Session B1
Paper #2100
INTEGRA: THE RELENTLESSLY THRILLING POTENTIAL
Orenda Orr oso1@pitt.edu, Haiyang Wen haw47@pitt.edu
Abstract—Engineers have dreamed of synthesizing a skinlike material that could be produced efficiently in an
assembly line system. Though the concept is far from
actualization, the progress made in the past years has been
promising. One such innovation is Integra. Integra,
developed in the 1980s, has revolutionized the concept
behind artificial skin. Instead of a complete man-made
synthetic skin, Integra utilizes an engineered “scaffold” that
prompts the body’s natural skin cells to grow a new dermis.
The body cannot reject its own skin cells, and the results
produce a healthier, more aesthetic skin. In today’s medical
industry, where the survivability rate for burn victims has
increased to almost a definite success, aesthetic and
functional outcomes have become the current aspirations for
the surgical procedures. In other words, Integra still has the
potential to continue leading and revolutionizing the way
burn victims, and reconstructive surgery in general, are
approached.
This paper will discuss and analyze the effectiveness of
Integra as a substitute in reconstructive surgery as well as
gauge its adaptability compared to some of the newly
developed products today. A focus will be given to the
current innovative techniques for Integra in reconstructive
surgery with an emphasis on complex appendages.
Additionally, a strong account between an Integra and a flap
treatment for specific reconstructive surgeries will be
analyzed in order to compare and highlight the favorable
uses of Integra for future surgeries. Further assessment of
Integra’s overall potential will conclude this paper.
common scenario for many burn victims. For that sole
reason, Integra has become a very substantial innovation for
the treatment of these burned victims, but with the growing
success rate of burn treatment, further applications for
Integra are starting to be discovered.
The treatment of Integra is usually a two-step process that
can span up to several weeks. Integra is primarily used to
close the wound and facilitate the healing of the lower
dermis. The epidermis, which is the surface layer of skin, is
then provided by another source, through the patient’s own
body or an artificial product, which is used in conjunction
with Integra [2]. Over the past twenty years, this
combination has proved to be and still is a very successful
technique in imitating the functionality and aesthetic appeal
of skin, the two facets that have become highly important in
today’s aspirational purposes of reconstructive surgery.
Naturally, Integra is not perfect and does contain a few
flaws. Although Integra has the apparent advantages of
being able to treat large-scale reconstructive procedures,
Integra is still susceptible to failure largely due to infection
and excess movement during the healing process. Over the
years, there have been a few innovations that have improved
Integra’s success rates and applicability. One, very common
development is the vacuum assisted closure system, or the
VAC, and we will be discussing the mechanism further in a
future section. Nevertheless, Integra still has the potential to
improve further as a major component in functional and
aesthetic reconstructive surgery.
IN COMPARISON TO SKIN: FLEXIBILITY STUDY
Key Words—Integra, Reconstructive Surgery, Synthetic,
Artificial, Skin, Burn Wounds, Burn Treatment, VAC,
Regeneration Template, Bilateral Syndactyly, Hand Surgery.
A very important characteristic of current artificial skin is its
similarity to the body’s natural skin. Skin that is less
flexible, and/or contains excess scarring and disfigurement
could both inhibit a person’s ability to perform daily
activities as well as increase their self-awareness of their
injuries. Integra is stressed to have the key characteristics of
being more aesthetically pleasing post-surgery and having a
closer similarity to actual skin in patients due to its minimal
scarring and regeneration of nearly normal skin [3]. By mere
observation, the immediate outcome of Integra always
appears to be an improved result of other treatments, but that
is not enough to prove its significance over the other
treatments. Below we have included a brief summary of an
objective case study that analyzes the long-term outcome of
Integra by measuring its elasticity in comparison to natural
skin.
This study, which allows a true depiction of the similarity
between Integra treated wounds and actual skin, is
conducted systematically with a Cutometer MPA 580, which
is a bioengineered mechanism that can measure the
INTEGRA: BRIEF HISTORY
Integra was developed in 1981 by two Boston surgeons as an
artificial skin substitute with an extremely interesting
feature. Unlike the skin graft, Integra is a temporary
bioactive skin substitute, which is commonly defined as a
bilayer structure with an internal biological layer and an
external silicon coating. Technically, Integra is not actual
skin; instead it mimics the biological composition of the
underside of a human dermis in order to coax the body’s
natural skin cells, scientifically known as fibroblasts, to
grow a new and healthy dermis [1]. This is very similar to a
flap treatment, which uses a patient’s own healthy skin as an
incubator for any deep wounds that penetrate into the
dermis. Unlike Integra however, flaps and other natural skin
treatments are insufficient when the body is unable to
provide a considerable source of healthy skin, which is the
University of Pittsburgh
Swanson School of Engineering
February 10, 2012
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Orenda Orr
Haiyang Wen
mechanical properties of skin in a completely objective
manner [3]. The main focus for this study was the
mechanical property of elasticity. There were six
participants in the case study, all who had been treated with
Integra and/or split-thickness skin grafting for a period
greater than a year. Both the Integra and SSG treated sites
were measured in comparison with the natural skin in each
case with the Cutometer MPA 580 in four different elasticity
properties: elastic function, gross elasticity, biological
elasticity, and viscoelastic ratio. Out of these measurements,
Integra was found to have a negative correlation with the
natural skin site in each of the elasticity properties while
SSG had no correlation [3].
This was just one of the few studies that objectively
measured the mechanical properties of Integra due to fact
that bioengineered devices, such as the Cutometer MPA 580,
have only recently been developed and used in case studies.
Though the results may have been substandard, Integra was
found to have significant correlations with natural skin,
indicting that Integra is a consistent product even if less
elastic. On the other hand, the elasticity for SSG treatments
is unpredictable at best, with no certainty that the healed
wound would be similar to the natural skin. So even though
Integra may not be a perfect replica of the biological organ,
but it is still consistently analogous compared to other
treatments. We will mention another recent study in a future
section that will discuss the functionality and strength of
Integra treated hand burns, further characterizing the
features of Integra.
move during the treatment of the reconstructive process [4].
These children were in need of pediatric Integra treatments,
which meant that they had wound beds that were often
amorphous, uneven, and normally prevented Integra from
fixating correctly. The locations included were the shoulder,
upper and lower limbs, trunk, and perineal region, giving a
total body surface area of 1% to 12%. 18 children were
found for the study, and were given Integra VAC treatments
for their surgical procedures. Of the 18 children that were
selected, 17 had VAC applied successfully with very few
complications. In the three weeks that the VAC was
applied, most of the Integra treatments fixated to the wound
bedding despite the contour of the body, which is a very
substantial result given the conditions. Despite a few hitches
during the study, the VAC was found to be a very good
technique to apply Integra to a wounded bed. [4].
The study may have focused on the use of VAC on
children, but even a general application of the VAC on more
mature cases can be a significant improvement. y.
Unfortunately, there aren’t many circulating studies
analyzing Integra with regular dressing techniques, which
each have their own limitations, but the addressed study has
given the VAC statistical results of its effectiveness as a
fixation device. The VAC is far from perfect though since
the device is slightly expensive and requires the patient to be
confined to the bed for a period of at least three weeks.
Nonetheless, the VAC has become a common supplement to
Integra related treatments and can be considered as an actual
feature that has improved the bilayer’s applicability. Even
further use of the VAC can also be seen in the next section
discussing the application of Integra on post-burn scars in
adolescents and children.
NEGATIVE PRESSURE VACUUM-ASSISTISTED
FIXATION OF INTEGRA ARTIFICIAL SKIN FOR
RECONSTRUCTIVE SURGERY
INTEGRA IN RECONSTRUCTIVE SURGERY
In our introduction, we mentioned that one of Integra’s
sleights is its tendency to be unsuccessful when faced with
excess patient movement and infection. This is due to
Integra’s application. Integra is a bilayer structure that relies
on the fusion between its biological layer and the surface of
the burn wound, or the wound bed [4]. If the fixation is not
cohesive due to excess patient movement or complex surface
areas, the Integra treatment may fail and become infected.
Recently, surgeons have implemented a vacuum-assisted
closure system (VAC) as a safeguard that prevents
contamination by applying negative pressure and prevents
movement through its sheer bulkiness.
The VAC was first introduced by Argenta in 1997
primarily for the treatment of chronic wound closure. Soon
after its development, surgeons started using the technique
as a “fixation device for split-thickness skin grafts, STSG, in
adults burn patients” [4]. The VAC is a two-step process.
First, a “sterile polyurethane ether sponge” is applied
directly over the burn wound, which is then covered by a
“self-adhesive plastic sheet, connected to an evacuation
pump with sub atmospheric pressure” [4]. In this study, the
addressed cases were children who are more inclined to
Integra, due to its improved elasticity and cosmetic
appearance, is known as one of the most widely accepted
synthetic skin substitute to be developed for burn patients
since its conception [3]. For the past twenty years, Integra
has been a major proponent in the surgical reconstructive
industry, but Integra harbors the ability and potential to be
used in more specialized cases. The following three subsections are documentations of Integra’s use in acute
reconstructive procedures that focus both on hands and postsurgical burn revisions. In each subsection, we will note
Integra for its favorability in surgical procedures that involve
more complicated applications for the burn treatments.
Revision Surgery
This subsection focuses on surgical procedures that analyze
the application of Integra on post-burn scars in adolescents
and children. Integra, along with the VAC, were applied to
all cases and drastically improved the scar tissues, which
originally limited functionality and were disfiguring. This
subsection will also solidify the transition between the
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Haiyang Wen
mechanisms and the surgeries since VAC is a common topic
in both.
addition, we will further compare the Integra treatment and
the more common flap treatment by analyzing the methods,
recovery processes, complications, and results of the two.
This subsection will tie into our introduction by providing
evidence that an Integra treated procedure is more aesthetic
and functional than a flap procedure. This subsection will
neatly bring readers to the conclusion of this paper.
Hand and Upper Extremity
We will focus on the hand in the next two subsections, since
it is a large focus in our paper. This first subsection will
detail Integra’s applications in hand burn surgery in general,
noting the methods, complications and results. With this
information we will attempt to emphasize that Integra is
better suited for delicate anatomical structures in comparison
with flaps. This subsection ties into the next subsection due
to the similar topic of reconstructive hand surgery.
THE RELENTLESSLY THRILLING POTENTIAL
This section will conclude our entire paper, and because it
immediately follows two specific example of a more recent
innovative use of Integra, we will be able to stress the fact
that Integra is still a strong component in current surgical
trends. This will fulfill the main goal that we had at the start
of the paper.
Functional Results of Burned Handed Treated with
Integra
In this third subsection, we will detail the long-term
functional evaluation of hand surgeries treated with Integra
in order to supply legitimate backing as well as include
surgical/financial statistics and/or charts of the procedures.
The analysis is conducted by using the 400 Point Evaluation
Test, which consists of four separate tests, “motility of the
hand, prehension strength, prehension and object
displacement with one hand as well as bimanual hand
function” [5]. In order to maintain the coherence of the
paper, we will briefly summarize Integra’s common
applications in reconstructive surgery in order to open up the
topic of its new innovative uses.
REFERENCES
[1] R. Demling, L. DeSanti. (2005). “Managing the Burn Wound.”
Burnsurgery.org.
[Online].
Available:
http://www.burnsurgery.org/Modules/BurnWound%201/sect_VIII.htm.
Section VIII
[2] D. Roos. (2009 November 04). “Skin Grafts.” HowStuffWorks.com
[Online].
Available:
http://health.howstuffworks.com/skin-care/information/anatomy/skingraft.htm
[3]D. Nguyen, T. Potokar, and P. Price. (2009 July 13). “An Objective
Long-Term Evaluation of Integra (a Dermal Skin Substitute) and Split
Thickness Skin Grafts, in Acute Burns and Reconstructive Surgery.” Burns.
[Online].
Available:
http://www.sciencedirect.com/science/article/pii/S0305417909004586. pp.
23-28
[4] D. Stiefel, C. Schiestl, and M. Meuli. (2009, March 18). “The Positive
Effect of Negative Pressure: Vacuum-Assisted Fixation of Integra Artificial
Skin for Reconstructive Surgery.” Journal of Pediatric Surgery. [Online].
Available:
http://www.sciencedirect.com/science/article/pii/S0022346808005988
[5] A. Cuadra, G. Correa, R. Roa, J. Pineros, H. Norambuena, S. Searle, R.
Heras, W. Calderon. (2011, October 29). “Functional Results of Burned
Hands Treated with Integra ®.” Journal of Plastic, Reconstructive &
Aesthetic
Surgery.
[Online].
Available:
http://www.sciencedirect.com/science/article/pii/S1748681511005171
[6] J. Jung, A. Woo, and G. Borschel. (2012 January). “The Use of Integra
Bilaminar Dermal Regeneration Template in Apert Syndactyly
Reconstruction: A Novel Alternative to Simplify Care and Improve
Outcomes.” Journal of Plastic, Reconstructive & Aesthetic Surgery.
[Online].
Available:
http://www.sciencedirect.com/science/article/pii/S1748681511003597
NEWLY INNOVATIVE USES
We will discuss some of the new techniques that utilize
Integra today, adding to the previous more common
applications. Once again, two accounts will be viewed in
subsections in order to continue the flow of the paper.
MODIFYING INTEGRA AS A REGENERATION
TEMPLATE IN DEEP TISSUE PLANES
In this subsection we will discuss the benefits of Integra
being used as a tissue regeneration template, which has only
been recently applied to reconstructive surgeries. We have
up to four cases that have been documented extensively in a
source and will be able to supply substantial evidence for
Integra’s potential for different applications. We will briefly
note one or two cases depending on the future requirements
for this paper.
ADDITIONAL RESOURCES
D. Stiefel, C. Schiestl, M. Meuli. (2010 February). “Integra Artificial Skin
for Burn Scar Revision in Adolescents and Children.” Burns. [Online].
Available:
http://www.sciencedirect.com/science/article/pii/S0305417909000837. pp.
114-120
J. Frame. (2006 May). “Modifying Integra as Regeneration Template in
Deep Tissue Planes.” Journal of Plastic, Reconstructive & Aesthetic
Surgery.
[Online].
Available:
http://www.sciencedirect.com/science/article/pii/S1748681505004122
M. Rizzo. (2011 December 29). “The Use of Integra in Hand and Upper
Extremity Surgery.” The Journal of Hand Surgery. [Online]. Available:
http://www.sciencedirect.com/science/article/pii/S0363502311014328
THE USE OF INTEGRA IN APERT SYNDACTYLY
RECONSTRUCTION
This subsection evaluates a study for an Integra and flap
treated bilateral syndactylies, a condition in which the
appendages of the hands or feet are fused together to the
point of disability [6]. This is a very recent study detailing a
procedure that has not ever been performed with Integra, and
will allow us to once again highlight its potential. In
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Haiyang Wen
ACKNOWLEDGEMENTS
We would like to acknowledge our dedicated writing
instructor, Beth Newborg, who has constantly given us
guidance in writing this paper despite the many obstacle that
have impeded our progress. We would also like to thank our
extremely supportive student co-chair, Alicia Kolling, for
making sure that we kept on top of our bi-weekly
assignments and sent us very encouraging and helpful
emails. And of course, we would like to thank our
wonderful adult co-chair, Dr. Laura Lund, for working with
us on this paper.
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