Optimizing Burn Injury Care: A Comparative Network Meta-Analysis of Skin Grafts' Efficacy
DOI:
https://doi.org/10.21776/ub.jkb.2025.033.03.8Keywords:
Burn injury, efficacy, reepithelialization, repigmentation, skin graftsAbstract
Burn injuries, causing approximately 180,000 deaths. Skin grafting serves as a cornerstone intervention in burn injury management. This study aimed to evaluate the efficacy of different types of skin grafts in promoting the healing process of burn injuries. The outcomes of the study were the reepithelialization time and repigmentation rate of skin graft. Quality appraisal was done using ROBINS-I and the Newcastle Ottawa Scale, while network and single arm meta-analysis were conducted using R-Studio. A literature search across 6 databases resulted in the selection of 7 articles. Quality assessment categorized 6 studies as low- and 1 as moderate-risk of bias studies. The device facilitated autologous skin cell increase in reepithelialization rate (OR=5.21; 95% CI=0.24-114.41), followed by autologous skin cell and synthetic graft (OR=0.47; 95% CI=0.04-5.98), topical agent (OR=0.30; 95% CI=0.06-1.47), and Xenograft (OR=0.09; 95% CI=0.00-4.89). Furthermore, the single-arm meta-analysis showed an overall repigmentation rate of 61.49%, with xenograft displaying the highest repigmentation rate (87.50%), followed by synthetic graft (70.32%), and autologous skin cell (37.54%). Xenografts have proven effective in promoting burn wound healing. Nevertheless, the outstanding efficacy and minimal repigmentation of device-facilitated autologous skin cell transplantation highlight its potential in clinical practice.
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1. Jeschke MG, van Baar ME, Choudhry MA, Chung KK, Gibran NS, Logsetty S. Burn Injury. Nature Reviews Disease Primers. 2020; 6(1): 1-26.
2. Rae L, Fidler P, and Gibran N. The Physiologic Basis of Burn Shock and the Need for Aggressive Fluid Resuscitation. Critical Care Clinics. 2016; 32(4): 491-505.
3. Won P, Celie KB, Rutter C, Gillenwater TJ, Yenikomshian HA. Burn Patient Perspectives on Disability Weights and the Philosophy of Disability: A Gap in the Literature. European Burn Journal. 2023; 4(4): 563-572.
4. Żwierełło W, Piorun K, Skórka-Majewicz M, Maruszewska A, Antoniewski J, and Gutowska I. Burns: Classification, Pathophysiology, and Treatment: A Review. International Journal of Molecular Sciences. 2023; 24(4): 3749.
5. Opriessnig E, Luze H, Smolle C, et al. Epidemiology of Burn Injury and the Ideal Dressing in Global Burn Care–Regional Differences Explored. Burns. 2023; 49(1): 1-4.
6. Levin NJ, Erben Y, Li Y, Brigham TJ, and Bruce AJ. A Systematic Review and Meta-Analysis Comparing Burn Healing Outcomes Between Silver Sulfadiazine and Aloe Vera. Cureus. 2022; 14(10): 1-8.
7. Ozhathil DK, Tay MW, Wolf SE, and Branski LK. A Narrative Review of the History of Skin Grafting in Burn Care. Medicina. 2021; 57(4): 1-28.
8. Paggiaro AO, Bastianelli R, Carvalho VF, Isaac C, and Gemperli R. Is Allograft Skin, The Gold-Standard for Burn Skin Substitute? A Systematic Literature Review and Meta-Analysis. Journal of Plastic, Reconstructive & Aesthetic Surgery. 2019; 72(8): 1245-1253.
9. Bogdanov SB, Gilevich IV, Melkonyan KI, Sotnichenko AS, Alekseenko SN, and Porhanov VA. Total Full-Thickness Skin Grafting for Treating Patients with Extensive Facial Burn Injury: A 10-Year Experience. Burns. 2021; 47(6): 1389-1398.
10. Wang Y, Beekman J, Hew J, et al. Burn Injury: Challenges and Advances in Burn Wound Healing, Infection, Pain and Scarring. Advanced Drug Delivery Reviews. 2018; 123: 3-17.
11. Gao G, Li W, Chen X, et al. Comparing the Curative Efficacy of Different Skin Grafting Methods for Third-Degree Burn Wounds. Medical Science Monitor. 2017; 23: 2668-2673.
12. Kubota Y, Mitsukawa N, Chuma K, et al. Hyperpigmentation After Surgery for a Deep Dermal Burn of the Dorsum of the Hand: Partial-Thickness Debridement Followed by Medium Split-Thickness Skin Grafting VS Full-Thickness Debridement Followed by Thick Split-Thickness Skin Grafting. Burns & Trauma. 2016; 4: 1-11.
13. Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 Statement: An Updated Guideline for Reporting Systematic Reviews. The BMJ. 2021; 372: 1-9.
14. Sterne JA, Hernán MA, Reeves BC, et al. ROBINS-I: A Tool for Assessing Risk of Bias in Non-Randomised Studies of Interventions. The BMJ. 2016; 355: 1-7.
15. Bae JM. A Suggestion for Quality Assessment in Systematic Reviews of Observational Studies in Nutritional Epidemiology. Epidemiology and Health. 2016; 38: 1-6.
16. Lo CK, Mertz D, and Loeb M. Newcastle-Ottawa Scale: Comparing Reviewers' to Authors' Assessments. BMC Medical Research Methodology. 2014; 14: 1-5.
17. McGuinness LA and Higgins JPT. Risk‐of‐Bias Visualization (Robvis): An R Package and Shiny Web App for Visualizing Risk‐of‐Bias Assessments. Research Synthesis Methods. 2021; 12(1): 55-61.
18. Allaire JJ. RStudio: Integrated Development Environment for R. (Online). https://www.r-project.org/conferences/useR-2011/abstracts/ 180111-allairejj.pdf
19. Karlsson M, Lindgren M, Jarnhed-Andersson I, and Tarpila E. Dressing the Split-Thickness Skin Graft Donor Site: A Randomized Clinical Trial. Advances in Skin & Wound Care. 2014; 27(1): 20-25.
20. Iv JHH, Molnar JA, Carter JE, et al. A Comparative Study of the Recell® Device and Autologous Split-Thickness Meshed Skin Graft in the Treatment of Acute Burn Injuries. Journal of Burn Care & Research. 2018; 39(5): 694-702.
21. Lo CH, Akbarzadeh S, McLean C, et al. Wound Healing After Cultured Epithelial Autografting in Patients with Massive Burn Injury: A Cohort Study. Journal of Plastic, Reconstructive & Aesthetic Surgery: JPRAS. 2019; 72(3): 427-437.
22. Gurbuz K, Demir M, and Das K. The Use of Dermal Substitute in Deep Burns of Functional/Mobile Anatomic Areas at Acute Phase after Early Excision and Subsequent Skin Autografting: Dermal Substitute Prevents Functional Limitations. Journal of Burn Care & Research. 2020; 41(5): 1079-1083.
23. Lo CH, Brown JN, Dantzer EJG, et al. Wound Healing and Dermal Regeneration in Severe Burn Patients Treated with Novosorb® Biodegradable Temporising Matrix: A Prospective Clinical Study. Burns. 2022; 48(3): 529-538.
24. Karlsson M, Steinvall I, Sjöberg F, Olofsson P, and Elmasry M. Burn Scar Outcome at Six and 12 Months After Injury in Children with Partial Thickness Scalds: Effects of Dressing Treatment. Burns. 2020; 46(3): 546-551.
25. Al Shlash SO, Al Madani JO, El Deib JI, et al. Demographic Characteristics and Outcome of Burn Patients Requiring Skin Grafts: A Tertiary Hospital Experience. International Journal of Burns and Trauma. 2016; 6(2): 30-36.
26. Radzikowska-Büchner E, Łopuszyńska I, Flieger W, Tobiasz M, Maciejewski R, and Flieger J. An Overview of Recent Developments in the Management of Burn Injuries. International Journal of Molecular Sciences. 2023; 24(22): 1-59.
27. Ryssel H, Gazyakan E, Germann G, and Öhlbauer M. The Use of Matriderm® in Early Excision and Simultaneous Autologous Skin Grafting in Burns—A Pilot Study. Burns. 2008; 34(1): 93-97.
28. Holmes IV JH, Molnar JA, Shupp JW, et al. Demonstration of the Safety and Effectiveness of the RECELL® System Combined with Split-Thickness Meshed Autografts for the Reduction of Donor Skin to Treat Mixed-Depth Burn Injuries. Burns. 2019; 45(4): 772-782.
29. Shimizu R and Kishi K. Skin Graft. Plastic Surgery International. 2012; 2012: 1-5.
30. Weathers WM, Bhadkamkar M, Wolfswinkel EM, and Thornton JF. Full-Thickness Skin Grafting in Nasal Reconstruction. Seminars in Plastic Surgery. 2013; 27(2): 90-95.
31. Lal ST, Banipal RP, and Bhatti DJ. Tolerance of Skin Grafts to Postoperative Radiotherapy. International Journal of Applied & Basic Medical Research. 2015; 5(3): 187-189.
32. Braza ME, Marietta M, and Fahrenkopf MP. Split-Thickness Skin Grafts. Treasure Island: StatPearls Publishing; 2023
33. Ray S and Rao K. Full Thickness Skin Grafts. In: Spear M (Ed). Skin Grafts - Indications, Applications and Current Research. London; IntechOpen; 2011.
34. Phua QH, Han HA, and Soh BS. Translational Stem Cell Therapy: Vascularized Skin Grafts in Skin Repair and Regeneration. Journal of Translational Medicine. 2021; 19: 1-11.
35. Weber CE, Li NY, Wai PY, and Kuo PC. Epithelial-Mesenchymal Transition, TGF-Β, and Osteopontin in Wound Healing and Tissue Remodeling after Injury. Journal of Burn Care & Research. 2012; 33(3): 311-318.
36. Sun X, Joost S, and Kasper M. Plasticity of Epithelial Cells During Skin Wound Healing. Cold Spring Harbor Perspectives in Biology. 2023; 15(5): 1-14.
37. Cheng RY, Eylert G, Gariepy JM, et al. Handheld Instrument for Wound-Conformal Delivery of Skin Precursor Sheets Improves Healing in Full-Thickness Burns. Biofabrication. 2020; 12(2): 025002.
38. Lin H, Yang Y, Wang Y, et al. Effect of Mixed Transplantation of Autologous and Allogeneic Microskin Grafts on Wound Healing in a Rat Model of Acute Skin Defect. PLoS One. 2014; 9(1): 1-11.
39. Tsukada S. Studies on the Pigmentation of Skin Grafts: The Ultrastructure of Epidermal Melanocytes. Plastic and Reconstructive Surgery. 1977; 59(1): 98-106.
40. Kim JS, Park SW, Choi TH, et al. The Evaluation of Relevant Factors Influencing Skin Graft Changes in Color Over Time. Dermatologic Surgery. 2008; 34(1): 32-39.
41. Chan RK, Rose LF, Wu JC, et al. Autologous Graft Thickness Affects Scar Contraction and Quality in a Porcine Excisional Wound Model. Plastic and Reconstructive Surgery. Global Open. 2015; 3(7): 1-9.
42. Liu T, Chen J, Wei B, Nie F, and Zhu G. Safety and Efficacy of Autologous Skin Tissue Cells Grafting for Facial Sunken or Flat Scars. Heliyon. 2023; 9(6): 1-6.
43. Hicks K and Thomas JR. Skin and Composite Grafts. Plastic and Aesthetic Research. 2022; 9(2): 1-11.
44. Elseth A and Nunez Lopez O. Wound Grafts. Treasure Island: StatPearls Publishing; 2022.
45. Kohlhauser M, Luze H, Nischwitz SP, and Kamolz LP. Historical Evolution of Skin Grafting-A Journey through Time. Medicina (Kaunas). 2021; 57(4): 1-14.
46. Lumbuun RF and Wardhana A. Peranan Eksisi Dini dan Skin Graft pada Luka Bakar Dalam. Cermin Dunia Kedokteran. 2017; 44(4): 249-254.
47. Elfiah U, Perdanakusuma DS, Saputro ID, Riasa IN, Lumintang LM, and Naufal MF. Skin Graft as a Modality Reconstruction of Post-Burn Contractures during Pandemic Area: Case Series. Bali Medical Journal. 2023; 12(1): 244-248.
48. Lee H, Chun W, and Kim G. Three-Dimensional Artificial Skin Construct Bioprinted with a Marine-Based Biocomposite. Biomacromolecules. 2023; 24(6): 2864-2878.
49. Šuca H, Čoma M, Tomšů J, et al. Current Approaches to Wound Repair in Burns: How far Have We Come from Cover to Close? A Narrative Review. Journal of Surgical Research. 2024; 296: 383-403.
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