The use of artificial dermis for corrective surgery on burn scars

A 20-year-old Thai man had postburn injuries to70% of his total body surface area incurred 2 years previously. There were lesions on his face, arms, trunk, and left leg. He also developed severe scar contractures on his left arm and had an open wound that was approximately 3 × 3 centimeters on his elbow over the joint. The extensive scarring resulted in difficulty in movement and flexibility of his elbow joint (Figure 1). We decided to use an artificial dermis, Pelnac (Gunze Co, Kyoto, Japan ), for the reconstruction of his hypertrophic scar because he had limited quality skin graft area for application to the wound area after the hypertrophic scar excision. The removal of scar contractures involved a total excision of scars from his left arm, forearm, elbow, and hand. The depth of the dissection was extended to normal subcutaneous tissue to achieve complete release of the scars. The scars over his left arm, forearm, elbow, and hand were excised deeply through to healthy fatty tissue. Figure 2 shows the 2 pieces of scars with healed shearing wounds over the left elbow joint area.

Figure 1

Figure 2

After the artificial dermis was applied onto the wound and stapled to the edges (Figure 3), the wound was covered with a nanocrystalline silver dressing and bandaged with an outer dressing. We changed the outer dressing on postoperative days 3, 7, and 10, and the patient was transferred to an operating room for removal of staples on day 14.

Figure 3

Figure 4a illustrates the wound after the artificial dermis was applied for 2 weeks, which demonstrated the complete (100%) acceptance of the artificial dermis. The outer silicone sheet layer was then removed (Figure 4b) and the neodermal formation was observed underneath (Figure 4c). An ultrathin epidermal skin graft with a thickness of 0.15 mm was harvested from his thighs using a dermatome (Zimmer, Swindon, UK). The epidermal skin graft was then meshed at a 1:1.5 ratio and then applied onto the artificial dermis template area (Figure 4d). We avoided harvesting a thick skin graft because the patient did not have sufficient healthy skin, and to prevent donor site scarring from harvesting too deeply. The donor site wound healed at day 15 after the surgery. The patient was discharged on day 21 and returned on day 7, at 1 month, and at 3 months after the surgery. The result was satisfactory. It harmonized with the surrounding normal skin without any complications when observed 3 months after the surgery. The patient could perform an almost complete elbow extension to 170°, compared with 120° extension before surgery. He also demonstrated no shearing wound, which often occurred over the scar contracture area, especially over joints, after too much extension and movement of his left elbow (Figure 5). Follow up at 1 year showed no recurrent shearing wound over the left elbow joint area (Figure 6).

Figure 4 a–d

Figure 5

Figure 6

The patient provided his written informed consent for publication of this case report including the clinical photographs.

Scar contracture after bum injuries is challenging. There are several methods by which to prevent and treat hypertrophic scars including topical agents, steroid injections, pressure garments, and surgery. The proper treatment of severe scar contracture is by a surgical procedure to release the skin tension.

One type of artificial dermis (graft for dermal defect) is a bilayer composed of an inner sponge layer of atelocollagen and an outer layer of silicone. It can be used in acute burn treatment and reconstruction procedures, as a single layer in trauma cases, or on other skin loss areas after surgery for tumor or nevus removal. It is very effective in functional and cosmetic improvements [7-10] and postprocedure contracture defects are found to be insignificant [11]. For the present patient, the cosmetic and functional appearance on his left arm was improved. He demonstrated an almost full extension of his left elbow joint compared with before the surgery. We have shown that artificial dermis is beneficial for scar reconstruction; especially when patients have a large burn area and do not have sufficient healthy skin graft area for application to the wound after scar excision. Moreover, this artificial dermis was developed for use in various indications. Growth factor was loaded into the inner layer, which can accelerate chronic wound healing and prolong its stability [12, 13]. The artificial dermis is impregnated with an antibiotic for application on contaminated wounds [14].

The use of an artificial dermis is effective in surgery for scar contracture. It is an alternative modality in solving scar problems; especially on large areas of burn injuries with a lack of sites for skin graft for wound coverage after scar excision.