Skin grafts have remained relatively unchanged since their introduction as a medical treatment for burns/wounds. This paper seeks to open an academic discussion as to whether their use-by date has now been passed. A skin graft substitute is described in a paradigm using fine leaf gelatine sheets which inherently possess several distinct advantages including, discarding the harvest of autologous tissue from patient donor sites. A clinical study will be needed to determine its suitability taken together with the understanding that experimental animal studies may not provide unequivocal answers to its in situ modus operandi.
Skin grafts were introduced in 1869 by Reverdin [
This paper seeks to kick start a reconsideration of skin grafts and introduces a new paradigm which it is hoped will be recognized on its merits for offering a readily available, off-the-shelf, graft substitute which is easy to use, is cheap, and can be re-applied by both medical and nursing staff as treatment gets underway. Also, it expands on the principles described in the author’s previous report on guided tissue regeneration of the human epidermis [
It is well known there is a clinical precedent for using gelatin sponges to staunch bleeding. Using that fact as a springboard leads to the thought of using fine leaf gelatine sheets as a skin graft substitute. At this juncture, the required thickness of the individual sheet is uncertain. It might need to be slightly thicker than the sheets found in the baking goods aisle of supermarkets being sold under commercial brand names, e.g. Dr Oetker™ fine leaf gelatine sheets. A sheet weighs approximately 2.5 grams (Silver grade/160 Bloom) and is Type A gelatin derived from pork skin (See www.modernistpantry.com/gelatin-sheets-silver.html [
1) A fine spray of a suitable mixture of lightweight antibiotics to both sides which will provide a measure of wettability to allow2) Thorough dusting (and subsequent adherence) of pure, sterile, corn starch granules on the total surface area of both sides of the sheet; any excess of which will be gently shaken off.
3) Application to the recipient area of the wound/burn site insuring that additional sheets will overlap half the width of the preceding sheet. It is expected that a lightweight gauze dressing will be gently overlaid with no pressure applied and their ends secured with surgical staples.
4) It is to be hoped that any seepage will be absorbed by the overlapping fine leaf gelatine sheets as well as the corn starch granules and the gauze dressing. Furthermore, with the passage of time and continuous natural airflow, these covering fine leaf gelatine sheets should naturally shrivel and be subject to easy removal.
5) New sheets, prepared as described in 1) and 2) above, will be applied to the wound/burn site. These will have larger perforations at spaced intervals to permit the cell spraying of an autologous mixture of papillary and reticular fibroblasts followed by the spraying on of autologous epidermal brown rosettes [
6) All fine leaf gelatine sheets used in this paradigm may also be embedded with suitable visible markers for bacterial and other contaminants allowing medical/nursing staff to see at first glance whether a wound/burn bed has become infected during treatment.
At the outset, it must be emphasized that these are a set of proposals, bolstered by an underlay of proven scientific principles, being put forward for consideration by the medical community. It is also envisaged that this framework will be improved upon. Certain matters are of necessity, simplified in the absence of a definitive clinical study.
It is worth recalling Turing’s words in 1950 [
…. in spite of modern efforts (author’s italics). Present day skin cell constructs do not reproduce the epidermal brown rosettes in vitro and no skin patches were formulated with that intra-epidermal micro pattern in mind. Both CEAs and cultured skin substitutes are expensive to produce and have their drawbacks e.g. incurring hypertrophic scarring and pigmentation problems in treatment of burns [
Describing her stay (as a Surgical Fellow at Queen Victoria Hospital, East Grinstead, England) in a published report [
Most trauma surgeons will be hard pressed to answer the question: “What is the precise weight, in grams, of the skin graft you are about to deploy?” It has not been considered that the weight of skin grafts in whatever shape or size, plus the application of dressings, might be leading to the “mechanical loading” of damaged tissue. The proposed covering sheets are too lightweight for this consideration to be advanced any further.
Secondly, there is total dependence on plasmatic imbibition for nutritional maintenance of the applied skin graft. The sheets with their cornstarch content will provide an additional carbohydrate source of nutrition for the natural regeneration of the underlying tissue as well as allowing for a measure of absorbance of wound seepage and drainage.
The dermis is not rebuilt as a consequence of skin graft overlay probably because the uppermost layer of the dermis, the papillary dermis layer of the graft is left relatively intact in both fulland split-thickness skin grafts (STSGs). There is therefore, no intercellular interaction or participation of this cellular layer in the subcutaneous architectural rebuild of damaged tissue.
As a result of the successful regeneration of the human epidermis [
It is to be hoped that the similar sort of service as that previously seen in the tissue repair of human epidermis [
In summary, a biodegradable nutritional source/cell scaffold and lightweight antibiotics are being applied to the wound/burn site via appropriate flexible sheets of fine leaf gelatine. These sheets have been used in the preparation of culinary desserts and to provide the gel coating of prescription drug capsules for decades without any contraindications. If manufactured from bone gelatin or from pig skin, official committees have ruled that there is very little chance of transmission of animal diseases to wound beds [11,12]. Hence, this denatured collagen material is also being manufactured as sponges and used clinically to staunch bleeding. It is expected that the cornstarch granules will adhere to the moist wound/burn site. Later on, as clinically required, cell spraying of an autologous mixture of dermal fibroblasts followed by autologous epidermal brown rosettes will be executed. It is paramount that the dressings used are lightweight and not weighing down on the recipient wound/burn site.
It is fervently longed that no future photograph of a healed, burnt buttock would ever again display a rather prominent meshed pattern, a wholly disagreeable cosmetic outcome, as can be seen on the website [
Well-padded dressings, immobilization periods, clinical worry about shear forces on the skin graft, meshing machines may all be confined to historical medical archives if this paradigm were to prove its worth.