From Basic Wound Healing to Modern Skin Engineering

Over the last decade, lymph node flap (LNF) transfer has turned out to be an effective method in the management of lymphoedema of extremities. Most of the time, the pockets created for LNF cannot be closed primarily and need to be resurfaced with split thickness skin grafts. Partial graft loss was frequently noted in these cases. The need to prevent graft loss on these iatrogenic wounds made us explore the possibility of attempting delayed skin grafting. We have herein reported our experience with delayed grafting with autologous banked split skin grafts in cases of LNF transfer for lymphoedema of the extremities. Ten patients with International Society of Lymphology stage II-III lymphoedema of upper or lower extremity were included in this study over an 8-month period. All patients were thoroughly evaluated and subjected to lymph node flap transfer. The split skin graft was harvested and banked at the donor site, avoiding immediate resurfacing over the flap. The same was carried out in an aseptic manner as a bedside procedure after confirming flap viability and allowing flap swelling to subside. Patients were followed up to evaluate long-term outcomes. Flap survival was 100%. Successful delayed skin grafting was done between the 4th and 6th post-operative day as a bedside procedure under local anaesthesia. The split thickness skin grafts (STSG) takes more than 97%. One patient needed additional medications during the bedside procedure. All patients had minimal post-operative pain and skin graft requirement. The patients were also reported to be satisfied with the final aesthetic results. There were no complications related to either the skin grafts or donor sites during the entire period of follow-up. Delayed split skin grafting is a reliable method of resurfacing lymph node flaps and has been shown to reduce the possibility of flap complications as well as the operative time and costs.

Sir: We read with interest the recent article by Yi and Kim (Plast Reconstr Surg. 2015;135:609e–616e). The authors compared the effect of simultaneous application of acellular dermal matrix with autologous split-thickness skin graft and that of split-thickness skin graft alone on traumatic full-thickness skin defects on the extremities, and concluded that the cograft of acellular dermal matrix with split-thickness skin graft produced better outcomes than split-thickness skin graft alone in terms of scar appearance, without increasing complications. The combination of acellular dermal matrix with epidermal coverage, usually an autologous split- thickness skin graft, has increasingly replaced the full-thickness skin graft to reconstruct full-thickness skin defects. However, the timing of split-thickness skin grafting remains controversial. For a split-thickness skin graft to attach promptly after transplantation, a well-vascularized wound bed is required. The thickness of a skin graft that can easily become vascularized is approximately 0.7 to 1.0 mm. Therefore, most acellular dermal matrices thicker than 1.0 mm are covered by a split-thickness skin graft 3 to 4 weeks later to allow sufficient vascularization and to avoid graft necrosis or loss.1 However, this two-step approach is lengthy, gives no guarantee of success, and is an additional stress factor for the patient. More recent approaches include use of thinner dermal layers, with the aim of transplanting acellular dermal matrix simultaneously with split-thickness skin graft.2 Several of the authors’ procedures might contribute to the success of their single-step technique: (1) the wound bed was completely débrided and prepared with well-vascularized granulation tissue before grafting, (2) negative-pressure therapy was applied throughout to stimulate angiogenesis and prevent complications, and (3) the application of meshed acellular dermal matrix and thin split-thickness skin graft improved the take rate and allowed better blood supply to the cograft. However, we still have great interest in the thickness of the acellular dermal matrix in this article. Does the meshed morphology of acellular dermal matrix compensate for the thickness of it? In addition, the split-thickness skin graft combined with acellular dermal matrix was meshed and expanded, whereas the split-thickness skin graft applied alone was neither meshed nor expanded and was 0.1 mm thicker than the cografted one. The difference interests and confuses us. Beyond this, the pigmentation merits specific attention. Melanocytes and fibroblasts are believed to contribute to the repigmentation process.3 Because acellular dermal matrix does not contain cellular components, it is acceptable in this article that the pigmentation subscore was not improved in the cograft group. In our experience, noncultured autologous cell suspensions, such as ReCell (Avita Medical, Northridge, Calif.), could commendably improve skin color, as it contains viable melanocytes and fibroblasts apart from abundant keratinocytes.4 As these authors move forward, it could be tentatively used to aid the cograft of acellular dermal matrix and split-thickness skin graft or even cografted directly with acellular dermal matrix to heal full- thickness skin defects. We agree with the authors that the one-step graft of acellular dermal matrix and split-thickness skin graft is more than welcome and encourage them and others to investigate this approach so that this very important technique can be more completely understood and taken advantage of. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. Panxi Yu, M.D.Zuoliang Qi, M.D., Ph.D.Plastic Surgery HospitalChinese Academy of Medical Sciences and Peking UnionMedical CollegeBeijing, People’s Republic of China

Introduction: Although the mortality and morbidity from burns have diminished significantly over the last few decades, these do not truly reflect whether the victim could lead a normal life, owing to postburn contractures (PBCs) and other deformities, which have functional and aesthetic implications. Objective: The main objective of this study was to compare the improvement in cervico-mental angle after surgery, using a goniometer; and to assess the postoperative complications, cosmetic outcome and patient satisfaction after contracture release and split-thickness skin grafting. Methods: In this prospective study, we have studied a total of 20 patients with PBCs of neck, who underwent contracture release and split skin grafting. The preoperative cervico-mental angles were compared to postoperative measurements using a goniometer. Results: In this study, we observed that the mean cervicomental angle before the surgery was 85.5° ± 12.8° and after the surgery was 106.4° ± 7.8°. The percentage improvement was 24.3% which was found to be statistically significant (P < 0.001). Patients were also classified based on age, gender, mechanism and classification of burns, time elapsed since burn injury. Postoperative complications, cosmetic outcome and patient satisfaction were also studied. Conclusion: PBCs can affect a patient's life functionally, aesthetically, and psychologically. Split-thickness skin grafting is a safe and reliable option for PBC neck. This causes improvement in cervicomental angle and thus range of movements of the neck in different axes (as measured by a goniometer). lthough the mortality and morbidity from burns have diminished significantly over the last few decades, these do not truly reflect whether the victim could lead a normal life, owing to postburn contractures (PBCs) and other deformities, which have functional and aesthetic implications. In this prospective study, we have studied a total of 20 patients with PBCs of neck, who underwent contracture release and split skin grafting. The preoperative cervico-mental angles were compared to postoperative measurements using a goniometer, and a significant improvement was noted. Overall patient satisfaction was also very good. Hence, split thickness skin grafting is a safe and reliable option for PBC neck.

Release of oral submucous fibrosis and reconstruction using superficial temporal fascia flap and split skin graft—a new technique

Recent progress in tissue-engineered skin grafts has alleviated the demand for autologous split thickness skin grafts for treatment of large skin wounds. In this study, a series of cost-effective nanofibrous scaffolds aimed at full-thickness wound healing are fabricated by blending gelatin (Gel) with poly(l-lactic acid)-b-poly( ε-caprolactone) (PLLCL) and electrospun to obtain composite Gel/PLLCL nanofibers in four different weight ratios (w/w) of 80:20 [Gel/PLLCL(20)], 70:30 [Gel/PLLCL(30)], 60:40 [Gel/PLLCL(40)], and 50:50 [Gel/PLLCL(50)]. The mechanical properties of these nanofibrous scaffolds were evaluated in both dry and wet conditions, and the Gel/PLLCL(40) retained suitable tensile stress (1.16 ± 0.03 MPa) to be handled even in wet conditions. Moreover, the proliferations of fibroblast cells on Gel/PLLCL(40) were 15%, 7% and 10% higher compared to cell proliferations on Gel/PLLCL(20), Gel/PLLCL(30), and Gel/PLLCL(50), respectively. In vitro results confirmed Gel/PLLCL(40) as the optimized scaffold composition suitable for skin tissue engineering. The healing ability of this scaffold was studied in vivo using mouse models. The Gel/PLLCL(40) greatly accelerated wound closure and regeneration occurring in the first 10 days of implantation compared to the control group. In addition, newly regenerated epidermis was only found in the nanofibrous scaffolds–treated group, and it was comparable to the epidermis of normal skin.

Background: Many patients require general anesthesia merely for skin grafting. EMLA cream which is aeutectic mixture of Lignocaine and Prilocaine provides surface anesthesia when applied on intact skin. Its role in venepuncture or IV cannula insertion in children is well documented. Aim and Objective: To compare effectiveness of EMLA over inltrative local anaesthesia in split skin graft harvest. Method: A prospective study was conducted on 64 patients who required skin grafting. Various indications for grafting were noted. The patients were randomly allocated to two groups. In one group 32 patients, graft was harvested after application of EMLA cream whereas in another group of 32 patients, graft was harvested by inltrating local anesthesia. Pain perceived during donor area preparation, graft harvesting and post-operative pain was recorded and compared between the two groups on Visual analogue scale and Likert scale. Results: Total 64 patients were included in the study with 32 patients in either group. Traumatic loss of skin was the most common indication in either group for skin graft harvest. As per visual analogue scale during the graft harvest, most of the patients were in the range of 4-7 score in either group (71.87% vs 53.12%). 75% of the patients were in the 4-7 score in both groups. As per likert scale during the graft harvest score of 4 was noted in 62.5% in group 1 vs 53.12% in group 2 patients. 81.25% patients in group 1 reported procedure as excellent versus 53.12% patients in group 2. Patients experienced more pain during inltration of local anesthesia. Whereas more bleeding was noted in EMLA group immediately after harvest of graft. Conclusions: EMLA cream can be effectively used as an alternative to local anaesthetic inltration for harvest of split thickness skin graft

To observe the effects of artificial dermis combined with basic fibroblast growth factor (bFGF) on the treatment of cicatrix and deep skin wounds. The clinical data of 72 patients with wounds repaired with artificial dermis, hospitalized in our unit from October 2010 to April 2015, conforming to the study criteria, were retrospectively analyzed. The types of wounds were wounds after resection of cicatrices, deep burn wounds without exposure of tendon or bone, and wounds with exposure of small area of tendon or bone, in a total number of 102. Wounds were divided into artificial dermis group (A, n=60) and artificial dermis+ bFGF group (B, n=42) according to whether or not artificial dermis combined with bFGF. In group A, after release and resection of cicatrices or thorough debridement of deep skin wounds, artificial dermis was directly grafted to wounds in the first stage operation. After complete vascularization of artificial dermis, wounds were repaired with autologous split-thickness skin grafts in the second stage operation. In group B, all the procedures were exactly the same as those in group A except that artificial dermis had been soaked in bFGF for 30 min before grafting. Operation area, complete vascularization time of artificial dermis, survival of skin grafts, and the follow-up condition of wounds in the two groups were recorded. Data were processed with t test and Fisher's exact test. (1) Operation areas of wounds after resection of cicatrices, deep burn wounds without exposure of tendon or bone, and wounds with exposure of small area of tendon or bone in the two groups were about the same (with t values from -1.853 to -0.200, P values above 0.05). Complete vascularization time of artificial dermis in wounds after resection of cicatrices, deep burn wounds without exposure of tendon or bone, and wounds with exposure of small area of tendon or bone in group B were respectively (15.6 ± 2.9), (14.7 ± 2.7), and (20.3 ± 4.4) d, and they were shorter by an average time of 2.7, 4.0, 7.4 d, respectively, as compared with those in corresponding types of wounds in group A [respectively (18.3 ± 4.7), (18.7 ± 4.2), and (27.7 ± 8.8) d, with t values from -2.779 to -2.383, P values below 0.05]. (2) The ratio of skin grafts with excellent survival in the three types of wounds in group B were higher than those in corresponding types of wounds in group A, but there were no statistically significant differences (with P values above 0.05). (3) Patients were followed up for 1 to 48 months, and there were no obvious cicatrices in skin graft sites and the donor sites during the following time. Artificial dermis combined with bFGF can effectively shorten the vascularization time of artificial dermis in wounds after resection of cicatrices and deep skin wounds.

To observe the clinical effect of modified skin soft tissue expansion in repair of devastating wound on the head due to electrical burn in the early stage. Twenty-one patients with partial scalp soft tissue defect accompanying skull exposure and necrosis in different degree due to high-voltage electrical burn were hospitalized from April 2009 to October 2014, with wound area ranging from 7 cm × 5 cm to 15 cm × 13 cm. The wounds were debrided as early as possible, and necrotic skulls were kept in situ and covered with porcine ADM and silver-containing dressing. Bacterial culture of exudate from the residual soft tissue was carried out 3 days after hospitalization. Pertinent antibiotics were applied topically to control infection, and autologous split-thickness skin grafts were transplanted. Two to three weeks after injury when the skin grafts survived, modified skin soft tissue expansion was carried out. The crossbow-form incision was made on the normal scalp 2 cm away from the edge of transplanted skin; a capsule cavity was formed by ladder-like dissection. An expander was inserted with the injection port laying outside. The expander was stretched by inflation and deflation. The incisions were sutured layer by layer. The time of continuing negative pressure drainage in the interval of expansion was extended. Volume of water reaching 2 to 3 times of the capacity of expander was injected for excessive expanding. The expanded skin flap was rotated to repair the wound after expansion was ended. Within 1 week after debridement, 4 kinds of bacteria were detected in the bacterial culture of wound exudate, including 4 cases of Staphylococcus aureus, 5 cases of Staphylococcus epidermidis, 5 cases of Pseudomonas aeruginosa, and 3 cases of Acinetobacter baumannii. A total of 26 expanders were imbedded. No infection or incision dehiscence in the expanding area or cracking and leakage of expander was observed during expanding period. Two to three months after injury, expanded skin flap transplantation was completed, and the wound was repaired. Raw wounds were seen in 4 expanded skin flaps after transfer, and they healed after dressing change. Punctiform ulceration at the seams of 2 flaps was observed one month after the operation, which healed after removing few pieces of sequestra by themselves. The other expanded skin flaps survived well. During the postoperative follow-up for 3 to 12 months, satisfactory appearance and hair growth was observed in the operation area. Repair of the devastating wound on the head due to electrical burn with modified skin soft tissue expansion could achieve the result of early wound covering and cosmetic repair without alopecia in one time.

We are pleased to present the Dermatologic Surgery Special Issue, which is focused on the extracellular matrix (ECM) in skin regeneration and dermopathy treatment. Regenerative medicine based on ECM is one of the most promising tools for skin rejuvenation and soft tissue regeneration. In addition, the occurrence of dermopathy is highly related to the disturbance of the ECM. In this issue, we provide the most recent advances in determining the role of the ECM in research and clinical application. This issue presents several articles on the cutting edge of dermatologic surgery. Dermatofibrosarcoma protuberans (DFSP) was discovered to have fibroblastic activity, and a variety of neural features were discovered, which validated DFSP’s fibroblastic origin and tendency toward neural differentiation. The efficacy and safety of picosecond laser therapy (PLT) was proven in the treatment of melasma. In addition, the efficacy and safety assessment found that the ECM is a dressing that promotes wound healing after PLT, which can shorten the downtime by alleviating erythema and edema and proceeding with scab shedding related to PLT. The treatment of keloids, a disease caused by ECM disorder, is an urgent problem in clinical practice. In this special issue, different keloid treatments are presented, including punch excision combined with drug injection, autologous split-thickness skin graft and postoperative radiotherapy, surgical excision with electron beam radiotherapy, and reduced incision tension of keloid surgery by tightening the fascia layer. The illumination of these promising strategies will be conducive to the development of future targeted therapies. Finally, we are fortunate to have several peer-reviewed literatures on the applications of ECM in skin regeneration medicine. Pingping Lin et al elucidated the dynamic composition and potential roles of the extracellular matrix in normal skin, the wound healing process, and abnormal skin scarring. Yixin Wang et al provided an overview of the clinical research, limitations, and potential application of botulinum toxin type A in the prevention and treatment of traumatic or postoperative scars. Weiyuan Zhang et al investigated the mechanism of Mesenchymal stem cell-derived extracellular vesicles (MSC-EVs) in reducing inflammation, promoting angiogenesis, promoting the proliferation and migration of epithelial cells and fibroblasts, and ECM remodeling during wound healing.

Leg ulcers (ulcus cruris): The frequent macrovascular causes Abstract. Four pathologies make up the macrovascular etiologies of leg uclers: Venous leg ulcers (50 %), mixed venous-arterial leg ulcers (20 %), arterial leg ulcers (5 %), and Martorell hypertensive ischemic leg ulcer (5 %). The remaining 20 % concern a large array of other etiologies. Every leg ulcer requires vascular (arterial and venous) work-up, that can be completed with microbiology, biopsy, and more in-depth internal diagnostics, as indicated. Venous leg ulcers are treated with compression therapy. Incompetent saphenous veins and tributaries are abolished if the deep venous system is patent. Occluded iliac veins are recanalised and stented, as possible. Refractory venous leg ulcers are grafted with split skin or punch grafts, depending on their surface. Extensive dermatolipofasciosclerosis may be tangentially removed by shave therapy or fasciectomy, that can be combined with negative pressure wound treatment (NPWT). Skin equivalents are an alternative to treat superficial venous leg ulcers that fail to epithelialise. Their indication in the treatment of more complex leg ulcers still needs to be better investigated and understood. The use of dermal matrices leads to more stable scars. Mixed venous-arterial leg ulcers heal slower and recur more frequently. Compression needs to be reduced. Refractory cases require arterial revascularisation, to transform the mixed venous-arterial into a venous leg ulcer. Arterial leg ulcers require arterial revascularization and split skin graft. Martorell hypertensive ischemic leg ulcer is still underrecognised and often confounded with with pyoderma gangrenosum, which leads therapy into a wrong direction. Necrosectomy, antibiotic treatment in the presence of relevant bacterial superinfection, and repeated split skin grafts eventually heal the vast majority of these extremely painful and potentially mortal wounds.

There is a need for biomarkers that predict the success of transplantation of venous leg ulcers (with autologous split-thickness skin grafts). The primary objective of this exploratory study was to investigate the association between split-thickness skin graft healing in venous leg ulcers and candidate wound fluid biomarkers representing inflammatory cell and endogenous proteinase activities, and bioactivity. A secondary objective was to compare biomarker levels of the 17 venous leg ulcers with sterile split-thickness skin graft donor-site wounds in another 10 patients with venous leg ulcers. Wound fluids were collected for 24 h using a validated method. The concentration of pre-operative matrix metalloproteinase-9 in wound fluid was higher in venous leg ulcers showing good healing (n = 10) than in venous leg ulcers showing poor healing (n = 7) 12 weeks after transplantation with meshed split-thickness skin grafts. The diagnostic value of matrix metalloproteinase-9 was good according to receiver-operating characteristic curve analysis. Matrix metalloproteinase activity in wound fluids from split-thickness skin graft donor-site wounds increased as a function of time and healing, but was still lower than matrix metalloproteinase activity in venous leg ulcer wound fluids, which showed increased levels of most biomarkers except for matrix metalloproteinase-9 and matrix metalloproteinase-2. In conclusion, wound fluid matrix metalloproteinase-9 concentration is a potential predictive biomarker of split-thickness skin graft healing in venous leg ulcers.

Objective To investigate the clinical effect of the first-stage wound vacuum suction after the release of scar, combined with the second-stage autologous medium-thickness skin graft in the functional reconstruction of severe burns. Methods Thirty-six patients with severe burns in the Kunshan 8·2 incident admitted to the Department of Burns and Plastic Surgery, Affiliated Kunshan Hospital of Jiangsu University from July 2015 to July 2016 were selected. All patients had a burn area greater than 80% of the total body surface area, the full thickness burn area was larger than 50% of the total body surface area, scar area was greater than 50% of the burn area, and the scarring of the functional site after burn (36 places) was limited. Patients were divided into experimental group and conventional surgery group according to different treatment methods used by patients, 18 cases in each group. In the experimental group, after the operation of the functional site scar release, the wound was continuously given negative pressure suction for 6 days. If the base of the wound was good, the second-stage was treated with autologous medium-thickness skin graft to repair the wound, and the dressing was changed regularly. In the conventional surgery group, after the functional site scar was released, the first-stage autologous skin graft was repaired and the dressing was changed regularly. On the 12 d after operation, the wound infection status of the two groups was observed and the survival rate of the two groups was calculated. The wound healing time after skin grafting in the skin grafting area and the scar score difference of the skin grafting area at 3, 6 and 10 months after operation were recorded. The functional recovery of the functional part of the patient was evaluated at 12 months postoperatively. Data were compared using t test, Wilcoxon rank sum test, χ2 test and Fisher exact probability method. Results On the 12 d after operation, the survival rate of autologous skin in the experimental group was (94.28±3.58)%, which was higher than that in conventional surgery group (89.06±3.89)%, the difference was statistically significant (t=4.245, P<0.05). There was 1 case infection in the experimental group and 3 cases in the conventional surgery group, the difference was no statistically significant (P=0.603). After skin grafting, the average healing time of the skin grafting area in the experimental group was (13.22±0.55) d, which was less than that in the conventional surgery group (16.44±0.57) d, the difference was statistically significant (t=6.462, P=0.0001). The scores of the scar in the skin grafting area of the experimental group were (4.22±0.89), (4.72±0.23), and (6.11±0.29)points at 3, 6 and 10 months after operation, respectively, which were lower than those of the conventional surgery group [(5.00±0.59), (6.78±0.24), (8.22±0.31) points], the differences were statistically significant (t=2.830, 7.857, 6.008; with P values below 0.05). After 12 months of follow-up, the functional recovery of the functional parts of the experimental group: best for 10 cases, better for 7 cases, poor 1 cases; conventional surgery group function recovery: best 5 cases, better 9 cases, poor for 4 cases. The improvement of the function of the experimental group was better than that of the conventional surgery group. The difference was statistically significant (χ2=6.210, P=0.045). Conclusions After the scar is released, the vacuum suction of the wound combined with the second-stage autologous skin graft can improve the survival rate of the skin, shorten the wound healing time, improve the scar in the skin graft, improve the activity of the functional parts, and have better clinical function reconstruction effect. Key words: Burns; Cicatrix; Negative-pressure wound therapy; Function reconstruction

All deeper burns especially second degree deep dermal and full thickness heals by scarring that causes restrictions in the movements and aesthetics issues for patients. Burn reconstructive surgery requires that the defects after release should be replaced with donor tissues which have matching texture and colour like autologous skin grafting or flap surgeries. Autologous platelet rich plasma contains concentrated platelets after graded centrifugation, which has various applications like alopecia, acne, reproductive techniques etc. Here we are using this method to test for role in take of Full Thickness Skin Graft post burn contracture. Full-thickness skin grafts include full thickness of the epidermis and dermis whereas split-thickness skin grafts include the entire epidermis and only partial dermis. The main complication of this procedure is risk of graft failure. Autologous platelet-rich plasma (APRP) as the name suggests is concentration of the patient’s own platelets in a small amount of plasma. It is enriched by growth factors, and it acts as a fibrin sealant and has various properties. Its important application is in skin grafting where it aids as a fibrin sealant and aids in the take of the graft by enriching it with growth factors and promoting angiogenesis The purpose of this case report is using autologous platelet rich plasma as a therapeutic method for accelerating take of Full Thickness Skin Graft in post burn contracture with better prognosis.

Autologous split-thickness skin grafts (STSGs) are considered the mainstay for the treatment of large full-thickness wounds. There have been few studies reporting the natural change of the skin function in STSGs after procedure, however. The objective was to evaluate the natural change of the skin function in STSG using noninvasive bioengineering methods. Eighteen patients were eligible for the study. The skin functions of the graft and the control site were evaluated by an evaporimeter, corneometer, mexameter, and cutometer at Postoperation Days 0.5, 1, 2, 3, 6, 9, and 12 months. Transepidermal water loss (TEWL) of the graft was maintained around that of the normal skin. The values of the skin hydration testing generally decreased during the follow-up period. Erythema was highly maintained for the whole period. For the pigmentation, the ratio tended to increase after 6 months. The skin pliability of the graft was abruptly decreased at 0.5 month, and it recovered from 3 to 12 months. The value did not reach that of the normal skin, however. Our results showed that the STSGs had changed within the frame of the skin function, including the TEWL, epidermal hydration, color, and pliability, throughout 1 year after surgery. The authors have indicated no significant interest with commercial supporters.

Objective: To explore the clinical effect of bi-layered artificial dermis combined with autologous skin graft in the repair of wounds with exposed bone and/or tendon. Methods: The medical records of 25 patients (aged 3 to 79 years, including 21 males and 4 females) with bone and/or tendon exposed wounds caused by various reasons, admitted to Nanfang Hospital of Southern Medical University from May 2014 to December 2018 were analyzed retrospectively. Of the 25 patients, 7 patients had exposed bone only, 13 patients had exposed tendon only, and 5 patients had exposure of both bone and tendon. The total wound area was 78.0 (53.4, 103.2) cm(2). The widths of bone exposure and tendon exposure were 3.2 (3.0, 3.6) cm and 2.0 (1.7, 2.4) cm, respectively. All wounds were implanted with bi-layered artificial dermis in the first stage after thorough wound debridement. After 2 to 3 weeks of vascularization of artificial dermis, autologous thin-to-medium-thickness skins or split-thickness skins were grafted to repair the wounds in the second stage. The vascularization of artificial dermis and its time, whether or not producing hematoma, the skin graft survival rate on day 7 post autologous skin grafting, whether or not repeating skin grafting, and the time of complete wound healing were observed and recorded. The patients were further followed up and observed for 3 or more months after discharge. Results: The vascularization of artificial dermis was achieved in 24 patients after the first transplantation with vascularization time being 11-21 (16±4) days. No hematoma was observed in the transplanted artificial dermis. Failed vascularization of grafted artificial dermis was observed in one patient who was later treated with negative pressure drainage and skin grafting alone, and was discharged with wound healing. The skin graft survival rate on day 7 post autologous skin grafting was 92.2%-100.0% ( (99.3±1.3)%), with the remaining wound areas recovered later by themselves or healed by dressing changes without repeated skin grafting. The complete wound healing time was 7-19 (11.9±2.8) days after autologous skin grafting. The patients were followed up for 3 to 60 months after discharge. Except for the pigmentation in skin graft area, the skin grafts survived well, being soft in texture and with no repeated ulceration, obvious hypertrophic scar, or contracture deformity. Conclusions: Artificial dermis combined with autologous skin grafting can effectively repair wounds with bone and/or tendon exposure, providing a repair strategy for this type of wounds.