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


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Copyright © 1999 by Springer-Verlag Berlin Heidelberg
Medicine & Public Health; Plastic Surgery
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