SUMMARY. The advantages of Integra have lead to an increase in its use after extensive burn injuries, in reconstructive Surgery after burns, and abroad in general reconstructive surgery as well At the Burn Center of FNsP Hospital in Ostrava Integra was used for the first time in March 2003. Since then, seven patients have undergone operations, involving the use of Integra in 14 body areas. In four of the patients scars after burns were corrected- on the neck, axilla, two on the trunk, two in the popliteal area and one between the toes. In three patients the artificial skin was applied after necronectomy. In a 7-month-old baby and in a 2-year-old child with burn injuries exceeding 25 % of the body surface it was applied twice on the trunk, once on the upper extremity and once on the lower extremity. In an adult female Integra was applied on her neck and axilla after burns to a lesser extent. We have evaluated the scars one year after surgery in two patients. Cosmetic appearance was good in both of them. We have noted good functional result after the reconstruction of axilla. After reconstruction in the neck area and reconstruction of the necrectomy in the neck area and axilla, the functional results were average. The average functional results in both patients are probably due to poor compliance with the immobilization and following rehabilitation program.
Key words: Integra, neodermis, autograft, reconstructions after burns, areas after necronectomy, results
The artificial skin Integra was developed and used by Burke and Yannas (I) in the early 1980s in the United States as a cellular two-layer skin substitute. Its underlying layer. based on bovine collagen, has defined porosity within 70-200 micrometers. which allows the host lymphocytes, macrophages, endothelium cells, and fibroblasts to move in and anchor. These cells create revascularization and, by a production of collagen along with synchronistic biodegradation of the matrix, they create so-called neodermis (16). According to histological studies of Stern in acutely burned patients (27) and Moiemen in patients who underwent reconstruction surgery (21), neodermis grows in 2 - 3, or 4 weeks after the application of Integra. Jeschke (15) noticed speedy production of neodermis with application of negative pressure to the healing area. The upper silicon layer, which prevents drying up of the tissues, performs temporarily as an epidermis. After the neodermis grows, according to the status of the burned patient, and if the donor sites are accessible, the upper silicon layer is slowly removed and replaced by an ultra-thin epidermal graft. Authors recommend a thickness of 0.002 - 0.006 inches (0.05 - 0.15 millimeters) (27, 21, 4, 14). The advantages of ultra-thin graft is fast healing of the donor sites and the opportunity to repeat harvesting at short intervals, as well as the absence of a net texture after hcaling in the operated area (9). According to the literature, in order to minimize the donor sites it is possible to use cultivated keratinocytes or composite biocompatible epidermal grafts, as published for example by Pandya (25), Hansbrough (7), and Chan (13). The above-mentioned application of Integra with a positive metabolic response. shortening of hospitalization and minimal immunology response in burn patients has led to a standardization of the method in vitally threatening burn injuries in the United States, for example. The quality of scars, minimization of donor sites. and its permanent healing has led to an expansion of the use of Integra particularly in the area of reconstructive surgeries after burns, and abroad also in general reconstructive surgery.
At our workplace we used Integra for the first time in March 2003. To date we hav c used this method in seven patients in 14 body areas. In four of the patients we used Integra for correction of burn scars: on the neck, in axilla, twice on the trunk, twice in the popliteal area, and once in the space between the toes (Tab. 1).
<% immagine "Table 1","../images/gr0000001.jpg","Using Integra 3/2003-8/2004, reconstruction after burn injury",230 %>After necrectomy we applied Integra to a seven-month-old and a two-year-old child twice on the trunk, once on the upper extremity, and twice on the lower extremity. In an adult female we used Integra on her neck and axilla (Tab. 2).
<% immagine "Table 2","../images/gr0000004.jpg","Using Integra 5/2003-8/2003, after excision",230 %>Integra was inserted into a bed perfectly rid of devitalized or scarred tissues (Fig. 1.2).
<% immagine "Fig. 1","../images/gr0000002.jpg","Burned child, 25% TBSA, before excision",230 %> <% immagine "Fig. 2","../images/gr0000005.jpg","Burned child after excision",230 %>Bleeding was .stopped by angiotripsy, point coagulation and local application of adrenalin solution. diluted 1:10,000. Non-meshed Integra was fixed to the edges of the defect by staples or single atraumatic sutures Prolen 5/0 (Fig. 3).
<% immagine "Fig. 3","../images/gr0000003.jpg","Integra sheet stapled to wound bed margins",230 %>After insertion into the concave area, any crease was excised and the edges were stapled or sewed by a continual stitch. Inadin and a layer of gauze. saturated in a 0.5% solution of argentnitrate, covered the surgical site. There was an elastic bandage on top of the gauze to complete the fixation. For ten days the operated site was immobilized in a desired position. and then the patients sorted gradual rehabilitation, In patients operated on the neck we used a nasoduodenal tube for feeding. A check-up for bleeding as well as bacteriological examination was performed daily and then every other day. In the 3rd and 5th week after ,surgery we performed an autograft by a dermo-epidermal graft with a thickness of 0.125 0.15 millimeters, which wan fixated to the edges by tissue glue Histoacryl. The attachment to the base was secured by Surfasoft film, fixated by staples (Fig. 4, 5).
<% immagine "Fig. 4","../images/gr0000006.jpg","Autografts, meshed 1:3, covering by Surfasoft, stapled to wound margins",230 %> <% immagine "Fig. 5","../images/gr0000007.jpg","Child with healed autografts",230 %>Layer of gauze, saturated in a boric acid. thicker gauze, and elastic compression reinforced the fixation.
We evaluated the scars of two patients in two body areas one year after the surgery. In four patients the surgery was performed less than a year ago, and one patient developed general inflammatory response 5 weeks after the application of Integra. The infiammation was confirmed by evaluation of humoral immunity, accompanied by a separation of the bottom layer without positive bacteriological antigens against beef collagen.
We evaluated the aesthetics of the scars (pėgmentation, vascularization, thickness, and elasticity) as well as functional results. If the surgery met the expectation of significantly improved function, the result was considered good. If it did not meet the expectation completely, the result was considered average (Tab. 3).
<% immagine "Table 3","../images/gr0000010.jpg","Survey of scars",230 %>During the evaluation the scars had a similar pigmentation as the surrounding tissues; they were not congested but were inward and elastic (Fig. 6).
<% immagine "Fig. 6","../images/gr0000008.jpg","Soft, elastic, non-fixed scar after usinf Integra",230 %>Good functional result was noted after the reconstruction of axilla (Fig. 7).
<% immagine "Fig. 7","../images/gr0000009.jpg","Good function result after reconstruction of scar contracture in axilla",230 %>After reconstruction of the neck and after necrectomy on the neck and ėn the axilla the results were average and required subsequent reconstruction. We attribute the funs tional result to reduced compliance in both of the patients during immobilization and following rehabilitation.
The advantage of using Integra has been documented by many authors (l, 9, 10, 5, 26). Resides the opportunity to use skin grafts repeatedly at short intervals. the use of ultra thin epidermal grafts. and its minimization in application of cultivated keratinocytes or composite biocompatible epidermal grafts (25, 12, 23), other advantages have been found in the use of Integra. King (17) found that after application of Integra to an extensively burned child, the utilization of protein as well as energy demands decreased when compared to children who were treated without it. Ryan and Schoenfeld (26) proved that the length of hospitalization is shortened by a third. They did not prove any difference in mortality in comparably burned patients who were treated with Integra or underwent standard treatment. The histology studies of Stern (27) and Michaeli (20) have proved minimal immune response to the bovine collagen and other components of Integra. which did not influence healing or the clinical course. One yesnr after surgery normal collagen structure in a scar and presence of elastic fibers was proved, as well as no skin adhesions or nerve endings (24). Integra is now also used for a full thickness skin toss, smaller defects (for example head, hands, gluteal avulsion, after acid burns above large joints, or for a coverage of thigh stump after amputation, for reconstruction), reconstruction of hypertrophic and contracting scars after burn injuries (21, 14. 24, It. 3), keloid and non-aesthetic scars in children and adults (19). According to the literature. Integra is used also for covering large defects after extensive congenital naevoid lipoma, skin tumors (23. 18), and donor sites after graft harvesting (30, 22). It is also used for chronic skin ulcerations, including post-radiation (28,6). The results of the majority of studies show good cosmetic result as well as function (29). However. Martinez and Res (19) for example found hypertrophic scars in 2 out of I 1 children treated by Integra. Hunt (11) published recurrent contractures on anterior neck in all five patients who were treated in that area. We consider the cause of such failure may have been an incomplete excision of the sear. insufficient immobilization of the operated area and poor compliance of patients in the subsequent rehabilitation program. These authors emphasize the careful choice of patients who arc able to participate with the immobilization and following rehabilitation. The disadvantage of Integra is its high cost, the need for two surgeries and the risk of infection complications (14). While some authors used Integra for less extensive reconstructive surgeries in order to achieve the best possible functional and cosmetic appearance of the scar, others recommend its use only if no donor sites are available (21,14, 16. 8). The majority of authors also consider this method a new alternative for reconstructive surgery. Its advantages and disadvantages should be considered while choosing various ther apies in individual patients (3).
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