The application of Integra in a challenging context

Integra dermal regeneration template is commonly used in the developed world. This case history documents the application of Integra for the first time in Gaza, Palestine. This single case history illustrates how a tried and tested technique can be imported to a more challenging environment. The emphasis in this case history is not to recount a well-known technique of Integra application but to outline how the environment has to be prepared and the surgeon adapt to minimise risk and maximise the chances of success. This first application of Integra in Gaza illustrates the importance of starting with simple cases when a technique is being piloted in an austere environment. Patient selection, local theatre set up, staff and surgical technique, as well as patient follow-up facilities, all need consideration before doing the first trial of even this most established of products in a new environment. Lay Summary Integra dermal regeneration template is a material that can be applied to resurface areas of scarring and burns contracture. The template consists of two layers: the upper layer is a Silone sheet that acts to protect the deeper layer that consists of a protein matrix. Once an area of troublesome scar has been surgically removed, it leaves a gap, or defect. The Integra can be applied to the defect and, providing the areas has a good blood supply, is free of bacteria and immobilised, a new blood supply enters the protein matrix. This allows the migration of cells, called fibroblasts, into the matrix. The fibroblasts will use the matrix as scaffolding to lay down new protein and eventually replace the matrix. The resultant structure is called a ‘neodermis’. The protective silicone sheet can then be removed and replaced by a conventional, very thin skin graft. The advantage to applying this Integra two-stage reconstruction technique to a scarred area is that the reconstruction will be elastic and expand. In children, this allows for growth without recurrence of contractures across joints. The application of Integra is a tried and tested technique. This case explains how, and with due care, it can be used for severe scarred cases in a challenging environment provided careful technique and follow-up are respected.