Wound bed preparation: approaches to replacement of dermis.

Cultured epidermal autograft (CEA) can provide a valuable source of protection in patients with large amounts of skin loss as a result of thermal injury. An unanswered question is: will the long-term outcome be better if a dermis is present? We have approached the problem by attempting to retain the cryopreserved allograft dermis that is originally placed as temporary wound coverage. The retained dermis provides a substantial, uniform, well-vascularized bed that accepts the CEA. The areas that are grafted with CEA have remained durable, and cosmesis is superior to that which results from meshed grafts. We report experience with our technique in three patients with total body surface area burns of 70% to 90% who had cryopreserved meshed (1:1.5) allografts placed immediately after tangential excision of their burns. Excision and application of the allografts were complete by day 14 or 15. CEA was placed on allodermis on days 24, 28, and 35, respectively. Patients 1 and 2, who survived and returned to work, had a "take" of at least a 90% of allograft and a permanent coverage CEA take of 88% and 81%, respectively. Patient 3, who died, had an allograft take of only 20% to 30% and a CEA take of less than 10%.