CASE REPORT: SUCCESSFUL TREATMENT OF SEVERE BURN WOUNDS USING HBO AND SKIN SUBSTITUTES, WITHOUT AUTOLOGOUS SKIN GRAFTING

Kazu Suzuki DPM CWS, Joel Aronowitz MD, Ralph Potkin MD.Tower Wound Care Center, Cedars-Sinai Medical Center, Los Angeles, CA.

CASE REPORT: SUCCESSFUL TREATMENT OF SEVERE BURN WOUNDS USING HBO AND SKIN SUBSTITUTES, WITHOUT AUTOLOGOUS SKIN GRAFTING

Kazu Suzuki DPM CWS, Joel Aronowitz MD, Ralph Potkin MD.Tower Wound Care Center, Cedars-Sinai Medical Center, Los Angeles, CA.

Introduction: Traditionally, severe burn wounds, beyond 3rd degree, are treated using autologous skin graft to replace the loss of full-thickness skin after the surgical excision of damaged tissue (escharotomy and debridement). Most of the patients seen in our wound care center are seniors over 70 years old with less-than-ideal skin integrity. This demographic often fails as a viable source of autologous skin graft harvesting. HBOT (Hyperbaric Oxygen Therapy) is known to aid in wound healing by reducing edema, promoting granulation tissue formation, and supporting skin graft to be incorporated.

Case History: 82yo female fainted in a steam shower, sustained multiple 3rd degree burn wounds on both feet. Patient refused a transfer to a burn center, wishing to be treated locally in CSMC. Wound care treatments were rendered in our out-patient wound care center in conjunction with HBOT.

Vascular Status: Posterior tibial pulses were barely palpable, B/L legs. At the bilateral ankles, SPP (Skin Perfusion Pressure) measurements were above 50mmHg. PVR waveforms were biphasic, mildly obstructed flow. The combined tests (shown right) indicated no ischemia and good wound healing potential. SPP values over 40mmHg predicts good wound healing potential, while SPP less than 30mmHg is diagnostic of Critical Limb Ischemia and predicts wound healing failure. (Castronuovo et al. 1997 and Yamada et al 2008, Journal of Vascular Surgery).

Treatment: The wound beds were prepared with multiple surgical debridements and papain-urea chemical debridement cream. The granulation tissue formation was promoted using Wound VAC® and HBOT (30 sessions, 90 min each at 2.0 ATA). Due to the patient’s lack of ideal skin donor site, the decision was made to utilize skin substitutes. Skin substitute (Alloderm®, LifeCell) was meshed, implanted, and secured using sutures and Wound VAC®. Subsequently, complete wound closure was achieved using moist wound dressing.

Discussions: Current development of “skin substitutes” has yielded remarkable improvements in commercially available sources of artificial “skin-like materials” used in place of autologous skin grafts. These “skin substitutes” have mostly eliminated the burden of large skin graft harvesting, which may require hospitalization with the associated morbidities, such as pain, infection, and additional wound care. Combining HBO and other adjunctive wound therapies, it is now possible to achieve complete healing of severe wounds without autologous skin grafts.

Product Tissue OriginAlloderm® Human cadaveric skin

GraftJacket® Human cadaveric skinDermagraft® Human neonatal foreskin

Apligraf® Human neonatal foreskinOasis® Porcine small intestine submucosa

Integra® Bovine collagen + chondroitin sulfate

Commonly Used Skin Substitutes in the US

Alloderm® (before hydration) Wound VAC®

Initial Presentation 2 weeks 4 weeks 16 weeks: Healed

SPP indicates good wound healing potential.

PVR shows mildly obstructed biphasic flow.

5 – 6 weeks: Wound VAC® Alloderm® grafted