Skin Grafts Or Skin Substitutes: What Is Your Preference?

Desmond Bell DPM CWS FACCWS

Over the past decade, we have witnessed the emergence of several technological advances that have had a direct impact on healing wounds that previously would have resulted in amputation or even death.

Three areas in which we have seen the greatest impact in wound healing in the past decade have been in the realms of negative pressure wound therapy, endovascular procedures and skin substitutes.

Others may argue that modalities such as hyperbaric oxygen therapy (HBOT) have had a similar impact but HBOT has been around much longer than 10 years. While it is an excellent adjunctive therapy when used appropriately, HBOT does not typically show the dramatic changes over a short period that the technological advances from the three aforementioned areas have shown.

Let us take a look at skin substitutes, specifically Apligraf (Organogenesis) and Dermagraft (Advanced BioHealing). These modalities contain cells that promote healing whereas acellular scaffold type dressings are primarily used for wound coverage. We know there is evidence to support their use in healing of wounds, whether diabetic foot (Apligraf and Dermagraft) or venous ulcers (Apligraf).1-4 We also know there is plenty of anecdotal information floating around that supports use for both products in certain off-label cases, such as burns and epidermolysis bullosa.

When do you make the decision to utilize a skin substitute? Why would you choose a skin substitute versus a skin graft? Are skin grafts more efficacious than skin substitutes?

The first thing to understand is that skin substitutes are not skin at all. Although they contain components that are present in living skin, they become absorbed at the wound site. One applies growth factors involved in new collagen synthesis and angiogenesis with the goal of producing new skin over time.

The mechanism of skin grafting is transferring the final product, skin, to the wound. The goal is that the graft remains viable. Incorporation at the site will also save precious time in the healing process.

In both instances, wound bed preparation is vital to success as is meticulous aftercare.

Pearls On Choosing A Treatment Modality

So which option is best: skin substitutes or skin grafting? It really depends on several factors:

• clinical judgment
• what is best for the patient
• setting
• available resources

In my practice, nearly every patient has diabetes and suffers from associated complications that often include neuropathy, peripheral arterial disease, hypertension or coronary artery disease. They are immunosuppressed and their ability to heal is already compromised and documented via the presence of their chronic, non-healing wounds.

As a result, I have taken the approach over time that creating a new wound by way of harvesting skin to be used for a graft may not be the best thing for a brittle patient. Skin substitutes have become a preferred option to skin grafting, all things considered.

Boyce and colleagues at the Shriners Burn Institute and the University of Cincinnati compared the efficacy of cultured skin substitutes to split thickness autografts.4 They assessed whether there was less need for autologous skin grafts in the treatment of massive burns. The study authors concluded that outcomes from cultured skin substitutes were not different from split thickness autografts. Additionally, Boyce and co-workers found that cultured skin substitutes could reduce requirements for donor skin autograft and improved outcomes for the closure of burn wounds.

Boyce and Warden found that cultured skin substitutes reduce the requirements for donor skin autograft for closure of excised, full-thickness cutaneous wounds.5 The skin substitutes also demonstrate a qualitative outcome not unlike that of meshed, split-thickness autografts. These results offer reductions in morbidity and mortality for the treatment of burns and chronic wounds, and for cutaneous reconstruction.

It should be noted that Boyce’s research both studies did not include either Apligraf or Dermagraft, but an in vitro process by which the authors utilized cultured skin substitutes containing fibroblasts and keratinocytes.

Has the acceptance and efficacy of skin substitutes resulted in a decrease in your utilization of skin grafts?

Do you have a preference when it comes to skin grafting versus skin substitutes? Why?
What is your rationale when determining to utilize one or the other?

Please share your thoughts and opinions on this topic. Your comments are greatly appreciated. Thank you for reading this blog.

References

1. Buchberger B, Follmann M, Freyer D, et al. The importance of growth factors for the treatment of chronic wounds in the case of diabetic foot ulcers. GMS Health Technol Assess. 2010; 6:Doc 12.
2. Falanga V, Margolis D, Alvarez O, et al. Rapid healing of venous ulcers and lack of clinical rejection with an allogeneic cultured human skin equivalent. Human Skin Equivalent Investigators Group. Arch Dermatol. 1998;134(3):293-300.
3. Marston W, Hanft J, et al. The Efficacy and Safety of Dermagraft in improving the healing of chronic diabetic foot ulcers: results of a prospective randomized trial. Diabetes Care. 2003; 26(6):1701-70.
4. Veves A, Falanga V, Armstrong DG, et al. Graftskin, a human skin equivalent, is effective in the management of noninfected neuropathic diabetic foot ulcers: a prospective randomized multicenter clinical trial. Diabetes Care. 2001; 24(2):290-295
5. Boyce ST, Goretsky MJ, Greenhalgh DG, et al. Comparative assessment of cultured skin substitutes and native skin autograft for treatment of full-thickness burns. Ann Surg. 1995; 222(6):743-752.
6. Boyce ST, Warden GD. Principles and practices for treatment of cutaneous wounds with cultured skin substitutes. Am J Surg. 2002; 183(4):445-456.

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