Wound Healing/Plastic Surgery
The use of skin substitutes and burn care—a survey

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Abstract

Objective

The aim of our Internet survey was to assess the preferences of burn specialists who use skin substitutes in patients with burns covering 20% or more of their total body surface area (TBSA).

Methods

An open, voluntary Internet-based cross-sectional survey was performed. Responses to 19 noncompulsory questions, and participant career and location information were collected.

Results

One hundred eleven specialists from 36 countries responded to our questionnaire. Sixty participants were located in Europe (54%), followed by 31 (28%) in North America, 15 (14%) in Asia, three (3%) in South America, one (1%) in Africa, and one (1%) in Australia. The importance of skin substitutes in medium-sized burns (covering 20%–60% TBSA) was rated as “essential” by 28% and “desirable” by 56% of the respondents. In severe burns >60% of TBSA, 81% of responders rated the use of skin substitutes as “essential” and 14% as “desirable”. Skin substitutes were used in daily clinical practice by 96% of all participants. Biological and synthetic dressings were used by 53%. A majority (86%) think that biological dressings do not pose a risk to patients. Allografts represent the most frequently used wound coverage (51%), followed by xenografts (28%). All participants of the survey indicated that as of yet, there is no ideal skin substitute available.

Conclusions

Split-thickness autografts still represent the most used wound cover for definitive treatment of severe burns. However, creation and implementation of an ideal skin substitute have yet to be achieved and therefore should be the focus of future work.

Introduction

The most important functions of skin substitutes are prevention of wound infection, retention of fluid, and replacement of normal skin to provide aesthetically and functionally pleasing results. The treatment of burn wounds requires the availability of wound dressings and skin substitutes that can be used under a wide range of conditions. Despite constant evolution in the development of skin substitutes, no single product stands out as the “gold standard” [1]. According to a recent survey by our group, practitioners around the world agree that currently no “ideal” burn dressing exists [2]. Depending on the severity of the burn wound, different materials are used. Allografts, xenografts, bovine and porcine collagen sheets, and dermal matrices are commonly used in burned patients; these products provide a nutritive bed that supports wound closure with meshed split-thickness skin grafts or meek grafts [3], [4]. In recent decades, advances in tissue engineering techniques have provided a number of synthetic skin substitutes, including in vitro grown skin tissue or dermal matrices that can recruit local cells to stimulate scarless healing. These techniques, however, are expensive, not widely used, and therefore only serve as an adjunct to the use of split-thickness or full-thickness skin transplants [5].

For the treatment of partial-thickness burns, dressing regimens, such as Suprathel (Polymedics Innovations GmbH, Denkendorf, Germany) [6], [7] and Biobrane (Smith & Nephew Healthcare Ltd., Hull, United Kingdom) [8] have emerged. The selection of dressings is dictated by the depth of the burn injury. Healing times were similar in patients treated with Biobrane and Suprathel, and overall scar quality did not differ significantly between the two [9]. When covering full-thickness burns, surgeons use dermal substitutes such as Matriderm (MedSkin Solutions Dr.Suwelack AG, Billerbeck, Germany) [10], [11], [12] or Integra (Integra lifesciences, Plainsboro, NJ) [13]. Animal studies have shown no significant differences in engraftment rates or vascularization between the two products [14]. The use of the aforementioned skin substitutes also provides treatment options for chronic skin injuries such as diabetic ulcers or pressure sores [15].

The availability of skin substitutes has increased in the recent years, and practitioners can choose from a variety of products with very different features that are suitable under particular conditions. The aim of the present study was to learn more about the treatment preferences of burn and wound care providers from around the world, to provide an overview of product features, and to delineate differences in the use of skin substitutes at different burn care clinics.

Section snippets

Methods

A total of 500 burn care specialists around the world received an email invitation to participate in a voluntary, online cross-sectional survey. A direct link to the online survey was included in the email [16]. The survey invitation was generated by a scientific nonprofit medical organization, the Austria Burn Treatment Research, and Prevention Study Group (www.abusg.com), together with experts from the burn community. Institutional review board study approval was obtained from

Results

Using the described methods above, we obtained 111 respondents from 36 countries in a 1 month period (Fig. 1). All 111 participants submitted a completed questionnaire, which is equivalent to a response completion rate of 22% (Table 1). Most of the participants were surgeons (87%) and most held senior appointments (42%). Three responders did not specify their profession and staff grade. Most responders were living in Europe (54%), followed by those in the USA (28%) and Asia (14%).

Generally

Discussion

The data presented in this global online poll among burn care specialists represent a follow-up to our previously published data [2]. In the previous publication, we were polling the “ideal wound dressing” in small-sized burn injuries (<20% TBSA), this time our focus was on skin substitutes for large burns (between 20% and 60% TBSA) similar to a recent publication by Kamolz et al. [21].

In summary, most participants consider skin substitutes for coverage of large burns as essential or at least

Conclusion

The main result of this survey is that split-thickness skin autograft remains the most used wound cover for severe burns, limited mainly by donor site availability in patients with a large percentage of TBSA burned. For temporary wound coverage, allografts are used by most responders, followed by xenografts. The latter represents an economic alternative to biological and synthetic skin substitutes, especially in developing countries. To date, most responders indicate that an ideal coverage for

Acknowledgment

We would like to thank Dr. Michael Giretzlehner (Research Institute for Symbolic Computation, Johannes Kepler University Linz, Austria) and Dr. David B. Lumenta for their assistance and their participation in the creation of the survey.

Authors’ contributions: All authors made substantial contributions to the conception or design of the work (P.W., H.K., L.K.B., D.P., and R.P.C.) or to the acquisition, analysis, or interpretation of data for the work (C.C.F., D.N.H., L.P.K.) and the drafting of

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    Funding: No outside or intramural funding was obtained for this study.

    1

    These authors contributed equally to this work.

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