Skin substitute

1. BURN: Dressing
Related to burn injuries.
Dr .Yacoub Alajy
Dr. M AL AISSAMI

2. Introduction:
 Historically, the main goal in burn
management was increasing the survival.
 last decennia,surgical emphasis has shifted
from survival to “quality of survival. Scar
and contructure.

3.  surgeons divide burns :
 deep burns requiring surgical therapy,
 superficial burns which heal spontaneous by
reepithelialization with minimal scarring.
 final decision for surgery generally remains
case and surgeon dependent, mainly depend
on the total burned surface area.

4.  The most minor burns are superficial burns.
 is difficult to estimate.
 Generally, less than 5% of all burn injuries requiring
treatment will necessitate admission to hospital.
 thermal burn injuries 2 million people are burned.
 Up to 80,000 are hospitalised,
 6500 die of burn wounds every year

5. Basic Principles of Wound Care
1. 1-Deroof blisters and debride loose skin
• 2-Clean wounds with warm saline or water
• 3-Take swabs for bacteriology
• 4-Apply non-adherent dressing
• 5-Apply gauze and crepe bandage
• 6-Regular dressing changes and re-assessment

6. :
Ideal Wound Dressings
• 1- mechanical and bacterial protection
• 2- moist environment at the wound/dressing
interface
• 3- gaseous and fluid exchange
• 4- non adherent to the wound
• 5- Nontoxic, nonsensitizing, and nonallergic
• 6-Well acceptable to the patient (e.g., providing
PAIN RELIEF and not influencing movement)
• 7-Cost effective

7. • 8-Highly absorbable (for exuding wounds)
• 9-Sterile
• 10-Easy to use (can be applied by medical personnel or
the patient)
• 11-Require infrequent changing
• 12-Available in a suitable range of forms and sizes

8. However…….
 There is a lack of evidence
regarding best dressings as
treatments for partial-thickness
burn injuries.

9. Change how often?
Frequent (daily)
Infrequent(2-3 d)
Good for infected or sloughy
wounds
increased risk of infection-
More pain for patient
less pain
More cost
saves time and cost
Impairs
epitheilialisation
enhanced epithelialisation
may speed healing

10. Change how often?
Accepted compromise for burns is every
2 days as a general rule

11. :
Types of Burn Dressings
• 1-Gauzes
• 2-Tulles
• 3-Silver Dressings
• 4-Antiseptics
• 5-Debriding agents
• 6-Hydrocolloids
• 7-Hydrogels
• 8-Silicone dressings
• 9-Fibre dressings
• 10-Biological and
Specialist dressings
for partial thickness
burns

12. Tulles:
• Tulle: A light, thin type of cloth that is like a net
• gauze cloth impregnated with paraffin for non-
traumatic removal
• -Does not stick to wound surface
• -Suitable for flat, shallow wound

14. Silicone Mesh Dressings
• Non adherent similar to Paraffin gauze but more
expensive
• May be antiseptic/antibiotic impregnated
• Examples
– Mepitel - Mepilex - Mepilex Border
– Atrauman

15. guazes
• -Most readily available simple wound dressings
• -Non-adherent coating
• -Absorbs exudate
• -Can be used as a primary or secondary dressing
• -Inexpensive
• -Highly permeable
• -Relatively non-occlusive
• FORMS: squares, sheets, rolls, and packing strips

16. Gauzes are
valuable as a carrier for antiseptics
to alter colonisation of the wound

17. HYDROCOLLOIDS
▪ slowly absorb fluids,
▪ change in the physical state of the dressing & the formation of gel covering
the wound. Thus, they are called interactive dressings
▪ Provide moist wound environment
▪ Promote granulation tissue
▪ Provide PAIN RELIEF by covering nerve endings
with both gel and exudate.
▪ Constituents are methylcellulose, pectin, gelatin,
and polyisobutylene.

18. HYDROCOLLOIDS
▪ USES:
▪ Both acute wounds and chronic wounds
▪ Mainly useful for promoting an environment for
epitheliasation
▪ Initially,changed daily
▪ once the exudate has diminished, dressings
may be left for up to 7 days
▪ Do not use on infected wounds!!

19. Brands: DuoDERM®; GRANULFLEX
• There is some
• reasonable literature advocating use of Duoderm to
enhance epthelialisation of facial burns
• The level of evidence is low

20. Hydrogel
▪ WATER i.e., > 70-90%
-some important characteristics of an IDEAL DRESSING
▪ Cool the surface of the wound, MARKED PAIN REDUCTION
▪ Maintain the moist wound environment
▪ on dry or necrotic wounds or on lightly exuding wounds
▪ Can be used at all stages of wound healing except for
infected or heavily exuding wounds

21.  MACERATE the healthy skin (mostly wound border
areas),
 decreasing the keratinocyte reepithelialization ratio or
leading to over wetting of split-skin donor sites.
 Brands: Tegagel®, Intrasite®

22. ALGINATE
:
FIBROUS POLYMERS
 from different types of algae and seaweeds.
 a LARGE AMOUNT OF EXUDATE wounds.
------Exudate upto 20 times their own weight
Available as Sheaths and Ropes-- BRANDS:
Kaltostat®
Algisite®
widely used for donor sites

23. Unusual but effective dressings
• Banana Leaf
• Potato peel
• Tilapia Skin
 Large amount of good low evidence level literature

24. :
Debriding Agents
• -Larval therapy
• -Nexobrid
• -Collagenase
• -Papaya and pineapple in low resource
settings
• -Autolytic
– Honey
–

25. :
Debriding Agents
• Honey:
– - now widely used in high income settings.
– -Excellent for debriding -- small infected or sloughy
wounds
– -Debrides necrosis but also allows epithelialisation

26. For Overgranulation:
• -Hydrocortisone
• -Terracortril
• -Fucidin H
-Small overgranulations concentrated
Silver Nitrate stick

27. Antiseptic :
• -Silver Sulphadiazine
– -Very broad spectrum
– -Relatively soothing to patient
– -Easy to use
– -Makes diagnosis of depth of burn more
difficult

28. Silver Impregnated dressings:
• Acticoat -Aquacell - Silvercel
– -Long duration of action
– -Good safety record in clinical practice
-RelativelyExpensive

29. Antiseptics used with gauze can
reduce colonisation of wound
Acetic Acid
0.5%
Chlorhexidine
0.5%
Dakin’s
Solution
less than
0.5%.
Iodine 4%
Silver Nitrate
0.5%
For
pseudomonas
gram positive
and negative
bacteria
if nothing else
is available
gram positive
bacteria
Excellent
antiseptic
Requires
frequent
application as
short duration
of action
duration of
action is short
Short
duration of
action
Not very active
against
pseudomonas
grey staining
of skin and
bedclothes
– Causes
allergic
reaction
thyroid
problem
s
methaemoglobi
naemia

30. Deep Burns
 The current golden standard is surgical
debridement and closure with autologous split
thickness skin grafts .
 Disadvntages:
 donor areas are limited in extended burns .
 the residual scars -unsatisfactory due to the
lack of dermis.

31. Skin subtitutes
 biological dressings,
 permanent
 temporary skin substitutes
used without a clear distinction.
 technicallysimilar products are commercialized as
“permanent” by one company and as biological
dressing by another

34.  Epidermal Skin Substitutes:
-culturing keratinocytes in 1975.
- expensive
-gels, sheets, or sprays—such as Epicel.
-3–5 weeks to produce 1.8m2 confluent sheets of cells
from a 2 cm2 biopsy
-fragile sheets
-cultivation time,Blistering, infection, and
contractures

35.  Replacement of the Dermal Layer
Acellular cellular
acellular:collagen-elastin-
hyaluronic acid
cellular means:
fibroblasts, vascular
endothelium, and
Smoothmuscle.
Human
collage
n Hyaluroni
c acid
Mammilian
collagen
bovine
porcine
intgra
biobrane
alloderm
dermal matrix
(Hyalomatrix)

36. 
cellular
Nonviable fibroblast
(Trancyte )
Viable fibroblast
Dermagraft-
TC/Transcyte

37. Integra:
• -most widely
• -bilaminar structure
• -1997
• -The median ‘take’ was 85%.
• -two-stage procedure, with a minimum interval of 2
weeks between the application of the Integra and the
split-skin grafting
• -after 5 week disappears.
• -relatively expens

39. Biobrane:
• -a bilaminate membrane
• -As the wound heals, Biobrane separates.
• -donor sites and superficial partial-thickness
• -burns within the first 6 h of injury
• clean wounds
• -expected to heal within 10–14 days
• - the length of inpatient treatment can be reduced by 46%
 as a “second skin” reducing pain and fluid loss and possibly
enhancing healing

40.  Combined Skin Substitutes:
 “take” ranging from zero to maximum 70%.
 commercialized as Apligraf (Graftskin).
 35$ for each 1 cm2.

42. Best choice in our department
Allograft is mainstay of surgery to
achieve major burn survival.

43. Allograft
• -Mainstay of treatment of huge wounds
• -Cryopreserved
-Glycerol preserved
• -fresh (up to 10 days)
• Advantages:
• -dermoprotection
• -promotion of reepithelialisation until autograft is possible
• Disadvantages:
• -Possible transmission of diseases.
• -Donor related

44. Repair with meshed
Autograft/Allograft Sandwich
(Alexander Technique)
 Repair with meshed Autograft/Allograft
Sandwich (Alexander Technique)

48. Dressing:
 Admission day: iodin 4% or Silver
Sulphadiazine
 Third day: acetic Acid 0.5% - Silver
Sulphadiazine

49. Conclusion:
 200 years after its discovery, the STG
technique remains the preferred
method.
 skin substitutes and biological
dressings are very expensive -topic of
controversy
 Allograft is mainstay of surgery to
achieve major burn survival.

50. The Last Judgement by
Michelangelo

52. Thanks ….