Beyond conventional skin grafts: dermal matrices and skin substitutes for deep burns: a systematic review

Background: Deep full-thickness burns are commonly treated with early excision and split-thickness skin grafts (STSG). However, limited dermal replacement may contribute to hypertrophic scarring and contractures. Dermal matrices and skin substitutes aim to provide a vascularizable neodermis that may improve scar quality and functional outcomes.We aimed to evaluate whether dermal matrices or skin substitutes provide superior scar quality, function, and safety compared with STSG in full-thickness burns. Methods: We conducted a systematic review following PRISMA guidelines. We searched MEDLINE/PubMed, Embase, and LILACS from inception through the pre-specified cutoff date. We included randomized controlled trials in adults and children with deep full-thickness burns comparing dermal matrices/skin substitutes (single-stage or two-stage approaches) versus conventional STSG alone/standard grafting. We did not pre-specify a fixed list of products; the interventions reviewed reflect those evaluated in eligible trials. Due to clinical and methodological heterogeneity, meta-analysis was not performed. Risk of bias was assessed using RoB 2. Results: Eight randomized controlled trials were included. In one trial, Novomaix + STSG delayed healing compared with STSG alone (graft take at 5–7 days: 80% vs. 95%; P = 0.003; time to closure: 28 vs. 16 days; P = 0.004). In adults treated with an electrospun PLGA bioveil, no significant differences were observed in graft take (99.0% ± 2.5 vs. 97.9% ± 7.0) or in VSS/POSAS scores at 12 months. In severe pediatric burns, Integra improved aesthetic outcomes at 12 months (Hamilton: 5.4 ± 1.7 vs. 7.7 ± 2.6; P = 0.003). Overall, most trials were judged at high risk of bias. Conclusions: Current evidence does not support routine use of dermal matrices over STSG in acute burn management. These technologies may be beneficial in selected settings (e.g., contracture reconstruction) or when combined with cellular approaches. Future multicenter randomized trials with standardized, long-term (≥ 12 months) functional and aesthetic outcomes are needed. Level of Evidence: Level I, therapeutic study.