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Speaker: [00:00:00] Welcome back to Behind the Knife:

Speaker 2: The Surgery Podcast. I'm Lauren Nasanoff, joining you from the Grady Burn Center in Atlanta, and today we're tackling a topic that comes up on service every single week and gets way less airtime than it deserves: skin substitute use for burn injury

Speaker: Which for that initiated, is not something you can pick up at a Halloween store.

Speaker 3: Wow, 12 seconds in.

Speaker: I've been holding it in all week.

Speaker 2: I'm joined today by Dr. Katie Romanowski, Dr. Victoria Miles, and Dr. Laura Johnson.

Speaker 4: Hi, everyone. Fair warning, three of us are gonna try and teach you something about burn surgery, and one of us is gonna try and make it funny.

Speaker 3: I both resent and resemble that remark.

I'm going to try to make it punny. Oh, no.

Speaker 2: Okay, we're getting somewhere. So let me set the scene. [00:01:00] This is a case that anyone who's spent time in a burn ICU has lived. You've just finished admitting a 22-year-old otherwise healthy male, flame burns from a car fire, 70% TBSA. You've done your ABCs, you've gotten access, you've done escharotomies, you've started fluid resuscitation.

You've bronched him, you've done wound care, you've warmed him up, and you've even updated the very worried family at bedside

Speaker: Okay, okay

Speaker 2: His urine output is trending in the right direction. His blood pressure is holding without pressors. You've put in orders. You've written your H&P. You've touched base with the bedside nurse. You are exhausted.

Speaker 4: You need to drink some coffee. You need to sit down on that stool outside the room and finally rest your feet.

Speaker 2: Exactly. So you're sitting there thinking about this poor guy because admitting a big burn is a lot of [00:02:00] work, but the admission is honestly the easiest part.

Speaker: The rest of his life is really the hard part.

Speaker 2: Right. So you start doing the math. He's 22. He's healthy. He's gonna survive this, but we've gotta get all that burn off of him and cover him somehow with the 30% of the sur- body surface area he has left.

And let's face it, a lot of that unburned skin is on his neck, his face, palms, soles of his feet, scalp and genitals, which is not optimal.

Speaker 4: Mm, the math is not mathing.

Speaker 2: The math is very much not mathing. So how many surgeries is this gonna take? How long in the ICU? And again, how am I going to cover 70% with 30% available?

Your attending did mention skin substitutes when this happened last month, but what does that actually mean? There are [00:03:00] so many products. What do they all do? When do you use one and not the other? Everyone has their own take on this. How do you even begin to wrap your head around it?

Speaker 3: Well, you've got to start with the derma of the problem.

Speaker 4: Ooh, there she goes.

Speaker 2: So that's what we're doing today. We're going to walk you through how we think about this, what we agree on, what we don't, and how to build a framework for these decisions. But before we go anywhere else, we want to pause for something a little unusual. We want to start by disclosing our industry relationships upfront.

Speaker 4: Which we think is really important because this field is a potential minefield of industry involvement. There are so few burn surgeons in this country, and many of us work with industry to ensure our patients are getting the best possible outcomes.

Speaker 2: A lot of the products we're going to talk about today come [00:04:00] from companies that fund research, sponsor meetings, and provide consulting arrangements.

Many of us are actively engaged in industry-funded and investigator-initiated studies. We think you deserve to know what's going in so you can weigh what we say accordingly.

Speaker: Consider some of us influencers, but for dermal

Speaker 4: templates.

Speaker 2: So I'll start. Recently, I've been engaged in contracted research for PolyNovo, Kerecis, and Avita.

Speaker 4: I am also engaged in contracted research for PolyNovo, Kerecis, and Avita

Speaker 3: I am a consultant for PolyNovo, receive royalties for up-to-date surgical nutrition topics, and have done contracted research for Spectral

Speaker: MD. I speak and consult for Avita Medical, Embed Biosciences, Vericel, and PolyNovo, but in lieu of personal compensation, as do my partners, all of our proceeds are directly donated by the companies to our center's burn charity fund to support [00:05:00] outreach, education, research, and survivor programs.

Speaker 2: Fantastic. So keep in mind all of this as you listen. And with that out of the way, let's get into it. I wanna start with what I think of as the holy grail of burn surgery, covering a patient in skin without ever taking a donor site, because donor sites are their own problem, and unfortunately, we are still fairly far from that grail.

Speaker 4: Yes, donor sites hurt.

Speaker 2: They hurt a lot, usually more than the grafted burn.

Speaker 3: And every donor harvest creates a second wound, a wound that has its own risk of infection, its own risk of delayed healing, and its own scar which can sometimes be more bothersome to the patient than their burn scars.

Speaker 4: And in massive burns, like our patient today with 70% involvement, there is simply not enough donor skin.

You can reharvest, but reharvesting takes [00:06:00] time, and the skin quality is never as good. Ultimately, it takes a toll on the donor site to continuously reharvest.

Speaker 2: And on the patient. So that's what's driving so much of this innovation in this space. The dream is to cover a burn without ever making a second wound

Speaker 3: Unfortunately, we're not there yet, but we are getting closer.

Speaker 2: So I wanna introduce to you the mental model I use when I'm explaining this to patients and families. Burn surgery is basically one of those little mazes you did as a kid in a restaurant. You know, on the paper place mat next to the tic-tac-toe.

Speaker: Crayons and everything.

Speaker 2: Exactly. At the beginning of the maze, there's a burn. At the end of the maze, the patient is covered in their own skin. Every path through the maze has to start with removal of the burned tissue. That's always the entrance. But beyond that, there are lots of options that vary in [00:07:00] complexity, depending on the specifics of the patient and their

Speaker 4: burn.

For a small, straightforward burn, the maze is really short. Excise, autograft, done.

Speaker 2: Right. But for our 70% guy, the maze gets really complicated really fast, and that's when we start reaching into our toolbox and pulling out all these tools, sometimes several, that help us construct the pathway through

Speaker 3: And here's the point that I really want everyone listening to internalize, because I see residents and fellows get this wrong all the time.

Skin substitutes are not skin. They do not replace the patient's own skin.

Speaker: Honestly, this is where the marketing and the medicine diverge. Skin substitute is almost a misnomer.

Speaker 2: Right. As of 2026, the reality is the patient's own skin, autologous tissue, [00:08:00] is still required for definitive coverage. Everything else we use is a tool, a bridge, a strategy.

It is not the end point.

Speaker 4: However, when you say skin substitute out loud, patients and families almost always hear magic skin.

Speaker: And residents too, they hear magic skin. But unfortunately, there is no magic skin.

Speaker 2: Someday, maybe,

Speaker 3: but today is not that day.

Speaker 2: So what are these products doing for us if they're not replacing skin?

Speaker 4: We're temporizing. We're optimizing the wound bed. We're expanding limited donor resources. Essentially, we're buying time, which hopefully means preventing infection, minimizing fluid loss, and sometimes decreasing pain for early mobilization and other therapeutic interventions.

Speaker 3: Unfortunately, only sometimes.

Speaker 4: Sometimes, not consistently. But again, the goal here is to [00:09:00] improve functional outcomes.

Speaker 2: Right. So we need a shared vocabulary before we start talking about specific products. And I want to start with the concept of the ideal skin substitute, because we know nothing we have meets every criterion, but the criteria are still how we're going to compare what we do have

Speaker 3: So if we ran the world, and we all agree that we should, what would perfect look like?

Speaker 2: Well, to start, perfect would be rapidly adherent to the wound bed, highly resistant to infection. It would serve a barrier function, so fluid, thermal, microbial, things that need to stay in, stay in, things that should stay out, stay out. It should be durable in the short term, and eventually lead to a grafted region that's pliable and mobile.

Speaker: Pliable and mobile, as opposed to the alternative, which is like a leather jacket.

Speaker 2: Which honestly is what a lot of these products give us if we [00:10:00] don't sequence things right. Also add on low antigenicity, which is gonna favor regeneration over scarring.

Speaker 4: And don't forget the practical side of things. It needs to be off-the-shelf available, it should have a long shelf life, and be temperature stable so you're not, not managing a minus 70 freezer.

It should always also be easy to apply and affordable. Don't forget the cost of this. When we're covering 20,000 plus square centimeters, a product that is $40 per square centimeter is not a sustainable option.

Speaker 3: And this one is somewhat underrated: it would be great if it could be see-through so you can expect, inspect the wound bed underneath.

Speaker: So this is all wonderful, but we all know that we're describing a product that definitely does not exist.

Speaker 2: Exactly. Nothing hits all of these. But again, when you're comparing two options, this is your rubric.

Speaker: It's kind of like listing the ideal partner. At some [00:11:00] point you have to just pick, and they're never gonna meet all of your metrics.

Speaker 2: Right. So now the question is, with the hundreds of products on the market that do exist, how do we start to organize our thinking? I use a four-axis framework.

Speaker: This is where the flow chart starts. If you haven't figured it out yet, burn surgeons are often mathematically inclined, meticulous, and quite algorithmic.

Speaker 2: Definitely. So axis one: what layer does the product replace? Epidermal, dermal, or composite, meaning a bilayer that includes both.

Speaker 3: Because those are your two layers of skin. Epidermis on top, dermis underneath. Some products replace one, some replace the other, and some try to do both.

Speaker 4: Mm. Axis two: is it cellular or acellular?

Acellular is just the scaffold. Cellular has living or cryo-preserved cells built into it. [00:12:00]

Speaker: Live cells are an empty scaffold, like a hotel with people versus an empty Airbnb.

Speaker 2: Love it. Axis three: origin. Where does the material come from? Is it autologous, so from the patient; allogenic, from another human; xenogenic, from another species; synthetic, fully manufactured; or biosynthetic, a hybrid.

Speaker 4: And of course, these categories carry different risk profiles with them, including infection transmission risk, immunogenicity, and cost.

Speaker 2: Right. And then axis four: duration. Is this something that's temporary, meaning it will be rejected, resorbed, or physically removed at some point, or is it we- we'll say permanent, meaning it becomes incorporated into the patient?

Speaker 3: And this is another area where residents tend to get tripped up. Some products get called permanent, but their [00:13:00] dermal scaffold is actually resorbing over time. It's the neodermis that grows in, that's the permanent part. So the thing itself isn't permanent, but the effect it has on the patient is.

Speaker: The skin setup dies, but its legacy lives on.

Speaker 4: Ha. Deeply, deeply moving.

Speaker 2: Oof. Well, the point is layer, cellularity, origin, duration. Every product on the market fits somewhere on that grid. Every one Okay, so we have a framework for the products, but now we need a framework for the patient. What are we thinking about when we're deciding which of these tools to reach for?

Speaker: Everything is concerning in a massive burn.

Speaker 4: I'm definitely concerned.

Speaker 2: So yes, everything. We have to think about everything. But let's structure the everything. Four categories again: wound factors, patient factors, phase of [00:14:00] care, and goal.

Speaker 3: Can we start with wound factors first?

Speaker 2: Definitely. So first, how deep is the burn?

Is it superficial partial, deep partial, or full thickness? How big is it? What's the total body surface area? Where is it? Because face, hands, joints, all of these demand different things from us, both cosmetically and functionally. How old is the burn? Is it fresh presentation versus a patient who's been sitting around for a week getting kind of crusty?

And then finally, etiology. Is this thermal, chemical, electrical

Speaker 4: Moving on to patient factors, we know that age matters. Comorbidities also matter: diabetes, smoking, peripheral vascular disease, chronic edema. All of these change what your wound bed is capable of doing. Donor site availability is a big factor, as is the immune [00:15:00] status of the patient.

And then finally, critical illness. Is this a patient stable enough for a multi-hour operation, or do we need to do this over multiple staged procedures?

Speaker: And really, every one of these aspects shifts your decision-making as a burn surgeon. And

Speaker 3: looking at phase of care is important, too. Are we in the emergent phase, just trying to get coverage on this wound?

Are we doing acute definitive closure? Or are we six months out dealing with a contracture that we're trying to reconstruct?

Speaker 2: And then, of course, we have to consider: What's the goal? What are we actually trying to accomplish with this particular product on this particular wound at this particular time?

Are we looking for a temporary barrier, dermal regeneration, definitive epidermal replacement?

Speaker 4: And I would argue the goal is perhaps the most important one of these factors, because the goal drives every other decision.

Speaker: If you don't know what you're [00:16:00] doing, you really don't know what to use.

Speaker 4: Right.

Speaker 2: Right.

Which brings me to something I want to make explicit for the residents and fellows listening. You're not actually restricted to using one tool at a time. Combination is the game. Some of the most interesting practices in modern burn surgery involve combining a dermal template with an autologous skin cell suspension, or applying a template first to build a wound bed and then coming back with a widely meshed autograft over it.

Speaker 4: Or a template plus sheet graft in cosmetic areas where you want an unmeshed result.

Speaker 3: We're painting by numbers. Or, sorry, we're not painting by numbers, we're mixing colors.

Speaker 2: The Bob Ross

Speaker: of skin substitutes.

Speaker 2: So now we're artsy mathematicians and mixing our metaphors. Okay, then. But when we're building a plan for a big [00:17:00] burn, the main thing is don't think just about which single product to use.

It's all about sequence. Think about combination So now that we've picked our product, we've done the case, we're feeling good, how do we know we did the right thing? How do we measure success

Speaker 3: Take. Take is king. Graft take and substitute take is the first thing you need to consider

Speaker: Did the skin sub stick?

Speaker 2: Did it stick? Beyond this, gotta look at the infection rate, time to healing or closure, and scar quality. There are actually objective scales for this, the POSS as being the most common. Also, functional outcomes, and again, cost.

Speaker 4: And every single one of those is measured exactly the[00:18:00]

sa- oh, wait, no. Slightly to- Definitely not ... dramatically differently. Slightly to dramatically differently across studies, which is why, a big reason why it's so hard to compare products in the literature.

Speaker 3: Yeah, the endpoints in these studies are not standardized. They have not accepted common data elements yet at all.

Speaker 2: Not even close. So when you're reading a paper that says product A is better than product B, you have to look at the endpoint. Sometimes they're comparing really different things, which actually brings me to the elephant in the room, which is this is really hard.

Speaker: It's really, really hard to choose the appropriate skin substitute.

Speaker 2: Three things make it hard, I would say. Number one, again, the data. What data do we have to support these decisions? The RCTs are limited. A lot of the evidence base is retrospective, single center, and industry studied.

Speaker 4: And this is where we raise the awareness of [00:19:00] industry issues, because so much of the innovation in this field is being driven by industry, which is not necessarily a bad thing.

A lot of really good products have come out of that drive and the partnership with physicians who are interested in this space, but it means we all have to be thoughtful readers.

Speaker 3: And we also have to really look at who funded the study before making any conclusions.

Speaker: And who's giving the talk at the conference.

Speaker 4: And be honest about what our own experience has taught us versus what a randomized trial may actually have shown.

Speaker 2: In addition to the data, absolutely. So number two is experience. There are so many products, so many considerations. Y- you do actually need the reps, which is one of the reasons the burn community is small and tight.

We learn from each other because there isn't a good textbook that keeps up with the field. We all don't just hang out once every couple months putting together [00:20:00] a podcast. We call each other on a regular basis saying, "What would you do for this? What, how would you handle this problem with this product?"

Or, "I don't know what to do next. Help me."

Speaker 3: Number three, the landscape is always changing. There's new products, mergers, discontinuations, expanded indications, natural disasters. All kinds of things can limit what you have available to you at any given time, and there's no good central repository of what's even currently available on the market really.

Speaker 2: Which is honestly part of why we made the supplementary table for this episode, so you have some kind of reference

Speaker: Behind the knife, providing the screenshots you didn't know you needed. Even today we had to adjust the table for a product that is no longer available.

Speaker 2: Exactly. All right, as we wind down, a few quick hits. [00:21:00] Fast questions, short answers. Katie, kick it off.

Speaker 3: Rapid fire ready.

Speaker 2: So how do you factor in cost?

Speaker 4: So I think here you have to think about your institutional formulary first.

What do you actually have available? Acquisition cost per unit area is important, but you have to think about the total episode cost too. Sometimes a more expensive product saves you a reoperation or a hospital day, and that's worth more than the sticker price, even if the C-suite takes some convincing.

Speaker: Cheap is not always cheap. If you have to remove a product and, and replace it three times, it's no longer cheap. We have some of those on the market now, and that's three episodes of general anesthesia for your patient. We also need to remember that staff familiarity is important. If you use too many different products, you'll never have good outcomes.

You and your staff need to know how to take care of a skin substitute to reach an optimal outcome.

Speaker 2: That's a good [00:22:00] point. Okay, on a different note, why does it matter so much to get a seal after a major burn excision?

Speaker 3: It's a, it's all about fluid loss, evaporative losses, and heat loss. You have just excised a huge area.

The patient is now leaking proteinaceous fluid and losing body heat. You need to get the area covered so that the patient can, uh, do, uh, do better.

Speaker: Getting seal stabilizes nutrition. It prevents infection and prevents renal failure.

Speaker 2: Absolutely. Okay, next question. Why do you think we are shifting more towards non-biologics?

Speaker: Longer shelf life, room temperature storage, no sourcing issues, better price point, durable when exposed to an infected wound bed.

Speaker 4: And let's not forget comparable outcomes in a lot of head-to-head studies.

Speaker 2: Where I would push back a little is the claim that [00:23:00] non-biologics have less hypertrophic scarring because of decreased immunogenicity.

Cost also depends on multiple factors. It's not universally cheaper

Speaker 3: However, there are g- there is good evidence for low infection rates with several synthetics, which I think is one of the biggest drivers to their use.

Speaker: The synthetics have really come up in the last five years. As opposed to Lauren, I'm still in the camp that I think synthetic use results in less hypertrophic scarring, but that's not yet been proven, so neither of us is right.

Speaker 2: Neither or everyone. But, you know. Next question. When you're grafting on a fat bed, do you have to do a round of skin substitute first before autografting?

Speaker 4: Ooh, it depends on the fat. If it's healthy, well-vascularized subcutaneous tissue, you can often graft directly. But if it's compromised or a burn bed with poor vascularity, exposed structures, then a dermal template first is a good idea.[00:24:00]

Speaker 3: And it's important to remember that fat is not the same as fascia.

Speaker: It also depends on the patient. Can they tolerate a two or three-stage operation? What's their cardiopulmonary status?

Speaker 3: And now for the hard part, and what every one of our listeners has been waiting to hear. What skin substitutes are you currently using, for what indication, and why?

Speaker: Allograft meshed cadaveric donor is my temporizer, although I am shifting to using Avita's PermeaDerm, a synthetic, in its place. The price point is superior, it's shelf stable, and we've seen similar outcomes. I'm interested in trialing Smith & Nephew's BioBrain for this purpose as well. For full thickness wounds that are adequately debrided, trauma or burn, I use biodegradable temporizing matrix or PolyNovo BTM.

For tunneling or undermining, I use PolyNovo MTX, which is BTM without the sealing membrane. [00:25:00]

Speaker 3: Great minds think alike. That is almost exactly what I do. Although I've not had the chance to use PermeaDerm yet, but I want to.

Speaker 2: I also have historically used a lot of allograft, but I'm increasingly looking toward alternatives.

We also have worked with PermeaDerm to variable effect, and I'm still figuring out quite where I think it works best. Currently, I'm a big fan of the Acellular Matrix, ACM, from MPM Medical, both for coverage and for their antimicrobial effects. It seems to be very effective in a wound bed that even has fungus and mold in it.

For wounds that need dermal buildup, I reapply BA- BTM often, reserving the biologic Integra from Integra Life Sciences primarily for recon purposes, 'cause I do think it limits secondary contracture.

Speaker 4: Ooh, I'm glad I get to go last so I can use all the abbreviations I want to. I'm still a one-and-done surgeon where [00:26:00] possible, but in acute burn cases I use one-to-one meshed allograft, with BTM as my option for deeper excisions.

I'm increasingly using ACM in wounds with questionable cleanliness, as Lauren mentioned, um, but I also, um, love to use amnion in products, uh, a- amnion products where necessary for facial healing. I'm glad that Integra's Primatrix is back on the market. I think it'll work really well for our less clean traumatic wounds, and I still use Integra for outpatient reconstructions when I need something

Speaker 2: All right, everybody.

That is our roundtable on skin substitutes for burn injury. We hope this gave you a framework for thinking about the problem, because we definitely didn't cover every product on the market. That would take us hours

We do have, as we mentioned, a supplementary reference table with the show notes that places every commercially available skin substitute that we could list on the four axis grid we walked through today. [00:27:00] So product names, composition, typical burn applications, relative cost tiers, and a full reference list

Speaker 3: So thankfully, you don't have to trust our memory.

Speaker 2: Thank you again to Katie, Victoria, and Laura for joining me today.

Speaker 4: Thanks, Lauren.

Speaker 3: Thanks, everyone. And don't forget to

Speaker: dominate

Speaker 2: the day.