Treatment Of Full-thickness Burns Research Articles

Use of Acellular Dermal Matrix in Reconstructive Surgery: A Review

In recent decades, tissue engineering advances have led to more skin substitutes becoming available. Acellular dermal matrix, initially developed for use in the treatment of full-thickness burns, is made by removing the cellular components from the dermis collected from donated bodies or animals. This class of scaffold is used to replace skin and soft tissue deficiencies in a variety of fields, including breast reconstruction, abdominal wall reconstruction, and burn treatment. Herein, we provide a detailed review of the clinical applications of acellular dermal matrix.

Initial Experience Combining Negative Pressure Wound Therapy With Autologous Skin Cell Suspension and Meshed Autografts.

The success of autologous split-thickness skin grafts (STSGs) in the treatment of full-thickness burns is often dependent on the dressing used to secure it. Tie-over bolsters have been used traditionally; however, they can be uncomfortable for patients and preclude grafting large areas in one definitive operation. Negative pressure wound therapy (NPWT) is used as an alternative to bolster dressings and may afford additional wound healing benefits. In our center, NPWT has become the dressing of choice for securing STSGs. While the RECELL® system is being used in conjunction with STSGs, it is currently unknown whether autologous skin cell suspensions (ASCS) can be used with NPWT. This report is a retrospective chart review of nine patients treated in this manner. All wounds were almost completely re-epithelialized within 14 days, and their healing was as expected. Wound healing trajectories are shown. There were no significant complications in these patients. This dressing technique can be considered as an option when using ASCS and widely meshed STSG.

730 Establishing Thresholds for Clinically Significant Donor Skin Reduction – Initial Findings from a Physician Delphi Consensus Panel

Abstract Introduction Definitive closure with autograft, as a current standard of care, is a critical outcome in severe burn treatment. Harvest of donor skin for autograft is associated with pain, scarring and potential infection. New treatment modalities aim to reduce the amount of donor skin required to achieve definitive closure of the burn wound. A threshold that defines the clinically significant reduction in amount of harvested skin for the treatment of deep partial (DPT) and full-thickness (FT) burns is not available. This study convened a Delphi Consensus Panel (DCP) to determine this threshold. The DCP is an accepted method to synthesize opinions and feedback from experts and to systematically achieve consensus. Methods Panel members were burn physicians with ≥3 years of experience post-residency, with either a total career experience of caring for ≥1,000 patients or working in a facility with an annual volume of ≥200 patients and caring for ≥500 patients. Round 1 consisted of open-ended questions regarding clinical decision-making, use of skin substitutes (SS) in DPT and FT burn treatment, and what would constitute a clinically significant reduction in donor skin. Results Panelists reported using SS to promote healing and achieve definitive closure without autograft for DPT burns, and as a temporizing measure between excision and surgery for FT burns. Total body surface area (TBSA) affected by burn and burn location influenced SS use. For DPT and FT burns, other patient outcomes influencing treatment decisions were cosmesis, pain control, and reducing functional limitations. Almost all panelists reported that reduction in the amount of donor skin were important. As expected in Round 1, a range for the minimum percentage of donor skin reduction regarded as clinically significant was provided for DPT (20%-50%) and FT (10%-20%) burns. The main factors influencing these estimates were TBSA burned, patient outcomes, patient preference, and patient type. Final results will provide consensus estimates for clinical significance for donor skin reduction based on subsequent rounds. Conclusions Preliminary results indicate that reduction of the amount of donor skin is important to physicians with burn care experience, and the thresholds for clinical significant reduction in donor skin are influenced by patient outcomes and preferences, TBSA burned, and patient type. Applicability of Research to Practice These data will provide a research-based definition surrounding the clinical significance of new treatment modalities for severely burned patients.

Photobiomodulation associated to cellular therapy improve wound healing of experimental full thickness burn wounds in rats

Adipose derived stromal vascular fraction (SVF) is a method of cell therapy potentially applicable for treatment of full thickness burns. Here we investigated if the association of photobiomodulation (PBM) with SVF therapy could improve wound healing in experimentally induced full thickness burn wounds in rats compared to the topical agent 2% silver sulfadiazine in a dose-dependent manner. Sixty-six male Wistar rats were divided in 4 groups containing 5 animals each which received the following treatments: 2% sulfadiazine (SD), SVF, SVF plus PBM at 30 mW (SVFL30), and SVF plus PBM at 100 mW (SVFL100). Two donor animals were used for each experimental series with 3, 7 and 30 days. Digital photography, microscopic analysis with Hematoxilin and Eosin (H&E), quantification of collagen type I by picrosirius red staining analysis and wound contraction evaluation were performed in order to quantify the results. At day 3 SVF alone or combined with PBM promoted increased early inflammatory response compared to SD. At day 7 SVFL30 and SVFL100 enhanced inflammatory cells infiltration, angiogenesis and fibroblast content compared to SVF and SD groups. At day 30 collagen concentration and wound contraction were higher in SVFL30 when compared to the other groups. In conclusion PBM promotes a synergistic outcome with SVF therapy with a dose dependent effect potentializing wound healing of experimental full thickness burns in rats through amplification of early inflammatory response, enhanced angiogenesis, fibroblast content, accentuated wound contraction and collagen concentration.

Evaluation of the efficacy of cell and micrograft transplantation for full-thickness wound healing

BackgroundSkin grafting is the current standard of care in the treatment of full-thickness burns and other wounds. It is sometimes associated with substantial problems, such as poor quality of the healed skin, scarring, and lack of donor-site skin in large burns. To overcome these problems, alternative techniques that could provide larger expansion of a skin graft have been introduced over the years. Particularly, different cell therapies and methods to further expand skin grafts to minimize the need for donor skin have been attempted. The purpose of this study was to objectively evaluate the efficacy of cell and micrograft transplantation in the healing of full-thickness wounds. Materials and methodsAllogeneic cultured keratinocytes and fibroblasts, separately and together, as well as autologous and allogeneic skin micrografts were transplanted to full-thickness rat wounds, and healing was studied over time. In addition, wound fluid was collected, and the level of various cytokines and growth factors in the wound after transplantation was measured. ResultsOur results showed that both autologous and allogeneic micrografts were efficient treatment modalities for full-thickness wound healing. Allogeneic skin cell transplantation did not result in wound closure, and no viable cells were found in the wound 10 d after transplantation. ConclusionsOur study demonstrated that allogeneic micrografting is a possible treatment modality for full-thickness wound healing. The allografts stayed viable in the wound and contributed to both re-epithelialization and formation of dermis, whereas allogeneic skin cell transplantation did not result in wound closure.

In vitro and in vivo assessment of lactic acid-modified chitosan scaffolds for potential treatment of full-thickness burns.

Autologous skin transplantation is today's "gold standard" treatment for full-thickness burns. However, when > 30% of total body surface area is damaged, there is an important shortage of autologous donor sites for skin grafting; then, treatment alternatives become crucial. Such alternatives can be based on polymeric scaffolds capable of functioning as protective covers and cells/factors carriers. Chitosan (CTS) is a natural-derived polymer with relevant biological-related properties but poor mechanical performance. Improved mechanical properties can be achieved through lactic acid grafting (LA-g); nevertheless, LA-g affects the biological response towards the CTS-based materials. In this work, CTS-LA scaffolds with different LA-g percentages were synthesized and evaluated to determine appropriate LA-g degrees for full-thickness burns treatment. In vitro results indicated that the higher the LA-g percentage, the lower the capability of the scaffolds to sustain fibroblasts culture. Scaffolds with LA-g around 28% (CTS-LA28) sustained cell culture and allowed normal cell functionality. Further evaluation of CTS-LA28 as acellular and cellular grafts in a full-thickness burn mouse model showed that at 28 days post-burn, macroscopic characteristic of the reparation tissue were closer to healthy skin when cellular grafts were used for treatment; histological evaluation also showed that dermis cellularity and collagenous fibers structure were similar to those in healthy skin when cellular grafts were used for burns treatment. © 2017 Wiley Periodicals Inc. J Biomed Mater Res Part A: 105A: 2875-2891, 2017.

Development of an integrative algorithm for the treatment of various stages of full-thickness burns of the first commissure of the hand

Burns of the first commissure of the hand can evolve into an adduction contracture of the thumb. We decided to conduct a review of the existing literature on the treatment of full-thickness burns of the first commissure in order to develop a treatment algorithm that integrates the various currently available procedures. A search of the existing literature was conducted, focusing on the treatment of a burn of the first commissure in its chronic and acute phases. A total of 29 relevant articles were selected; 24 focused exclusively on the chronic contracture stage, while 3 focused exclusively on the acute burn stage, and 2 articles studied both stages. A therapeutic algorithm for full-thickness burns of the first commissure of the hand was developed. With this algorithm we sought to relate each degree and stage of the burn with a treatment.

Adipose tissue stromal vascular fraction in the treatment of full thickness burns in rats.

To analyze the healing effects of stromal vascular fraction (SVF) application compared to wound dressing with 2% silver sulfadiazine in full thickness burn wounds in rats. Animals were divided into two groups: 2% silver sulfadiazine group and SVF group. Both groups received occlusive bandages while the first one was treated with 2% silver sulfadiazine and the latter was treated with injections of SVF prepared from adipose tissue extracted from an animal donor. The animals were accompanied through 3, 7 and 30 days for evaluation of macroscopic, microscopic and morphometric aspects. On day three, a significant increase (p<0.05) of infiltration of polymorphonuclear, fibrin formation and fibroblasts migration in SVF group was observed. On the 7th day the mononuclear infiltrate, angiogenesis, collagen and fibroblasts were significantly increased in the SVF group (p<0.05). At 30 days significantly increased collagen deposition was observed in the SVF group (p<0.05) . Adipose tissue derived stromal vascular fraction injections promotes better wound repair than 2% silver sulfadiazine in the treatment of full thickness burn in rats during the evaluated experimental period.

Invasive Squamous Cell Carcinoma in Full-thickness Burn Wounds After Treatment with Cultured Epithelial Autografts.

In vitro expansion of cells using cultured epithelial autografts (CEAs) is a useful technique to provide skin coverage in extensive burn injury patients with limited donor site availability.1,2 However, preparation time of over 2 weeks and lack of a dermal component increase the risk of invasive infection and make the skin susceptible to shearing trauma. Besides, there have been reports of graft site malignancy after treatment of full-thickness burn with CEAs.3,4 We had earlier described a patient with reports of squamous cell carcinoma (SCC) at multiple full-thickness wound sites treated with CEAs.3,4 The patient was involved in a gas explosion, which resulted in full-thickness burns to 95% of total body surface area. Given the lack of donor sites, most of his body, including bilateral lower extremities, was grafted with CEAs. The lower extremities had to be grafted up to 3 times because of limited “take” of the CEAs. In our previous communications, we had described the development of SCCs in 6 different locations of the left lower extremity of the patient, which manifested about 14 years after the initial treatment with CEAs.3,4 We are now reporting 8 additional SCCs in the patient’s lower extremities over the past 9 years (October 2005–April 2015).

Recipient wound bed characteristics affect scarring and skin graft contraction.

The use of autograft skin is essential in the treatment of full thickness burns and large cutaneous defects. Both autograft thickness and condition of the wound bed modulate aesthetic and functional outcomes. Thicker autografts contract less and maintain greater functionality as the scar matures. The presence of hypodermis can also positively affect the eventual appearance and functionality of the wound site by modulating contraction and alleviating inflammation and cellular stress responses. In this study, we characterize wound-site physical and cellular characteristics following split-thickness skin grafting onto hypodermis vs. onto fascia. Compared to autografts grafted onto fascia, identical thickness autografts grafted onto fat demonstrated reduced contraction, enhanced mobility and vascularity, and reduced topographical variability. Grafts onto fat also showed reduced levels of myofibroblasts and leukocytic infiltration. The status of the wound bed prior to engraftment is an important contributor of skin quality outcome. The presence of hypodermis is associated with improved functional and aesthetic qualities of split thickness skin grafts, which are correlated with reduced presence of myofibroblasts and leukocytic infiltration.

Safety and efficacy of excision and direct closure in acute burns surgery: Outcome analysis in a prospective series of 100 patients and a survey of UK burns surgeons’ attitudes

Many burns surgeons avoid excision and direct closure of acute burns owing to concerns over wound dehiscence, scarring and infection. There is no evidence in the literature to support this practice. We present outcomes of a prospective series of 100 patients who underwent excision and direct closure of 138 burns over a 2-year period, along with results from a survey sent to 33 senior burns surgeons to gauge attitudes towards direct closure in burns surgery. 47% of survey respondents never perform direct closure. Dehiscence was cited as the most common concern, followed by hypertrophic scarring (HTS). In our cohort, the superficial dehiscence rate was 12% and the HTS rate was 16%, with no scarring contractures. Patients with healing time greater than 14 days were more likely to develop HTS (p=0.008), as were those with wound dehiscence (p=0.014). Patients undergoing part-grafting in addition to direct closure took significantly longer to heal than those undergoing direct closure alone (p=0.0002), with the donor site or graft delaying healing in the majority. Excision and direct closure of acute burn wounds avoids donor site morbidity and has an acceptable complication rate. It is a safe and effective treatment for full thickness burns in selected cases.

Mesenchymal stem cells combined with an artificial dermal substitute improve repair in full-thickness skin wounds

Autografts represent the gold standard for the treatment of full thickness burns. Factors such as lack of suitable donor sites and poor skin quality, however, have led to the development of artificial dermal substitutes. The investigation of mechanisms leading to enhanced functionality of these skin substitutes has been attracting great attention. This study aimed to investigate the effect of autologous stem cells on the integration and vascularization of a dermal substitute in full-thickness skin wounds, in a murine model. Two cell populations were compared, whole bone marrow cells and cultivated mesenchymal stem cells, isolated from mice transgenic for the enhanced green fluorescent protein, which allowed tracking of the transplanted cells. The number of cells colonizing the dermal substitute, as well as vascular density, were higher in mice receiving total bone marrow and particularly mesenchymal stem cells, than in control animals. The effect was more pronounced in animals treated with mesenchymal stem cells, which located primarily in the wound bed, suggesting a paracrine therapeutic mechanism. These results indicate that combining mesenchymal stem cells with artificial dermal substitutes may represent an important potential modality for treating full thickness burns, even in allogeneic combinations due to the immunoregulatory property of these cells.

Biodegradable Polysaccharide Gels for Skin Scaffolds

A variety of skin substitutes are used in the treatment of full-thickness burns. Substitutes made from skin can harbor latent viruses, and artificial skin grafts can heal with extensive scarring, failing to regenerate structures such as glands, nerves, and hair follicles. Biodegradable and biocompatible hydrogels, however, rarely mimic the strength of the epidermis. Therefore, novel and practical skin scaffold materials remain to be developed. Polysaccharides form hydrogels with predicted inherent biocompatibility. This paper describes the preparation and biocompatibility of unique hydrogel skin scaffolds from plant-extracted polysaccharide mixtures of specific sources, types, and molecular weight fractions. These hydrogels have a range of mechanical and degradation properties with the potential to fulfill the multiple, diverse functions of artificial skin, including protection, compatibility with different cell types, biodegradation, and release of needed signals for cell growth and wound healing.

Long‐Term Followup of Dermal Substitution with Acellular Dermal Implant in Burns and Postburn Scar Corrections

Full-thickness burn and other types of deep skin loss will result in scar formation. For at least partial replacement of the lost dermal layer, there are several options to use biotechnologically derived extracellular matrix components or tissue scaffolds of cadaver skin origin. In a survey, we have collected data on 18 pts who have previously received acellular dermal implant Alloderm. The age of these patients at the injury varied between 16 months and 84 years. The average area of the implants was 185 cm2. Among those, 15 implant sites of 14 patients were assessed at an average of 50 months after surgery. The scar function was assessed by using the modified Vancouver Scar Scale. We have found that the overall scar quality and function was significantly better over the implanted areas than over the surrounding skin. Also these areas received a better score for scar height and pliability. Our findings suggest that acellular dermal implants are especially useful tools in the treatment of full-thickness burns as well as postburn scar contractures.

Comparative assessment of cultured skin substitutes and native skin autografts for treatment of full-thickness burns.

Comparative assessment of cultured skin substitutes and native skin autografts for treatment of full-thickness burns.

Treatment of full-thickness burn by planned replacement of glutaraldehyde porcine skin with autograft. (Chinese)

Treatment of full-thickness burn by planned replacement of glutaraldehyde porcine skin with autograft. (Chinese)

Sildimac: A New Delivery System for Silver Sulfadiazine in the Treatment of Full-Thickness Burn Injuries

Wound care is painful for the patient with a burn injury and tedious for the burn unit staff but necessary to remove exudates and debris and to limit infections. In an effort to circumvent daily dressing changes while ensuring optimal wound protection, Sildimac (Marion Laboratories, Kansas City, Mo.), a new drug delivery system for silver sulfadiazine, was developed. When silver sulfadiazine, a topical antimicrobial commonly used for the treatment of burns, is incorporated into the delivery system, the drug is released in a sustained fashion. We report here the results of a multicenter evaluation of the safety and efficiency of Sildimac for treatment of full-thickness burn wounds. Sildimac, when left in place for up to 4 days, appears to be as effective as twice-daily wound cleansing and application of Silvadene cream 1% (Marion Laboratories, Kansas City, Mo.) for the treatment of full-thickness burns.

Treatment of full-thickness burns with Travase: Results of a clinical trial

Travase (sutilains) is a sterile preparation of proteolytic enzymes, prepared commercially from Bacillus subtilis, in a hydrophobic ointment base. There are a number of reports of its use in the treatment of burns and other conditions where necrotic tissue is present (Travenol Laboratories, unpublished data). In a small clinical trial carried out in this unit we have studied the effectiveness of Travase in the débridement of the burn wound; we have found it to be a potent and effective means of removing burned tissues.

Early excision as the method of choice in the treatment of full-thickness burns. Transactions of the 5th Panhellenic Congress of Surgery 5

Early excision as the method of choice in the treatment of full-thickness burns. Transactions of the 5th Panhellenic Congress of Surgery 5

Evaluation of therapy in burns by morbidity studies

1. 1. Morbidity factors are suggested to serve as criteria in evaluating therapy for patients with burns. These include length of hospitalization as affected by extent of full thickness burn, number of operations required to correct full thickness burns of a given magnitude, and total number of admissions required to correct full thickness burns. 2. 2. It is necessary to determine the depth and extent of skin destruction in each case to be able to employ these criteria. 3. 3. Although the over-all combined hospitalization is increased for late admissions, the time required to correct given areas of full thickness loss at the University of Michigan is approximately the same for both early and late admissions. 4. 4. A comparison of length of hospitalization between the 1946 to 1952 period and the 1953 to 1959 period of this study revealed no significant change. 5. 5. There is a relationship between the area of skin burned to its full thickness and hospitalization, but not between the age and hospitalization. 6. 6. Both the average number of operations and average number of readmissions required in treatment of full thickness burns are reported.