Clinical Experience Using Cadaveric Skin for Wound Closure in Taiwan

  Abstract: Taiwan’s skin banking program was initially set up to provide a ready source of cadaveric skin for patients with severe burns. However, human cadaveric skin may offer a useful alternative to conventional dressings in other wounds as well. Methods. In this retrospective review, cadaveric skin transplantation was used as temporary coverage in 145 patients with chronic ulcers, diabetic foot ulcers (DFU), necrotizing fasciitis, and acute traumatic wounds. Sex, age, number of debridements, and number of cadaveric skin transplantations were analyzed using statistical methods. Results. After clinical determination of engraftment 1 week after cadaveric skin allograft, skin samples harvested for histology in 15 cases revealed migration of epithelia from patient’s skin to the surface of cadaver skin and the presence of granulation tissue in the base of the cadaver skin. All wounds exhibited good wound-bed preparation after cadaveric skin transplantation, and could eventually be resurfaced with a skin autograft. Conclusion. Human cadaveric skin, in addition to being the mainstay in burn therapy, is a good biological dressing for chronic ulcers, DFUs, necrotizing fasciitis, and acute traumatic wounds.

Introduction

  Skin banking in Taiwan started in 2006 with the primary purpose of providing a ready source of skin allografts for severely burned patients to enable expedient wound coverage after early excisions of burn wounds. Many major burn centers use cadaveric skin as temporary biological dressings in cases of massive thermal injury. The relatively low cost and availability permit early, complete excision of the burn wound, which reduces mortality, length of hospital stay, and even blood loss.^1–5 In addition, cadaveric skin mitigates pain and aids wound-bed preparation before the placement of autografts.6 Research demonstrates that many other applications in wound healing support the use of cadaveric skin as a true biological dressing.⁶   From the establishment of the skin bank at the Tri-Service General Hospital, Taiwan, in 2006 until 2011, human cadaveric skin was used as temporary coverage to treat 145 patients with chronic ulcers, diabetic foot ulcers (DFU), necrotizing fasciitis, and acute traumatic wounds.   In this study, the authors describe their clinical experience using human cadaveric skin in the treatment of various wounds, and compare the number of debridements and cadaveric skin transplantations performed among them. The histological features of the interface between the patient’s skin and the cadaveric skin were also analyzed.

Methods

  One hundred forty-five patients with chronic ulcers, DFU, necrotizing fasciitis, and acute traumatic wounds treated at the Tri-Service General Hospital between 2006 and 2011 were included in this study. Wounds with exposure of bone were excluded.   All wounds underwent a series of debridements until no necrotic tissue or pus was found (Figure 1A-1B). Human cadaveric skin was obtained to cover the wounds. All cadaveric skin was harvested, processed, and frozen at the Tri-Service General Hospital skin bank in accordance with the guidelines of the American Association of Tissue Banks. All potential donors were screened for positive serology to hepatitis B surface antigen, hepatitis C, HIV, HTLV-1, and VDRL. Harvested skin samples were also sent for microbiological analysis and were released for use only if there was no evidence of infection with pathogenic organisms.   Cadaveric skin-covered wounds were evaluated via clinical examination 1 week postoperatively. A skin sample (1 cm × 2 cm), including cadaveric skin and patient’s skin, was harvested for histological analysis in 15 patients (Figure 2). The wounds with good adherence of the cadaveric skin (Figure 1C) were definitively closed with a skin autograft (Figure 1D). Patients with cadaveric skin breakdown underwent another debridement and were covered with cadaveric skin, followed by re-evaluation of adherence 1 week later. The number of cadaveric skin allografts performed (229) and the number of skin allografts (184) were recorded.   Retrospective statistical analyses were performed using the SPSS for Windows package, version 10.1. Patient profiles and number of cadaveric skin allografts were compared between the 5 groups using chi-squared and Kruskal–Wallis tests. The methodology chosen is reflected in Table 1, and the level of significance was set at P < 0.05 for all statistical analyses.

Results

  Table 1 shows the patient profiles and the clinical results. Among the 145 patients included in the study, 51 had chronic ulcers, 26 had DFU, 16 had necrotizing fasciitis, and 52 had acute traumatic wounds.   All wounds were resurfaced with a skin autograft after cadaveric skin allografting (Figure 1E). Patients with necrotizing fasciitis needed a significantly larger number (4.5 ± 0.6) of debridements (P < 0.05) than patients with chronic ulcers, DFU, and acute traumatic wounds. Patients with necrotizing fasciitis exhibited a significantly larger number (1.5 ± 0.1) of allografts than patients with chronic ulcers (1.0 ± 0.0), and acute traumatic wounds (1.2 ± 0.1; P < 0.05). In all chronic ulcers, only 1 skin allograft was required to achieve good wound-bed preparation for skin autografting. No breakdown of the skin grafts was found during the average 13-month followup. The average number of days for each wound type to be ready for allografting was 7 days for chronic ulcers; 9.8 days for DFU; 10.5 days for necrotizing fasciitis wounds; and 8.4 days for traumatic wounds.   Skin samples (1 cm × 2 cm) harvested from 15 patients (5 with chronic ulcers, 3 with DFU, 2 with necrotizing fasciitis, and 5 with acute traumatic wounds) showed migration of epithelia from the patient’s skin to the surface of the cadaveric skin (Figure 3A) and the presence of granulation tissue at the base of the cadaveric skin, which is a hallmark of tissue repair (Figure 3B).

Discussion

  Even though new materials (ie, Hyalomatrix®, Terudermis®, Integra®) were used over time at the Tri-Service General Hospital for wound bed preperation,⁷ cadaveric skin has long been the standard biomaterial for temporary skin replacement in patients with extensive burns.⁸ To date, there is no better alternative to the biological properties of cadaveric skin.⁹ Many studies have reported that cadaveric skin has dermal elements that modulate the nature of the wound bed to create a milieu that is ideal for keratinocyte growth and skin reconstitution.^10–14 Although cadaveric skin traditionally offers temporary coverage for large wounds in burn patients, recent investigations suggest a host of additional applications.⁶ Snyder¹⁵ treated nonhealing ulcers with cadaveric skin, which appeared advantageous in preventing wound desiccation, controlling infection, and substantially reducing pain. Carucci et al¹⁶ suggested that cadaveric skin may be useful in stimulating granulation tissue after Mohs microscopic surgery for the treatment of skin cancers involving the nose. In the current study, human cadaveric skin was used as temporary biological coverage after adequate debridement in stable wounds of chronic ulceration, DFU, necrotizing fasciitis, and acute traumatic wounds.   Foot ulcers continue to be one of the most serious complications of diabetes. A prospective comparison of DFU treated with either a cryopreserved skin allograft or a bioengineered skin substitute showed skin allografts resulted in a higher percentage of wounds closing.¹⁷ The authors used skin allografts for temporary coverage in DFU and achieved good wound bed preparation for skin autograft wound coverage.   Snyder et al¹⁸ suggested that the severity of tissue damage, as indicated by undermining damage to fascia, may correlate with delayed wound healing. Necrotizing fasciitis is a rapidly progressive, devastating infectious disease of the soft tissue, clinically characterized by fulminant destruction of tissue, systemic signs of toxicity, and increased rate of mortality. Rapid progression and propensity for soft tissue destruction warrants early intervention to decrease mortality and morbidity.¹⁹ In the author’s experience, patients with necrotizing fasciitis need the largest number of debridements and more cadaveric skin allografts than patients with chronic ulcers and traumatic wounds. Histological studies postulate that cadaveric skin does not actually “take” in the traditional sense. It is hypothesized that granulation tissue actually replaces the cadaveric skin, which provides an appropriate matrix for epithelial relining. Studies performed by Oliver et al²⁰ are in agreement with this hypothesis; their results indicate that, although cultured allografts do not survive, they may modulate the proliferation and differentiation of spontaneously regenerating epithelium. In this study, the authors found migration of epithelia from the patient’s skin to the surface of the cadaveric skin, and the presence of granulation tissue at the base of the cadaveric skin, in 15 patients with good histological adhesion of the cadaveric skin. All 145 wounds were eventually closed using a skin autograft because of the presence of adequate granulation in the wound bed. Dermal or bi-layered skin substitutes, hydrocolloids, and composite dressings are typically used by clinicians as temporary skin coverage;¹⁵ however, the author’s perspective of performance and clinical outcomes showed cadaveric skin can achieve the same purpose.

Conclusion

  In conclusion, the authors described their experience using cadaveric skin allografts as temporary biological coverage in cases of chronic ulcers, DFU, necrotizing fasciitis, and acute traumatic wounds. The cadaveric skin yielded good wound-bed preparation and led to the closing of all wounds with a skin autograft. Patients with necrotizing fasciitis needed the largest number of debridements and more cadaveric skin allografts.

Acknowledgement

  This study was supported by the Tri-Service General Hospital, National Defense Medical Center, Taiwan, Republic of China, under grant TSGH-C100-126.

References

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