Addressing the Challenge of Complex Wound Defects: The Scope of a Dermal Matrix
Editorial Summary
Complex, full thickness soft tissue injuries pose a great challenge to every clinician. In patients where primary closure is not possible, other options need to be considered. Traditionally, small defects were covered using a split thickness skin graft (STSG) and larger defects were resurfaced using full thickness skin grafting (FTSG). STSG and FTSG alone can compromise the final functional and aesthetic outcome. Dermal templates improve the quality of the reconstruction. This article is an overview of the application and efficacy of a dermal substitute: MatriDerm® (Medskin Solutions Dr. Suwelack AG, Germany).
Introduction
Skin is a barrier from the external environment; this is its primary function.
In clinical scenarios where there is a full thickness skin defect present, traditionally a full thickness skin graft (FTSG) or a flap was used for healing. However, these procedures sometimes come with complications, compromised outcomes, and the generation of donor site scars. Using a split thickness skin graft (STSG) alone however can contribute to scar contraction, contour defects, and functional deficits.1 Several dermal substitutes have been developed over the last decades, and more recently innovation in this area has led to the development of products that allow clinicians to consider long-term prognosis and aesthetic outcomes, as well as the priority of healing the wound.2,3
What Is a Dermal Substitute?
Dermal substitutes are biomatrices that carry out the functions of the cutaneous dermal layer of skin by providing scaffolding and thereby contributing to the control of pain and scarring. This dermal architecture also facilitates tissue growth and wound healing.4 These substitutes have an integral role in reconstructing full thickness defects in the acute and chronic setting, and also reduce scarring.
With concerns raised over the possibility of dermal substitutes potentially compromising skin grafts by acting as a barrier between the graft and the wound, many dermal substitutes have been developed with the intention of application as part of a two-step methodology;
the product is first applied to the wound in an initial procedure, and the skin graft is applied later in a second procedure.3 An ideal dermal substitute however gives the surgeon the possibility to apply the skin graft directly, without the need to wait for weeks, or in case a two-step procedure is needed already after a few days, due to the fast integration and vascularization of the dermal template.
What Is the ‘Ideal’ Dermal Substitute
The role of the dermal substitute is essentially to replace the injured layers of skin, which can extend from superficial epidermis down to the deep dermal layer, sometimes a full thickness skin loss, and sometimes with exposed tendon or bone. Full thickness injury is defined as involving all the layers of the skin and is deficient in keratinocytes, stem cells and fibroblasts;3 therefore the role of an ‘ideal’ dermal substitute is one that can replace the deficient layers, accelerate vascularization and cell growth and minimise post-operative complications, and should have the following properties:
• Bioabsorbable
Accelerate wound healing and wound closure
• Promote vascularization and cell growth
Prevent infection
• Lead to regeneration of new skin
• Limit scar formation
• Lead to functional as well as aesthetic outcome
There is evidence for the use of MatriDerm® in a broad range of indications, as well as treating
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exposed structures such as tendons and bones.
Dermal templates have evolved as a blueprint for dermal repair by enhancing elasticity and pliability of the reconstructed skin. The versatility that MatriDerm® provides to the clinician is the key to its continued success in a wide scope of clinical conditions; carrying with it the added advantage of a single stage procedure where traditionally two stage procedures were needed, teamed with a tactile flexibility in the product usage, MatriDerm® leads to a reduction of economic factors such as hospitalization days and complications.
Mode of Action
The multi-faceted challenges involved with healing these types of wounds and achieving the most satisfactory results in individual cases has led to a wide range of dermal substitutes that are now available, potentially at the clinician’s disposal depending on economic and geographic factors, encompassing synthetic, biosynthetic or biological materials providing temporary or permanent coverage of wounds.
MatriDerm® is a dermal substitute suitable for one-step as well as two-step repair of fullthickness skin defects in combination with STSG. It is associated with an accelerated wound healing that allows the skin graft to be added directly (one-step) or after a few more days (two-step), in contrast to traditional dermal substitutes where it takes weeks until the epidermal graft can be placed. The product was developed with the challenges of the two-step graft procedure in mind; naturally, a patient will appreciate as few procedures as possible, and fewer days waiting for the skin graft.
MatriDerm® is a dermal substitute of bovine origin and provides an elastic and stable neodermis generated by a three-dimensional matrix consisting of collagen type I, III, and V, additionally supplemented by elastin
hydrolysate which contributes to an improved elasticity and aesthetic outcome of the new skin.5 MatriDerm® promotes the regeneration of dermis as a scaffold and consequently decreases scar tissue formation. It also provides optimal dermal wound bed preparation as regenerated skin, with extensive formation of rete ridges and capillary loops. Min J et al. writes that the elasticity of the skin reconstructed with MatriDerm® was not found to be significantly different from that of surrounding normal skin. 6 This supports the conclusion that grafted skin in combination with MatriDerm® has an elasticity similar to normal skin.
Application
MatriDerm® is applied to the wound bed and then covered by the physician’s preferred secondary dressing or graft. If more than one sheet is used, the sheets should overlap by around 2 - 3 mm. It is advised to utilize the dry MatriDerm® application. Essentially, the clinician must ensure that MatriDerm® is evenly attached to the wound bed and that air bubbles are gently removed, before rehydrating it with saline or Ringer’s solution that is not warmer than room temperature. Negative Pressure Therapy (NPWT) can be used as a bolster for compression and splintage to minimize movement between the wound bed and MatriDerm®. This is accomplished by encouraging blood vessel sprouting (vascularization) and cell proliferation, which improves the adhesion of the collagen elastin matrix.
Indications
MatriDerm® is useful for applications such as, burns (reconstructive and acute), trauma and acute wounds, chronic wounds, cancer excision, adhesion barrier, donor sites, mucosal defects and exposed structures.
Clinical Applications
Trauma and Acute Wounds
Another practical application of MatriDerm® is in the reconstruction of post-traumatic wounds. Clinicians from Italy treated post traumatic wounds with MatriDerm® combined with skin grafting, compared with skin grafting alone. Findings showed 95% of wounds treated with MatriDerm® and skin graft showed reepithelialisation at two weeks. Furthermore, the assessments showed a reduction in wound contraction, improvement of elasticity, and quality of scar.7
Tissue loss in the finger presents a reconstructive challenge to surgeons and often requires techniques involving flaps and/ or grafting. The aesthetic outcomes are frequently less satisfactory and there are also relatively low rates of functional satisfaction. Healing times are also comparatively long.
To address this, Fulchignoni et al. conducted a study to evaluate the efficacy of MatriDerm® in finger reconstruction. The authors report that MatriDerm® is a valid solution, and that in most cases of fingertip injuries the wound was in an advanced state of healing three weeks after application of MatriDerm®, and that in these cases grafting could be avoided.3,29
Burns: Acute and Late Reconstruction
Dermal substitutes are an integral part of burn care management. Acellular dermal matrices like MatriDerm® are a cost-effective alternative in the treatment of full-thickness burns.
During the acute stage of burns treatment, the usage of a dermal substitute may improve functional and cosmetic results, thereby improving the quality of life in the long term. The collagen elastin dermal substitute allows for immediate application of a dermal substitute
under a split thickness skin graft.3,8
The added advantage that MatriDerm® confers is that it can be used as a single stage procedure under a skin graft, reducing scar contracture in both early and late reconstructions.
MatriDerm® can also be applied in the facial aesthetic subunits for delayed paediatric burns reconstruction. In burn reconstruction, the use of MatriDerm® beneath split skin grafts improves both cosmetic results and functional skin movement. The strong early evidence for this method in reconstructing paediatric patients with full-thickness facial burns shows excellent cosmetic results in terms of texture and colour, as well as normal or nearly normal ocular and oral function at the 12-month followup.3,9
Chronic Wounds
Deep wounds with exposed tendons are also amenable to reconstruction in a one step process with STSG and MatriDerm®. Wetzig manages to reconstruct complex wounds with tendon exposure in patients with significant co-morbidities; these types of defects with exposed tendons would normally necessitate flap reconstruction.3,28 Cervelli et al. applied MatriDerm® and STSG in a one step reconstruction of an infected diabetic foot ulcer after debridement. Utilized in conjunction with antibiotics, a significant reduction in ulcer size was achieved.7 Furthermore, MatriDerm® has documented usage in large complex post necrotising fasciitis patients with joint and tendon exposure.3,18
Flap Donor Sites
The suitability of MatriDerm® for use in donor site coverage is well evidenced. The donor site from a radial forearm free flap procedure involves full thickness forearm skin defects, which require a dermal substitute and skin
“Dermal substitutes are an integral part of burn care management. Acellular dermal matrices like MatriDerm® are a cost-effective alternative in the treatment of fullthickness burns.”
graft. Watfa et al. conducted a study on the use of MatriDerm® in transgender patients after a radial forearm free flap reconstruction of phallus, using the contralateral arm as control. The authors conclude that application of MatriDerm® with a split-thickness skin graft significantly decreases post-operative complications, preserving sensory function and decreasing morbidity of the donor site.3,30
Similarly, Cristofari reports on a study on the efficacy of MatriDerm® on radial forearm flap donor site coverage in terms of functionality, skin quality and patient satisfaction on aesthetic outcome, finding MatriDerm® a reliable solution associated with improved DASH and VSS scores and higher mean patient and surgeon satisfaction, compared to the other techniques used.3,31
References
1. Bloemen MC, van Leeuwen MC, van Vucht NE, van Zuijen PP, Middelkoop E. Dermal substitution in acute burns and reconstructive surgery. A 12-year follow-up. Plast Reconstr Surg 2010; 125(5): 1450-59
2. Halim AS, Khoo TL, Yussof SJM. Biologic and synthetic skin substitutes: An overview. Indian J Plast Surg 2010; 43(Suppl): S23–S28.
3. Enoch, S., & Kamolz, L. (2010). Indications for the use of MatriDerm® in the treatment of complex wounds.
4. Lee K. H. Tissue engineered human living skin substitutes: Development and clinical application. Yonsei Medical journal. 2000; 41(6): 774. 9
5. Lempert et Al. Long-term experience with a collagen-elastin scaffold in combination with split-thickness skin grafts for the treatment of full-thickness soft tissue defects: improvements in outcome—a retrospective cohort study and case report . Langenbecks Arch Surg. 2022; 407(1): 327–335. Published online 2021 Sep 4. doi: 10.1007/s00423-021-02224-7
6. Min J et Al. The Use of Matriderm and Autologous Skin Graft in the Treatment of Full Thickness Skin Defects Arch Plast Surg. 2014 Jul; 41(4): 330–336.
7. Cervelli V et al. The use of MatriDerm and skin grafting in post-traumatic wounds. Int Wound J 2011 Aug
8. Zajicek et al. Dermal Replacement with Matriderm- First experience at the Prague Burn Centre. Acta Chir Plast.2020 Winter
9. Jackson Sh., Roman S., Matriderm and Split Skin Grafting for Full-Thickness Pediatric Facial Burns, Journal of burn care and research, 2019
10. de Vries HJ, Middelkoop E, Mekkes JR, Dutrieux RP, Wilde- vuur CH, Westerhof H.
Dermal regeneration in native non- cross-linked collagen sponges with different extracellular matrix molecules. Wound Repair Regen. 1994;2:37–47.
11. de Vries HJ, Mekkes JR, Middelkoop E, Hinrichs WL, Wilde- vuur CR, Westerhof W.
Dermal substitutes for full-thickness wounds in a one-stage grafting model. Wound Repair Regen. 1993;1:244–252.
12. Haslik W, Kamolz LP, Nathschlager G, Andel H, Meissl G, Frey M. First experiences with the collagen-elastin matrix Matriderm as a dermal substitute in severe burn injuries of the hand. Burns 2007;33:364–368.
13. BranskiLK,HerndonDN,PereiraC,etal.Longitudinalassess- ment of Integra in primary burn management: A randomized pediatric clinical trial. Crit Care Med. 2007;35:2615–2623.
14. Wainwright DJ. Use of an acellular allograft dermal matrix (AlloDerm) in the management of full-thickness burns. Burns 1995;21:243–248.
15. Eaglstein WH,AlvarezOM,AulettaM,etal.Acuteexcisional wounds treated with a tissueengineered skin (Apligraf). Der- matol Surg. 1999;25:195–201.
16. Heimbach D, Luterman A, Burke J, et al. Artificial dermis for major burns: A multi-center randomized clinical trial. Ann Surg. 1988;208:313–320.
17. Haslik W, Kamolz LP, Manna F, Hladik M, Rath T, Frey M. Management of full-thickness
Conclusion
MatriDerm® is a highly versatile and reliable dermal substitute applicable to a wide range of clinical conditions, and is very well evidenced by numerous studies in terms of efficacy, healing time, and quality of functional and aesthetic outcome. The added benefit of the option of a single stage procedure, combined with tactile flexibility in the product usage, earns MatriDerm® a reputation as a world leading product in the field of wound care.
skin defects in the hand and wrist region: First long-term experiences with the dermal matrix Matriderm. J Plast Reconstr Aesthet Surg. 2010;63:360–364.
18. Ryssel H, Gazyakan E, Germann G, Ohlbauer M. The use of MatriDerm in early excision and simultaneous autologous skin grafting in burns: A pilot study. Burns 2008;34:93–97.
19. Hansbrough JF, Dore C, Hansbrough WB. Clinical trials of a living dermal tissue replacement placed beneath meshed, split-thickness skin grafts on excised burn wounds. J Burn Care Rehabil. 1992;13:519–529.
20. Sheridan RL, Hegarty M, Tompkins RG, Burke JF. Artificial skin in massive burns: Results to ten years. Eur J Plast Surg. 1994;17:91–93.
21. van Zuijlen PP, van Trier AJ, Vloemans JF, Groenevelt F, Kreis RW, Middelkoop E. Graft survival and effectiveness of dermal substitution in burns and reconstructive surgery in a onestage grafting model. Plast Reconstr Surg. 2000;106:615–623.
22. Santi G., Greca C., Bruno A., the use of dermal regeneration template (Matriderm 1mm) for reconstruction of a large full-thickness scalp and calvaria exposure, Journal of burn care and research, 2016.
23. Jackson Sh., Roman S., Matriderm and Split Skin Grafting for Full-Thickness Pediatric Facial Burns, Journal of burn care and research, 2019.
24. Dunne J., Wilks D., previously discounted flap now reconsidered: Matriderm and split thickness skin grafting for tendon cover following dorsalis pedis Fascio-cutaneous flap in lower limb trauma, Journal of plastic surgery, 2014.
25. Angelis B., Gentile P., Agovino A., Chronic ulcers: MATRIDERM(®) system in smoker, cardiopathic, and diabetic patients, journal of tissue engineering, 2013.
26. Kang S., Park J., Shon Hyun, Skin graft using MatriDerm® for plantar defects after excision of skin cancer, Dovepress, 2019
27. Wood BC Caputy G. Skin grafts. 2011; available at http://emedicine.medscape.com/. Accessedarticle/1295109-overview. Accessed 06/10/2022.
28. Wetzig T, Gebhardt c, Simon JC. New Indications for artificial Collagen-Elastin Matrices? Covering Exposed Tendons. Dermatology 2009; 219(3): 272–3
29. Fulchignoni C, Rocchi L, Cauteruccio M, Merendi G. Matriderm dermal substitute in the treatment of post traumatic hand’s fingertip tissue loss. J Cosmet Dermatol. 2022 Feb;21(2):750-757. doi: 10.1111/jocd.14115. Epub 2021 Apr 7. PMID: 33786967.
30. Watfa W, di Summa PG, Meuli J, Raffoul W, Bauquis O. MatriDerm Decreases Donor Site
Morbidity After Radial Forearm Free Flap Harvest in Transgender Surgery. J Sex Med. 2017 Oct;14(10):1277-1284. doi: 10.1016/j.jsxm.2017.08.003. Epub 2017 Aug 23. Erratum in: J Sex Med. 2020 Sep;17(9):1825. PMID: 28843466.
31. Cristofari S, Guenane Y, Atlan M, Hallier A, Revol M, Stivala A. Coverage of radial forearm flap donor site with full thickness skin graft and Matriderm®: An alternative reliable solution?
Ann Chir Plast Esthet. 2020 Jun;65(3):213-218. doi: 10.1016/j.anplas.2019.06.009. Epub 2019 Aug 21. PMID: 31445777.
“The added advantage that MatriDerm® confers is that it can be used as a single stage procedure under a skin graft reducing scar contracture in both early and late reconstructions.”
September - October 2022
