Surgeons share how they evaluate whether a wound bed is ready for either an acellular dermal matrix or a skin graft
A 32-year-old male presented with internal degloving to the lower extremity, which left his patellar tendon exposed even after staged debridement and management with vacuum.
His surgeon chose to use Integra® Meshed Bilayer Wound Matrix (IMBWM) for wound management together with continued VAC. The patient subsequently received skin grafting. Six months later, the patient’s knee had recovered full range of motion.
How does tissue remodeling following the application of IBWM actually occur?
Cleared by the FDA for use in wound management 20 years ago, IBWM is an advanced wound care device comprised of a porous matrix of cross-linked bovine tendon collagen and glycosaminoglycan and a semi-permeable polysiloxane (silicone) layer.
When IBWM is placed on a surgically debrided or excised wound, the advanced wound care device provides the needed framework for the blood vessels and dermal skin cells to remodel the damaged site.
As skin cells migrate into the matrix, the collagen is slowly resorbed into the body and replaced with new collagen that is naturally produced by the skin. In approximately 14 to 21 days, the scaffold is eventually remodeled as the patient’s cells rebuild the damaged site and the silicone layer is removed.
Complete wound closure occurs as epidermal cells migrate from the wound edges. For larger wounds, a thin skin graft of the person’s epidermis may be applied to the wound area to facilitate complete wound closure.
Here is what the clinical sequence of tissue remodeling with IBWM looks like:
All chronic wound patients must have accurate diagnosis and treatment of underlying disease and risks. There must be thorough pre-operative control of inflammation, ulceration, debris and bioburden, and edema (as best as the disease and available treatments permit).
Prepare wound bed using standard methods to ensure wound is free of debris and necrotic tissue. Regardless of how well the wound has been prepared and how healthy it looks, IBWM must not be placed on an existing wound surface. The entire existing wound must be completely excised or surgically debrided to ensure the wound bed and edges contain viable tissue.
IBWM is applied to the excised wound bed. Fluids invade the matrix within minutes of application, adhering it to the wound. The IBWM must conform to and contact the wound surface. Tension within the material will shear the matrix from the silicone, so the material must not be stretched. It can be affixed with sutures, staples, or any suitable alternative.
Dermal cells begin migrating into the matrix and establish a new vascular network. The scaffold is eventually remodeled as the patient’s cells rebuild the damaged site.
The silicone layer is removed. The collagen template biodegrades and is absorbed into the body.
Epidermal cells migrate from the wound edges to complete wound closure. For larger wounds, a thin epidermal autograft may be considered to facilitate wound closure. A thin 0.004 – 0.006 inches (0.1016 – 0.1524 mm) epidermal autograft may be applied over the new remodeled skin. Epidermal coverage over the wound yields a permanent and lasting wound closure.
Tissue Remodeling Timeline*
(*Typical progression observed. May not represent an actual case.)
After placement of the Integra template, the matrix picks up a reddened appearance due to infiltration of fluid in the wound bed.
Neodermis formation is well underway. Cellular infiltration has altered the matrix color. The matrix is now a red to pinkish color.
Vascularization is occurring. The color is now orange/peach in appearance.
Prior to silicone removal, the neodermis is mature and ready for epidermal autograft. The color is now vanilla in appearance.
Integra Bilayer Wound Matrix
Indications
Integra Bilayer Wound Matrix is indicated for the management of wounds including: partial and full-thickness wounds, pressure ulcers, venous ulcers, diabetic ulcers, chronic vascular ulcers, surgical wounds (donor sites/grafts, post-Moh’s surgery, post-laser surgery, podiatric, wound dehiscence), trauma wounds (abrasions, lacerations, second-degree burns, and skin tears) and draining wounds. The device is intended for one-time use.
Contraindications
- This device should not be used in patients with known sensitivity to bovine collagen or chondroitin materials.
- The device is not indicated for use in third-degree burns.
Precautions
- Do not resterilize. Discard all opened and unused portions of Integra Bilayer Wound Matrix.
- Device is sterile if the package is unopened and undamaged. Do not use if the package seal is broken.
- Discard device if mishandling has caused possible damage or contamination.
- Integra Bilayer Wound Matrix should not be applied until excessive exudate, bleeding, acute swelling and infection are controlled.
- Debridement or excision must be done thoroughly to remove any remaining necrotic tissue that may cause infection.
- The following complications are possible with the use of wound dressings. If any of the conditions occur, the device should be removed: infection, chronic inflammation (initial application of wound dressings may be associated with transient, mild, localized inflammation), allergic reaction, excessive redness, pain or swelling.
Integra Meshed Bilayer Wound Matrix
Indications
Integra Meshed Bilayer Wound Matrix is indicated for the management of wounds including: partial and full-thickness wounds, pressure ulcers, venous ulcers, diabetic ulcers, chronic vascular ulcers, surgical wounds (donor sites/grafts, postMoh’s surgery, post-laser surgery, podiatric, wound dehiscence), trauma wounds (abrasions, lacerations, second-degree burns, and skin tears) and draining wounds. Integra Meshed Bilayer Wound Matrix may be used in conjunction with negative pressure wound therapy. The device is intended for one-time use.
Contraindications
- This device should not be used in patients with known sensitivity to bovine collagen or chondroitin materials.
- This device is not indicated for use in third-degree burns.
When used with Negative Pressure Wound Therapy, follow Contraindications for the specific Negative Pressure Wound Therapy device utilized, such as in the presence of: • Exposed arteries, veins, organs, anastomotic sites or nerves • Malignancy in the wound • Untreated osteomyelitis • Untreated malnutrition • Necrotic tissue (with or without eschar present) • Non-enteric and unexplored fistulas • Sensitivity to silver (if silver dressings are used)
Warnings and Precautions
- Do not resterilize. Discard all opened and unused portions of Integra Meshed Bilayer Wound Matrix.
- Device is sterile if the package is unopened and undamaged. Do not use if the package seal is broken.
- Discard device if mishandling has caused possible damage or contamination.
- Integra Meshed Bilayer Wound Matrix should not be applied until excessive exudate, bleeding, acute swelling and infection are controlled.
- Debridement or excision must be done thoroughly to remove any remaining necrotic tissue that may cause infection.
- Do not stretch, expand, spread or remesh the device.
- The following complications are possible with the use of wound dressings. If any of the conditions occur, the device should be removed: infection, chronic inflammation (initial application of wound dressings may be associated with transient, mild, localized inflammation), allergic reaction, excessive redness, pain or swelling.
When used with Negative Pressure Wound Therapy, follow Warnings and Precautions for the specific Negative Pressure Wound Therapy device utilized, such as: • Precautions for patients who are or may be receiving anticoagulant therapy or suffering from difficult hemostasis; • Excessive bleeding is a serious risk associated with the application of suction to wounds and may result in death or serious injury. Careful patient selection, in view of the above-stated contraindications, warnings and precautions, is essential. Carefully monitor the wound and collection circuit for any evidence of a change in the blood loss status of the patient. Notify the Physician of any sudden or abrupt changes in the volume or the color of exudate.
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