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and subsequent research have shown some excellent clinical outcomes after using Integra for burn-wound coverage compared with standard split-thickness autografting.
We present the successful use of Integra to resurface a latissimus dorsi muscle flap 2 years after acute coverage of a compound fracture of the tibia and fibula. We believe that this is the first time that the two techniques have been used in combination.
1. Case report
A 14-year-old Caucasian female sustained an isolated injury to the right ankle after jumping from a moving bus, which then ran over her leg. She was admitted to the Accident and Emergency Department of Glasgow Royal Infirmary.
Examination revealed a IIIB compound fracture of the medial malleolus and a Weber's A fracture of the distal fibula. The anteromedial aspect of the right lower leg had been degloved from the mid-tibial area to the distal end of the first metatarsal. The foot was viable and sensation was intact.
After wound debridement and examination under anaesthesia, the fractures were found not to require fixation. Soft-tissue coverage was obtained using a free left latissimus dorsi muscle flap, which was vascularised by end-to-end anastomosis to the posterior tibial vessels. A split-thickness skin graft harvested from the left thigh was meshed (2:1) and used to cover the muscle flap.
There were no postoperative complications and the patient was discharged 13 days after surgery.
Despite intermittent use of a pressure garment on the right ankle, hypertrophic scarring developed and was found to be significant at the wound edges at 1 year review. Eight months later the graft became unstable and there were several episodes of ulceration with delayed healing. Radiographs confirmed that there were no foreign bodies present.
Two years after the initial surgery the patient was readmitted with a view to improving the appearance of the scar. The skin graft was excised from over the muscle flap (Fig. 1) , the muscle was debulked and a sheet of Integra (10 cm×25 cm) was applied and fixed with sutures. Irrigation catheters were placed over the Integra, and the lower leg was immobilised in a back slab. Antibiotics and daily injections of Betadine were given via the catheter until discharge 8 days postoperatively.
Figure 1Medial view of the right leg, showing previously grafted surface at the time of excision.
The silastic layer of the Integra was peeled off 23 days later. It had taken 100% and was well vascularised. A thin split-thickness skin graft, unmeshed, from the left lateral thigh was applied and secured with glue (Fig. 2) .
Figure 2(A) Anterior and (B) medial views of the right leg at the time of second-stage resurfacing with Integra; ultra-thin skin grafts have replaced the outer layer of the Integra.
Six months after the last procedure, the patient is delighted with the result. The contour of the lower leg has been significantly improved and the skin quality is already far superior to the previously grafted surface, being softer and more pliable. A degree of colour discrepancy remains, but this is expected to improve with further maturation of the graft (Fig. 3) .
Figure 3(A) Anterior and (B) medial views 6 months postoperatively.
The properties of Integra impart to it various advantages over other methods of wound coverage with respect to final functional outcome and cosmesis. The usual material of choice for covering a muscle flap is a meshed split-thickness autograft; however, the aesthetic outcome is often poor. This is the first published report to demonstrate that the appearance and functional characteristics of a free muscle flap can be improved by resurfacing with Integra.
Integra consists of a 2 mm inner layer of bovine collagen fibres and shark-derived chondroitin-6-sulphate, with a 0.1 mm outer layer of polysiloxane polymer. When grafted onto a freshly excised viable wound bed, the artificial matrix acts as a template for a new dermis to be generated by fibrovascular ingrowth. Within 5 weeks, the inner layer is biodegraded and replaced with host-derived dermis, which ultrastructurally resembles normal dermis rather than scar tissue. The silastic sheet acts as a temporary epidermal equivalent, preventing fluid loss and providing a barrier against infection, until the regenerating dermis can support autologous epidermal cells. It is replaced by an epidermal autograft after 2–3 weeks.
The dermis gives strength and elasticity to the skin and prevents wound contraction. By permanently replacing lost human dermis, Integra has the capacity to limit scarring, hypertrophy and wound contracture and to promote long-term graft stability. In contrast, covering full-thickness wounds with split-thickness autografts provides only a small amount of dermis, compromising functional and cosmetic results.
As the Integra provides the dermal component, an ultra-thin skin graft can be used in the second stage of resurfacing. This causes significantly less donor-site morbidity than conventional split-thickness skin grafting.
Split-thickness autografts are often meshed to allow a smaller donor site to be used and for wound exudates to escape, but, as the dermal component is also meshed, the pattern remains, which is less than ideal from a cosmetic point of view. However, even if meshed, the thin epidermal skin graft used in the second stage of Integra resurfacing results in a final appearance that is smooth and flat with little evidence of the meshed pattern.
A potential problem with Integra is that it has no intrinsic immunological defences; therefore, it is imperative that it is kept free from infection to prevent its loss.
Frequent inspection is required, with prompt identification and evacuation of any exudate that collects under the silastic sheet. However, when handled correctly, it is a reliable means of wound coverage, with take rates of between 90%
In our case, 100% take was achieved in both stages.
The use of Integra also has some disadvantages. Obviously, two operative procedures are required. In a patient with an isolated wound, as in this case, a one-stage procedure to cover the wound would be more desirable. With advances in tissue engineering, this may be possible with Integra in the future.
Ultimately, Integra is expensive, currently costing approximately £1000 for a sheet measuring 25 cm×12 cm. This must be weighed against the relative benefits it brings to each patient.
In conclusion, we have found that Integra provides a highly effective means of resurfacing a free muscle flap. It produces a superior aesthetic result to standard autografting, probably leads to improved function and has negligible donor-site morbidity. Potentially, it could also be used acutely in the treatment of large defects requiring muscle-flap coverage.
Acknowledgements
We thank the staff of the Medical Illustration Department, Glasgow Royal Infirmary, for their help in preparing the photographs.
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