One of the main treatment options for skin defects is split-thickness skin grafting (STSG). However, when the surface and depth of the skin defect is extensive, such as in severely burned patients, donor site morbidity limits the available thickness and surface of skin autografts. This necessitates STSG with meshing and expansion of the grafts, resulting in unaesthetic healing and may lead to hypertrophic scars.
In the past two decades, the concept of a bi-layered wound coverage in the treatment of extensive full thickness wounds has become widely accepted (Demling et al. 2007; Nguyen et al. 2010). In this concept, a dermal substitute is used in combination with a STSG. The combined use of a dermal and epidermal analog mimics normal skin anatomy and may therefore improve aesthetic outcome and diminish scar hypertrophy (Pirayesh et al. 2007).
A dermal substitute can be defined as a bio-matrix that fulfills the functions of the normal cutaneous dermal layer. The general requirements of a dermal substitute are protecting the wound from infection and fluid loss and providing a stable and biodegradable template that improves the synthesis of new dermal tissue. The dermal substitute thus provides a scaffold during the healing process to the cells infiltrating the wound bed to promote tissue growth and to enhance wound healing (Lee 2000). This results in newly formed dermal tissue rather than scar tissue which is better able to resist tear forces and is more elastic and thus less painful (van der Veen et al. 2010).
Several dermal substitutes have become available, derived from synthetic or biological materials. The biological materials can either be derived from allogeneic material (human) or xenogeneic material (mainly porcine and bovine). Biological dermal substitutes show high similarity to native dermis and provide a 3-dimensional extra-cellular matrix of collagen and elastin without cells (Shahrokhi et al. 2014). To date, the biological derivates are preferred in clinical practice (Truong et al. 2005; Shahrokhi et al. 2014).
The use of the first human-derived dermal substitute, AlloDerm® was described in 1995 (Wainwright 1995). AlloDerm® is made of human cadaver skin that has been chemically treated in multiple stages to remove all donor cells. Good results have been described on its use, however, the production of AlloDerm® is a complex process and comes at high costs (Reported price in 2013; €21.7/cm2; Butterfield 2013).
In 2008, Richters et al. developed a cost-efficient technique to create an acellular dermal matrix from glycerol preserved allogeneic skin (Richters et al. 2008). The resulting non-profit dermal substitute is available as Glyaderm (Glycerol preserved Acellular Dermis) by the Euro Tissue Bank (ETB-BISLIFE, Skin Department, Beverwijk, The Netherlands). The use of glycerol preservation and Na-OH incubation removes all antigenetic structures and cells.
To date, treatment of full thickness defects with Glyaderm has only been described as a two-staged procedure. In the first stage, Glyaderm is applied to a granulating wound bed and covered by sterile dressings. The second stage, split thickness autografting, is usually performed 5–7 days later (Pirayesh et al. 2015). This protocol has shown to have good clinical outcomes, with better scar quality and aesthetic outcomes compared to STSG alone. The main disadvantage of this protocol is the use of two stages. Glyaderm was introduced in 2017 in the Radboudumc (Nijmegen, the Netherlands) to aid closure of selected full thickness wounds, for instance wounds overlying a joint surface or with a large surface. A new protocol was used, were Glyaderm was applied in a single-staged procedure. This article describes the results of the first ten cases.