Skin Graft With Amniotic Membrane: Case Report of the Sandwich Technique in a Burn Hand

Summary:

Deep burns of the hand represent a major reconstructive challenge due to the critical functional role of the hand and the high risk of long-term disabling sequelae. The “sandwich” technique, combining an autologous skin graft with an amniotic membrane, has been described as a biological dressing with potential anti-inflammatory and wound-healing properties. A 32-year-old woman presented with a full-thickness burn involving the right palm and wrist after contact with an industrial thermal press. Following eschar excision, a full-thickness skin graft was harvested from the inner region of the ipsilateral arm; the donor site was closed primarily by advancing the wound edges with absorbable monofilament intradermal sutures and covered with Micropore tape to reduce tension. Because of incomplete well-vascularized perfusion of the recipient bed and the risk of functional impairment, an amniotic membrane was placed as an additional protective layer over the graft. By the seventh postoperative day, the graft showed satisfactory take, with no evidence of infection. At 12 months of follow-up, complete integration was achieved, with preserved joint mobility and a favorable aesthetic outcome. This case illustrates the technical feasibility of using preserved amniotic membrane as an overlay biological dressing over a full-thickness skin graft in a functionally critical palmar burn. Although satisfactory healing was observed, no causal conclusion can be drawn regarding improved graft integration, scar modulation, or functional preservation based on a single case. Further comparative studies are needed to determine whether the benefits reported in other grafting contexts also apply to full-thickness skin grafting.

Burn injuries are a significant public health concern in Colombia, with mortality rates of 1.28 per 100,000 inhabitants and more than 5000 deaths reported in less than a decade. In Bogotá, 5439 burn-related hospitalizations were documented between 2008 and 2016, predominantly in men (65%). Upper limbs are affected in approximately 39% of burns, and the hands in up to 80% of severe cases due to their constant exposure and protective role.¹

Hand burns are a major reconstructive challenge because the hand is essential for fine motor control, grip, autonomy, and return to work. Its limited subcutaneous coverage and frequent exposure increase the risk of contractures, joint stiffness, impaired grip synergy, chronic pain, and emotional distress, including anxiety and depression, all of which worsen functional disability.²

This context requires surgical strategies that are effective, feasible, and adaptable to resource-limited settings. The “sandwich” technique with preserved amniotic membrane provides stable full-thickness autograft coverage while reducing secondary contracture; the membrane also acts as a biological dressing that limits moisture loss and promotes growth factor activity. Its regenerative, anti-inflammatory, antimicrobial, antifibrotic, and low-immunogenic properties support faster reepithelialization, reduced scar fibrosis, less pain, fewer dressing changes, and improved graft integration without increasing infection risk.^3,4 This article presents the technique as a reconstructive option that may address some limitations of conventional approaches and prioritizes comprehensive functional rehabilitation in deep burns involving critical areas such as the thenar region.

CASE REPORT

A 32-year-old woman sustained a deep burn to the right hand following contact with an industrial heat press during a work-related activity. She was diagnosed with a full-thickness burn measuring approximately 6 × 5 cm, involving the palmar surface of the right hand, specifically the thenar and hypothenar regions, with extension to the forearm (Fig. 1).

Fig. 1.

Right hand: third-degree burn affecting the thenar and hypothenar regions and the anterior aspect of the right wrist.

TREATMENT: SURGICAL PROCEDURE

After aseptic preparation, hydrogel (Dermygel), petrolatum, and sterile plastic film were applied, achieving a moist chamber and promoting autolytic debridement, which was evident by day 7. Surgical eschar excision was then performed without a tourniquet, allowing continuous tissue-perfusion assessment. After excision to the fascial and palmar aponeurotic planes, no grossly necrotic tissue was identified, and the exposed tissues appeared viable. However, the recipient bed lacked the robust punctate bleeding typically expected after adequate excision, suggesting limited or borderline perfusion in the deepest areas of the burn (Fig. 2). A full-thickness skin graft was harvested from the ipsilateral inner arm, and the donor site was closed primarily with intradermal sutures. The graft was adapted to the palmar defect and secured with simple continuous sutures (Fig. 3).

Fig. 2.

Right hand: after eschar excision and removal of necrotic and devitalized tissue in the thenar, hypothenar, and wrist regions.

Fig. 3.

Right hand: placement of an amniotic membrane over the full-thickness skin graft.

Due to the limited recipient-bed perfusion, perilesional involvement, and the high functional risk of long-term sequelae, preserved glycerol-stored amniotic membrane was rinsed with saline and applied over the skin graft as an additional layer, completing a sandwich-type coverage (Fig. 3). Nitrofurazone-impregnated gauze was then placed over the graft and amniotic membrane, followed by a secondary securing dressing to reduce friction and shear. The membrane was supplied by the District Institute of Science, Biotechnology and Innovation in Health (IDCBIS in Spanish), a public tissue bank. It was stored in glycerol and rinsed 3 times with room-temperature saline for 10 minutes before application.

On postoperative day 7, the dressing was removed, revealing satisfactory graft integration. Partial persistence of the amniotic membrane over the wound bed and the presence of blood-filled vesicles were observed; these were drained using a syringe.

Because the patient lived in a remote rural area, follow-up was conducted via telemedicine. Formal physiotherapy could not be completed due to transportation limitations; virtual guidance was attempted but was limited by pain. At 12 months, the graft showed adequate integration, with a pliable scar and no evident flexion contracture. The patient also reported returning to work involving hand use without perceived limitations compared with her preinjury status (Fig. 4).

Fig. 4.

Twelve months postoperatively: complete graft integration, with partial hypertrophy and no evidence of functional contractures.

DISCUSSION

The sandwich technique, combining an autologous skin graft with allografts such as cadaveric skin or amniotic membrane, has long been used in deep-burn reconstruction. By reducing moisture loss and promoting reepithelialization, it supports scar modulation and improved healing.^5–9 In Colombia, where occupational and hand burns are frequent, it may help preserve mobility and reduce disabling sequelae.¹

Most evidence on amniotic membrane involves split-thickness, meshed, microskin, or Meek grafting techniques; therefore, these findings cannot be directly extrapolated to full-thickness skin grafting. This case should be interpreted as a description of technical feasibility rather than as solid evidence of superiority or functional benefit.^8,10

In this case, devitalized tissue was meticulously excised to obtain a clean, well-vascularized wound bed before grafting. The amniotic membrane promotes regeneration by increasing the expression of keratinocyte growth factor, epidermal growth factor, basic fibroblast growth factor, and transforming growth factor-β. It also modulates inflammation through HLA-G–mediated immune tolerance, regulatory molecule upregulation, pro-inflammatory cytokine suppression, and T-cell proliferation inhibition. Together, these mechanisms create a favorable microenvironment for graft survival and integration.⁴

Evidence supports the biological properties of amniotic membrane, including its growth factor content and anti-inflammatory, antimicrobial, and antifibrotic activity. These attributes make it a valuable adjunct in skin grafting, with potential relevance for scar modulation, although these effects cannot be confirmed from a single case.⁹

Because this was a single case, the specific contribution of the amniotic membrane cannot be isolated. Comparative studies with predefined functional and wound-healing outcomes are needed.⁷

In the case reported, using the sandwich technique with amniotic membrane rather than cadaveric grafts was associated with early coverage and satisfactory healing in a critical anatomical area. These findings suggest that the biological properties of the membrane may enhance the benefits of early surgical coverage and support its broader use in burn reconstruction. Further studies are warranted to validate these outcomes.

CONCLUSIONS

This case illustrates the technical feasibility of applying preserved amniotic membrane as an overlay biological dressing over a full-thickness skin graft in a deep palmar burn. Although satisfactory graft integration and healing were observed, the absence of a comparison group and objective functional measurements prevents definitive conclusions regarding superiority, graft take, scar modulation, or functional preservation. Further comparative studies are needed to determine whether benefits reported in other grafting contexts extend to full-thickness skin grafting in functionally critical areas.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.

PATIENT CONSENT

Written informed consent was obtained from the patient for publication of the case details and accompanying clinical images.

ACKNOWLEDGMENTS

All authors declare the use of ChatGPT (OpenAI, GPT-4, January 2026 version) solely to assist in verifying and refining the grammar and scientific language during the translation of the article from Spanish to English. The tool was accessed via a cloud-based application programming interface and was used exclusively for linguistic enhancement. It did not generate original scientific content, contribute to the study design, or influence the interpretation of the results. No fine-tuning or custom parameters beyond the default settings were applied.

ETHICAL APPROVAL

This case report was conducted in accordance with all applicable ethical standards for clinical research and publication. Formal approval from an ethics committee was not required for this single-patient case report.