Dermal Replacements in General, Burn, and Plastic Surgery by Lars-Peter Kamolz & David Benjamin Lumenta

Author:Lars-Peter Kamolz & David Benjamin Lumenta
Language: eng
Format: epub
Publisher: Springer Vienna, Vienna

9.4 Fibrin Sealant for Graft Fixation

Over the past decades, new techniques in burn surgery have improved outcome and significantly reduced mortality (Pereira et al. 2004, 2006; Muller and Herndon 2007). The generally accepted approach in burn surgery consists of early excision followed by appropriate coverage to prevent hypothermia, protein and fluid loss, and risk of exogenous infection. The standard treatment for full-thickness wounds after excision is coverage by meshed split-thickness skin grafts (Janzekovic 1970; Herndon and Parks 1986; Muller and Herndon 2001; Thompson et al. 1987). As far as graft fixation is concerned, autograft skin is usually affixed to the wound bed by sutures or skin staples. These methods, however, are either time-consuming (in case of sutures) or associated with the need of additional anesthesia and lengthy removal procedures (Kulber et al. 1997; Zederfeldt 1994). In addition, it is often difficult to achieve full contact of graft and underlying wound surface, especially in severely burned patients with large grafted wound areas.

Fibrin sealant has emerged as an alternative fixation method for autografts (Furst et al. 2007; Buchta et al. 2005). It consists of thrombin and fibrinogen, is biologically degradable and nontoxic to the human tissue, and was primarily developed as a fast-clotting agent for hemostatic purposes. A novel application method is a slow-clotting version (Artiss®, Baxter Inc) with a smaller amount of thrombin, applied to the wound in a thin layer using a spray applicator. It has been shown effective for autograft fixation in both human (O’Grady et al. 2000; Gibran et al. 2007; Redl 2004) and porcine (Mittermayr et al. 2006) studies. A major advantage of this method is the fact that it prevents seroma and hematoma formation by providing complete contact between wound bed and graft. It also acts as a scaffold for collagen-producing fibroblasts, provides a matrix for vascularization, and possibly creates a barrier against infection (Currie et al. 2001; Jabs et al. 1992). After a short and steep learning curve, the use of fibrin sealant also significantly decreases the length of surgical procedures, especially in cases when grafts have to be applied to the face or areas where standard fixation methods are difficult to use. Most surgeons also find that bolsters can be omitted after fibrin sealant use. Since graft adherence and revascularization in the early postoperative phases translate into an accelerated wound closure in the late phase, it is likely that formation of hypertrophic scarring may also be reduced, although there is no controlled data as of yet. Rare side effects are allergic reaction to the fibrin sealant protein and air or gas embolism after application. Also, the cost of fibrin sealant is considerable, which reduces its applicability for most burn surgeons to a few carefully selected indications (Fig. 9.4).

Fig. 9.4Use of fibrin sealant (Artiss®) for graft fixation. (a) A 12-year-old girl with severe circumferential burn scar contracture of the right elbow. (b) Large defect after circumferential scar incision. (c) Application of Artiss® onto the wound bed using a Tissomat® spray device and immediate coverage with a non-meshed split-thickness skin graft.

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