Overview
Definition:
The Integra Dermal Regeneration Template (DRT) is a bilayered, artificial skin substitute composed of a porous collagen-glycosaminoglycan (CG) matrix and a silicone outer layer
It acts as a scaffold to facilitate cellular infiltration and neovascularization, ultimately leading to the formation of a neodermis.
Epidemiology:
While not a disease entity, Integra DRT is used in managing large full-thickness skin defects, particularly those resulting from burns, trauma, and reconstructive surgeries
Its application is critical in scenarios where autologous skin grafting is limited due to donor site availability.
Clinical Significance:
Integra DRT significantly improves outcomes in managing complex wounds by providing a biological scaffold that promotes dermal regeneration, reduces the need for extensive skin grafting, and ultimately leads to a more functional and aesthetically pleasing healed wound
It is a key technology in modern reconstructive surgery.
Indications
Major Burns:
Management of large full-thickness and deep partial-thickness burns where immediate split-thickness skin grafting is not feasible due to insufficient donor sites.
Traumatic Wounds:
Treatment of extensive full-thickness skin loss from trauma, degloving injuries, or crush injuries.
Reconstructive Surgery:
Used in plastic and reconstructive surgery for defect coverage after tumor excision, scar revision, or congenital anomaly correction where soft tissue coverage is compromised.
Chronic Wounds:
Potential use in select chronic non-healing wounds with significant tissue loss, although less common than in acute settings.
Preoperative Preparation
Wound Assessment:
Thorough assessment of wound bed viability, depth, and absence of infection is crucial
Granulation tissue should be healthy and well-vascularized.
Debridement:
Aggressive surgical debridement of all non-viable tissue (eschar, necrotic debris) is essential to create a clean wound bed for the template to adhere and vascularize.
Infection Control:
Management of any active infection with appropriate antibiotics and wound cultures is mandatory before application.
Donor Site Selection:
If combined with a split-thickness skin graft (STSG), careful planning of donor site availability and orientation is required.
Procedure Steps
Template Preparation:
The Integra DRT is typically hydrated in sterile saline according to manufacturer instructions
The silicone layer is then removed, exposing the porous CG matrix.
Placement:
The CG matrix is carefully placed onto the prepared wound bed, ensuring complete contact with the granulation tissue
It can be trimmed to fit the defect precisely.
Anchoring:
The template is secured using sutures or staples around the periphery to prevent displacement and ensure close apposition to the wound bed
Initial hemostasis is important.
Secondary Dressing:
A non-adherent dressing is placed over the CG matrix, followed by a moist absorbent dressing to maintain a suitable environment for cellular infiltration and to protect the matrix
The silicone sheet may be re-applied loosely over the top in some protocols, or a separate silicone sheet may be used as a temporary covering for the neodermis later.
Skin Grafting Timing:
Once the CG matrix is adequately vascularized (typically 10-21 days), the silicone layer is removed, and a thin STSG is applied to the newly formed neodermis
The timing is critical and depends on the visual cues of neovascularization and epithelialization.
Postoperative Care
Dressing Changes:
Dressings are managed according to wound bed status and surgeon preference, with focus on maintaining moisture and observing for signs of infection or graft take.
Immobilization:
Immobilization of the grafted area is important to prevent shearing forces that can disrupt the graft-Matrix interface or the graft itself.
Monitoring For Infection:
Close monitoring for signs of infection (redness, swelling, purulent discharge, fever) is essential throughout the healing process.
Pain Management:
Adequate pain control is provided, especially during dressing changes and for the donor sites.
Nutritional Support:
Appropriate nutritional support, including adequate protein intake, is crucial for optimal wound healing and regeneration.
Complications
Infection:
Wound or graft infection can compromise template adherence and dermal regeneration, leading to failure.
Poor Vascularization:
Inadequate vascularization of the CG matrix by the wound bed can prevent successful neodermis formation.
Hematoma Seroma:
Accumulation of blood or fluid beneath the template can impede adherence and lead to complications.
Graft Failure:
Failure of the overlying skin graft can occur due to poor recipient bed vascularization, infection, or mechanical shear.
Scarring:
Hypertrophic scarring or keloid formation can occur, particularly in predisposed individuals or with suboptimal wound healing.
Key Points
Exam Focus:
Understand the bilayered structure of Integra DRT and its role in dermal regeneration
Key aspects include indications, wound bed preparation, timing of STSG, and potential complications.
Clinical Pearls:
Aggressive debridement is paramount for success
Monitor for signs of neovascularization closely to time the STSG optimally
Avoid shearing forces post-operatively.
Common Mistakes:
Failure to adequately debride the wound bed
Applying Integra to an infected wound
Incorrect timing of the secondary skin graft
Inadequate post-operative immobilization.