Bone burn reconstruction using fish skin xenograft: A case series report

Fourth-degree burns with bone exposure present a major reconstructive challenge due to periosteal loss, infection risk, and limited vascularity. Traditional flap procedures are complex, invasive, and costly, with prolonged hospitalization and pain. Acellular fish skin (AFS) xenograft has emerged as a biologically active, omega-3–rich matrix that supports granulation and epithelialization in complex wounds. This case series reports outcomes of a two-stage reconstruction using AFS followed by split-thickness skin grafting (STSG) in four patients with bone-exposed burns (three tibial, one cranial). After surgical debridement and irrigation, AFS (Kerecis®, Ísafjörður, Iceland) was rehydrated in sterile saline and applied to the wound as a periosteal substitute. Seven days after the AFS application, a thin-meshed STSG (mesh ratio 1:1.5–1:3) was placed over the wound. This dressing strategy reduced the frequency of dressing changes and was associated with decreased patient-reported pain and lower resource use; however, these observations require confirmation in larger studies. All patients achieved complete epithelial coverage within 3–4 weeks, and after six months of follow-up, tissue repair was flexible, of high quality, and demonstrated favorable aesthetic outcomes. No infections, graft losses, or major complications were observed. The two-stage AFS + STSG technique appears to promote rapid epithelialization and durable wound coverage with minimal morbidity, representing a simple and less invasive alternative for bone-exposed burn reconstruction when flap surgery is not feasible.