Outcomes of dermal substitutes in burns and burn scar reconstruction: A systematic review and meta-analysis

Abstract

Dermal substitutes have been introduced in burn care to improve wound healing outcomes; however, their use remains limited in standard treatments. This systematic review and meta-analysis aimed to evaluate the outcomes of dermal substitutes in patients with burns and patients requiring burn scar reconstruction and subsequently contribute to optimising the integration of dermal substitutes into clinical practice and reducing the knowledge gap. A comprehensive search across various databases included human studies from peer-reviewed journals on dermal substitutes for deep dermal and full-thickness burns, and scar reconstruction across all ages. Data from comparative trials were extracted, focusing on patient and wound characteristics, treatment specifics, and outcomes related to wound healing and scar quality. Meta-analysis was performed on trials reporting similar post-burn measures, with statistical heterogeneity assessed. Outcomes were presented using mean differences or odds ratios with 95% confidence intervals. A total of 31 comparative trials were included. The overall quality of the studies was considered moderate. The meta-analysis indicated delayed re-epithelialization 4-7 days after treatment with a collagen-elastin matrix compared to split-thickness skin graft in acute burns (-7.30%, p = 0.02). Significant improvement in subjective scar quality was observed with acellular dermal matrix compared to split-thickness skin graft in acute burn wounds 6 months post-operative (-1.95, p <0.01). While acknowledging the initially delayed wound healing, incorporating dermal substitutes into the surgical treatment of burn patients holds promise for enhancing scar quality. However, future research must prioritise outcome measure uniformity, address variations in dermal substitute application, and standardise indications for consistent and effective practices.

Keywords: burn reconstruction; burns; dermal substitutes; meta‐analysis; surgery; systematic review; tissue engineering.

FIGURE 1

PRISMA flow chart. Identification of studies via databases and registers.

FIGURE 2

(A) Assessment of risk of bias using the Cochrane Collaboration's risk of bias tool 2—acute burn wounds Low risk; Some risk; High risk. (B) Assessment of risk of bias using the Cochrane Collaboration's risk of bias tool 2—reconstruction of burn scars. Low risk; Some risk; High risk.

FIGURE 3

(A) Comparison 1. Matriderm® versus split‐thickness skin graft: Mean difference in % graft take (5–7 days post‐surgery) in acute burns. (Ryssel et al.: We did not receive information on standard deviation, therefore this study was not included in the definitive meta‐analysis. In this study among 10 patients, the graft take in the dermal substitute group and the control group was 83.4% and 82.5%, respectively (p = 0.25). We did not expect that this would have changed the overall results. ²¹ ) (B) Comparison 1. Matriderm® versus split‐thickness skin graft: Mean difference in % re‐epithelialization (4–7 days post‐surgery) in acute burns. (C) Comparison 1. Matriderm® versus split‐thickness skin graft: Odds ratio of regrafting procedures during admission in acute burns. (Definition regrafting: The number of grafted wounds that required regrafting during the period of admission. Ryssel et al.: There were no complications in both groups. This was statistically not possible, but we do not expect with a odds ratio of 1.00 this would have a difference on the overall results in this meta‐analysis. ²¹ ) (D) Comparison 1. Matriderm® versus split‐thickness skin graft: Mean difference in scar elasticity (Uf‐ratio) measured by Cutometer (12 months post‐surgery) in acute burns. (E) Comparison 1. Matriderm® versus split‐thickness skin graft: Mean difference in scar assessment score by Vancouver scar scale (12 months post‐surgery) in acute burns. (F) Comparison 3. Acellular dermis matrix versus split‐thickness skin graft: Mean difference in healing time (days) in acute burns. (G) Comparison 3. Acellular dermis matrix versus split‐thickness skin graft: Mean difference in scar assessment score by Vancouver Scar Scale (6 months post‐surgery) in acute burns. (H) Comparison 4. Glyaderm® versus split‐thickness skin graft: Mean difference in % graft take (7 days post‐surgery) in acute burns. (I) Comparison 4. Glyaderm® versus split‐thickness skin graft: Mean difference in scar assessment score by Adapted Vancouver Scar Scale (12 months post‐surgery) in acute burns.

FIGURE 4

(A) Comparison 1. Matriderm® versus split‐thickness skin graft: Mean difference in scar elasticity (Uf) measured by Cutometer (12 months post‐surgery) in reconstructed scars after burns. (B) Comparison 1. Matriderm® versus split‐thickness skin graft: Mean difference in scar assessment score by Vancouver Scar Scale (12 months post‐surgery) in reconstructed scars after burns. (C) Comparison 1. Matriderm® versus split‐thickness skin graft: Mean difference in % contraction measured by Planimetry (12 months post‐surgery) in reconstructed scars after burns. (D) Comparison 2. Matriderm® versus Integra®: Mean difference in scar assessment score by Vancouver Scar Scale (12 months post‐surgery) in reconstructed scars after burns. (The experimental group is Matriderm®, and the control group is Integra®. Almeida et al. compare Matriderm® 1‐mm Flex in a one‐stage procedure with Integra® Double Layer in a two stage procedure, while Vana et al. compare Matriderm® 2‐mm in a two‐stage procedure with Integra® Double Layer in a two‐stage procedure). (E) Comparison 2. Matriderm® versus Integra®: Mean difference in % scar contraction measured by Planimetry (12 months post‐surgery) in reconstructed scars after burns. (The experimental group is Matriderm®, and the control group is Integra®. Correa et al. compare Matriderm® 1‐mm Flex in a one‐stage procedure with Integra® Double Layer in a two stage procedure, while Vana et al. compare Matriderm® 2‐mm in a two‐stage procedure with Integra® Double Layer in a two‐stage procedure).