contracture of skin graft in human burns: effect of artificial dermis

JBUR-4443; No. of Pages 7

Contracture of skin graft in human burns:Effect of artificial dermis

Gi-Yeun Hur, Dong-Kook Seo, Jong-Wook Lee *

Department of Plastic and Reconstructive Surgery, Hangang Sacred Heart Hospital, Hallym University Medical Center,

Seoul, Republic of Korea

b u r n s x x x ( 2 0 1 4 ) x x x – x x x

a r t i c l e i n f o

Article history:

Accepted 11 August 2014

Keywords:

Burn

Skin graft

Contracture

Size

Artificial dermis

a b s t r a c t

Background: Skin grafts with an artificial dermis have been widely used as a part of the

efforts to minimize contractures and reduce donor-site scars. We conducted a prospective

randomized clinical trial to study the effect of a dermal substitute by measuring the size of

the graft after surgery for months.

Method: The artificial dermis (Matriderm, Dr. Suwelack Skin and Health Care AG, Billerbeck,

Germany) was applied in combination with a split-thickness autograft in 40 patients with

acute burn wounds or scar reconstruction. Demographic and medical data were collected on

each patient. We directly measured the graft size by using a transparent two-ply film

(Visitrak Grid, Smith & Nephew Wound Management, Inc, Largo, FL, USA) intraoperatively

and 1, 2, 3, and 6 months postoperatively. For effective data comparison, the size of the graft

at the time of surgery was taken to be ‘‘100%.’’ Then, the size in each phase was estimated in

percentage (%).

Result: During the 1st month, the average size was 89%. The figure decreased to 86% and 82%

in the 2nd and 3rd months, respectively. In the 6th month, it slightly rebounded to 85% but

failed to return to the original state. The size of patients with acute burns was smaller than

the size of scar patients as follows: 85–91% in the 2nd month, 81–87% in the 3rd month, and

85–96% in the 6th month.

Conclusion: This study examined the progress of skin grafts through the measurement of

graft size in the human body. The grafted skin underwent contracture and remodeling for 3–6

months. In terms of skin contraction, an acute burn was more serious than scar reconstruc-

tion. The use of an artificial dermis that contains elastin is very effective from the functional

and esthetic perspective by minimizing contractures and enhancing skin elasticity.

# 2014 Elsevier Ltd and ISBI. All rights reserved.

Available online at www.sciencedirect.com

ScienceDirect

journal homepage: www.elsevier.com/locate/burns

1. Introduction

A skin graft has been the most common way of healing skin

defects caused by burns or other injuries. Contracture, which

* Corresponding author at: Department of Plastic and Reconstructive SuCenter, 12 Beodeunaru-ro 7-gil, Yeongdeungpo-gu, Seoul 150-719, Rep

E-mail address: [email protected] (J.-W. Lee).

Please cite this article in press as: Hur G-Y, et al. Contracture of skin gdx.doi.org/10.1016/j.burns.2014.08.007

http://dx.doi.org/10.1016/j.burns.2014.08.0070305-4179/# 2014 Elsevier Ltd and ISBI. All rights reserved.

comes after the surgical procedure, causes a functional or

cosmetic impairment and it could indicate corrective

surgery. Among the patients with burns who received skin

grafts, in fact, >30% suffer from hypertrophic scars or

contractures [1].

rgery, Hangang Sacred Heart Hospital, Hallym University Medicalublic of Korea. Tel.: +82 2 2639 5704; fax: +82 2 2676 2431.

raft in human burns: Effect of artificial dermis. Burns (2014), http://

http://dx.doi.org/10.1016/j.burns.2014.08.007

mailto:[email protected]



http://www.sciencedirect.com/science/journal/03054179

http://dx.doi.org/www.elsevier.com/locate/burns


Fig. 1 – Slits are made on harvested skin using the scalpel

blade No. 11 for drainage. We can control the size and

density of slits without expansion.

b u r n s x x x ( 2 0 1 4 ) x x x – x x x2


Wound contracture is a natural biological response to heal

the wound. In mammals with loose skin such as the rabbit

and mouse, a thin muscle layer under the skin makes

effective skin movement possible so that wounds heal

through contracture. In the case of humans, however, the

skin is firmly attached to the subcutaneous tissues. There-

fore, contracture constricts the adjacent tissues resulting in

physical disability [2].

Recently, artificial dermis has been widely used as a part of

efforts to minimize contractures. Even though there have been

many studies designed to measure the effects of artificial

dermis, most experimental papers have targeted animals or

models instead of patients. Even in clinical papers, an indirect

method that represents a subjective satisfaction level or skin

quality is mostly used [3–5].

It is believed that, as a scale that directly reveals

contracture levels, the size of the graft would suggest the

effect of the artificial dermis in addition to literature review by

observing the change pattern. Therefore, this study attempted

to observe the size of the graft after surgery using dermal

substitutes for months and unveil its effects objectively.

2. Materials and methods

2.1. Study design and patient

In this study, the size of the graft was measured in 40 patients

who were hospitalized or underwent an operation in the

Department of Plastic Surgery at Hangang Sacred Heart

Hospital from September 2010 to December 2011. Except for

14 patients who were lost to follow-up or had small grafts

(�10 cm2), 26 patients (31 surgical sites) were investigated.

Specifically, a patient’s gender and age, cause of burn, surgical

site, and the size of the graft at and after (1, 2, 3, and 6 months

later) surgery were examined.

2.2. Material

The artificial dermis (Matriderm, Dr. Suwelack Skin and Health

Care AG, Billerbeck, Germany) used in this study was a 1-mm-

thick porous membrane developed for skin grafts. It consisted

of type I collagen fiber coated with 3% a-elastin hydrolysate,

which was extracted from the ligamentum nuchae of cattle.

2.3. Operative procedure

A wound was washed with povidone iodine solution and then

treated aseptically. Debridement was performed using a razor

blade until the pinpoint bleeding of the wounded tissue was

found. Then, the bleeding was controlled using an appropriate

device such as Bovie electrocautery. Split-thickness skin (6–9/

100000) was harvested from the unburned parts (hip or thigh in

general) using a Zimmer dermatome (Zimmer Inc., Dover, OH,

USA). We made a slit on the harvested skin using the scalpel

blade No. 11 for hematoma drainage (Fig. 1). We did not use a

mesh expander; we use a sheet graft usually for good quality.

After applying Matriderm on a wound in which the bleeding

was controlled, it was cut to fit the wound. Then, it was

hydrated with a saline solution. After placing the harvested


skin on the hydrated Matriderm, it was fixed with a skin

stapler. Then, the size of the graft was measured. A wet

compressive dressing was changed every other day, and the

bandage was removed 2–3 weeks later.

2.4. Size measurement techniques

After placing the transparent two-ply film (Visitrak Grid, Smith

& Nephew Wound Management, Inc, Largo, FL, USA) on the

skin graft during and after (1, 2, 3, and 6 months later) the

surgery, the middle of the graft was marked on the film. The

bottom layer, which was in direct contact with the wound, was

removed, and the film on top was placed on the Visitrak digital

pad. Then, if the shape marked with the Visitrak pen was

drawn, the area (cm2) was automatically calculated.

2.5. Data analysis

Data were edited and analyzed using IBM1 SPSS1 Statistics

Standard version 21 (IBM Corporation, Armonk, NY, USA). We

compared the data using the non-parametric Wilcoxon

signed-rank test. A P value < 0.05 was considered to be

statistically significant.

3. Results

Skin grafts on 31 body parts in 26 patients (nine women, 17

men, age: 28.5 � 21.3 (1–61) years) were investigated. Among

them, 22 patients were suffering from acute burns whereas

four patients had a scar. In terms of causes of the wound, acute

burns were divided into scalding, contact, flame, oil, and

electrical burns in the order of decreasing frequency. In

addition, the causes of the scar were divided into scald, flame,

and hot oil burns. The sites were mainly legs and upper limbs

(Table 1).

The size of the graft was measured in patients suffering

from both acute burns (27 sites) and scars (four sites). For

effective data comparison, the size of the graft at the time of




Table 1 – Patient demographics.

Acute burn(22 patients, 27 sites)

Reconstruction(four patients, four sites)

Total(26 patients, 31 sites)

Sex distribution M:F = 15:7 M:F = 2:2 M:F = 17:9

Age (mean) 1–61 years (27.7 years) 13–47 years (32.5 years) 1–61 years (28.5 years)

The type of injury

Scalding burn 12 cases One case 13 cases

Contact burn Five cases Five cases

Flame burn Three cases Two cases Five cases

Electrical burn One case One case

Oil burn One case One case Two cases

Operation site

Head and neck One site One site

Trunk Two sites Two sites

Upper extremity 10 sites Two sites 12 sites

Lower extremity 14 sites Two sites 16 sites

M: male, F: female, y: years.

Table 2 – Scatter plot shows change of graft size.

X axis: postoperative months. Y axis: graft size calculated (%), the

size of graft at the time of surgery was taken to be ‘‘100%.’’

Table 3 – Graft size calculated to percentage of theoriginal wound area.

Acute burn Reconstruction Total

1st month 89.0 89.0

(n = 12) (n = 12)

2nd month 85.4 91 86.2

(n = 13) (n = 2) (n = 15)

3rd month 81.3 86.9 81.9

(n = 16) (n = 2) (n = 18)

6th month 84.8 94.6 85.3

(n = 17) (n = 1) (n = 18)

n: number of cases.

b u r n s x x x ( 2 0 1 4 ) x x x – x x x 3


surgery was taken to be ‘‘100%.’’ Then, the size in each phase

was estimated in percentage (%). During the 1st month, the

average size in 12 sites was 89% (11% contracture). The figure

decreased to 86% and 82% in the 2nd and 3rd months,

respectively (Table 2). In the 6th month, it slightly rebounded

to 85% but they failed to return to the original state. (Table 3)

(Fig. 2). Between the operation and 1 month, there is a

statistically significant difference in graft size, but no signifi-

cant difference between 1 and 2, 2 and 3, and 3 and 6 months.

In addition, there is a significant difference between the

operation and each month. In terms of contracture of the skin

graft, a difference was found between acute burn surgery and

scar surgery. In terms of the average size of the graft, patients

with acute burns were smaller than scar patients as follows:

85–91% in the 2nd month, 81–86% in the 3rd month, and

84–94% in the 6th month. In other words, acute burn surgery


was more serious than scar surgery in terms of contracture

(Table 2). However, the number of the population of scar

reconstruction (n = 4) is too small to compare statistically. In

addition, in each group, the contracture got worse over time,

reached a peak in the 3rd month, and slightly loosened in the

6th month (but failed to return to the original level) just like the

entire experimental group.

4. Discussion

The harvested skin immediately contracted, which is called

‘‘primary contraction.’’ This contraction, which is caused by

elastic fibers in the dermis, is more serious in full-thickness

skin (41%) than in split-thickness skin (9%) [6,7]. On the

contrary, the contracture from which patients suffer is called

‘‘secondary contraction.’’ It has been known that the

contracture is caused by contraction in the scar, which is

formed between the wound bed and the graft. This contraction

caused by myofibroblasts at the bed of the recipient site begins

10 days after the grafting and lasts for 6 months. As the grafted

skin is thick, the bed of the recipient site is rigid, and as the

skin is well grafted, the secondary contraction weakens [6,7].

Even though contracture (i.e., ‘‘secondary contraction’’)

begins with a biological response for healing by reducing the

size of the wound, it causes a functional and cosmetic problem

by twisting adjacent tissues. According to a study, 38% of




Fig. 2 – (1) (Preoperative view) 10-month-old boy scalded by hot soup on his right arm. (2) (6 Days after operation) well-taken

graft. The area of the graft was 13.1 cm2 (forearm), 15.1 cm2 (upper arm) at operation. (3) (2 Months after operation) the area

of the graft was 11.4 cm2 (87%), 13.4 cm2 (88.7%). Scar is very hard. (4) (3 Months after operation) the area of the graft

(maximal shrinkage) was 10.7 cm2 (81.7%), 10.1 cm2 (66.9%). (5) (6 Months after operation) the area of the well-matured graft

was 11.6 cm2 (88.5%), 10 cm2 (66.2%). Scar is soft and light colored.

b u r n s x x x ( 2 0 1 4 ) x x x – x x x4


patients with burns experience contracture in three body sites.

Skin grafting is highly related with contracture inasmuch as

the length of stay, size of the burn, and skin graft were

considered as the predictor variables for the occurrence of

contracture and graft size as the predictor variable for severe

contracture [1].

To reduce the occurrence of contracture during

skin grafting, appropriate wound treatment and graft


immobilization are provided. In addition, a splint or anti-

scar agent is used for months after surgery. Despite these

efforts, the grafts always shrink, and it is hard to predict the

contracture levels.

There are various ways of measuring the quality of grafted

skin such as the Vancouver scar scale, moisture loss rates,

pigment, erythema, and elasticity using a skin analyzer. In

fact, they have been handled in various studies [5,8–11], but




b u r n s x x x ( 2 0 1 4 ) x x x – x x x 5


the results have been subjective or greatly influenced by

environment. In addition, they indirectly reveal the patients’

inconvenience. However, it is very hard to find a study on

changes in the size of the graft, which is directly related with

patients’ discomfort.

The wound surface area is a reasonable and accurate index

for wound progress. By monitoring changes in wound size, it is

possible to assess healing effects or detect signs of aggravation

early. In addition, these data are helpful in enhancing

communication between doctor and patients and quality of

patient care [12]. Animal tests [13] or model tests that were

performed with some tissues have been partially released.

However, it has been more difficult to find a study on changes

in graft size in the human body.

Thanks to great reliability and high effectiveness, VISI-

TRAK has been used in measuring graft size in many wound-

related studies [12,14–16]. Because this technology became

less reliable as wound size decreased [17], small grafts

(�10 cm2) were excluded in this study. Despite the advantages

of fast measurement and relatively low price, it was hard to

clarify the border between the graft and adjacent scar because

of blurring. According to many studies, the leading cause of

error was found in positioning the margin of the scar, not in

calculating the size itself [10,12,18]. In this study as well, there

was one case that the graft area rather increased in acute

burns because of this kind of error. In patients with scar

reconstruction, however, the border of the graft stayed clear

over time. As a result, it was possible to obtain more accurate

and consistent test results.

According to this study, contracture occurred in the first 1–3

months after skin grafting, and there was a slight improvement

from the 3rd to the 6th month because of the remodeling

(maturing) process. It is known that remodeling in which the

immature type III collagen is gradually replaced with type I

mature collagen could last for months. The wound contraction,

which begins as myofibroblasts, plays a pivotal role occurring 6

days after a-smooth actin (a-SMA) was located and increases

until the 15th day. Then, it disappears in 4 weeks [19].

According to a clinical trial with the acellular dermis of pigs

in China, relatively decent contracture rates were observed

with 5.42% (1 month), 6.28% (3 months), 6.52% (6 months), and

6.67% (12 months). [20] In fact, contracture continued for 12

months while contraction started to lessen in the 6 month in

our study. We used scar ointment, a silicon sheet, and a

compression garment for scar management and Matriderm.

As a result, it was able to reduce the contracture period.

According to a comparative study on a total of 27 cases

(skin grafting only vs. Matriderm + skin grafting) for >1 year,

‘‘skin grafting only (76%)’’ was greater than ‘‘Matriderm + skin

grafting (71%)’’ in terms of the graft size without a statistical

significance. In other words, contracture was more serious

when an artificial dermis was used [10]. It is more difficult to

deal with an artificial dermis, as it requires considerable

clinical experience and understanding. Not an artificial dermis

itself but graft survival is considered to be the cause of

contracture. We tried to make total engraftment with a

substitute for a long time, so we were able to reap its full

benefits. In this reference, skin grafting was carried out using a

mesh. That is why contracture seemed more serious than our

study.


According to a study on the cases in which Matriderm was

performed on the hands of 17 patients, 96% of graft survival

and superior functional and cosmetic results were reported.

Among them, the graft size was measured in five patients.

When they were observed for 1 year, the contracture rate was

11%. Among three of them, a contracture rate of 10% was

found on the flap donor site (clean wound), which is similar to

the rate of scar reconstruction rate (5.4%) in this study. In

terms of acute burn, 12% and 15% of contracture rates were

observed, which are close to the result of this study (15.2%)

[21]. It appears that good results could be obtained in other

joints as well as in the hand because many joints are in the

recipient site.

The advantage of Matriderm, which reduces wound

contracture and promotes dermal reconstruction, prevents

myofibroblasts in the dermis from differentiating into con-

tractile myofibroblasts in the early stage of wound treatment

[22]. It is known that elastin in the ingredients of Matriderm

regulates collagen contraction, interrupts the differentiation

of myofibroblasts, and reduces the formation of scars [22].

Elastin is not sufficiently reconstructed during the healing

process. Even though it is formed, it still stays in an immature

state. Because of the failure of a return to the normal state in

terms of amount and quality, scar tissues are still hard without

elasticity even though a decade has passed [23]. It is expected

that the artificial dermis including elastin would substitute the

destructed elastic fibers or enhance elasticity through resyn-

thesis [24]. This kind of result has been proven in a human

punch biopsy [25]. In particular, skin elasticity is very useful in

enhancing motor functions at joint are surgery.

In terms of skin pliability, elasticity, maximum extension

and immediate retraction, ‘‘Matriderm + mesh auto-dermal

grafting’’ was better than ‘‘skin grafting only’’ for the first 3

months. Since the 3rd month, however, no difference was

found [10]. In a subjective assessment by a doctor or patient,

however, ‘‘Matriderm’’ was superior in a 12-year follow-up [9].

In patients with massive burns in which the donor sites are

limited, the skin is extended just like a net for mesh auto-

dermal grafting. However, hypertrophic scars are often found

between the nets, which are not a good sign from the esthetic

and functional perspective. In a mesh with a larger ratio, the

scars are more uneven. When Matriderm was used, however,

it was better than ‘‘skin graft only’’ in terms of skin evenness

according to the measurement of the skin using the

cutometer. In other words, it appears that the artificial dermis

substituted the dermis and made the skin smoother [10].

In an acute-burn experimental group (except for hands),

‘‘Matriderm’’ was far lower than ‘‘skin graft only’’ in terms of

graft survival rates. In terms of scar reconstruction, on the

contrary, no particular difference was observed between the

two groups [8]. It appears that scar reconstruction was better

than acute burns in terms of contracture in this study because

contracture lessens as graft survival increases. In scar

reconstruction with Matriderm, elasticity and pliability im-

proved by 20–33% and 50%, respectively, compared to ‘‘skin

graft only’’ [8,10]. This kind of result was not statistically

significant in acute burns, which seems to be related with the

difference in graft survival rates.

In conventional skin grafting, the skin was harvested from

the donor site by 0.010–0.01500, [6] causing a severe scar. The




b u r n s x x x ( 2 0 1 4 ) x x x – x x x6


use of dermal substrates, however, has dramatically reduced

scars in the donor site by thinning the skin to be harvested up

to 0.005–0.00600. This effect is the biggest advantage of an

artificial dermis. It would be very effective in treating acute

burns as well as in scar reconstruction.

We obtained a better contracture rate compared with other

reports [10,20], because we managed the graft carefully and

actively (e.g., proper wound bed preparation, drainage, and

immobilization) to improve graft survival. Only a sheet graft is

chosen for less contracture. For faster maturation, we carry

out an aggressive scar management using a pressure garment

and an anti-scar agent.

This study was performed against a limited number of

patients; therefore, it has statistical limitations including

inconsistency in observations. In particular, there is a big

difference in the number of patients between the acute burn

and scar reconstruction groups; therefore, there are some

problems in comparing the two groups directly. However, this

study is significant in that it had an experimental group that

had sufficient grafts with 31 sites, and the graft size was

observed and reported for months. It would be statistically

significant if more patients were observed over 1 year. We will

get more scar patients, and then we can compare the results in

another paper.

5. Conclusion

This study examined the progress of skin grafts through the

measurement of graft size in the human body. The grafted skin

underwent contracture and remodeling for 3–6 months. In

terms of skin contraction, acute burns were more serious than

scar reconstruction. The use of an artificial dermis that contains

elastin is very effective from the functional and esthetic

perspective by minimizing contractures and enhancing skin

elasticity. These advantages would be very useful during joint

surgery especially. In addition, an artificial dermis reduced

additional losses by minimizing damage in the donor sites.

Conflict of interest

There are no conflicts of interest and no financial help related

to this report.

Acknowledgments

No funding was received for this work. We thank Dr. Hyeong

Tae Yang and Dr. Yoon Soo Cho for their advice concerning

statistical issues, and Dr. Rock-Kuen Ju for his assistance

regarding data arrangement.

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contracture of skin graft in human burns: effect of artificial dermis

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