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Where the loss of skin is large enough that direct closure or traditional grafting are not enough, skin substitutes take the place of skin. These are materials that are processed by the body to make a scaffold for the body's own regeneration and can be bioengineered materials from biological, synthetic, or combined sources. They are not permanent replacements for skin. They establish the conditions for regeneration to occur.
In Dr. Anup Dhir's practice, skin substitutes are applied in reconstructive plastic surgery and burn surgery to treat complex wounds where traditional skin grafting is not an option or is delayed, and where dermal regeneration is the clinical goal. Integra, Matriderm, Myriad and Endoform are the four most utilized products. They all have different mechanisms, indications and road in reconstructive pathway.
Burns, trauma, tumour removal, and chronic wounds result in a loss of the epidermis and dermis in full thickness wounds. A split-thickness skin graft can heal the wound, but only cover the epidermal layer of the wound. The dermal layer that gives the skin its elasticity and tensile strength, and determines the functional architecture of the skin, does not self-regenerate in large wounds. When the wound surface is raw, the grafts do not form the smooth, pliable skin that is native to the human body without dermal reconstruction, as it will result in stiff, fragile scar tissue with poor long-term results.
To overcome this, skin substitutes are used, providing a scaffold of collagen which the patient's own fibroblasts and vascular cells can migrate in. As the scaffold degrades, it is replaced by organised native tissue. The outcome is a wound bed that can receive a thinner skin graft resulting in better functional and aesthetic outcomes than grafting on raw tissue.
They are also used as a means of providing a temporary bridge for individuals who are not suitable for immediate grafting or for patients without sufficient donor skin or a skin wound that will heal sufficiently for a graft to take place.
Integra is a bilayer dermal regeneration template made up of a scaffold of bovine collagen and glycosaminoglycan (against the bottom) and a temporary silicone epidermis (on top). It has been studied for more than 30 years for clinical use in reconstructive and burn surgery, and is one of the most widely used skin substitutes today.
Integra is applied to a clean wound bed and over a 2-3 week period, host fibroblasts and blood vessels migrate into the collagen scaffold. During this period the silicone layer provides a temporary barrier, thereby preventing infection and loss of fluids from the wound. With the confirmation of vascularisation the silicone is removed and a thin split-thickness skin graft is placed over the newly formed neodermis under the silicone.
Integra is especially appropriate for deep burns on large areas of body, full thickness wounds over the joints where scar contracture will restrict function, and complex reconstructive circumstances where maintaining the integrity of tissue planes is important. This two-stage process necessitates a wound management phase between the two stages which may lead to loss of the template if infection occurs during vascularisation.
The dermal layer generated by Integra is thicker and more structured than that generated by grafting alone, resulting in greater long-term pliability, less contracture and improved cosmetics.
Matriderm is a single-layer dermal substitute, which consists of a mixture of bovine collagen types I, III and V with alpha-elastin hydrolysate. It contains elastin which is the distinguishing factor from Integra. Elastin is a structural protein that allows skin to rebound and bend, and has been found to be present in the scaffold, aiding to create a more elastic, less stiff neodermis.
Matriderm's main clinical advantage is that it allows simultaneous single-stage application with a split-thickness skin graft. The graft is directly grafted on the Matriderm matrix in the same operative sitting, something that decreases the total number of procedures, compared to the two-stage protocol of Integra. This is especially handy in patients where minimising anaesthetic exposure is a priority.
Provides good results with moderate depth burns, traumatic degloving injuries and reconstructive burns where donor skin is available at the same time. The elastin component has been shown to result in demonstrably improved pliability and cosmesis of scars than grafting without a dermal matrix, especially in paediatric patients and across joints.
Myriad is an acellular dermal matrix (ACDM) prepared from porcine dermis and free of cellular materials, but retaining the natural collagen and elastin structure of the extracellular matrix. It possesses the structural framework of real dermis so it possesses a very organised scaffold for tissue ingrowth.
Myriad is employed in burn reconstruction as well as other reconstructive plastic surgery procedures such as abdominal wall surgery, breast reconstruction after mastectomy, and closure of complex oncologic defects. Its mechanical properties are very similar to those of the native dermis, and it is therefore a good choice when there is a requirement for structural integrity of the reconstruction as much as for wound coverage.
The decellularisation process makes rejection rare because there is a significant reduction in the immunogenicity of the tissue. Generally, the integration into host tissue is consistent but there must be sufficient vascularity and preparation of the wound bed for consistent results.
Endoform is an ovine forestomach matrix isolated from sheep stomach tissue and naturally occurring extracellular matrix scaffold comprised of collagen, fibronectin, laminin and glycosaminoglycans. The same structural proteins are present in the dermal wound healing environment, which is what differentiates Endoform from the passive coverage it simply provides.
It is most frequently employed for chronic and complex wounds like diabetic foot ulcers, venous leg ulcers, pressure ulcers, and those that do not respond to regular wound treatment. As the wound heals, endoform breaks down to release bioactive matrix components which actively modulate the wound environment and promote organised tissue formation.
In contrast to Integra and Matriderm which are used as part of a staged surgical reconstruction, Endoform can be applied in the outpatient or clinic setting and changed at intervals during the dressing. This allows for use in wound management without the need for the use of an operative list and is appropriate for patients who are not general anaesthetic candidates.
No single product suits every wound. The decision depends on wound depth and size, the availability of donor skin, the number of procedures the patient can tolerate, the anatomical location, and whether the clinical goal is acute coverage, dermal regeneration, or chronic wound management.
Integra is the choice for large deep burns and complex reconstructions where dermal quality over time matters more than operative simplicity. Matriderm suits single-stage reconstruction where donor skin is available and elasticity of the final result is a priority. Myriad is appropriate for structural reconstructions requiring the mechanical properties of native dermis. Endoform addresses the chronic wound space where repeated non-surgical application is the practical route.
Dr. Anup Dhir assesses each patient individually to determine which product, or combination of approaches, will produce the best functional and cosmetic outcome for that specific wound. A consultation covers wound history, patient fitness, prior treatments, and long-term goals before any reconstructive plan is agreed.
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