Skin grafts and biologics

Recommendations

Identify and Treat the Cause
1 NA Level of Evidence
Not Assessed


Address patient-centered Concerns
2 NA Level of Evidence
Not Assessed


Provide Local Wound Care
3 Use early excision and skin grafting to enhance healing of deep burn wounds. Level of Evidence
Not Assessed
4 Select the appropriate skin grafting technique for the clinical situation. Level of Evidence
Not Assessed
5 Use biologic dressings to provide an optimal wound healing environment and to minimize scarring. Level of Evidence
Not Assessed


Provide Organizational Support
6 Provide infrastructure and training for optimnal graft procedures. Level of Evidence
Not Assessed


Background

Excision and grafting

Early surgical excision and grafting are the treatment of choice for deep burns.
For optimal function and cosmetic outcomes, critical areas should be grafted first. Layered or sequential excision is the method of choice in many centres. Approximately 200 mL blood loss is expected for each percent total body surface area (TBSA) excised and grafted. Use of tourniquets for extremity wounds, infiltration of a crystalloid with 2% epinephrine beneath the burn, electrocautery and epinephrine-soaked sponges may minimize blood loss.

Skin grafts and substitutes:

Depending on the clinical situation, a variety of skin grafting options are available. Negative pressure wound therapy may be used in conjunction with skin grafting to optimize outcomes in complex grafting problems, such as grafting on the hand and on bone.
• Split-thickness skin grafts: These grafts are used for most burns. Sheet grafts are always used for the face and are ideal for burns covering <40% TBSA. These grafts achieve the best cosmetic outcome and are associated with a 50% decrease in the length of pressure garment therapy.
• Full-thickness skin grafts with primary closure of donor site: This option should be used for small burns, as it produces excellent functional and cosmetic outcomes and minimal donor site morbidity.
• Skin expansion: Expansion may be necessary for burns of more than 40% TBSA, using a meshing device. The least expanding mesh possible should be used for cosmetically and functionally important areas.
• Cultured autologous epidermal sheets: These cultures need 2–3 weeks to grow; they are fragile and they are often associated with unstable epithelium and hypertrophic scarring. The use of cultured epidermal sheets is usually limited to patients with burns covering 85–90% TBSA.
• Skin substitutes: The problem of wound contraction after skin grafting has led to the development of products with both an epidermal and a dermal component. Living skin equivalents, such as Apligraf; bilayer products, comprised of bovine collagen-based dermis and silastic epidermis; and bilayered sproduct of autologous fibroblasts in a collagen-glycosaminoglycan matrix with autologous keratinocytes all have application in preventing wound contraction after skin grafting.

Biologic dressings

Biologic dressings, or biosynthetic skin substitutes, act as temporary skin substitutes, which prevent wound contamination and reduce pain and fluid loss. They usually consist of a superficial epidermal analogue and a deeper dermal analogue. Biologic dressings may also deliver growth factors and matrix proteins to the wound, providing an optimal wound healing environment, speeding epithelialization and minimizing scarring. These dressings are associated with lower infection rates and faster healing rates than silver sulfadiazine.

Biologic dressings should be applied within the first 6 hours after the burn. The initial application may loosen, necessitating reapplication. Biologic dressings gradually peel off as skin epithelializes underneath them. Early separation of dressing from skin indicates an infection or a deeper wound requiring surgical treatment.

References

Essential Publications
1 Skin substitute (Suprathel) Quality Indicator
 Type: RCT
Schwarze H, Ku(Suntscher M, Uhlig C, Hellmann H, Prantl L, Noack N, Hartmann B. Suprathel, a new skin substitute, in the management of donor sites of split-thickness skin grafts: Results of a clinical study. Burns 2007; 33(7):850-854.
This two-centre RCT demonstrated the medical benefits of Suprathel (skin substitute) on wound healing, patient comfort and ease of care. Suprathel treated patients had a significantly lower pain score, and as compared to Jelonet had better plasticity and attachment to wound surfaces (p = 0.0002). There was no significant difference between Suprathel and Jelonet with regards to healing time and re-epithelization. The material effectiveness contributes to the reduction of overall treatment cost.
2 Skin substitute (cultured autologous keratinocytes) Quality Indicator
 Type: RCT
Magnusson M, Papini RP, Rea SM, Reed CC, Wood FM. Cultured autologous keratinocytes in suspension accelerate epithelial maturation in an in vivo wound model as measured by surface electrical capacitance. Plast.Reconstr.Surg. 2007; 19(2): 495-499.
This double-blinded, RCT analyzes the difference between cultured epithelial autografts and Dulbecco's Modified Eagle's Medium for the treatment of acute wounds. A statistically significant difference in surface electrical capacitance observed in the cultured epithelial autograft compared with the Dulbecco's Modified Eagle's Medium treated wounds at 5 days (p = 0.012) and 7 days (p = 0.036). It demonstrates that healing rate increased with the cultured epithelial autograft treatment.
3 Skin substitute Quality Indicator
 Type: RCT
Boyce ST, Kagan RJ, Greenhalgh DG, Warner P, Yakuboff KP, Palmieri T, Warden GD. Cultured skin substitutes reduce requirements for harvesting of skin autograft for closure of excised, full-thickness burns. Journal of Trauma-Injury Infection & Critical Care 2006; 60(4): 821-829.
The data obtained from this prospective RCT study suggests that cultured skin substitutes (CSS) provide medical benefits and reduced complications for closure of wounds greater then 50% TBSA.
4 Skin substitute (Suprathel) Quality Indicator
 Type: RCT
Uglig C, Rapp M, Hartmann R, Hierlemann H, Planck H, Dittell KOKI. Surprathel- An innovative, resorbable skin substitute for the treatment of burn victims. Burns 2007; 33(4): 221-229.
A good preliminary study examining the benefits of Surprathel in comparison to conventional paraffin gauze or Omiderm indicating that there was significantly less pain with Surprathel than with paraffin gauze or Omiderm.


Enablers for practice

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