1. Biosynthetic Skin Substitutes for Large Burns: A Review
JCR Wormald1 JA Dunne1 A Murray2 JM Rawlins3
1 Plastic Surgery Department, Chelsea and Westminster Hospital, UK
2 Plastic Surgery Department, Stoke Mandeville Hospital, UK
3 Plastic Surgery and Burns Department, State Adult Burn Unit, Fiona Stanley Hospital, Perth WA, Australia
Introduction
Biosynthetic skin substitutes are often essential in the management of large surface area burns, where donor-site options and availability of autologous grafting is limited. They can promote healing and provide temporary or permanent wound cover for burns reconstruction. Their implementation in burns centres continues to increase and new technologies arise. This review provides an update on the current evidence base for their efficacy in burn injuries and review of emerging innovative skin substitutes.
Author
Design
Outcome
Evidence Level
Priyesh (2015)
Glyaderm dermal substitute plus SSG vs. SSG alone in full thickness burns (RCT)
No difference in graft take but greater elasticity of skin at 1 year in experimental group 2
Vloemans (2014)
Methods of treating paediatric partial thickness burns (systematic review)
Biobrane and amniotic membrane earlier epithelialisation than silver dressings, poor long-term scar data 3
Wood
(2012)
Dressings vs Biobrane vs ReCell and Biobrane in paediatric scalds (RCT)
Earlier time to healing with Biobrane and ReCell and Biobrane, fewer dressings
Solanki
AWBAT-D vs Duoderm on SSG donor sites (RCT)
Significantly earlier time to healing with Duoderm
Rahmanian- Schwarz (2011)
Suprathel vs Biobrane in superficial partial thickness burns in adults
Comparable time to healing, elasticity and cosmesis at 8 months follow-up
Pham (2007)
Systematic review - safety profile of bioengineered skin substitutes
Duoderm, Transcyte, Apligraf, Biobrane as safe as biological replacements
Methods
We performed a systematic review of use of biosynthetic skin substitutes in burn injuries using MEDLINE, Embase, Pubmed and the Cochrane library. Burns and Journal of Burn Care and Research were hand-searched. Reference lists of identified papers were reviewed. The search was undertaken in February 2016.
Results
Integra is effective at cover of exposed tendon and joints in the hand producing good elasticity and similar thickness to normal skin (Nguyen, 2010, Danin, 2012). Comparison of Matriderm and Integra in vivo demonstrates comparable engraftment, neodermis formation and vascularization (Bottcher-Haberzeth, 2012). Suprathel demonstrated significantly less pain compared to Omniderm (Uhlig, 2007), and favourable antimicrobial activity compared to Aquacel and Acticoat in vitro (Ryssel, 2010). Superficial partial thickness wounds may heal more rapidly with Biobrane than Suprathel (Rahmanian-Schwarz, 2011), while Transcyte may promote faster re-epithelialisation than Biobrane (Kumar, 2004), with Duoderm and Biobrane comparable (Cassidy, 2005). Glyaderm plus skin graft provides greater elasticity at one year compared to skin graft alone (Pirayesh, 2015). Further results in Table 1.
Discussion and Conclusions
Survival after large surface area burns is increasing and thus reconstruction and functional and scar outcomes gain importance. Replacing the complex structure of the dermis has proven challenging, and early studies have shown encouraging results in release of time-dependent healing factors and use of adult stem cells to develop in vitro skin. Future directions include the use of tissue engineering with biomaterials and 3D printing to create higher specification skin substitutes.
Table 1. Evidence summary of biosynthetic skin substitutes (OCEBM Levels of Evidence Working Group*. "The Oxford 2011 Levels of Evidence”)
Mr. Justin CR Wormald MBBS(hons) MRes(hons) MRCS
Core Surgical Trainee (CT1)
Chelsea and Westminster Hospital NHS Foundation Trust
London