Induced Membrane‐Assisted Skin Grafting for Chronic Refractory Wounds: Extending the Masquelet Concept Beyond Bone Reconstruction

We read with great interest the recent article by Gao et al. on the use of the Masquelet membrane induction technique combined with free skin grafting for chronic refractory wounds with exposed bone or tendon in aged patients [1]. In that study, the authors used a staged reconstructive strategy. Antibiotic-loaded bone cement was first implanted to induce the formation of a vascularised membrane, followed by secondary free skin grafting after membrane maturation. The reported outcomes were encouraging, with satisfactory graft survival and functional recovery. These findings suggest that this method may offer a practical reconstructive option for complex wounds in aged patients. Chronic refractory wounds with exposed bone or tendon remain a major therapeutic challenge, particularly in ageing populations with comorbidities such as diabetes mellitus, peripheral vascular disease and impaired regenerative capacity [2]. In such patients, conventional reconstruction, including local or free flap transfer, is often limited by frailty, poor vascular status and increased perioperative risk. Against this background, the staged approach proposed by Gao et al. appears clinically meaningful because it may provide a simpler and potentially safer alternative for wound coverage in patients who are not ideal candidates for complex microsurgical procedures. The success of this technique likely depends, at least in part, on the biological properties of the induced membrane itself [3]. Experimental studies have shown that Masquelet membranes are highly vascularised tissues that secrete a range of bioactive factors, including vascular endothelial growth factor (VEGF), transforming growth factor-β (TGF-β) and bone morphogenetic proteins (BMPs) [3, 4]. These mediators promote angiogenesis, extracellular matrix remodelling and regulation of the local inflammatory milieu, thereby creating a biologically favourable environment for tissue repair. From this perspective, the induced membrane may improve wound bed quality and facilitate subsequent skin graft integration. From a pathophysiological perspective, impaired microcirculation is widely regarded as a major contributor to delayed healing in chronic wounds, particularly in aged and diabetic populations. Reduced perfusion, tissue hypoxia and persistent inflammation can hinder granulation tissue formation and thereby compromise reconstructive outcomes [2]. The vascularised membrane generated by the Masquelet technique may help overcome some of these limitations by improving local perfusion and enhancing angiogenic activity [3]. In this context, the findings of Gao et al. further support the view that biologically active membranes may help re-establish a regenerative microenvironment in complex wounds. Another important question is whether this strategy could be integrated with other advanced wound management approaches. Negative pressure wound therapy (NPWT), for example, has been widely used to improve microcirculation, promote granulation tissue formation and control wound exudate [5, 6]. Combining NPWT with induced membrane formation during the early treatment phase may further optimise wound bed preparation before secondary grafting. This multimodal approach may represent a worthwhile direction for future clinical investigation. Despite these promising findings, several limitations should be noted. The study included a relatively small number of patients and lacked a comparative control group, which limits assessment of the relative effectiveness of this technique compared with other reconstructive options. In addition, the retrospective design introduces potential bias related to patient selection and perioperative management. Accordingly, prospective studies with larger cohorts and well-controlled comparative designs are needed. Direct comparisons with dermal substitutes, NPWT-assisted reconstruction and flap-based procedures would help clarify the indications and potential advantages of induced membrane-assisted skin grafting. Further studies exploring the biological behaviour of induced membranes in chronic wound settings, particularly with respect to angiogenesis, inflammatory modulation and extracellular matrix remodelling, could provide valuable mechanistic insights [3, 4]. From a practical clinical perspective, the strategy described by Gao et al. may represent an attractive reconstructive option for aged patients with complex wounds who are not ideal candidates for extensive flap surgery. By combining biological membrane induction with a relatively straightforward skin grafting procedure, this approach may offer a useful balance between surgical safety and effective wound coverage. In conclusion, the study by Gao et al. broadens the scope of the Masquelet concept beyond bone reconstruction and highlights its potential value in complex soft-tissue wound repair. Further well-designed clinical studies are needed to validate these findings and better define the role of induced membrane-assisted reconstruction in contemporary wound management. The authors declare no conflicts of interest. Data sharing not applicable to this article as no datasets were generated or analysed during the current study.