lesion. Results. In this study, 12 patients were treated with PELNAC™: 11 out of 12 patients showed a good attachment over a median time of 21.3 days (range 14-27). After almost 23 days, all patients were ready to undergo a full-thickness skin grafting. Conclusion. This study assesses the benefits of PELNAC™ and proposes this method as an alternative to traditional approaches, especially in situations where the latter techniques cannot be applied.

Objective: Pediatric burns are a major source of injury and in the absence of adequate care can lead to lifelong functional loss and disfigurement. While split thickness skin autografts are the current standard of care for deep partial and full-thickness burns, this approach is associated with considerable morbidity. For this reason, alternative skin substitutes such as allografts have gained interest. Approach: In the present study, we present a case series of 30 children with various types of burns treated with dehydrated human amnion chorion membrane (dHACM). Results: We show that treatment with dHACM is associated with an excellent rate of healing comparable to split thickness skin grafts with less rate of hypertrophic scar and contracture. Innovation: Treatment with dHACM is particularly attractive as it consists of many tissue regenerative factors, such as growth factors and immune modulators, thus it will reduce the risk of scaring. Conclusion: While dHACM is associated with an increased upfront cost, treating patients with small to moderate-sized burns with dHACM in their regional centers works to decrease downstream costs such as management of prolonged pain from donor-site morbidity, revisional surgeries from scar and contractures of split thickness grafts, and avoiding the cost of transfer to higher level centers of care. Our findings challenge the current standard of care, suggesting that dHACM provides an alternative to the current use of split thickness skin grafting and is a safe, feasible, and potentially superior substitute for the management of small to moderate total body surface area partial and full-thickness pediatric burns.

The purpose of this study was to evaluate the therapeutic effects of artificial dermis combined with autologous split‐thickness skin grafting (STSG) compared with autologous intermediate‐thickness skin grafting (ITSG) alone in severely burned patients. Fifty‐six severely burned patients admitted to our hospital from December 2017 to January 2019 were enrolled and evenly grouped according to the random number table method [AD‐STSG group: 28 patients, receiving the treatment of artificial dermis (AD) combined with autologous STSG; ITSG group: 28 patients, receiving autologous ITSG treatment alone]. The healing time and Vancouver Scar Scale (VSS) score of the donor area and graft area, survival rate and infection status of the autologous skin, psychological status (determined by Self‐rating Anxiety Scale and Self‐rating Depression Scale), and the activity of functional parts of all enrolled patients were included in the evaluation. General items of patients in AD‐STSG group and ITSG group, including age, sex, and degree of burn, were all comparable. A significantly shortened healing time of donor skin in AD‐STSG group was observed when compared with ITSG group (P

Management of extensive lower extremity soft tissue and skin loss can be a very difficult to achieve by any surgeon. There can be several associated comorbidities that need to be considered and addressed with these patients. The approach is multifactorial and requires commitment from both the surgeon as well as the patient. There are several protocols that have been formulated throughout the literature addressing soft tissue and skin coverage of the limbs. This article provides a review of the literature and describes the evaluation, harvesting, transplantation, and management of skin grafting techniques to the lower extremities.

Background: Venous leg ulcers (VLUs) present a significant economic burden on the US healthcare system and payers (US$14.9 billion). Aim: To evaluate the quality of life (QoL) of patients with VLUs; to analyze the limitations of standard of care (SOC) for VLUs; and to explain how using bilayered living cellular construct (BLCC) with SOC for treatment of VLUs can help heal more VLUs faster (than using SOC alone) as well as help improve QoL and help reduce the burden on the US healthcare system and payers. Materials & methods: This is a review study. The search was conducted in February 2020 by way of electronic databases to find relevant articles that provided information related to QoL of patients with VLUs, limitations of SOC for VLUs and economic analyses of using BLCC for treatment of VLUs. Results: VLUs impact patients’ physical, functional and psychological status and reduce QoL. A total 75% of VLU patients who used SOC alone failed to achieve healing in a timely fashion, which led to increased healthcare costs and healthcare resource utilization. Although the upfront cost is high, the greater effectiveness of BLCC offsets the added cost of the product during the time period of the studies. Therefore, BLCC helps to improve the QoL of VLU patients. As an example, for every 100 VLU patients in a healthcare plan, the use of BLCC can create cost savings of US$1,349,829.51. Conclusion: Payers’ coverage of BLCC results in reduction of the overall medical cost for treating VLU patients.

Background There is not an ideal biomaterial for tissue-engineered skin substitutes (TESSs), and most of the studies or existing therapies use xenogeneic origin natural biomaterials or biosynthetic scaffolds. Objective To analyse clinical, histological integration and homeostasis parameters of a human TESS manufactured with fibrin-hyaluronic acid biomaterial (HA-Skin), grafted in immunodeficient mice for 8 weeks, and compared with the gold standard treatment (Autograft), a human TESS manufactured with fibrin-agarose biomaterial (AG-Skin) and secondary wound healing dressings. Methods Human TESSs and autografts were implanted into BALB/c mice after surgical excision. Secondary wound healing approach was achieved with biosynthetic collagen wound dressing (Biobrane® ) and fibrin-hyaluronic acid or fibrin-agarose biomaterial without cells (Total N = 44). Clinical integration and homeostasis parameters were evaluated every two weeks for two months. Histological and immunohistochemical analyses were performed four and eight weeks after grafting. Results HA-Skin, AG-Skin and Autograft groups showed a proper clinical integration and epithelization eight weeks later. Scar evaluation revealed better results for Autograft and HA-Skin. Homeostasis analysis indicated similar values of transepidermal water loss and elasticity between HA-Skin (6.42 ± 0.75 g/h/m2 , 0.42 ± 0.08 AU), Autograft (6.91 ± 1.28 g/h/m2 , 0.40 ± 0.08 AU) and healthy mouse skin (6.40 ± 0.43 g/h/m2 , 0.35 ± 0.03 AU). Histological results showed that human TESSs and autografts presented better skin structuration and higher expression of cytokeratins. Conclusions This study suggests that human TESS based on fibrin-hyaluronic acid biomaterial could be suitable for clinical application in the treatment of several dermatological pathologies (wound healing).

Summary Purpose After harvesting a radial forearm flap (RFF) an optimal aesthetic and functional restitution of the donor site is required. In order to cover the secondary defect of the donor site, several solutions are currently available, but there is still no real evidence of the most reliable option. A retrospective study was conducted in order to evaluate a new technique of forearm coverage with artificial dermis: the association of full thickness skin graft (FTSG) with Matriderm®. Methods Our study included all RFF performed during a 34-month period. Forty-three forearm secondary defects after harvesting a RFF (16 men, 27 female) were included. Forearm donor site was covered using three techniques: a simple FTSG, split thickness skin graft (STSG) with Matriderm® or FTSG with Matriderm®. Clinical evaluations based on residual functionality, skin quality and aesthetic result were assessed using respectively the Disabilities of the Arm, Shoulder and Hand (DASH) score, the Vancouver Scar Scale (VSS) score and a blind panel questionnaire. Results FTSG with Matriderm® showed an improved DASH (10.6/100) and VSS score (5.5/13) if compared to the other techniques, mean surgeon satisfaction score was 3/5, mean patient satisfaction score was 3/5 in the FTSG with Matriderm® group. Conclusion The results of this study revealed that the new association of FTSG with Matriderm® improves the DASH score and the aesthetic outcomes resulting to be a reliable solution in treating full thickness forearm skin defects after RFF harvesting.

Summary Background In a previous study, our group demonstrated that cultured autologous fibroblast-seeded artificial dermis was superior to artificial dermis for covering defects after surgical excision of basal cell carcinoma (BCC) in terms of scar quality. However, utilizing cultured cells for clinical purposes requires Food and Drug Administration–approved facilities and techniques and a lengthy culture period. The purpose of this retrospective study was to compare the effects of tissue-engineered dermis containing stromal vascular fraction (SVF) cells with artificial dermis on scar quality after surgical excision of BCC on the nose. Methods Between April 2010 and February 2018, patients who were treated with tissue-engineered or artificial dermis grafts and those with a follow-up period of greater than a year were included in this study. The Patient and Observer Scar Assessment Scales (POSAS) were compared between two groups according to the location of the graft, which was classified based on nasal subunits: the upper two-thirds zone; the lower one-third zone, except for the ala; and the alar zone. Results A tissue-engineered dermis composed of SVF cells and an artificial dermis were applied to 30 and 47 patients, respectively. In upper two-thirds and lower one-third zones, except for the ala, no statistically significant differences were found in any parameters. In the alar zone, statistically significant differences were detected in 10 of 21 POSAS parameters. Conclusion To cover nasal defects, the tissue-engineered dermis graft may be superior to the artificial dermis graft regarding scar quality at the ala. However, there were no significant differences in other zones.

We aimed to evaluate the results of dermal substitute implantation after early excision in the acute phase of major burn cases within the scope of efforts to reduce contractions and scar formation in functional anatomic areas (face, neck, axilla, elbow, popliteal). Twelve patients with major burn who were treated in the burn center between September 2017 and September 2018 were included in the study. In these patients, Nevelia® dermal substitute was implanted into 24 functional areas with deep partial or full-thickness burns after surgical debridement of the wound. Autologous split-thickness skin graft was applied to these areas after 14 to 21 days. The patients were followed for 4 to 14 months (mean 6 months). Postoperative scar formation was assessed by the Vancouver Scar Scale at the end of the follow-up period. A simple qualitative staging system was used for aesthetic and functional evaluation. The time from burn injury to dermal substitute implantation was 3 to 21 days. Skin graft take was complete in 22 of 24 regions and partial in one of them, while graft loss developed in one region. In the implantation sites, the Vancouver Scar Scale ranged from 1 to 7. The aesthetic and functional evaluation showed excellent/good results in 21 of 24 anatomic regions, moderate results in 2 regions, and poor results in 1 region. The use of dermal substitute in deep burns of functional/mobile anatomic areas at the acute phase after early excision and subsequent skin autografting has opened a new alternative area in the burn surgery arena to prevent contractures and functional limitations.

Despite the abundance of skin substitutes in the worldwide market, major hurdles in developing more complex tissues include the addition of skin appendages and vascular networks as the most important structure. The aim of this research was a clinical feasibility study of a novel prevascularized skin grafts containing the dermal and epidermal layer using the adipose stromal vascular fraction (SVF)-derived endothelial cell population for vascular network regeneration. Herein, we characterized hydrogel with emphasis on biological compatibility and cell proliferation, migration, and vitality. The therapeutic potential of the prevascularized hydrogel transplanted on five human subjects as an intervention group with diabetic wounds was compared with nonvascularized skin grafts as the control on five patients. Wound planimetric and biometric analysis was performed using a Mann-Whitney nonparametric t-test (p ≤ .05). The fibrin-collagen hydrogel was suitable for skin organotypic cell culture. There was a significant (p ≤ .05) increased in skin thickness and density in the vascular beds of the hypodermis measured with skin scanner compared with that in the control group. No significant macroscopic differences were observed between the intervention and control groups (p ≤ .05). In summary, we report for the first time the use of autologous dermal-epidermal skin grafts with intrinsic vascular plexus in a clinical feasibility study. The preliminary data showed that SVF-based full-thickness skin grafts are safe and accelerate the wound healing process. The next stage of the study is a full-scale randomized clinical trial for the treatment of patients with chronic wounds.

Background: Little is known about the efficacy of newer skin substitute scaffolds to reconstruct complex lower extremity wounds. The investigators present a multihospital experience of reconstructive surgeons utilizing collagen-GAG bilayer wound matrix in lower extremity soft-tissue reconstruction with the goals to (1) characterize a suitable patient population, (2) categorize failures to optimize patient selection, and (3) determine wound factors affecting success. Methods: Subjects underwent collagen-GAG–based lower extremity wound reconstruction from May of 2010 to June of 2017. The primary outcome variable was 180-day graft success, defined as eventual split-thickness skin grafting after bilayer wound matrix application; failure was defined as inadequate wound bed for split-thickness skin grafting, requirement for vascularized tissue transfer, or eventual amputation. Eligible subjects had at least one lower extremity wound and were at least 18 years old. Exclusion criteria included third-degree burn wounds or failure to follow up for at least 60 days postoperatively. Predictor variables included demographics, medical comorbidities, perioperative characteristics, postoperative complications, and cost-related data for each hospitalization. Results: There were 147 subjects with 191 wounds. Mean patient age was 60.1 years (range, 21.0 to 95.6 years), and mean body mass index was 30.5 kg/m2 (range, 14.4 to 64.7 kg/m2). Average wound size was 73.1 ± 137.7 cm2, with 49.0 percent of subjects receiving adjunct postoperative negative-pressure wound therapy. Seventy percent of wounds were successfully healed at 180 days. Most were localized between the knee and ankle (50.8 percent) or foot (46.1 percent). Tendon exposure (p < 0.05), bone exposure (p < 0.01), and bone excision (p < 0.04) were associated with reconstructive failure. Conclusions: The authors present the largest reported multihospital, multidisciplinary experience with collagen-GAG wound matrix for lower extremity reconstruction. Tendon and/or bone exposure and socioeconomic factors were associated with failure. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Wound healing is a complex physiological process that occurs in the human body involving the sequential activation of multiple cell types and signaling pathways in a coordinated manner. Chronic wounds and burns clearly decrease quality of life of the patients since they are associated with an increase in physical pain and socio-economical complications. Furthermore, incidence and prevalence of chronic wounds (unlike burns) have been increasing mainly due to population aging resulting in increased costs for national health systems. Thus, the development of new and more cost-effective technologies/therapies is not only of huge interest but also necessary to improve the long-term sustainability of national health systems. This review covers the current knowledge on recent technologies/therapies for skin regeneration, such as: wound dressings; skin substitutes; exogenous growth factor based therapy and systemic therapy; external tissue expanders; negative pressure; oxygen; shock wave, and photobiomodulation wound therapies. Associated benefits and risks as well as the clinical use and availability are all addressed for each therapy. Moreover, future trends in wound care including novel formulations using metallic nanoparticles and topical insulin are herein presented. These novel formulations have shown to be promising therapeutic options in the near future that may change the wound care paradigm.

Background Burn injuries are the third leading cause of preventable death in children worldwide, resulting in over 100 000 annual hospitalisations. In the paediatric population, scalds are the commonest mechanism and burn injuries of greater than 40% total burn surface area (TBSA) are associated with a high mortality and morbidity rate. Aims The aim of this study was to review mortality in paediatric burns in a tertiary burns centre over a 60-year period, providing an understanding of local causes of mortality and directing future clinical research. Methods We reviewed data collected prospectively from patients treated for burn injuries at the WCH from 1960 to 2017. Data of age, gender, mechanism of injury and TBSA were collected. TBSA of 40% and greater were included in the study. Results All patients with total burn surface area (TBSA) less than 40% survived. There were a total of 75 patients who sustained burns of or greater than 40% TBSA. Overall mortality was 34% (26 of 75) of which 24 occurred in the 1960s. Of the 21 patients who died of flame burn injuries, 12 of them were described as clothes catching alight from being in close proximity to the source of flame. Average length of stay for patients who did not survive was 7 days (1–26). Conclusion Mortality has since declined and the prognosis for survival good, even in TBSA of greater than 90%. The investigations in fabric flammability led by Dr Thomas Pressley and Mr Murray Clarke prompted the rewriting of Australian standards for production of children’s clothing. This, in combination with advances in paediatric resuscitation, surgical techniques as well as wound care has improved survival rates and outcomes in extensive burn injuries. Future studies focus to see not only better survival rates, but also better aesthetic and functional outcomes in burn survivors.

The use of decompressive craniectomy in children is controversial and often reserved for patients with refractory intracranial hypertension. Following decompression, skin closure in select cases can be challenging due to brain herniation and swelling through the craniectomy defect. In these cases, partial cortical debridement is sometimes performed. We describe two cases in which a synthetic skin substitute was used to facilitate a tension-free closure, rather than performing a partial lobectomy. At 6-month follow-up, both patients are at preoperative cognitive baseline, with some residual hemiparesis. We believe that use of a synthetic skin substitute for skin closure after decompression is a suitable option for closure of traumatic scalp wounds and may contribute to improved functional outcome in patients with severe intraoperative brain swelling.

Human skin incurs damage in various ways; a few of the recognizable factors are electric burns, chemical burns, scalding burns, surgery, and physical injuries, such as automobile accidents. If skin damage is extensive and severe enough [second degree and total body surface area (TBSA) involvement of >20%], the skin will lose the ability to regenerate itself. Burn wounds are treated in various ways. For full-thickness skin defects, the mainstay of treatment is an autologous split-thickness skin graft. However, there are some limitations due to scars, poor elasticity, and limitations in the joint movements due to contractures. Recently, artificial dermis has been widely used to minimize contractures. The use of dermal replacements for the treatment of burns brings new hope in maintaining the characteristics of the normal dermis. Herein, Insuregraf® was used for skin regeneration in patients who had burn injury from flames, electricity, heat, or steam. The mean take-rate values at 7 and 14 days after operation were 94.55 ± 3.02% and 97.40 ± 2.57%, respectively. Furthermore, areas covered by Insuregraf® showed higher mean values of trans-epidermal water loss (24.6 ± 3.9 g h-1 m-2), gross elasticity (Ua/Uf = 0.76 ± 0.24), and biological elasticity (Ur/Uf = 0.55 ± 0.1). These values were much better than those of the control where Insuregraf® was not used (p = 0.030, p = 0.040, and p = 0.013, respectively). Furthermore, the biomechanical scar properties of Insuregraf® and Matriderm were very similar. Hence, we suggest that Insuregraf® can be used in the medical field.

AIM This article presents the development of a novel preparation and processing method as well as indication for clinical applications of human allogeneic acellular dermal matrix, which was developed originally in the Central Tissue Bank (CTB) for use in burn medicine and reconstructive surgery. METHODS Acellular dermal matrix (ADM) is a biological material assigned for utilization in several surgical procedures due to its unique structure and advantageous properties. The article focuses on a novel preparation and processing method developed by CTB, which differs in its impact on the structure, biological and biomechanical properties of the final ADM compared to the wide range of commercially available ADM products and currently available ADM products of other tissue banks. RESULTS The ubiquitous acellular allogeneic dermal collagen matrix is the main substance participating in advantageous properties facilitating the use of ADM in numerous indications from dermal replacement and soft tissue augmentation to more extensive surgical reconstructive procedures. Dermal substitutes play an essential role in the reconstruction of full-thickness skin defects, both in acute and chronic wounds, defects of fasciae, peritoneum, etc., and there is a strong evidence that they can improve the final scar quality as well. Differences in preparation methods of ADMs are recently causing concerns among surgeons utilizing the ADMs. We present three different cases with favourable outcomes by using human acellular ADM grafts. CONCLUSIONS Although ADMs did not fulfil all of the requirements for an ideal dermal substitute, their applications have been advanced for diverse indications in soft tissue reconstructions and augmentations. Early revascularization of the allografts reduces bacterial contamination. Research and development of new generation of acellular dermal matrices with incorporated autologous in vitro cultured cells will likely yield new products and give new hope for continued improve-ments in functional and cosmetic outcomes (Fig. 9, Ref. 60).

Animal studies indicate treating burn injuries with running water (first aid) for 20 min up to 3 h after burn reduces healing time and scarring. We have previously demonstrated the benefits of first aid in minor burn injuries with respect to a reduction in wound depth, faster healing, and decreased skin grafting utilisation. The purpose of this cohort study was to assess the effect of first aid on clinical outcomes in large body surface area burn injuries (≥20%).Data was prospectively collected for patients with ≥20% TBSA burns from 2004- 2018. Multivariate regression analysis was used to determine the association of adequate first aid with 8 outcomes - mortality, total length of stay, total body surface area (TBSA), percentage/proportion of TBSA that was full thickness [PFTI], TBSA grafted, number of re-grafting sessions, intensive care admission, and intensive care length of stay. Adequate first aid was defined as the application of 20 min of cool, running tap water up to 3 h following the burn injury.390 patients were identified. Adequate first aid was received in 35.6% (139) of patients. There was a trend towards a reduction in mortality (OR 0.37; 95% CI 0.12-1.13; P = 0.08). Patients who received adequate first aid had a statistically significant 9.8% reduction in TBSA (95% CI -13.6% to -6.1%; P 0.0001) as well as a 12% lower PTFI compared to patients who received inadequate first aid (95% CI -19% to -4%; P 0.01). Whilst there was no significant effect of adequate first aid on the TBSA grafted (P = 0.37), adequate first aid was associated with a significantly less number of re-grafting sessions (95% CI --0.29 to -0.08; P 0.001).Adequate first aid with 20 min of running water is associated with improved outcomes in large burn injuries. Significant benefits are seen in a reduction in TBSA, proportion of the burn wound that is full thickness, as well as decreased re-grafting. This has significant patient and health system benefits and adds to the body of evidence supporting 20 min of cooling in burns care.

Objective This open-label, controlled, randomized study assessed the safety, tolerability, and efficacy of StrataGraft tissue compared to autograft in the treatment of deep partial-thickness (DPT) burns. Methods Thirty subjects with DPT thermal burns (3%–43% total body surface area) were treated with StrataGraft tissue as follows: cohort 1, ≤220 cm2 refrigerated tissue; cohort 2, ≤440 cm2 refrigerated tissue; and cohort 3, ≤440 cm2 cryopreserved tissue. On each subject, two comparable areas of DPT burn were randomized to receive StrataGraft tissue or autograft. Coprimary end points were the percent area of the StrataGraft tissue treatment site undergoing salvage autografting by Day 28 and wound closure of treatment sites by 3 months. Results By Day 28, no StrataGraft tissue treatment sites underwent autografting. By 3 months, 93% and 100% of the StrataGraft tissue and autograft treatment sites achieved complete wound closure, respectively. No significant differences in observer total and overall opinion POSAS scores between StrataGraft tissue and autograft treatment sites were observed at any timepoint. The most common adverse event was pruritus (17%). Conclusions StrataGraft tissue treatment of DPT thermal burns reduced the need for autograft, resulted in wound closure and treatment-site cosmesis comparable to that of autograft, and was well tolerated.

Management of post-operative soft-tissue defects on the lower legs is challenging owing to arterial and venous insufficiency, poor skin quality including epidermal and dermal atrophy, insufficient tissue laxity, and increased risk of infection. This paper highlights the management of post-operative soft-tissue defects on the lower extremity that cannot be closed primarily or by reconstruction with a local flap. A systematic review of the literature was performed using the National Library of Medicine (NLM) PubMed online database. Articles were included if they reported the management of post-operative lower extremity soft-tissue defects with secondary intention healing, full-thickness skin graft, split-thickness skin grafts, or skin substitutes. Sixty-three articles were included for analysis. There are several options for managing surgical defects on the lower legs and the method chosen should depend on various factors, including the quality of the skin, vascularity and size of the defect, medical history of the patient, and the experience of the surgeon.

In order to address the confounder of TBSA on burn outcomes, we sought to analyze our experience with the use of autologous skin cell suspensions (ASCS) in a cohort of subjects with hand burns whose TBSA totaled 20% or less. We hypothesized that the use of ASCS in conjunction with 2:1 meshed autograft for the treatment of hand burn injuries would provide comparable outcomes to hand burns treated with sheet or minimally meshed autograft alone. A retrospective review was conducted for all deep partial and full-thickness hand burns treated with split-thickness autograft (STAG) at our urban verified burn center between April 2018 and September 2020. The exclusion criterion was a TBSA greater than 20%. The cohorts were those subjects treated with ASCS in combination with STAG (ASCS(+)) vs those treated with STAG alone (ASCS(−)). All ASCS(+) subjects were treated with 2:1 meshed STAG and ASCS overspray while all ASCS(−) subjects had 1:1, piecrust, or unmeshed sheet graft alone. Outcomes measured included demographics, time to wound closure, proportion returning to work (RTW), and length of time to RTW. Mann–Whitney U test was used for comparisons of continuous variables and Fisher’s exact test for categorical variables. Values are reported as medians and 25th and 75th interquartile ranges. Fifty-one subjects fit the study criteria (ASCS(+) n = 31, ASCS(−) n = 20). The ASCS(+) group was significantly older than the ASCS(−) cohort (44 [32–54] vs 32 years [27.5–37], P = .009) with larger %TBSA burns (15% [9.5–17] vs 2% [1–4], P < .0001) and larger size hand burns (190 [120–349.5] vs 126 cm2 [73.5–182], P = .015). Comparable results were seen between ASCS(+) and ASCS(−), respectively, for time to wound closure (9 [7–13] vs 11.5 days [6.75–14], P = .63), proportion RTW (61% vs 70%, P = .56), and days for RTW among those returning (35 [28.5–57] vs 33 [20.25–59], P = .52). The ASCS(+) group had two graft infections with no reoperations, while ASCS(−) had one infection with one reoperation. No subjects in either group had a dermal substitute placed. Despite being significantly older, having larger hand wounds, and larger overall wounds within the parameters of the study criteria, patients with 20% TBSA burns or smaller whose hand burns were treated with 2:1 mesh and ASCS overspray had comparable time to wound closure, proportion of RTW, and time to return to work as subjects treated with 1:1 or piecrust meshed STAG. Our group plans to follow this work with scar assessments for a more granular picture of pliability and reconstructive needs.

Introduction Wound healing affects millions of people annually. After injury, keratinocytes from the wound edge proliferate, migrate, and differentiate to recapitulate the 3-dimensional (3D) structure needed to provide a barrier function. If the wound is too large, skin grafting may be required. We are interested in discovering novel strategies to enhance the wound healing process. It may be possible to recreate a viable and histologically accurate skin tissue using 3D printing. We hypothesize that keratinocytes and dermal fibroblasts can be bioprinted into a viable skin substitute. Methods Adult human dermal fibroblasts (HDFa) and adult human epidermal keratinocytes (HEKa) were cultured and subsequently printed with a 3D bioprinter within a hydrogel scaffold. After printing the HDFa and HEKa separately, cell viability and histological appearance were determined by sectioning the printed tissue and performing hematoxylin and eosin staining. The stained histological sections were analyzed for tissue morphology. Results The HEKa and HDFa cells suspended in the hydrogel were successfully printed into 3D scaffolds that resembled skin with hematoxylin and eosin staining. Conclusions The HEKa and HDFa cells can be grown on 3D-printed hydrogels successfully. In addition, HEKa and HDFa cells can survive and grow when suspended in a hydrogel and 3D printed. Future potential applications of these results could lead to the creation of viable skin tissue for wound healing and surgical repair.

The use of intermediate skin substitutes between debridement and final autografting is routine for many practitioners. Materials such as xenografts and allografts have been promoted to help with wound coverage before autografting. However, there is limited data for their use in relatively small burn wounds (50% graft failure), and time to complete healing (no further wound care required). Twelve patients (12%) had unpredictable graft beds, and their procedure was staged. These patients underwent surgical debridement and were dressed in antimicrobial dressing for an average of 5 days before autografting. No patients had intermediate skin substitutes between procedures. Eighty-eight patients (88%) were debrided and grafted in a single stage. In the staged group, there was a 0% rate of graft failure compared with 9.1% rate of graft failure in the primarily grafted group (P = .004). There was a similar length of stay and time to complete healing in the staged group and primarily grafted group (P = .496 and P = .571). There was a significantly shorter time from injury to first procedure between the staged group and the primarily grafted group (8.7 days and 13.5 days, P = .014). In the eight instances of graft failure, infection or inadequate debridement was the cause. Seven of these eight cases required further surgical intervention. Intermediate skin substitutes are an unnecessary step in grafting small burns. These add only complexity and cost to patient care. Many patients can be debrided and grafted in a single stage. Debridement alone with delayed grafting is a highly effective surgical method when the wound bed is not suitable for immediate grafting. The use of intermediate skin substitutes in small burns requires further investigation as this study finds low benefit for this product.

Background Facial burns have significant physical and psychologic effects on patients. Human dehydrated amniotic membrane represents novel technology, yet its outcome has not been sufficiently studied to guide practice. The objective of our study is to compare the benefits of amniotic membrane (DHAM) to amniotic/chorionic membrane (DHACM) skin substitutes to treat partial thickness facial burns. Methods Retrospective review of data collected from our institutional burn registry from 2012 to 2016. Demographic characteristics including age, total body surface area (TBSA) burn and injury severity scores were collected and outcome measures were compared between the 2 groups. Paired sample t-test and Chi-squared were used with significance defined as P Results A total of 77 adult patients with partial thickness facial burns who received DHAM and DHACM skin substitutes were included in the analysis. The mean age for the DHAM group was 39.8 compared to 41.4 for the DHACM. Mean TBSA was similar, with 10.9% in the DHAM group compared to 8.3% in the DHACM. Patients receiving DHAM had higher requirement for skin substitute surgical reapplications as compared to the DHACM group (23.7% versus 5.1%, P ≤ 0.05). Remaining morbidities remained low and not significantly different between patients receiving DHAM and DHACM substitutes (P > 0.05). Conclusion The DHAM and DHACM skin substitutes are valid and safe alternatives in the treatment of adult partial thickness facial burns.

Hydroxyurea is an oral medication associated with painful, nonhealing ulcers, for which there is no effective treatment but permanent discontinuation of hydroxyurea. The authors present a case of leg ulcers that likely occurred as a result of hydroxyurea use in a patient with essential thrombocythemia. Topical treatment with allogeneic platelet-rich plasma and artificial dermis completely healed the leg ulcers without hydroxyurea cessation.

Dermal substitutes coupled with split thickness skin graft are the primary method of treating most severe full-thickness burns particularly when there is a lack of healthy donor skin. Although dermal replacements optimize functional and aesthetic outcomes in patients, the risk of infection and the amount of time required to process most dermal substitutes delay treatment potentially compromising graft take and the overall healing process. The purpose of this case series is to describe the treatment course of patients with severe burn injuries using a novel synthetic Biodegradable Temporizing Matrix (NovoSorb BTM) in conjunction with RECELL Autologous Cell Harvesting Device, a new methodology allowing for a timely point-of-care preparation of an autologous skin cell suspension in combination with a 3:1 split-thickness skin graft. To the best of our knowledge, this is the first reported case series to describe the treatment algorithm and clinical outcomes of deep full-thickness burns utilizing BTM in conjunction with RECELL ASCS.

Summary Background Dermal regenerative matrices (DRMs) have been used for several decades in the treatment of acute and reconstructive burn injury. The objective of this study was to perform a systematic review of the literature to assess clinical outcomes and safety profile of DRMs in full-thickness burn injury. Methods Comprehensive searches of MEDLINE, EMBASE, CINAHL, and Cochrane Library were performed from 1988 to 2017. Two independent reviewers completed preliminary and full-text screening of all articles. English-language articles reporting on DRM use in patients with full-thickness burn injury were included. Results Literature search generated 914 unique articles. Following screening, 203 articles were assessed for eligibility, and 72 met inclusion criteria for analysis. DRM was applied to1084 patients (74% acute burns, 26% burn reconstruction). Of the twelve studies that described changes in ROM, significant improvement was observed in 95% of reconstructive patients. The most frequently treated reconstructive sites were the neck, hand/wrist, lower extremity, and axilla. Vancouver scar scale was used in eight studies and indicated a significant improvement in the scar quality with DRM. The overall complication rate was 13%, most commonly infection, graft loss, hematoma formation, and contracture. Conclusions Although variability in functional and cosmetic outcomes was observed, DRM demonstrates improvements in ROM and scar appearance without objective regression. Essential demographic data were lacking in many studies, highlighting the need for future standardization of reporting outcomes in burns following application of dermal substitutes.

BackgroundOne Australian loses a limb every 3 h as a result of infected diabetic foot ulcers (DFU). This common condition accounts for substantial morbidity and mortality for affected individuals and heavy economic costs for the health sector and the community. There is an urgent need to test interventions that improve wound healing time, prevent amputations and recurrent ulceration in patients presenting with DFU whilst improving quality of life and reducing health care costs.MethodsOne hundred and fifty eligible participants will be randomised to receive an autologous skin cell suspension, also termed ‘spray-on’ skin (ReCell®) or standard care interventions for their DFU. The primary outcome is complete wound healing at 6 months, but participants will be followed up for a total of 12 months to enable secondary outcomes including total overall costs, ulcer free days at 12 months and quality of life to be assessed.DiscussionOutpatient costs for dressings, home nursing visits and outpatient appointments are key cost drivers for DFU. If spray-on skin is effective, large cost savings to WA Health will be realised immediately through a shortened time to healing, and through a higher proportion of patients achieving complete healing. Shortened healing times may enable participants to return to work earlier. Any economic benefits are likely to be amplified across Australia and other similar demographic settings where aging populations with increased diabetes rates are considered major future challenges.Trial registrationAustralian New Zealand Clinical Trials Registry ACTRN12618000511235. Registered on 9 April 2018.

A new model of tissue-engineered artificial autologous human skin developed in Andalusia is currently being transplanted into patients suffering from large burns within the Andalusian Public Healthcare System. This product is considered an advanced therapy medicinal product (ATMP) in Europe, and its clinical use implies meeting transplant and medicinal product legal requirements, being the Guidelines of Good Manufacturing Practice for ATMPs of particular importance. The preclinical research and clinical translation of the product have represented a technical, regulatory, and organizational challenge, which has taken 10 years since the first preclinical experiments were designed. Twelve patients with large burns, including 3 pediatric patients, have hitherto received artificial autologous skin grafts with an overall survival rate of 75% and positive clinical, homeostatic, and histologic results. Achieving such a milestone within our Healthcare System was possible through a multidisciplinary approach and the joint efforts of multiple publicly funded institutions and units under the coordination of the Andalusian Initiative for Advanced Therapies. In this article, we present the organizational model set up to facilitate collaboration and logistics among the professionals involved, totaling more than 80 people. The similarities between the tissue-engineered artificial autologous human skin transplant and other organ and tissue transplants, in terms of logistic requirements, reveal how regional and hospital transplant coordination have played a crucial role.

Supplemental digital content is available in the text., OBJECTIVE To investigate differences in wound-related costs; product waste; lower-extremity amputations; and number of applications, hospitalizations, and emergency room visits among patients treated with three cellular and/or tissue-based products. METHODS This retrospective intent-to-treat matched-cohort study analyzed the full Medicare claims dataset from 2011 to 2014. Patients who received either a bilayer cellular construct (BLCC), dermal skin substitute (DSS), or cryopreserved human skin allograft (CHSA) were concurrently matched for Charlson Comorbidity Index, age, sex, and region, resulting in 14,546 study patients. Key variables were reported at 60, 90, and 180 days after the first product application. RESULTS There were no statistically significant differences in the distribution of Charlson Comorbidity Index, age, sex, and region among cohorts. Wound-related costs and product wastage were lower for CHSA patients relative to both BLCC and DSS patients at all time intervals (P < .05). Patients treated with CHSA received fewer product applications than DSS at 90 and 180 days (P < .05). Amputations were significantly higher among patients treated with DSS than either CHSA or BLCC (P < .0001). CONCLUSIONS The data demonstrate that wound-related costs, product waste, amputations, and frequency of applications are lower for CHSA than DSS. Wound-related costs and product waste are lower for CHSA compared with BLCC. Further claims analysis and prospective clinical trials could help develop appropriate quality measures and reimbursement models to ensure smarter spending for the growing population of patients with chronic wounds.

Aim: Skin substitutes are frequently used to treat chronic diabetic foot ulcers (DFU), and many different options are available. While the clinical efficacy of many products has been evaluated, a comprehensive cost-effectiveness analysis comparing the most popular skin substitutes and using the most recent cost data has been lacking. Methods: This study compared eight skin substitutes using published efficacy rates combined with the Centers for Medicare and Medicaid Services (CMS) 2018 cost data. The study criteria resulted in the inclusion of seven studies that described efficacy rates for treatment of DFUs using the skin substitutes. Results: The results revealed wide discrepancies between these skin substitutes for the costs of treatments and healing rates in hospital outpatient departments and physician office settings. Healing rates for 12 and 16 weeks ranged from 28% to 68%, while the average cost for treating one DFU varied from $2001 to $14,507 and $1207 to $8791 in the hospital outpatient department and physician's office setting, respectively. The estimated patient share of costs for treating a single DFU ranged from $400 to $2901 and $241 to $1758 in the hospital outpatient department and physician's office setting, respectively. Most importantly, the estimated number of wounds healed out of 100 DFUs per $1000 expenditure with each patient ranged from 3.9–26.5 DFUs in the hospital outpatient department, and 4.3–36.4 DFUs in the physicians' office setting. Conclusions: This study revealed that the costs of a skin substitute itself did not necessarily correlate with its healing efficacy. These results provide a comprehensive cost-effectiveness analysis to enable integrated health-care systems, health professionals and reimbursement payers to make informed value decisions when treating DFUs.

The use of split-thickness skin autografts (STSA) with dermal substitutes is the gold standard treatment for third-degree burn patients. In this article, we tested whether cryopreserved amniotic membranes could be beneficial to the current treatments for full-thickness burns. Swines were subjected to standardised full-thickness burn injuries, and then were randomly assigned to treatments: (a) STSA alone; (b) STSA associated with the dermal substitute, Matriderm; (c) STSA plus human amniotic membrane (HAM); and (d) STSA associated with Matriderm plus HAM. Clinical and histological assessments were performed over time. We also reported the clinical use of HAM in one patient. The addition of HAM to classic treatments reduced scar contraction. In the presence of HAM, skin wound healing displayed high elasticity and histological examination showed a dense network of long elastic fibres. The presence of HAM increased dermal neovascularization, but no effect was observed on the recruitment of inflammatory cells to the wound. Moreover, the use of HAM with classical treatments in one human patient revealed a clear benefit in terms of elasticity. These results give initial evidence to consider the clinical application of HAM to avoid post-burn contractures and therefore facilitate functional recovery after deep burn injury.

Objective Evaluate the results obtained using a Dermal Regeneration Template (DRT) associated or not with the Negative Pressure Wound Therapy (NPWT) for skin cover in paediatric patients who were victims of burns. Method Retrospective study of a cross-sectional study that evaluated the medical records of children submitted to the application of DRT, associated or not with NPWT, for the treatment of burned children admitted to the Joana de Gusmao Children's Hospital (JGCH) in Florianopolis, in the period from January 2011 to December 2016, totalling 45 patients. Results The majority of the patients were pubescent (31.8%) males (56.8%), and the main aetiology of the burn was flammable substances (75%). In the group that used only DRT, the average take of DRT was 85% with an average time of maturity of 17.65 days and the mean take rate of the skin graft was 85.2%. In the group that used DRT plus NPWT, the mean DRT take was 99.8%, with a mean maturation time of 16.68 days and the mean of the skin graft take rate was 89.1%. Conclusion NPWT associated with DRT offers a higher rate of success in the treatment of complex wounds caused by burns, promotes increased DRT take rate, reduces DRT maturation time and increases the take rate of the skin graft.

There have been significant advances in the care of burns over the past decade. As a result of the improved survival of burn patients, attention has shifted to the optimized management of their wounds. Traditionally, autografts have been described as the gold standard treatment in cases of deep second- and third-degree burn wounds; however, they are limited especially in large surface area burns. As such, advancements have been made in the development of biologic dressings, which attempt to mimic the function of the lost epidermis and/or dermis. The ideal biologic dressing is nontoxic, lacks antigenicity, is immunologically compatible, and is sterile. Additionally, easy storage conditions, long shelf lives, and reasonable costs are key determinants of whether biologic dressings may truly be widely used in the clinical setting. Biologic dressings serve an important role as skin substitutes in the setting of acute burn injury. This review aims to summarize the multitude of available biologic dressings and their applications. METHODS: The PubMed and Google Scholar databases were searched for the following terms either alone or in combination: "burn injury," "biologic membrane," "skin substitutes," "biosynthetic dressings," and "acellular membrane."

Background Due to limited graft donor sites in extensive burns, re-harvesting of a single donor area is very common. Given the importance of fetal fibroblasts in accelerating fetal wound healing, fetal cell-based skin substitutes have emerged as a novel therapeutic modality for regenerating damaged skin. In this trial, we aimed to evaluate the safety, feasibility and potential efficacy of application of amniotic membranes seeded with fetal fibroblasts for accelerating donor sites healing in burn patients. Methods In this randomized, double-blind, phase I clinical trial, 10 patients with total burn surface area of 10–55% were enrolled. Three equal parts (10 × 10 cm) were selected in donor site of each patient and covered by Vaseline gauze (control group), amniotic membrane (AM group), or amniotic membrane seeded with fetal fibroblasts (AM-F group). Adverse events, pain intensity scores, and wound sizes were recorded on days 4, 8, 11, 14, and 20 post-treatment. Also, histological assessments were done on days 0 and 14 after the surgery. Results All patients underwent surgery, and no adverse events occurred during the procedure and follow-up period. Significantly lower pain intensity and higher healing rates were observed in AM-F and AM groups compared to the control group. Moreover, mean complete re-epithelializatin in AM-F and AM groups were 10.1 ± 2.4 and 11.3 ± 2.9 days, showing that the healing process was significantly accelerated compared to the control group with mean closure time of 14.8 ± 1.6 days. Histological assessment showed lower inflammatory cells infiltration in AM-F and AM groups compared to control group. Conclusions This study indicated the safety of transplantation of amniotic membrane seeded with fetal fibroblasts for treatment of donor sites in burn patients; however, preliminary assessments showed no benefits for this therapeutic modality over amniotic membrane alone. Thus, to draw accurate conclusions, further trials in larger populations should be conducted. Level of Evidence: This study is assigned as level I.

Background Reconstruction of the plantar surface of the foot is challenging because of its distinctive anatomy and microarchitecture. Unfortunately, no single coverage option meets the needs of all patients and defects. A comprehensive literature review is presented to better define available reconstructive options for resurfacing the plantar foot. Methods A systematic literature search was performed to identify articles relating to reconstruction of the plantar skin and soft tissue. The PubMed, Embase, and Scopus databases were queried for published articles. After the exclusion of duplicate records, 1624 articles were available for review. A total of 280 unique articles were included for analysis, with a total of 2684 individual reconstructions. Results Of the articles reviewed, 10 percent described a skin grafting technique, 53 percent described a locoregional flap, 32 percent described free tissue transfer, and 5 percent described multiple reconstructive methods. Isolated heel defects were the most frequently reconstructed subunit of the plantar foot (73 percent). The latissimus dorsi muscle was the most commonly used free flap, whereas the reverse sural artery flap was the most commonly used locoregional flap. Protective sensation was noted in most locoregional and free flap reconstructions, regardless of primary neurotization; however, improved two-point discrimination was noted when neurofasciocutaneous flaps were used. Complication rates varied widely, although rates of flap loss approached those of flaps performed at other anatomical sites. Conclusions Numerous methods exist for reconstructing the plantar surface. Proper flap selection should be determined by the size of the defect, the availability of donor tissue, and the surgeon's experience and comfort with the reconstructive technique.

Outcomes following standard wound care (SWC) for diabetic foot ulcers (DFUs) remain suboptimal. Supplementing SWC with tissue engineered allogeneic cellular wound therapies represents an emerging treatment strategy. This review aimed to evaluate the efficacy and safety of allogeneic skin substitutes and human placental membrane allografts in the management of DFUs. Ovid MEDLINE and Embase databases were searched from inception to October 2017. Any randomized controlled trial (RCT) with an allogeneic skin substitute or placental membrane allograft intervention group was included. Our primary outcome measure was the proportion of completely healed ulcers. Secondary outcome measures included time to complete wound healing and local adverse event rates. Each study was assessed for risk of bias and the quality of evidence was appraised using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach. Moderate quality evidence from 11 included RCTs demonstrated that both allogeneic cellular approaches improve the proportion of completely healed ulcers at 6 and 12 weeks. One RCT showed that a placental membrane allograft was superior to an allogeneic skin substitute, although this has yet to be repeated in other studies. The addition of allogeneic cellular wound products to SWC improves DFU outcomes. Further studies are required to conclusively establish if placental membrane allografts are superior to allogeneic skin substitutes.

Purpose: This study aims to assess the efficacy and safety of Pelnac dermal regeneration template assisted by vacuum sealing drainage (VSD) and a split-thickness skin graft to cover the large skin ...

Skin substitutes are one of the main treatments for skin loss, and a skin substitute that is readily available would be the best treatment option. However, most cell-based skin substitutes require long production times, and therefore, patients endure long waiting times. The proteins secreted from the cells and tissues play vital roles in promoting wound healing. Thus, we aimed to develop an acellular three-dimensional (3D) skin patch with dermal fibroblast conditioned medium (DFCM) and collagen hydrogel for immediate treatment of skin loss. Fibroblasts from human skin samples were cultured using serum-free keratinocyte-specific media (KM1 or KM2) and serum-free fibroblast-specific medium (FM) to obtain DFCM-KM1, DFCM-KM2, and DFCM-FM, respectively. The acellular 3D skin patch was soft, semi-solid, and translucent. Collagen mixed with DFCM-KM1 and DFCM-KM2 showed higher protein release compared to collagen plus DFCM-FM. In vitro and in vivo testing revealed that DFCM and collagen hydrogel did not induce an immune response. The implantation of the 3D skin patch with or without DFCM on the dorsum of BALB/c mice demonstrated a significantly faster healing rate compared to the no-treatment group 7 days after implantation, and all groups had complete re-epithelialization at day 17. Histological analysis confirmed the structure and integrity of the regenerated skin, with positive expression of cytokeratin 14 and type I collagen in the epidermal and dermal layer, respectively. These findings highlight the possibility of using fibroblast secretory factors together with collagen hydrogel in an acellular 3D skin patch that can be used allogeneically for immediate treatment of full-thickness skin loss.