Jeffrey Shupp, MD, FACS, Burn Center Director, MedStar Washington Hospital Center talks about a new option for helping some burns heal.
Interview conducted by Ivanhoe Broadcast News in September 2019.
When there’s an extensive amount of burn damage to the skin, what is the traditional way of helping the patient?
SHUPP: The mainstay of closing burn wounds is to graft the patient with skin that’s harvested from uninjured areas of their body. That skin is harvested and then usually meshed so that we can expand a piece of skin to cover a larger area than where we harvested it from.
When you say harvest, where are you usually taking it from?
SHUPP: In a patient that doesn’t have extensive burns but needs skin grafting surgery, we usually prefer to take it from the thigh. But in large thermally injured patients where most of their body is burned, then we harvest skin from anywhere.
What is the challenge of treating a patient this way?
SHUPP: Having enough normal or uninjured skin to get the wounds closed before infection sets in.
How soon after an injury or how quickly is it important for doctors to close the wounds?
SHUPP: We typically start dealing with burn wound infection after about the first week. Initially, the skin is sterile because the heat that injured the skin also killed the bacteria that lives on the skin. But the bacteria begin to regrow and can then infect the wounds, which is devastating because without the skin in place, there’s no barrier for infection. We try to take patients to the operating room as early as 24 to 48 hours after their injury and begin temporarily closing the wounds with things like cadaveric skin or skin from other animals like pig skin. There are some synthetic skins that we can use, but many of these products aren’t permanent and are only temporizing the patient until we can find enough of their own skin to close the wounds permanently.
Tell me the option where you’ve tested it and it’s now available.
SHUPP: The technology is called ReCell. It basically takes a piece of donor skin from the patient and enzymatically turns it into a cell suspension or a liquid skin that can then be sprayed back on the patient. In the traditional sense, we typically mesh four to one, three to one, even six to one. What that means is you will take a 200 square centimeter piece of skin and mesh it four to one, then you’ll have 800 square centimeters of skin to graft with. The advantage of the ReCell technology is that you can mesh skin, or expand skin, 80 times that of its original size. You can see the magnitude of the ability for you to get more coverage with smaller pieces of skin.
What size of skin can you take and then what size will it expand to? Is it a quarter size that goes to the size of a football?
SHUPP: If you took a one centimeter by one centimeter piece of skin, which is slightly larger than a hole punch, that could be expanded to be 80 square centimeters, which is almost the size of an index card.
And that is with the spray?
SHUPP: Correct.
Why is this so critical for people in your field?
SHUPP: It allows us to do grafting with much smaller donor sites. The other advantage is that you can use the spray to treat the donor site which accelerates the donor site’s healing. And then, you can re-harvest from a site much sooner. So those two strategies make the product very helpful in getting wound closure in a very large burn patient.
Can you walk me through what doctors have to do with the mesh, the grafting, and the spray?
SHUPP: In the kit, which comes self-contained, is all the chemicals you need to make the cell suspension. You’ll harvest a piece of donor skin much like you would for conventional grafting, although it’s much smaller inside of the apparatus, so the kit has a small incubator. You put that small piece of skin in the incubator for a time period. The enzyme in the incubator helps disassociate the cells, and then you bring the skin back out of the incubator on a tray and agitate it briefly with a scalpel and then you dilute in a buffer. It then gets sucked up into a syringe. The syringe is outfitted with an atomizer so that you can spray it on. Most of the kits can process several pieces of skin so you can do this repeatedly.
Have you personally done the surgeries with the spray?
SHUPP: Yes. We’ve been involved in all the clinical trials here at MedStar Washington Hospital Center. And now we’re finally using it commercially. I just used it this morning on a patient that has his entire leg from his groin to the tips of his toes burned. The problem is he also has his other leg and both arms burned. So instead of using his entire back for donor site, I used some areas on his flank and was able to graft his entire left leg without opening a bunch of donor sites.
What does this mean for the patient?
SHUPP: Whenever you harvest skin, you create additional wounds. The patient doesn’t necessarily just have pain at the wounds that were caused by the burn injury. When we take them to surgery, we must open new wounds that they didn’t have before in order to get the burn wounds closed. So, at the very basic part of it, it means less donor sites for the patients, which means decreasing their total wound burden. Other advantages that we’re still learning about is cosmetics. Using grafting in conjunction with the suspended skin cells can help blend the cosmetic pattern a little bit better, not just in pigment but in topography of the grafting sites.
Is there a different look with the skin that has been sprayed on? Is it smoother because you don’t have the meshing?
SHUPP: Yes. In my opinion, it makes for a more aesthetic outcome because we’re using this with widely meshed autograft right now. You take the conventional skin grafts and use the widest mesh that you can possibly use. Then, you spray the skin cells on over top of that. And, in my opinion, the areas that get the spray are less able to tell what that mesh pattern looked like.
Can you describe the first time you used it and saw the results?
SHUPP: A lot of us were skeptical at first because when you spray this clear solution on, you’re seeing the cells. But, when we took the dressings down on the first few research patients and saw that the wounds were closing, it was very eye opening. That’s why we got excited and started to not just participate in clinical trials, but other research around the technology.
Life-changing for your patients? Life-saving for your patients? How would you describe it?
SHUPP: I think it can be both. Especially for the patient that has a much larger burn.
What can you tell me about your patient’s, Ms. Gash, injuries and treatments?
SHUPP: The study that Ms. Gash was in was comparing standard of care skin grafting to skin grafting with one less size expansion. So, if the standard of care that I would’ve chosen for her wounds was a two to one mesh autograft than the research site, we would have been asked to increase that to three to one. This means making the expansion area larger which would be less aesthetic and take longer to heal. But the research site got over sprayed with ReCell. The patients going through the trial can see where the donor sites were for each site because that was one of the things we were measuring – how much of the patient’s skin did it take to achieve result A versus result B. She was very informed and knew that the donor site that was created to close the control wound was much larger than the donor site that we needed to use to close the experimental wound. She expressed from the very beginning she wished she could have had the research site on both sides. So, for that study, the patient needed to have similar wounds that could be split into halves so that they could be within subject control for the study. That’s what we’re watching. What is the final outcome of those two wounds? And in her case, even with the wider meshed autograft, the experimental side to her looks just as good, if not better, than the control side.
How do you describe this? Spray skin?
SHUPP: Just that way. We are taking a piece of your skin and turning it into a liquid and we’re going to reapply it using a spray nozzle. That allows us to use less of your skin to cover larger wounds.
What is the name of the company and the name of the product?
SHUPP: Avita is the name of the company and ReCell is the name of the device.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
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