skin graft

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Title:
Outpatient Use of Integra® and Subatmospheric Pressure in the
Management of Wound and Burn Reconstruction
Authors:
Dean DeRoberts, M.D., Christopher A. Park, M.D.,
Anthony J. DeFranzo, M.D., Malcolm W. Marks, M.D.,
Joseph A. Molnar, M.D., Ph.D.
Wake Forest University School of Medicine, Winston-Salem, NC
Introduction: Integra® (Integra Lifesciences Corporation, Plainsboro NJ) is an artificial
dermis derived from bovine collagen and chondroitin-6-phosphate. It possesses a matrix
that allows for ingrowth of capillaries and fibroblasts. As it was designed to be a dermal
regeneration template with natural metabolic turnover, the hope was that the ultimate skin
produced from this product would more resemble skin than scar (1). It is covered with a
silicone layer that functions as a temporary epidermis. This silicone layer is removed
after engraftment of the dermal matrix and a thin split-thickness skin graft is applied.
The product was originally designed to be life saving for patients with extensive burns.
This application has been well evaluated in earlier studies in multiple centers (2,3).
However, Integra® has found many other uses recently, including treatment of
contractures and complex wounds (4,5). The proposed benefit of wounds treated with
Integra® and subsequent skin graft compared to skin graft alone include increased
thickness and durability, improved mobility and cosmesis, reduced recurrence of
contractures and keloids, and the ability to cover exposed tendons, muscles, and joints.
Traditional management of Integra® required antibiotic dressing changes for 2-4 weeks
to allow vascularization prior to skin graft. The application of Integra® using
subatmospheric pressure (V.A.C.®, KCI Inc., San Antonio TX) has been suggested to be
easier, faster, and more consistent than previous dressings. The use of subatmospheric
pressure has allowed grafting as soon as 5 days after Integra® placement with no interval
dressing changes minimizing the tedium and morbidity of standard dressings (5).
Concerns of cost in the use of Integra® with the V.A.C.® have limited its use. These
costs could be minimized by using this technique in an outpatient setting sparing the
expense of hospital stay.
Methods: Ten patients were chosen for outpatient reconstructive surgery with Integra®
and subatmospheric pressure. Age range was 4 – 58 years. Five patients underwent burn
reconstruction (axillary and antecubital fossa contracture release), one patient underwent
scalp keloid excision and reconstruction, one patient required coverage of a toe defect
after Mohs excision of squamous cell carcinoma, and three patients underwent
reconstruction of traumatic foot/ankle wounds. Wound sizes ranged from 7.5 – 276 cm2.
After wound preparation and Integra® application in the operating room, the V.A.C. was
applied as the dressing. The patients were admitted for overnight stay in our observation
hospital for pain management and verification of V.A.C. function. Patients were
discharged on postoperative day one with home V.A.C (one patient was discharged
immediately postoperatively). Some patients were seen in the clinic in 3 – 5 days for a
wound check but others were managed entirely at home. Patients returned to the
operating room 7 – 10 days later for V.A.C. removal and split thickness skin grafting.
The V.A.C. was again applied as a post-graft dressing and the patient was discharged on
an outpatient basis (one patient stayed in observation hospital overnight) before returning
in 4 days for V.A.C. removal in the clinic (Table 1).
Results: All patients were successfully reconstructed with near complete take of
Integra® at the time of grafting. Split thickness skin graft takes ranged from 75 - 100%;
mean 92% (Table 2). No patients required additional grafting.
Conclusion: Integra® may be successfully used for reconstruction of difficult areas as an
outpatient in combination with subatmospheric pressure (V.A.C.®). This allows for
successful reconstruction, expedited treatment versus standard Integra® application, and
decreased morbidity and costs. Further prospective studies are required to demonstrate
the cost savings, uses, and limitations of this technique.
Table 1:
Length of Stay (Days)
PATIENT
1
2
3
4
5
6
7
8
9
10
MEAN
INTEGRA
1
1
1
1
1
1
1
0
0
1
0.8
INTERVAL
7
9
9
7
7
7
8
10
7
9
8
SKIN GRAFT
0
0
0
1
0
0
0
0
0
0
0.1
Table 2:
Percent Graft Take
PATIENT
1
2
3
4
5
6
7
8
9
10
MEAN
PERCENT
100
90
95
75
85
95
98
85
97
95
92%
References:
1.
Honari, S., Gibran, N. S., Engrav, L. H., Clayney, C., and Heimbach, D. M.
Three years’ experience with 52 Integra (artificial skin) patients since FDA
approval. J. Burn Care Rehabilitation. 2000, 21:190.
2.
Sheridan, R. L., Hegarty, M., Tompkins, R. G., and Burke, J. F. Artificial skin
in massive burns: Result to ten years. Eur J Plastic Surgery 1994, 17:91.
3.
Moiemen, N. S., Staiano, J. J., Ojeh, N. O., et al. Reconstructive surgery with a
dermal regeneration template: Clinical and histologic study. Plastic and
Reconstructive Surgery 2001, 108:93.
4.
Orgill, D. P., Straus, F. H., II, and Lee, R. C. The use of collagen-GAG
membranes in reconstructive surgery. Ann N.Y. Acad Sci 1999, 888:233
5.
Molnar, JA et al. Acceleration of Integra Incorporation in Complex Tissue
Defects with Subatmospheric Pressure. Plastic and Reconstructive Surgery
April 2004, 113(5):1339–1346.
This paper was presented in part at the annual meeting of the American Burn
Association, Chicago, Illinois, May 13, 2005.
Joseph A. Molnar, MD, Ph.D., receives research funds from KCI, Inc. (the manufacturer
of the V.A.C.®) and receives compensation for presentations at educational symposia
sponsored by KCI, Inc.
Joseph A. Molnar, MD, Ph.D., receives research funds from Integra Life Sciences, Inc.
(the manufacturer of Integra Dermal Regeneration Template) and receives compensation
for presentations at educational symposia sponsored by Integra Life Sciences, Inc.
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