Calcified Integra membrane: one possible cause of skin graft
failure in the second stage of Integra use
A. S. Ghattaura
T. S. Potokar
Received: 23 April 2007 / Accepted: 22 July 2008 / Published online: 12 August 2008
Abstract The use of Integra as an artificial dermal
regeneration template is well established. Following initial
use of Integra to resurface the wound bed, the second stage
involves removal of the silicone layer and application of a
split skin autograft. Previous histological studies have
shown that neo-vascularisation of the Integra occurs
between 2 and 4 weeks, and therefore, skin grafting over
the Integra is recommended at any time after this period.
We present a case of an infant with 38% total percentage of
body surface area in whom we performed early burn
excision and immediate application of Integra. In this case,
the second stage of skin grafting was delayed, resulting in
the formation of a crusty white membrane over the Integra.
Histological analysis with a Von Kossa stain revealed
evidence of calcification within the superficial layers of
the Integra. Each leg was initially treated differently. In one
leg, mechanical scrubbing of this layer was performed. The
subsequent results of grafting in this leg were unsatisfac-
tory, and repeat grafting was necessary. In the other leg,
tangential excision using a Watson knife was performed
before grafting. This produced much better results in terms
of skin graft ‘take’. The causes of calcification in
biomaterials are discussed, and recommendations are made
on the basis of the clinical findings in this particular case.
Recent advances in tissue engineering have led to the
increased use of biomaterials in many areas of medicine.
Artificial heart valves, prosthetic blood vessels, and
implantable drug delivery systems have been available for
many years and have a proven record of efficacy and safety
. Skin substitutes such as Integra (Integra Life sciences,
Plainsboro, NJ, USA) have been developed for use in the
reconstruction of large skin defects. This dermal regenera-
tion template is now one of the most commonly used
biomaterials in plastic and reconstructive surgery. In the
subspecialty of burns, the use of this product has become
almost routine [1, 5].
Integra is a bilaminar membrane consisting of porous
bovine collagen and shark glycosaminoglycan (chondroitin-
6-sulfate), covered by a temporary epidermal substitute
(silicone). This construct acts as a matrix for the influx of
host fibroblasts and endothelial cells. Once the Integra has
been vascularised (at about 3 to 4 weeks), the silicone layer is
removed, and a thin split skin graft is applied. Ultimately, the
Integra is replaced by endogenous collagen, and eventually,
this matures into the neo-dermis. This neo-dermis resembles
normal dermis in terms of pliability and contour.
Like most of the biomaterials used in medicine, Integra
has a proven record of clinical effectiveness and safety.
However, we present the case of an 11-month-old child in
whom the Integra became calcified, resulting in failed skin
grafting during the second stage. Although reports of
calcification of biomaterials such as prosthetic heart valves
are common throughout the scientific literature, we believe
that this is the first reported case of calcification in Integra.
Eur J Plast Surg (2009) 32:47–50
A. S. Ghattaura
T. S. Potokar
A. S. Ghattaura (*)
4 Devon Place, Mumbles,
Swansea, West Glamorgan, Wales SA3 4DR, UK