30th Mar 2017 6:43:15 AM

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Skin Substitutes

In 2012 in South Africa and further afield, there was a lot of publicity about a three-year-old child who had about 60 per cent total body surface area (TBSA) burned after her father allowed her too close to a barbeque (braai) party on New Year's Day. The newspapers typically reported a larger body area being burned than was necessarily the case; they did not typically report that there was brain damage to the child.
While it was claimed that the ethanol fuel gel exploded, it is a common cause of burns when people put any sort of accelerant on a cooking fire to speed it up.

Patience and safety go together. Do not add gel, paint-thinners, petrol or any similar substance to a barbeque. Children should be kept away from cooking on open flames where possible.
All that said, extensive TBSA burns require a concerted effort to save a patient's life. And a concerted effort to maximise the quality of the life that will follow survival.

There are a variety of options available to the patient.
Donor skin
These can include taking donor skin from elsewhere on their own body to patch the damaged area.
The donor (given) skin is often taken off the body with something similar to a cheese slicer, pulling a thin layer off the top. That is often taken from the patient's upper thighs if they were not damaged by the burns; the thighs are chosen because it is an area of the body not usually visible in day-to-day activities.
While at first looking scarily-pink, these donor sites usually heal into barely-noticeable rectangular patches of the same colour as the rest of the patient's unharmed skin.
The skill lies in not cutting too deep. In South Africa you must hope that the paediatric registrar is supervised by an experienced consultant.
When our child Sthabile had donor skin taken from her thigh to place on her foot in late 2012, the thigh bled profusely because the skin was cut too deep. The graft to the foot did not "take" and the child had to recover and then go through the whole process again with double the cost in money, extensive ward and theatre time, time-away-from-school and pain and double the risk with repeated general anaesthesia.

Cadaver skin
A patient's parent can donate skin but it will not provide a permanent solution, just a covering in an emergency.
The same can be done with cadaver skin (skin from a dead person) but the source must be safe e.g. not from someone who is HIV positive. The time taken to get accurate blood tests might prevent "harvesting" of cadaver skin.

Meshed skin
If a big area of the body needs to be covered, the patient's own skin may be cut away and put through a skin mesher. This makes the sheet of skin into a mesh with the appearance a bit like fishnet tights or like a string vest.
This mesh allows the patient's skin to "regenerate" (grow) within a supporting scaffold of their own skin.
Meshed skin should be avoided for highly-visible areas such as the scalp, face, upper arms, forearms, upper chest.
Every surgeon should imagine the burned baby as a sensitive teenager in the years to come; maybe as a girl wanting to wear a pretty dress to her Matric dance.
Then the surgeon can make the most sensitive decisions regarding the placement of skin. Survival is paramount but aesthetics need to be taken into consideration after that.
Many years after the skin has healed, the meshed skin looks a bit like the scales of a fish or the skin of a crocodile or some other reptile. It adds to the teasing that the burns survivor will face.

Integra
Integra is a skin substitute which we have used to good effect, e.g. on Oscar Mlondolozi Hadebe when he was operated on at Albert Luthuli Hospital by Prof Anil Madaree. All those years ago it cost R25000 and had to be flown in from France specially for the child. We were also offered Integra to use on Sizwe Hlope when he had surgery planned at Milpark Hospital.
That surgery did not happen as the toddler was starved for more than 20 hours and was ultimately too distressed to cope without food any longer.
As we had the "audacity" to complain about the child's maltreatment, the surgeon threw a tizzy fit and the operation was cancelled. We returned the Integra to the kind donor at that time (Johnson & Johnson) as there were then only seven surgeons in South Africa trained in its use and we had no certainty of getting an Integra-trained surgeon to complete the urgent procedure.

Pelnac
We have used Pelnac to good effect on Franklin Mochiadibane when we sent him to Groote Schuur Hospital in Cape Town for surgery with Prof Don Hudson and Dr Sean Moodley. It is a porcine skin substitute. In 2012 Deon Beyers at Medunsa was trialling a new version. The product was originally developed by Pro Morimoto et al in Japan.
In 2012 a patch measuring about 8cm by 6cm would cost R6284 in the private sector hospitals in South Africa and about R3800 in the state sector hospital in South Africa.

Spray on Skin
Spray on skin was developed by Dr Fiona Woods in Perth, Australia. It is more durable that cloned skin and infinitely more affordable, but it is still sourced from the patient's own skin. It has been used repeatedly to good effect at the Red Cross Children's War Memorial Hospital in Cape Town by Professor Heinz Rode. Prof Rode is probably the most-skilled and kindest burns surgeon that we know of, in South Africa. He has saved the life of a children with extensive TBSA burns including a little girl with 80 per cent TBSA in 2012.

Cloned Skin
Cloned skin has been used on two South African burns survivors (in 2012 and 2013), at the Garden City Clinic in Johannesburg by surgeons including Dr Ridwan Mia, a Children of Fire trustee. While the surgery appears to have worked well, with the vast number of severely-burned children who need surgery in Africa every year, it is not a process that we would ever fund. Newspapers stated that the cost of flying the skin to Boston USA to be grown and flying it back was R800,000 for each of the child patients. This figure is confusing as the second child had a far smaller body area to repair (at 35 per cent TBSA). Additionally with the second child she was also burned around New Year festivities and yet was given the cloned skin only at end April 2013 when she was no longer in the acute stage. As a charity we would think that extremely expensive procedures would be prioritised for life-saving procedures more than aesthetics, and when aesthetics are a consideration, we would prioritise our spending on body areas that are visible in the course of normal daily activities.

Other skin issues:
Collagen induction

We have used collagen induction to good effect on Bongani Phakati and Zanele Jeza, where an individual roller (used only on one patient) with 200 needles, induced the keloided skin to repair itself.

Keloids and hypertropic scars
Surgery on any patient who shows a tendency to keloid (to form raised scars) should be undertaken with great caution. The surgery may significantly worsen the scars.
Pressure garments should be sewn in advance and adjusted to fit snugly as soon as the wounds have healed.
Silicon sheet or products like Scarban should be obtained to wear on top of the skin and under the pressure garment, to reduce the tendency to keloid.
Massage with Bio Oil and aqueus cream can help a lot.

There are many other skin substitutes. This is not a comprehensive guide and any person intending to use the products should talk directly to their own surgeon. This website section will be updated from time to time.



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