Thermoregulation in burn patients during exercise.

The purpose of this study was to assess the ability of patients with burns on 30 to 40% and 60% or greater of their BSA to thermoregulate their core temperature during exercise in the heat. Two groups (n = 3 in each) of subjects with healed third-degree burns (34.0 +/- 1.4% and 77.7 +/- 12.4%, respectively) and a group of unburned subjects (n = 2) exercised for 1 hour on a cycle ergometer at 75 Watts in an environmental chamber set at 35 degrees C and 60% relative humidity. Subjects were monitored for rectal and skin temperatures, heart rate, whole body sweat rate, skin blood flow, and active sweat gland density (number per cm ) in unburned, burned, and harvested skin. The results demonstrated that patients with burns on 60% or greater BSA did not show an intolerance to moderate exercise in the heat, as evidenced by only a moderate rise in rectal temperature and heart rate. Furthermore, the responses were similar to those of the unburned subjects.

A multicenter clinical trial to evaluate the topical hemostatic efficacy of fibrin sealant in burn patients.

Current surgical management of deep partial-thickness and full-thickness burn wounds involves early excision and grafting. Blood loss during these procedures can be profound, thus prompting the use of topical hemostatic agents to control and minimize hemorrhage during grafting. The primary endpoint of this multicenter trial was to evaluate the efficacy of fibrin sealant as a topical hemostatic agent during skin grafting. The secondary endpoint was to obtain data to support the existing safety profile of a human fibrin sealant (FS) in participating patients as indicated by the type, severity, and frequency of any adverse events within the 24-hour postoperative period. A multicenter prospective, open label, Phase III multicenter, randomized, comparative clinical trial evaluated the use of fibrin sealant in burn patients undergoing skin graft procedures. Each patient served as his or her own control in this randomized, unblinded study of the effect on time to hemostasis in donor sites treated with the investigational FS product. At operation, 1 contiguous donor skin harvest site was bisected into 2 equal halves, 1 of which was then randomly selected and treated with fibrin sealant. At the end of the fibrin sealant application, the time to hemostasis in each of the donor site halves was identified by the operating surgeon and recorded by the research coordinator. The use of any other topical hemostatic agents was prohibited. A significant difference (P < .001) was demonstrated in the mean time to hemostasis between the fibrin sealant treated donor sites when compared painwise to the control sites. The significant difference was consistent across the 6 participating study centers. There were no adverse events associated with the use of fibrin sealant. The investigational FS product was shown to be efficacious, because it significantly decreases the time to hemostasis at the donor skin harvest site in patients undergoing skin grafting and was noted not to cause any adverse reactions.

Enteral nutritional support and wound excision and closure do not prevent postburn hypermetabolism as measured by continuous metabolic monitoring.

BACKGROUND: Estimation of nutritional needs in burn patients is difficult. In 24 severely burned patients, we measured CO2 production and O2 consumption continuously during their period of mechanical ventilation. METHODS: Patients with extensive burns were placed on a continuous metabolic monitor (CMM) (Puritan Bennett Co., Kingwood, TX), and metabolic expenditure was recorded each 24 hours. High protein enteral feedings were started within several hours of admission, and administration rates were adjusted to meet daily caloric demands as determined by the CMM. Full-thickness wounds were excised as early as patient condition permitted, and wounds were closed with autograft, allograft, or TransCyte (Advanced Tissue Sciences Inc., La Jolla, CA). Daily 24-hour caloric needs as measured by CMM were compared with baseline caloric needs predicted by the Harris-Benedict equation and also compared with actual daily caloric intake. Patients were removed from study when they were off continuous mechanical ventilation. RESULTS: A total of 24 patients were studied, with a mean age of 46 years and a 44% total body burn size (partial- and full-thickness). All full-thickness burns were completely excised by a mean of 6.5 days postburn. Mean daily energy expenditures remained elevated through the duration of the study period (42 days), with a mean elevation of 184.9% of baseline as predicted by Harris-Benedict equation. Patients received enteral feedings, which met 99.4% of actual caloric needs as predicted by CMM during the study period. CONCLUSION: Continuous metabolic monitoring demonstrates that early wound excision and wound closure, coupled with aggressive enteral nutritional support with high protein formulas, do not prevent the marked hypermetabolism that accompanies thermal injury.

Bioactive interleukin-8 is expressed in wounds and enhances wound healing.

BACKGROUND: Wound healing is a sequential biological process that involves the integration of chemotaxis of neutrophils, mitosis and migration of keratinocytes, and remodeling of the scar, all of which are regulated by specific soluble mediators. To modulate wound healing specific mediators have to be identified and functionally characterized. Therefore we addressed this study on the polymorphonuclear leukocyte (PMN) attractant interleukin-8 (IL-8) and its function in epidermal wound healing. MATERIALS AND METHODS: Peptide purification, bioassays for PMN chemotaxis, and sequential IL-8 measurements were performed on human wound fluid from burn blisters and skin graft donor sites. Histology for IL-8 immunoreactivity was included. In vitro human keratinocytes were assayed for proliferation, migration, and integrin expression after IL-8 treatment. Wounding experiments with topical IL-8 were performed in a chimeric mouse model. RESULTS: IL-8 was found to be the major bioactive chemoattractant for PMNs in human blister and skin graft donor site wound fluids (mean levels ranging from 173 ng/ml Postoperative Day (POD) 1 to 2130 ng/ml (POD 5)). Released intracellular epidermal IL-8 immunoreactivity at the wound edge was considered as an immediate source of IL-8 while NH(2)-terminal analysis revealed the 77-amino-acid residue form as a second source of IL-8 possibly PMN derived. In vitro experiments on the effect of recombinant human (rh) IL-8 on keratinocyte proliferation revealed a rise in cell number (4.8-fold, ED(50) = 0.6 ng/ml), which was accompanied by an increase in cells in S phase and overexpression of the integrin subunit alpha6. In vivo topically applied IL-8 (1 microg/ml) on human skin grafts in a chimeric mouse model enhanced reepithelialization in IL-8 treated animals over controls due to elevated numbers of mitotic keratinocytes. Wound contraction was significantly diminished by topical IL-8. CONCLUSIONS: These results indicate the sequential function of endogenous IL-8 in all phases of human wound healing. Topical IL-8 may be useful in impaired wound healing.

Fibroblast sheets enable epithelialization of sounds that do not support keratinocyte migration.

Keratinocyte migration over the wound bed is the single most important parameter for wound epithelialization. Therefore, improvement of the wound bed matrix holds considerable promise for the shortening of hospitalization time in patients with ulcers, burns, and chronic wounds. We investigated wound epithelialization in athymic mice in the presence or absence of a sheet of cultured human fibroblasts. The physiology of keratinocyte growth on fibroblast sheets was investigated in tissue culture using histology, immunofluorescence, and electron microscopy. Keratinocytes from human skin explants were unable to attach or migrate on full-thickness dorsal wounds of athymic mice. Placement of a fibroblast-seeded polyglactin mesh on the wounds resulted in dramatically increased keratinocyte outgrowth. Similarly, human keratinocytes showed good outgrowth on fibroblast sheets at the air/liquid interface in tissue culture. Outgrowth was correlated inversely with fibroblast viability, indicating that the observed effect was due to the complex extracellular matrix secreted by the fibroblasts and matrix-bound growth factors rather than ongoing growth factor release. Collagen IV, a promoter of keratinocyte migration, was found to be abundant in the fibroblast-derived matrix. This study demonstrates that wounds which are unable to support keratinocyte migration can undergo epithelialization if a conducive substrate, supplying appropriate extracellular matrix and/or matrix-bound growth factors, is applied.

A comparison of the outgrowth potentials of split-thickness skin grafts sectioned by scalpel, mechanical mesher, and CO2 laser.

Mechanical meshers that press blades through immobilized skin are routinely used to expand split-thickness skin grafts, and scanned incisional lasers are currently under investigation for the same purpose. However, in contrast to the atraumatic wound edge that is created on these grafts by a sliding scalpel blade, the skin "crushing" and skin coagulation that can occur with the use of mechanical meshers and lasers are thought to reduce the outgrowth potential of the epidermis. With the use of an in vitro explant outgrowth system, epithelialization derived from wound edges that were created by a scalpel, a mechanical mesher, and a CO2 laser at various settings was studied. The area of epithelialization around skin explants was not significantly different for skin bridges produced by scalpel cuts and those produced by the skin mesher, and histologic sections demonstrated similar epiboly-growth under these explants. In contrast, wounds created with the CO2 laser showed impaired epithelialization. Incisions were made at several power settings, ranging from 11 passes at 4 mW to 1 pass at 24 mW. Only minor differences were demonstrated, with the lower laser power yielding slightly better results. Recruitment of keratinocytes into the proliferative state, as assessed by bromodeoxyuridine incorporation, was equivalent for scalpel and mesh cut skin. This data does not support concerns about decreased graft viability resulting from the crushing blade action used by mechanical meshers. The possibility of cutting and meshing skin grafts with lasers of the far-infrared and mid-infrared light spectrum are discussed.

Safety and efficacy of TransCyte for the treatment of partial-thickness burns.

Standard treatment for extensive partial-thickness burns in the United States and in much of the world involves the application of topical antimicrobial agents and repetitive wound débridements and dressing changes. We evaluated a new biologic wound covering, TransCyte (Advanced Tissue Sciences, La Jolla, Calif, formerly marketed as Dermagraft-Transitional Covering), for the treatment of partial-thickness burns. This material is composed of human newborn fibroblasts which are then cultured on the nylon mesh of Biobrane (Dow B. Hickam, Inc, Sugarland, Tex); the thin silicone membrane bonded to the mesh provides a moisture vapor barrier for the wound. A prospective, randomized, comparison study of silver sulfadiazine and TransCyte was performed with the use of paired wound sites on 14 patients. Wounds treated with TransCyte healed more quickly (mean 11.14 days to 90% epithelialization vs 18.14 days, P = .002). A noncomparison evaluation was then done for an additional 18 patients, and it confirmed excellent wound healing and an absence of infections. There were no infections in the 32 wound sites treated with TransCyte. In the first study group, late wound evaluations (3, 6, and 12 months postburn) were performed with use of the Vancouver Scar Scale. The results indicated that wound sites treated with TransCyte healed with less hypertrophic scarring than sites treated with silver sulfadiazine (P < .001 at 3 and 6 months, P = .006 at 12 months).

Bilateral facial nerve paralysis after high voltage electrical injury.

A case of bilateral facial nerve paralysis of a patient who received a high voltage electrical burn is presented. This is an extremely unusual neurologic condition and has not been previously reported in association with electrical injuries. The patient regained nearly complete neurologic function several months after the incident.

Comparison of resuscitation with diaspirin crosslinked hemoglobin (DCLHb) vs fresh blood in a rat burn shock model.

Diaspirin crosslinked hemoglobin (DCLHb; Baxter Healthcare Corp, Deerfield, IL) is hemoglobin-based oxygen carrier which, in our laboratory, improved hemodynamic parameters in a rat burn shock model. Our objective was to compare the effects on hemodynamic parameters and metabolic acidosis of resuscitation with different doses of fresh blood (FB) vs DCLHb. Male Wistar rats (200 to 250 g), surgically prepared for an acute study, were randomly assigned to one of five treatment groups. (n = 8): I. SHAM (not burned, not resuscitated), II. DCLHb 2 ml/kg/% Total Body Surface Area (TBSA) burn and 2 ml/kg/% TBSA burn of Lactated Ringers (LR), III. DCLHb 1 ml/kg/% TBSA burn and 1 ml/kg/% TBSA burn of LR IV. FB 2 ml/kg/% TBSA burn and 2 ml/kg/% TBSA burn of LR V. FB 1 ml/kg/% TBSA burn and 1 ml/kg/% TBSA burn of LR After placement of indwelling catheters, the following baseline hemodynamic values were obtained mean arterial pressure (MAP), cardiac output (CO), stroke volume (SV), systemic vascular resistance (SVR) and base excess (BE). The animals were immediately intravenously resuscitated after receiving a 30% scald burn and were followed for 6 hours. Resuscitation was based on the Parkland formula. Blood was obtained from donor male Wistar rats. The animals were euthanized at 6 hours. MAP remained within normal range in all groups. The SVR, CO, SV and BE were normalized earlier in the LR-DCLHb groups when compared to the LR-FB groups (p < 0.05). Early resuscitation with DCLHb is superior to FB in improving hemodynamics in this model. There appears to be a direct relationship between dose and effect with the use of DCLHb. DCLHb could be useful in decreasing resuscitation fluid requirements in acute burns without compromising general tissue perfusion.

Multicenter trial to evaluate the safety and potential efficacy of pooled human fibrin sealant for the treatment of burn wounds.

OBJECTIVE: The primary purpose of this multicenter study was to evaluate the safety and potential efficacy of a solvent/detergent-treated commercial fibrin sealant (human) for topical hemostasis in skin grafting. METHODS: The study involved a prospective evaluation of changes in viral titers in patients with burns less than 15% after treatment with fibrin sealant (human). Each patient served as his/her own control for an unblinded, randomized comparison of donor site hemostasis and healing. Preoperative serum was obtained to screen for viral titers. At autografting, the recipient site and one of two randomly chosen donor sites were treated with fibrin sealant (human). The use of other hemostatic agents, including epinephrine was prohibited. Each donor site was covered with gauze to collect blood for estimation of the relative amount of bleeding. The healing of the graft and donor sites was observed. Viral titers and wounds were checked monthly for 6 months, and at 9 and 12 months postoperatively. RESULTS: Viral titers for human immunodeficiency virus; hepatitis A, B, and C; Epstein-Barr virus; and cytomegalovirus were obtained before and after treatment. Of 47 patients, 34 completed the full year of observation. After treatment, there were no seroconversions to any of the aforementioned viruses. Bleeding at the recipient site appeared well controlled with fibrin sealant (human). Although investigators felt that fibrin sealant (human) improved donor site hemostasis, differences in hemoglobin measurements of blood-soaked dressings failed to reach significance. No differences were noted with regard to acceleration of donor site healing, graft take, or scar maturation at the two groups of donor sites. Anecdotally, the maturation of the recipient site appeared to be accelerated. CONCLUSION: Fibrin sealant (human) is safe for use during excision and grafting, and its topical hemostatic potential needs to be examined in patients with larger burns. Its role in scar maturation also needs to be investigated.

The effects of diaspirin cross-linked hemoglobin on hemodynamics, metabolic acidosis, and survival in burned rats.

OBJECTIVE: Diaspirin cross-linked hemoglobin (DCLHb) is a vasoactive hemoglobin-based oxygen carrier or "blood substitute" that has been shown to improve base deficit in several experimental studies of hemorrhagic shock. Our objective was to determine if the addition of DCLHb to the resuscitation regimen would improve hemodynamic parameters, metabolic acidosis, and survival in our rat burn shock model compared with currently used resuscitation therapy. METHODS: This was a randomized, controlled, experimental rat study. Male Wistar rats, weighing 200 to 250 g, were surgically prepared for an acute study. After placement of indwelling catheters, baseline hemodynamic values (mean arterial pressure, cardiac output, systemic vascular resistance, stroke volume, and base excess) were obtained. Thirty-two rats were used in the study, and they were either subjected to a 30% scald burn (experimental group) or sham burned (control group). The experimental animals were immediately intravenously resuscitated and followed for 6 hours. The resuscitation was based on the Parkland formula (4 mL/kg for each 1% of total body surface area [TBSA] burn), with 50% of the calculated fluid amount to be administered at a constant rate during the first 8 hours after burn. The animals were resuscitated for 6 hours and received between 9.00 and 11.25 mL of fluid depending on weight. The experimental animals were randomly assigned to one of three treatment groups: group I, lactated Ringer's solution; group II, lactated Ringer's solution-human serum albumin; group III, lactated Ringer's solution-DCLHb. Group I (n = 8) received 4 mL/kg lactated Ringer's solution for each 1% of TBSA burn. Group II (n = 8) received 2 mL/kg lactated Ringer's solution and 2 mL/kg human serum albumin for each 1% of TBSA burn. Group III (n = 8) received 2 mL/kg lactated Ringer's solution and 2 mL/kg DCLHb for each 1% of TBSA burn. The sham group (n = 8) was not burned and was not resuscitated. Animals that survived up to 6 six hours were killed. RESULTS: We found that mean arterial pressure, cardiac output, stroke volume, and base excess were all improved in the DCLHb-lactated Ringer's solution-treated animals compared with the other experimental treatment groups. The 6-hour mortality rates were zero of eight (lactated Ringer's solution-DCLHb group), zero of eight (sham group), three of eight (lactated Ringer's solution-human serum albumin group), and six of eight (lactated Ringer's solution only group). CONCLUSION: Early resuscitation with DCLHb is superior to non-oxygen-carrying resuscitative fluids in improving hemodynamics and survival in this model of burn shock. DCLHb might improve general tissue perfusion in the acute postburn period, and it could be useful in the early management of patients with severe burns.

Skin replacements.

There is much progress to be made to optimize the development of laboratory-grown temporary and permanent skin replacements. Replacement of both epidermal and dermal layers is important for achieving optimal take of cultured grafts and for optimizing the quality of wound healing. Although the use of retained cadaver allodermis on the wound bed may improve the performance of cultured epithelium, the development of successful, complete dermal-epidermal skin replacements (composite grafts) would greatly simplify burn management. In the future, handling and stability of the cultured grafts should be improved, and clinical outcomes should be expected to be superior. Unfortunately, funding for this type of applied research has not achieved high priority from the federal government granting agencies, despite the great clinical need for improved technology. Future progress depends largely upon commercial support.

Enteral nutritional support in burn patients.

Early and continued nutritional support has been determined to be an important component of therapy for seriously burned patients. The hypermetabolic response to severe injury requires increased calorie and protein intake to blunt the catabolism and loss of lean muscle mass. Enteral feeding has been found to directly nourish the gastrointestinal tract and may help reverse the defective gut barrier which accompanies burn shock. In contrast, intravenous nutritional support appears to lack effectiveness in burn patients and may actually increase morbidity and mortality.

Acellular human dermis promotes cultured keratinocyte engraftment.

In full-thickness skin injury, loss of dermis may result in compromised wound repair, including contracture, hypertrophic scarring, and wound breakdown. This report examines the effect of an acellular dermal matrix on in vivo skin repair. Human keratinocytes cultured onto a synthetic hydrophilic dressing were applied with (N = 9) and without (N = 11) an acellular dermal matrix to full-thickness skin defects on athymic mice. Host cells progressively repopulated the acellular dermal component of the grafts. All animals with dermal matrix revealed fully differentiated epidermis by postoperative day 21. Human keratinocytes persisted in all animals grafted with dermal matrix, compared to only 63.6% of those animals without a dermal component. Planimetric analysis revealed significantly reduced wound contraction (p = 0.016) in animals receiving the dermal matrix. Histologic, immunohistochemical, and electron microscopic analyses also were performed. These studies suggest that an acellular dermal matrix can effectively direct regeneration of normal skin morphology.

Functions of the POU domain genes Skn-1a/i and Tst-1/Oct-6/SCIP in epidermal differentiation.

Here we report on investigation of the role of the POU domain genes Skin-1a/i (Skn-1a/i/Epoc/Oct-11) and Testes-1 (Tst-1/Oct-6/SCIP) in epidermis where proliferating basal keratinocytes withdraw from the cell cycle, migrate suprabasally, and terminally differentiate to form a multilayered, stratified epithelium. The expression of the Skn-1a/i and Tst-1 genes is linked to keratinocyte differentiation in vivo and in vitro, whereas the ubiquitous POU domain factor Oct-1 is expressed highly in both proliferating and post-mitotic keratinocytes. Analysis of Skn-1a/i gene-deleted mice reveals that the Skn-1a/i gene modulates the pattern of expression of the terminal differentiation marker loricrin and inhibits expression of genes encoding markers of the epidermal keratinocyte wounding response. Although epidermis from Tst-1 gene-deleted mice develops normally, epidermis from mice deleted for both Skn-1a/i and Tst-1 is hyperplastic and fails to suppress expression of K14 and Spr-1 in suprabasal cells when transplanted onto athymic mice. This suggests that Skn-1a/i and Tst-1 serve redundant functions in epidermis. Therefore, at least two POU domain genes, Skn-1a/i and Tst-1, serve both distinct and overlapping functions to regulate differentiation of epidermal keratinocytes during normal development and wound healing.

Role of melanoma growth stimulatory activity (MGSA/gro) on keratinocyte function in wound healing.

Melanoma growth stimulatory activity/gro alpha (MGSA), a member of the alpha-chemokine family, is produced by a variety of dermal and epidermal cells and can act in a paracrine and autocrine fashion. However, little is known about the importance of MGSA in wound healing. In this study, we quantified the levels of MGSA protein in burn blister and donor site wound fluids. We studied the effects of MGSA on proliferation and migration of primary human keratinocytes and modulation of their integrin expression. Blister fluids contained 0.79 ng/ml (range 0.018 to 4.86 ng/ml) MGSA. Substantial increasing amounts of MGSA were found in donor site fluids from day 1 through day 5 with mean levels ranging from 1.77 to 103 ng/ml at postoperative day 5, which correlated with increasing amounts of tumor necrosis factor alpha (r = 0.86), a known stimulus for MGSA production. In vitro proliferation experiments revealed a maximum stimulation (2.6-fold) with 10 ng/ ml MGSA for 7 days over unstimulated keratinocyte controls; the ED50 was 0.2 ng/ml. DNA content analysis revealed an increase in S phase with 10 ng/ml MGSA stimulation. In cultured keratinocytes, MGSA enhanced the mean fluorescence intensity for alpha 6, while no significant change was seen for beta 1, alpha 2 and alpha 5. We also studied the effect of topically applied MGSA (50 ng/cm2) on the healing of meshed split-thickness human skin grafts on athymic mice. In these wounds, MGSA stimulated the rate of epithelialization (P < 0.05) at day 7, and an increased proportion of mitotic keratinocytes was observed. Wound contraction was significantly (P < 0.05) reduced on days 7 and 14 in the MGSA-treated group. These results suggest that MGSA participates in wound healing by stimulating keratinocyte proliferation.

Clinical trials of a biosynthetic temporary skin replacement, Dermagraft-Transitional Covering, compared with cryopreserved human cadaver skin for temporary coverage of excised burn wounds.

Human cadaver allograft skin (HCAS) is widely used for covering excised burn wounds when limited available skin donor sites or the overall patient condition does not permit immediate grafting with autologous skin. However, recurring problems are associated with HCAS including limited supply, variable quality, ultimate immune rejection, and the potential for bacterial and viral disease transmission. These problems speak for the need for development of a dependable substitute for HCAS. We evaluated the ability of a biosynthetic analogue of human skin to temporarily close excised burn wounds in humans. Dermagraft-TC (Advanced Tissue Sciences, Inc.) (DG-TC) is composed of human neonatal fibroblasts cultured on a synthetic dressing (Biobrane; Dow Hickam, Inc.) that consists of nylon mesh fabric covered with a thin layer of silicone rubber membrane, which provides an epidermal "barrier." The material is stored frozen and thawed immediately before use. DG-TC is semitransparent, thus facilitating continuous observation of the underlying wound surface. Burn wounds in 10 patients (mean age 33.5 years, mean burn size 39.9% total body surface area) were surgically excised. Two variants of the DG-TC skin analogs were tested: a material that was cryopreserved to maintain fibroblast viability (DG-TC Red) and a material that was frozen without efforts to maintain fibroblast viability (DG-TC Blue). A control site on each patient received cryopreserved HCAS. Each study site was approximately 1% total body surface area. When clinically indicated, patients were returned to the operating room where the skin replacements were removed, the wound bed was evaluated and prepared for grafting, and the wounds were closed with meshed split-thickness autograft skin. The results showed that adherence to the wound and subsequent autograft "take" were excellent with both DG-TC variants and were at least equivalent to HCAS. No evidence of immune rejection of DG-TC was seen, whereas in four patients evidence of epidermal sloughing/rejection was noted in the HCAS control sites, which limited persistence of those grafts on the wound. Further clinical trials with this skin analogue are in progress.

A multicenter clinical trial of a biosynthetic skin replacement, Dermagraft-TC, compared with cryopreserved human cadaver skin for temporary coverage of excised burn wounds.

This multicenter study compared the use of a biosynthetic human skin substitute with frozen human cadaver allograft for the temporary closure of excised burn wounds. Dermagraft-TC (Advanced Tissue Sciences, Inc.) (DG-TC) consists of a synthetic material onto which human neonatal fibroblasts are cultured. Burn wounds in 66 patients with a mean age of 36 years and a mean burn size of 44% total body surface area (28% total body surface area full-thickness) were surgically excised. Two comparable sites, each approximately 1% total body surface area in size, were randomized to receive either DG-TC or allograft. Both sites were then treated in the same manner. When clinically indicated (> 5 days after application) both skin replacements were removed, and the wound beds were evaluated and prepared for grafting. DG-TC was equivalent or superior to allograft with regard to autograft take at postautograft day 14. DG-TC was also easier to remove, had no epidermal slough, and resulted in less bleeding than did allograft while maintaining an adequate wound bed. Overall satisfaction was better with DG-TC.