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In patients with Epidermolysis Bullosa (EB), surgery may be required to remove Squamous Cell Carcinoma (SCC) of the hands or to correct pseudo-syndactyly. Dermal substitutes may represent a suitable tool to promote the healing of surgical wounds in EB. We review our experience with a collagen-elastin dermal matrix to promote surgical wound healing due to hand surgery to correct pseudo-syndactyly or SCC resection in patients affected by EB. Overall, 12 patients (mean age, 29±11 years, range 13-51; four females) with EB were considered, with a total of 25 different interventions (16 SCC removals; three amputations for recurrent infiltrating SCC; six pseudo-syndactyly corrections). All patients received a collagen-elastin dermal matrix sheet. Neodermis was achieved in all patients, and no adverse events potentially associated with the graft occurred. No SCC recurrence was reported at sites operated for either SCC resection or amputation. The opening of the first or second commissure appears to be maintained for over 1 year after the procedure, preserving digital function. We believe that the application of a dermal substitute, together with a close dressing protocol, may represent a suitable strategy for obtaining physiological tissue regeneration and maintaining proper hand function in patients with EB.

The complexity of the dermal layer of skin means that damage to this section can result in permanent impairment of function. Partial or total dermal loss is a feature of deep burns and chronic wounds such as pressure sores or diabetic ulcers. The issues posed by traditional skin grafts have led to substantial research being carried out in the fields of tissue engineering and biomaterials science to develop a vast array of alternative skin substitutes. Given the large number of different materials, manufacturing methods, and techniques for implementation described for artificial skin substitutes, many classification systems have been created to simplify their categorization. Some of these systems are oriented toward clinicians while others toward researchers. However, none address the needs of both groups and none are intuitive. The creation of an effective classification system would be particularly helpful in the regulation, distribution, organization, and selection of skin substitutes. The aim of this review is to examine existing methods of classification of skin substitutes, and to propose a new system that uses an algorithm that is inspired by factorial design. Our system allows multiple factors to be simultaneously investigated or in this case, described, since all skin substitutes possess multiple characteristics: (1) cellularity (acellular or cellular), (2) layering (single layer or bilayer), (3) replaced region (epidermis, dermis, or both), (4) materials used (natural, synthetic, or both), and (5) permanence (temporary or permanent). The factors and levels are combined into an algorithm where all the possible combinations are shown. The multifactorial and palindromic structure of our system should enable all users to quickly understand the makeup of a selected skin substitute, or search for a skin substitute depending on their specific requirements. We feel that our proposed classification can be used by clinicians and biomedical researchers alike, which should be an advantage given the multidisciplinary nature of the tissue engineering field and the science that underpins the development of skin substitutes. We also touch upon some of the state-of-the-art skin substitutes that are commercially available or under development to demonstrate how our new method of classification might work.

Objective To assess the efficacy of biodegradable temporising matrix (BTM) in complex wound reconstruction. Methods The authors conducted a systematic review and meta‐analysis as per the preferred reporting items for systematic review and meta‐analysis (PRISMA) guidelines following a literature search assessing BTM in complex wound reconstruction. The primary outcome measures included the proportion of BTM integration as well as integration time. Secondary outcomes included graft take over BTM, infection rate and other complications as well as scar outcome. Results Twenty six studies met the inclusion criteria with a total of 1153 complex wounds. The mean proportional integration was 92.7% at (95% confidence intervals [CI] 88.57, 96.87, p < 0.001) with a mean integration time of 34.05 days (95% CI 33.33, 34.79, p < 0.001). The infection rate was low at 12.6% with an untransformed proportion metric assessment (0.126, 0.08–0.168, p < 0.001) at the site of BTM application. Favourable scar outcomes were reported using the matching assessment using photographs with scars (MAPS) and patient and observer scar assessment scales (POSAS). Conclusion BTM offers a robust dermal template in reconstruction of complex wounds. The authors recommend for randomised controlled trials to enhance the current evidence base.

Background Absence of almost the entire reticular dermal layer is inherent to the use of autologous split-thickness skin grafting (STSG) to close full-thickness wounds, often resulting in hypertrophic scars and contractures. Many dermal substitutes have been developed, but unfortunately most have varying results in terms of cosmetic and/or functional improvement as well as patient satisfaction, in addition to high costs. Bilayered skin reconstruction using the human-derived glycerolized acellular dermis (Glyaderm®) has been reported to result in significantly improved scar quality using a two-step procedure. Unlike the necessary two-step procedure for most commercially available dermal substitutes, in this study we aimed to investigate the use of Glyaderm® in a more cost-effective single-stage engrafting. This is a method which, if autografts are available, is preferred by the majority of surgeons given the reduction in costs, hospitalization time and infection rate. Methods A prospective, randomized, controlled, intra-individual, single-blinded study was performed, investigating the simultaneous application of Glyaderm® and STSG vs. STSG alone in full-thickness burns or comparable deep skin defects. During the acute phase, bacterial load, graft take and time to wound closure were assessed and were the primary outcomes. Aesthetic and functional results (secondary outcomes) were evaluated at 3, 6, 9 and 12 months follow-up using subjective and objective scar measurement tools. Biopsies for histological analysis were taken at 3 and 12 months. Results A total of 66 patients representing 82 wound comparisons were included. Graft take (>95%), pain management and healing time were comparable in both groups. At 1 year follow-up, the overall Patient and Observer Scar Assessment Scale assessed by the patient was significantly in favour of sites where Glyaderm® was used. Not infrequently, patients attributed this difference to improved skin sensation. Histological analysis showed the presence of a well-formed neodermis, with donor elastin present for up to 12 months. Conclusions A single-stage bilayered reconstruction with Glyaderm® and STSG results in optimal graft take without loss of Glyaderm® nor the overlaying autografts due to infection. The presence of elastin in the neodermis was demonstrated during long-term follow-up in all but one patient, which is a crucial factor contributing to the significantly improved overall scar quality as evaluated by the blinded patients. Trial registration The trial was registered on clinicaltrials.gov and received the following registration code: NCT01033604.

Background Burn injuries are a major global health concern, especially when large areas of the body are affected, limiting the availability of healthy skin for autologous skin grafting. This makes traditional skin grafting challenging. Skin substitutes have been developed to address these challenges. To date, there is limited research on Pelnac dermal substitute use for treatment of acute deep dermal burn injuries. This study aims to evaluate the effectiveness of Pelnac dermal substitute in treating such injuries on the upper limb. Methods This randomized control trial was conducted on 46 cases of acute burn injuries presented to the Kasr Al-Ainy Cairo University Hospital’s burns unit from March 2021 to August 2022. The patients were divided into two groups: the Graft-Only Group, consisting of 23 patients, and the Pelnac Group, comprising 23 patients. The primary outcome was the graft take success rate. The secondary outcomes included scar quality assessment, functional outcomes, and patient satisfaction with aesthetic appearance and functional recovery. Results In terms of coverage success, Graft only Group achieved 100% success rate, while Pelnac take was unsuccessful in the first 17 patients. Upon observing the first successful case, we noted that there was no dermis remaining after excision, prompting us to implement more thorough debridement from the outset to reach the subcutaneous fat or fascia. Consequently, the Pelnac coverage was successful in the subsequent four patients, with a 22.7% success rate, (followed by autografting as a second stage). In terms of scar quality improvement, as measured by the Vancouver Scar Scale, the Pelnac group had a significantly lower average VSS value (2.40∓1.52) compared to Graft Only Group (7.45∓1.68) with (P<0.001). Pelnac Group also had significantly higher patient satisfaction with aesthetic appearance compared to the graft-only group ( P  < 0.001). There were no significant differences between the two groups regarding patient satisfaction with functional recovery and the average DASH score ( P  > 0.05). Conclusions Pelnac could be regarded as a promising modality for the treatment of acute full thickness burns and can be used in partial thickness burns, specifically in instances of major burns with extensive surface area damage. In these cases, more thorough debridement from the start, reaching a bed of fat or fascia, and then applying Pelnac to increase its take is essential, to serve as a protective cover for the wound bed where it helps to prevent fluid loss and contamination. Level of Evidence: Level I, therapeutic study.

Current advances in basic stem cell research and tissue engineering augur well for the development of improved cultured skin tissue substitutes: a class of products that is still fraught with limitations for clinical use. Although the ability to grow autologous keratinocytes in-vitro from a small skin biopsy into sheets of stratified epithelium (within 3 to 4 weeks) helped alleviate the problem of insufficient donor site for extensive burn, many burn units still have to grapple with insufficient skin allografts which are used as intermediate wound coverage after burn excision. Alternatives offered by tissue-engineered skin dermal replacements to meet emergency demand have been used fairly successfully. Despite the availability of these commercial products, they all suffer from the same problems of extremely high cost, sub-normal skin microstructure and inconsistent engraftment, especially in full thickness burns. Clinical practice for severe burn treatment has since evolved to incorporate these tissue-engineered skin substitutes, usually as an adjunct to speed up epithelization for wound closure and/or to improve quality of life by improving the functional and cosmetic results long-term. This review seeks to bring the reader through the beginnings of skin tissue engineering, the utilization of some of the key products developed for the treatment of severe burns and the hope of harnessing stem cells to improve on current practice.

full-thickness skin defects remain a reconstructive challenge. Novel regenerative modalities can aid in addressing these defects. A literature review of currently available dermal and epidermal regenerates was performed. The mechanism and application for each skin substitute was analyzed to provide a guide for these modalities. Available epidermal substitutes include autografts and allografts and may be cultured or noncultured. Dermal regenerate templates exist in biologic and synthetic varieties that differ in the source animal and processing. Epidermal and dermal skin substitutes are promising adjunctive tools for addressing certain soft tissue defects and have improved outcomes in reconstructive procedures. The following article provides a comprehensive review of the biologic materials available and the types of complex wounds amenable to their use.

The formation of severe scars still represents the result of the closure process of extended and deep skin wounds. To address this issue, different bioengineered skin substitutes have been developed but a general consensus regarding their effectiveness has not been achieved yet. It will be shown that bioengineered skin substitutes, although representing a valid alternative to autografting, induce skin cells in repairing the wound rather than guiding a regeneration process. Repaired skin differs from regenerated skin, showing high contracture, loss of sensitivity, impaired pigmentation and absence of cutaneous adnexa (i.e., hair follicles and sweat glands). This leads to significant mobility and aesthetic concerns, making the development of more effective bioengineered skin models a current need. The objective of this review is to determine the limitations of either commercially available or investigational bioengineered skin substitutes and how advanced skin tissue engineering strategies can be improved in order to completely restore skin functions after severe wounds.

Background In literature, there are no guidelines to identify which dermal matrix should be chosen and should be used in different cases. The aim of our study was to evaluate if there are any patient personal characteristics that could influence the success of the corrective surgery with Integra® and Matriderm® dermal matrices and the wound healing process. Methods We conducted a retrospective analytical single-center clinical study. The sample involves 113 patients treated with dermal matrix positioning surgery from the pool of the Plastic Surgery Department of the “Spedali Civili” of Brescia between January 2015 and March 2021. Our study evaluated the success of treatment, the scarring result, and the type of dermal matrix used, taking into account all the possible influencing factors. Results Taking into account the type of matrix used, significant differences in diagnosis ( p = 0.002) and lesion site ( p = 0.029) were found. By means of multivariate analysis, the presence of central nervous system (CNS) pathology appeared to be an independent, statistically significant factor which increased 4 times the risk of surgery failure and 11 times the incidence of non-optimal scarring. In the Integra® group, the presence of chronic diseases incremented the risk of intervention failure by fivefold. CNS diseases resulted independent risk factors respectively for surgery failure (increased risk of 16) and non-optimal scarring (increased risk of 21) in the Matriderm® group. Even with no statistical significance, Integra® and Matriderm® also showed different trends considering diagnosis and site of the lesion treated. Conclusions Occurrence of complications during wound healing should be prevented and avoided in order to achieve the best result in corrective surgeries. The presence of chronic diseases is an influencing factor for the success of treatment, regardless of the type of dermal substitute used. Pathologies affecting the CNS turned out to be one of the most significant factors considered. Type and lesion sites could also take part in the failure of corrective surgery with dermal matrices and/or non-optimal scarring. Level of evidence: Level III, risk/prognostic.

Objective Artificial dermal substitutes (DSs) are fundamental in physiological wound healing to ensure consistent and enduring wound closure and provide a suitable scaffold to repair tissue. We compared the clinical and histological features of two DSs, Pelnac and Integra, in the treatment of traumatic and iatrogenic skin defects. Methods This prospective observational study involved 71 randomly selected patients from our hospital. Wound healing was analyzed using the Wound Surface Area Assessment, the Vancouver Scar Scale, and a visual analog scale. Histological and immunohistochemical evaluations were also performed. Results At 2 weeks, greater regeneration with respect to proliferation of the epidermis and renewal of the dermis was observed with Pelnac than with Integra. At 4 weeks, the dermis had regenerated with both DSs. Both templates induced renewed collagen and revascularization. Differences in the Vancouver Scar Scale score were statistically significant at 4 weeks and 1 year. Pelnac produced a significant increase in contraction at 2 weeks with increasing effectiveness at 4 weeks. Integra produced a higher percentage reduction in the wound surface area and a shorter healing time than Pelnac for wounds >1.5 cm deep. Conclusion Our observational data indicate that both DSs are effective and applicable in different clinical contexts.