Early Excision and Application of Matriderm with Simultaneous Autologous Skin Grafting in Facial Burns

Sir: A 24-year-old woman was admitted to the Chelsea and Westminster Burns Unit with a 9 percent full-thickness chemical burn to almost all of the face, anterior neck, upper chest, and both wrists after being assaulted with sulfuric acid. Surgical treatment consisted of early tangential excision, Versa jet hydro surgery (Smith & Nephew, Hull, United Kingdom), and application of cadaveric skin. This process was repeated on four further occasions. On postoperative day 10, the face and anterior neck were resurfaced with 1-mm-thick Matriderm (Dr. Suwelack Skin and Health Care, Billerbeck, Germany), applied as a one-stage procedure, in cosmetic units with an overlying 8/1000-inch split-thickness sheet graft, also applied in cosmetic units (Fig. 1). Grafts were secured with 6-0 Prolene and staples and dressed with Jelonet (SmithKline & Nephew, United Kingdom) and Furacine (Sanico, Turnhout, Belgium). The back was chosen as the donor site to provide a large homogenous graft. The dressings were changed at days 4, 6, and 11; all areas of Matriderm adhered; and all areas of graft took, apart from a small 1.5-cm2 area in the left preauricular region. The patient was kept sedated and ventilated for this period to minimize shearing.Fig. 1.: Matriderm has been applied following excision of full-thickness burns to the face and is being moistened with saline; split-thickness sheet grafts are being applied over the top of this.Early scar management was initiated with neck splintage followed by topical silicone gel (Kelo-Cote; Advanced Biotechnologies, Silverdale, Wash.), massage, moisturization, and a polypropylene facial mask (North Sea Plastics, Glasgow, Scotland) once the wounds were healed. At 4 months postoperatively, the patient shows better-than-expected results in terms of facial contour, texture, and expression as compared with alternative techniques (Fig. 2).Fig. 2.: Quality of facial expression, 4 months after full-thickness burns to the face reconstructed with Matriderm with split-thickness skin grafting, with the patient frowning (left) and smiling (right).Full-thickness burns to the face represent one of the most difficult challenges for burn surgeons and often have unsatisfactory outcomes. Key features of facial skin remain difficult to reproduce (e.g., color, texture, contour, and expression). The dermal substitute Integra (Integra LifeSciences, Plainsboro, N.J.) has previously been used in facial burns1,2 as a two-stage procedure. In addition, Klein et al. prefer to use thick autograft if sufficient donor skin is available. Matriderm is a second-generation dermal substitute consisting of a freeze-dried matrix composed of bovine collagen and elastin that can be applied as a one-stage or a two-stage procedure. A randomized controlled trial of early burn excision and simultaneous Matriderm use demonstrated significant improvements in skin elasticity.3 Matriderm has also been used in the acute setting for hand burn wound closure, where again the quality of the dermis was highlighted and range of movement was improved.4 This is the first documented case of using Matriderm for primary burn wound closure on the face. We believe we have shown that the procedure can be performed safely and that it results in improved cosmesis and skin quality compared with alternative techniques. The proven benefits of increased skin pliability and function in hand reconstruction clearly lend themselves to facial burn surgery. We appreciate that at 4 months this represents a relatively early result; however, we feel that this is likely to offer a useful and reliable reconstructive tool in the future. Duncan D. Atherton, M.R.C.S. Raymond Tang, M.R.C.S. Isabel Jones, F.R.C.S. Mohammad Jawad, F.R.C.S. Chelsea and Westminster Burns Unit London, United Kingdom ACKNOWLEDGMENTS The authors thank Iain Muir-Nelson, Director, Department of Maxillofacial Prosthetics, St Georges Hospital London; the occupational therapists; the clinical psychologist; and the intensive care team. DISCLOSURE None of the authors has any commercial associations that might pose or create a conflict of interest with information presented in this article. No intramural or extramural funding supported any aspect of this work.