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Case Series/Study
Fish skin grafts are increasingly being used for a wide range of wound repair. Its versatility is attributed to the fish skin’s protein composition which closely resembles that of human skin. The graft’s porous microstructure provides for efficient ingrowth of dermal cells and capillaries, further supporting the body’s own ability to regenerate by recruiting the body’s own cells (1). The primary objective of this case series is to show proof of this graft's powerful angiogenic capacity by providing evidence of it's healing over avascular structures.
Previous studies have shown that the fish skin grafts mediate significantly faster healing compared to porcine or amniotic/chorionic products. (2,3). Human/mammalian tissue require extensive processing and treatment with the harsh detergents which dissolve components of the native tissues which reduces it to a matrix of inactive collagen connective tissue only. Pathogen transmission risk from the Icelandic cod (Gadus morhua) to humans is nonexistent. This allows for gentle processing of the fish skin, preserving its native structure and chemical components. Specifically, it includes Omega-3 fatty acids, which are not found in mammalian tissue. Omega-3’s are highly effective as antimicrobial agents and in modulating the inflammatory response of the acute wound healing stage (4)
Methods:
In the four cases presented, the wounds were prepared as necessary and grafts applied. Deeper wounds had graft applied in multiple layers. The incorporating graft islands and peripheral wound edges were fenestrated at follow up visits to allow for saturation of blood to allow for further incorporation of graft. This contrasts directly with post-operative protocols of other grafts, where sanguineous saturation is not encouraged. Additional grafting was performed as needed.
Results: In all cases after only a single application there is significant granulation tissue over both exposed tendon and bone, without the assistance of NPWT. Additionally, as the wounds healed into healthy skin one notes an initial purplish hue of the newly forming skin, which similar in appearance to a healing STSG. All wounds resulted in healthy, elastic skin formed in conjunction with Langer lines.
Discussion: The graft’s capacity to heal over avascular structures makes it a promising treatment for wounds with exposed tendons or bone. Observing how similar the graft healing process is to that of a STSG makes it a viable replacement for a STSG as opposed to preparing the wound bed for it. Further investigation of the graft’s versatility is warranted to provide more evidence of its effectiveness and wide applicability.
Trademarked Items: *Kerecis TM , Kerecis, Isafjordur, Iceland
References: (1) Magnusson, S. et al. Decellularized fish skin: characteristics that support tissue repair. Laeknabladid 101, 567–573 (2015).
(2) Baldursson, B. T. et al. Healing rate and autoimmune safety of full-thickness wounds treated with fish skin acellular dermal matrix versus porcine small-intestine submucosa: a noninferiority study. Int. J. Low. Extrem. Wounds 14, (2015)
(3) Zelen CM et al.. A prospective, randomised, controlled, multi-centre comparative effectiveness study of healing using dehydrated human amnion/chorion membrane allograft, bioengineered skin substitute or standard of care for treatment of chronic lower extremity diabetic ulcers. Int Wound J. 2015 Dec;12(6):724–32.
(4) Crapo, P. M., Gilbert, T. W. & Badylak, S. F. An overview of tissue and whole organ decellularization processes. Biomaterials 32, 3233–3243 (2011).