Dermal Scaffolds in Complex Extremity Wound Reconstruction: Impact of Early Application on Grafting and Flap Requirements—A Systematic Review

Complex extremity wounds from burns or trauma often involve exposed tendon or bone, making direct skin grafting unreliable and increasing the likelihood of flap reconstruction. This review evaluated whether early dermal scaffold application reduces subsequent surgical requirements. PubMed, Embase, the Cochrane Library and clinical trial registries were searched for studies published between 2016 and 2026. Of 409 records screened, 10 studies comprising 415 scaffold-treated wounds in 414 patients were included. Outcomes were synthesised descriptively and stratified by aetiology; meta-analysis was precluded by heterogeneity. Across nine non-randomised studies (393 patients), 38 (9.7%) healed without grafting and 352 (89.6%) were grafted. Graft avoidance differed markedly by aetiology: 32 of 192 trauma patients (16.7%) versus 0 of 190 burn patients (0%). All trauma events arose from three studies of small, highly selected defects, whereas three further trauma cohorts using immediate or staged grafting reported none. In the single randomised trial, scaffold take succeeded in 5 of 22 patients (22.7%) and all were grafted, whereas the graft-only comparator achieved complete coverage success, although scar quality was better with the scaffold (Vancouver Scar Scale 2.40 vs. 7.45, p < 0.001). No study contained a flap comparator, and certainty of evidence was very low for five of seven outcomes and low for two. Current evidence suggests early dermal scaffold application may reduce reconstructive burden in selected trauma wounds, whereas in burns scaffolds appear to enable staged grafting rather than replace it. Reconstructive downstaging is presented as an exploratory framework, not a validated outcome. © 2026 The Author(s). Wound Repair and Regeneration published by Wiley Periodicals LLC on behalf of The Wound Healing Society.