Photo Credit: Nymphoenix
Split-thickness grafts may be an alternative to full-thickness grafts due to less donor site morbidity and better results for joint-involved burn reconstruction.
Artificial dermis (AD) used with split-thickness skin grafts (STSG) were associated with fewer donor site complications and may serve as a viable alternative to full-thickness skin grafts (FTSG) for joint-involved burn wounds, researchers reported in the International Wound Journal.
However, this lower rate of adverse events also came with less recovery of joint mobility.
“For joint-involved burn wounds, in consideration of functional recovery, [an FTSG] is better than [an] STSG for lesser secondary contractures. However, the major disadvantage of FTSG is the limitation of available donor sites,” study authors Jui-Po Yeh, MD, and Ko-Chien Lin, MD, wrote.
Previous studies have used AD-STSG for burn injuries on patients’ hands and feet, the authors noted. “However, few studies have evaluated the scar quality and recovery rate of joint activity between artificial dermis with split-thickness graft and full-thickness skin graft.”
Real-World Patient Data: Skin Grafts
The researchers conducted a retrospective review of 28 patients treated at a tertiary burn center. All patients were treated between August 2021 and August 2023 and received skin grafts with either full-thickness or split-thickness grafts with AD. Dr. Yeh and Dr. Lin reviewed patients’ medical records and photographs, gathering demographic information, clinical features like burn wound size and depth, involved joint sites, whether patients had infections before grafting, the specifics of their surgeries, and the interval between application of AD and skin grafting, as well as the type of artificial skin used.
The primary outcome of the study was the percentage of skin-graft take. Secondary outcomes included recovery rate of joint range of motion, incidence of scar contracture requiring further revision, 12-month scar quality, and rates of complications such as donor site morbidity and infection. All patients had joint-involved burn wounds, and patients who underwent adjuvant treatment such as hyperbaric oxygen therapy or topical growth factors were excluded from the study.
In total, 12 patients received AD-STSG, and 16 patients received FTSG for reconstruction. Most patients (n=20) were men, and the median age was 51.
Patients in the AD-STSG group had significantly larger injuries than those in the FTSG group, with a median wound size of 112.5 cm2 (interquartile range [IQR], 71.3) versus 67.5 cm2 (IQR, 76.3). Aside from this, the two groups had no significant differences in terms of sex, age, areas of joint involvement, wound depth, or prevalence of infection before grafting.
The researchers reported that the median size of AD used among the 12 patients who received AD was 75 cm2. A median of 14 days elapsed between when clinicians applied AD and the skin graft.
Is STSG With AD Ever Better?
According to Dr. Lin and Dr. Yeh, the two groups had similar skin graft take rates: 96% for the FTSG group and 95% for the AD-STSG group. The researchers noted that these rates were consistent with those of earlier studies. No patients experienced postoperative infections.
In many respects, FTSGs outperformed grafts with AD and split-thickness skin. Patients in the AD-STSG group had a median 12-month Vancouver Scar Scale score of 6 (IQR, 1.5) compared with 4 (IQR, 1.3) in the FTSG group, showing that the full-thickness group had significantly better scar quality at 1 year.
Patients who received full-thickness grafts also showed a superior recovery of range of motion in the affected joints versus the AD-STSG group, with a median recovery rate of joint activity of 82.5% (IQR, 15%) versus 70.0% (IQR, 7.5%; P<0.01).
Scar contracture requiring further revision occurred in 25% (n=3) of patients who received AD and in 12.5% (n=2) of patients who received full-thickness grafts, Dr. Yeh and Dr. Lin reported, though this difference was not significant.
However, the researchers continued, no patients who received AD-STSG experienced donor site morbidity, whereas two patients who received full-thickness grafts had partial wound dehiscence at the donor sites. According to Dr. Yeh and Dr. Lin, this resulted from tension over the donor wounds during skin closure. Both patients with wound dehiscence had relatively large grafts, measuring 210 cm2 and 240 cm2, respectively.
“… With better cosmetic and functional outcomes in our study, FTSG seemed to be superior to AD-STSG for reconstructing joint-involved burn wounds,” Yeh and Lin wrote. “Nevertheless, two of our patients in the FTSG group with larger skin defects (both >200 cm2) experienced partial donor wound dehiscence, prolonged wound healing time (more than a month), and scar hypertrophy. By contrast, AD-STSG did not cause donor site morbidity in our study. Therefore, for larger burn wounds around joint areas, AD-STSG could be an alternative treatment over FTSG, owing to lesser donor site morbidity and admissible functional outcomes.”
