SUMMARY. The use of artificial skin restores the depth and the elasticity of the skin, through restoration of the dermis. with no significant morbidity. Thus we have permanent release of contractures and a pleasing contour with satisfactory functional and cosmetic results. Still, these advantages must be weighed against the necessity for meticulous surgical technique and intensive post-operative care, the waiting period and the cost of the product.
Key words: artificial skin, elasticity, contractures, functional and cosmetic results
The preservation of elasticity and the cosmetic restoration of the skin are a major challenge for the plastic surgeon. The restoration of the skin is essential for life. but the restoration of the dermis (its elasticity) is crucial for the quality of life.
The aim of the article is to present the indications and problems that arise from the use of artificial skin for restoration of the dermis, and to evaluate the functional and cosmetic outcome.
Artificial skin (IntegraŠ) is a bioartificial, bilaminate dermal substitute with an outer silicone layer that has an epidermislike structure acting as an environmental barrier and an inner layer- with a porous structure composed of bovine collagen and chondroitin 6-sulfate, in which the migration of the patients endothelial cells Lind fibroblasts occurs.
During the period from 2001 until mid-2005 we used artificial skin in 24 patients in our Department. Fifteen patients had post-burn contracture. 6 had post-traumatic defects, 1 had a major skin leiomyoma of the upper extremity, 1 had a congenital giant nevus of the upper extremity and 1 had vascular dysplasia of the tibia (Fig. 1).
<% immagine "Fig. 1","gr0000008.jpg"," ",230 %>Of these patients, 14 were females and 10 were males, age ranging from 13 to 52 years. The sites where the Integra was used were: 8 for the upper extremities, 6 for the lower extremities, 2 for the face, 2 for the neck and 6 for the chest and abdomen. All the patients had a twostage operation. In the first stage the defect was excised and the artificial skin was placed, while in the second stage the outer silicone layer of the artificial skin was removed and the defect was covered with a thin (<0.5 mm) split skin autograft.
Method. This is a two-stage operation with an interval of 3 to 4 weeks. The first stage involves the debridement of the damaged area or the surgical removal of the lesion and coverage with the artificial skin. The second stage involves removal of the silicone layer and coverage with skin autografts
Procedure. During the first stage we perform excision of the area involved deep into the normal subcutaneous tissue with meticulous hemostasis. The Integra is then tailored to fit the wound and is sutured under slight tension with staples. We then apply dressings. using splints at the limbs and soft collars at the neck areas. We remove the dressings after 5 clays and inspect the Integra During the second stage (3-4 weeks later) we remove the outer silicone layer and perform skin grafting with thin partial thickness skin autografts. We then apply dressings, which we remove after 5 days.
The defects were located: A on the upper extremities, 6 on the tower extremities. 2 on the face, 2 on the neck and 6 on the chest and abdomen (Fig. 2-7).
<% immagine "a","gr0000009.jpg"," ",230 %> <% immagine "b","gr0000010.jpg"," ",230 %> <% immagine "c","gr0000011.jpg"," ",230 %> <% immagine "d","gr0000012.jpg"," ",230 %> <% immagine "e","gr0000013.jpg"," ",230 %> <% immagine "f","gr0000014.jpg"," ",230 %> <% immagine "g","gr0000015.jpg"," ",230 %> <% immagine "h","gr0000016.jpg"," ",230 %>Fig.2 A 45-year-old woman with a post-burn contracuture of the upper extremity
Fig.4 A young male patient with a post-burn contracuture of the thorax
Fig.5 A 40-year-old female patient with a post-burn contracuture of the neck
Fig.5 Leiomyoma of the upper extremity
Fig.6 A 19-year-old female patient with a post-burn contracuture of the pubis
Fig.7 An extensive post-burn contracture of the abdomen in a 32-year-old patient
In 20 cases there was a 100% take of the artificial skin, while partial infection appeared in 2 cases. These patients were treated with removal of the outer silicone layer and antimicrobial therapy. The elasticity of the skin was restored in all cases. and an increased range of motion with no contractures appeared. There was a fast reepithelization of the donor sites. Post-operative contrac ture appeared ěn 1 case.
There were also 2 cases that presented with hematoma underneath the Integra (treated conservatively) and resulted in a partial take.
The artificial skin offers a durable dermal matrix of considerable strength, which can be tailored according to the defect. The donor site heals rapidly with reduced morbidity and scarring. The recipient site presents with an acceptable sear after maturation and a very satisfactory functional result. On the other hand, the 3-4 weeks waiting period between the two stages, and avoidance of infection, are necessary for a successful outcome. Also, the advantages must be weighed against the necessity for meticulous surgical technique and intensive post-operative care, the waiting period and, of course, the cost of the product.
Address for correspondence: