The 1999 Clinical Research Award - Cultured skin substitutes combined withintegra artificial skin to replace native skin autograft and allograft forthe closure of excised full-thickness burns

Prompt and permanent closure of excised full-thickness burns remains a crit ical factor in a patient's recovery from massive burn injuries. Hypothetica lly, Integra Artificial Skin (Integra) may replace the need for allografts for immediate wound coverage, and cultured skin substitutes (CSS) that cont ain stratified epithelium may replace the need for autografts for definitiv e wound closure. To test this hypothesis, 3 patients with full-thickness bu rns of greater than 60% of their total body surface areas had their eschar excised within 14 days of admission. Integra was applied, and a skin biopsy was collected from each patient for the preparation of CSS. At 3 weeks or more after the application of the Integra and the collection of skin biopsi es, the outer silastic cover of the Integra was removed and CSS were grafte d. The CSS were irrigated with nutrients and antimicrobials for 6 days and then dressed with antimicrobial ointment and cotton gauze. Treated wounds w ere traced on days 14 and 28 after the grafting of CSS for determination of engraftment and wound closure, respectively. Cost analysis was not perform ed. Engraftment on postoperative day (POD) 14 was 98% +/- 1% (mean +/- stan dard error of the mean), the ratio of closed:donor areas on POD 28 was 52.3 +/- 5.2, and no treated sites required regrafting. The histology of the cl osed wounds showed stable epithelium that covered a layer of newly formed f ibrovascular tissue above the reticulated structure of the degrading Integr a. The clinical outcomes of the closed wounds after POD 28 demonstrated smo oth, pliable, and hypopigmented skin. Two patients who had received CSS gra fts over Integra on their backs were positioned supine on air beds from POD 8 or POD 9 with minimal graft loss because of mechanical loading. One pati ent with a full-thickness burn of 88% of the total body surface area was co vered definitively at 55 days postburn. These results demonstrate that the combination of CSS and Integra can accomplish functionally stable and cosme tically acceptable wound closure in patients with extensive full-thickness burns. This combination of alternatives to the conventional grafting of spl it-thickness skin permits the substitution of cadaveric allograft with Inte gra and the substitution of donor autograft with CSS. This approach to the closure of excised full-thickness burns is expected to reduce greatly the t ime to definitive closure of burn wounds and to reduce the morbidity associ ated with the harvesting of donor sites for split-thickness skin autografts .