Loss of full-thickness skin over a large body area repre-
sents one of the major challenges in reconstructive sur-
gery. In burned patients this problem is particularly sig-
nificant because the prognosis has improved following
the introduction of early escarectomy, but this procedure
can expose the patient to the risk of insufficient autolo-
gous tissue for immediate cover.
Large third degree burn surfaces introduce new techni-
cal challenges which we still look forward to solving.
Preparation of the recipient bed for the autologous skin
is one of the topical subjects. Homologous skin grafts
as eterologous grafts, fresh or preserved, have been tried
on humans to prepare the field for the definitive cover. Fi-
nally, research on skin culture and in vitro expansion of
keratinocytes and fibroblasts have opened new needs for
Recent investigations promoted by research in tissue en-
gineering give new opportunities for management using both
artificial or semi-artificial materials. Improvements are mea-
sured in terms of absence of granulating tissue, take of sec-
ond step grafts, wound contractions, and in functional results.
Original and effective results have been reported on
wounds treated with Integra. Integra is a new bi-layered
semi-artificial bioengineered material. The deep layer is
of bovine collagen origin, the superficial layer is made
of silicone. Unlike other wound treatments, Integra is
not designed to debride necrotic tissue, this must be done
surgically. Integra stimulates the formation of a regenera-
tion like dermal replacement through cellular migration
into a dermal regeneration template collagen matrix.
The neodermis is secondary to the migration of fibro-
blasts, budding vessels, and macrophages into the Integra
dermal regeneration template. The temporary silastic epi-
dermal substitute layer works as a temporary skin barrier.
Doctor Cedidi et al., in their paper underline the good
results obtained on regions with very thin subcutaneous
tissue like the pretibial area where they used Integra im-
mediately after escarectomy. After 16 days, without re-
moving Integra, lesions were ready to be grafted and
showed thin pink neodermal tissue. The final result was
natural and the tissue was elastic and traction resistant.
Sixteen days is the period required to obtain a vascu-
larized neodermis. During this period, in which the porous
matrix of fibers of cross-linked bovine tendon collagen
and glycosaminoglycan are biodegraded and the ingrow-
ing fibroblasts create a neodermis, the Integra has to stay
fixed to the wound bed.
If this process is successful, at the end of the treatment
there will be no thick granulating tissue and no sign of
chronic infection. Prevention of granulating tissue growth
is one of the major qualities of Integra.
The authors emphasize that this procedure is useful in
subjects in which it can be sure that there will be no con-
tamination. Infection puts limits on the application of the
dermal regeneration template.
The necessity of topical control, for example in large
burn surfaces, is essential to the application of Integra.
The authors report two patients with trunk lesions with
bad results due to the contamination of the field. Also, dis-
tribution of the injury can complicate the use of Integra
since it has to be firmly fixed; it is good on the legs, but
more difficult on the trunk. Bleeding and hematomas
and fluid collections are better tolerated by mesh materials
than sheets. In extensive skin escarectomies care must be
taken to avoid fluid collection. For these reasons the use of
tissue engineered Integra is sensitive to inflammation and
fluid collection. Its use will only be successful if accurate
technical skill is exercised during both the operative and
postoperative period. If successful, however, it provides
a functional replacement dermis without scar contraction.
Products of tissue engineering in general, such as Int-
egra, seem therefore to have substantial potential in treat-
ing burn, trauma, and reconstructive surgery.
University of Milan, Medicol School,
Institute of Plastic Surgery,
Piazza Ospedole Maggiore n. 3,
I-20162 Milano, Italy
Thank you for inviting me to comment on this paper. Int-
is the most prominent of a number of exciting bio-
synthetic skin substitutes which have recently become
available for use in the treatment of burn injury. These
products are potentially life-saving in cases of extensive
burn injury. They are also very expensive. For these rea-
sons, it is most important to determine whether Integra
performs satisfactorily in clinical situations and this paper
is therefore welcome.
The history of the development of Integra
vant. The original artificial skin envisaged by Yannas
and Burke was designed to provide wound coverage fol-