Evolution of a concept with enzymatic debridement and autologous in situ cell and platelet-rich fibrin therapy (BroKerF)

Background Deep partial-thickness burns are traditionally treated by tangential excision and split thickness skin graft (STSG) coverage. STSGs create donor site morbidity and increase the wound surface in burn patients. Herein, we present a novel concept consisting of enzymatic debridement of deep partial-thickness burns followed by co-delivery of autologous keratinocyte suspension and plated-rich fibrin (PRF) or fibrin glue. Material and methods In a retrospective case study, patients with deep partial-thickness burns treated with enzymatic debridement and autologous cell therapy combined with PRF or fibrin glue (BroKerF) between 2017 and 2018 were analysed. BroKerF was applied to up to 15% total body surface area (TBSA); larger injuries were combined with surgical excision and skin grafting. Exclusion criteria were age <18 or >70 years, I°, IIa°-only, III° burns and loss of follow-up. Results A total of 20 patients with burn injuries of 16.8% ± 10.3% TBSA and mean Abbreviated Burn Severity Score 5.45 ± 1.8 were identified. Of the patients, 65% (n = 13) were treated with PRF, while 35% (n = 7) were treated with fibrin glue. The mean area treated with BroKerF was 7.5% ± 0.05% TBSA, mean time to full epithelialization was 21.06 ± 9.2 days and mean hospitalization time was 24.7 ± 14.4 days. Of the patients, 35% (n = 7) needed additional STSG, 43% (n = 3) of whom had biopsy-proven wound infections. Conclusion BroKerF is an innovative treatment strategy, which, in our opinion, will show its efficacy when higher standardization is achieved. The combination of selective debridement and autologous skin cells in a fibrin matrix combines regenerative measures for burn treatment. Lay Summary Patients suffering from large burn wounds often require the use of large skin grafts to bring burned areas to heal. Before the application of skin grafts, the burned skin must be removed either by surgery or using enzymatic agents. In this article, we describe a method where small areas of skin are taken and skin cells are extracted and sprayed on wound areas that were treated with an enzymatic agent. The cells are held in place by a substance extracted from patients’ blood (PRF) that is sprayed on the wound together with the skin cells. We believe this technique can be helpful to reduce the need of skin grafts in burned patients and improve the healing process.

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The Efficacy of Five Different Wound Dressings on Some Histological Parameters in Children With Partial-Thickness Burns

Journal of Burn Care & Research ◽

10.1093/jbcr/iraa063 ◽

2020 ◽

Vol 41 (6) ◽

pp. 1179-1187 ◽

Cited By ~ 1

Author(s):

Birsen Harma ◽

Mehmet Gül ◽

Mehmet Demircan

Keyword(s):

Stratum Corneum ◽

Gold Standard ◽

Statistical Significance ◽

Healing Process ◽

Total Body Surface Area ◽

Wound Dressings ◽

Control Group ◽

Burn Wounds ◽

Partial Thickness ◽

Partial Thickness Burns

Abstract An ideal dressing should ensure that the wound remains moist with exudates but not macerated. Currently, there is no dressing available to suit all wounds, at all stages of the healing process. Although silver-containing dressings are the gold standard for burn wound care, few high-level trials have been completed comparing the clinical utilities of these dressings. In our study, five different types of wound dressings: carboxymethyl cellulose hydrofiber dressing with ionized silver (CMCH-Ag), polyethylene-polyethylene terephthalate aqua fiber dressing with elementary silver (PPAF-Ag), calcium alginate (CA), calcium + zinc alginate (CZA), and 0.2% nitrofurazone-embedded (NF) gauze dressings were compared in regard to histopathological parameters. Children aged between 0 and 18 years with small or middle-sized partial-thickness burns that affected less than 30% of the total body surface area were included in this study. The study groups (CMCH-Ag, PPAF-Ag, CA, and CZA) and the control group (NF) were randomly attained. Wound healing was evaluated by punch biopsies on the 21st day. The thickness of the stratum corneum and the epithelium, the number of papillae, and the papillary length were calculated and compared. The histological parameters of healing, except the stratum corneum thickness, did not show any statistical significance among the groups (P > .05). The dressings that included silver, calcium, or zinc showed useful and similar effects in noninfective burn wounds when compared with nitrofurazone-only dressings. Thus, it may be concluded that silver-containing wound dressings should not be considered as the gold standard in noninfective partial-thickness burn wounds in children.

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664 “Minimally Invasive” Skin Grafting with Enzymatic Debridement and Autologous Skin Cell Spray

Journal of Burn Care & Research ◽

10.1093/jbcr/irab032.310 ◽

2021 ◽

Vol 42 (Supplement_1) ◽

pp. S187-S188

Author(s):

Steven Kahn ◽

Ashley Hink ◽

Jordan Karsch ◽

Elizabeth Halicki ◽

William L Hickerson ◽

...

Keyword(s):

Minimally Invasive ◽

Skin Graft ◽

Donor Site ◽

Standard Of Care ◽

Full Thickness ◽

Skin Cell ◽

Partial Thickness ◽

Small Pore ◽

Partial Thickness Burns ◽

Enzymatic Debridement

Abstract Introduction Minimally invasive surgery is increasingly becoming standard of care across numerous subspecialties. However, burn surgery has lagged behind; as the mainstay of reconstruction still involves wound excision with a knife, a commensurately sized skin graft, and a painful donor site. In recent years, several new technologies have the potential to be used synergistically to perform “minimally invasive” skin grafts. Enzymatic debridement with bromelain and autologous skin cell spray (ASCS) have independently been shown to reduce the need for split-thickness skin graft (STSG) and decrease the donor site size when grafting is performed. Bromelain is more likely to preserve healthy dermis and ASCS allows an 80:1 expansion. Due to constraints regarding the temporal course of these products only being available via studies before one was FDA approved, these two therapies have not been utilized together in the US until recently. A paucity of literature regarding their use in combination currently exists. Methods This study is a single site review of patients treated the continued access study protocol for bromelain-based enzymatic debridement and with ASCS per the FDA-approved instructions for use. Enzymatic debridement was performed over a 4-hour period with appropriate analgesia. Deep partial-thickness burns with residual dermis were treated with ASCS after enzymatic debridement and superficial dermabrasion. Wounds were dressed with a small pore non-adherent film and layered gauze. Full-thickness burn injuries were treated with conventional STSG. Results Two patients were treated over a 2 week period. One was a 51 yr old male with 17% TBSA superficial and deep partial thickness flame burns, of which 11% were deemed deep enough to warrant treatment with enzymatic debridement. 15% TBSA was treated with ASCS including the arms, back, and posterior neck with a 24 sq cm donor site. Wound closure was noted post-operative day 7 with complete re-epithelialization. The second patient was a 21-year-old male with several comorbidities impairing wound healing (diabetes [HgbA1c of 9.9], scurvy, and zinc deficiency. He had deep-partial and full-thickness burns to bilateral feet. The dorsum of the right foot was reconstructed with ASCS only and a 6 sq cm donor site, and the left foot was treated with a 3:1 meshed STSG and ASCS overspray with 100% take. Conclusions Enzymatic debridement and ASCS can be utilized to treat deep partial-thickness burns with a “minimally invasive” reconstruction. The donor sites in both patients were much smaller than had they been treated with a conventional meshed STSG. Further study is needed to determine which subsets of patients and burn wound characteristics are optimal for this combination of technologies. More data regarding outcomes such as length of stay, costs, and scar formation compared to standard of care is also warranted.

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Combined Complex Skin Repair in Patient With Extensive Burns: A Case Report

Journal of Burn Care & Research ◽

10.1093/jbcr/irab037 ◽

2021 ◽

Author(s):

Xingxin Gao ◽

Min Zhang ◽

Yuan Lin ◽

Dehui Li ◽

Liming Zhang

Keyword(s):

Recombinant Human Growth Hormone ◽

Donor Site ◽

Total Body Surface Area ◽

Human Growth ◽

Skin Grafting ◽

Current Treatment ◽

Limiting Factors ◽

Split Thickness Skin Graft ◽

Skin Repair ◽

Extensive Burns

Abstract Auto-skin grafting is the current treatment of choice for extensive burns. Nevertheless, the lack of donor sites for skin grafting remains one of the greatest limiting factors for the treatment of extensively burned patients. We present the case of a 53-year-old male patient with deep and full thickness burns on 91% of the total body surface area. We used the Meek technique for split-thickness skin graft expansion to treat this patient. In order to obtain sufficient skin for grafting, we repeatedly harvested the same anatomical areas. Acceleration of burn wounds, recipient, and donor site healing was achieved by systemic treatment with recombinant human growth hormone and topical recombinant human epidermal growth factors. This combined, complex treatment modality contributed to the successful skin repair in this patient.

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Use of Biobrane® to Dress Split-Thickness Skin Graft Adjacent to Skin Graft Donor Sites or Partial-Thickness Burns

Journal of Burn Care & Research ◽

10.1097/bcr.0b013e3182779945 ◽

2013 ◽

Vol 34 (5) ◽

pp. e308 ◽

Cited By ~ 6

Author(s):

Azzam Farroha ◽

Quentin Frew ◽

Naguib El-Muttardi ◽

Bruce Philp ◽

Peter Dziewulski

Keyword(s):

Skin Graft ◽

Split Thickness Skin Graft ◽

Partial Thickness ◽

Thickness Skin ◽

Graft Donor ◽

Partial Thickness Burns

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The use of Urgotul™in the treatment of partial thickness burns and split-thickness skin graft donor sites: a prospective control study

International Wound Journal ◽

10.1111/j.1742-481x.2009.00611.x ◽

2009 ◽

Vol 6 (4) ◽

pp. 295-300 ◽

Cited By ~ 18

Author(s):

Pearlie WW Tan ◽

Wong Chin Ho ◽

Colin Song

Keyword(s):

Skin Graft ◽

Split Thickness Skin Graft ◽

Prospective Control Study ◽

Prospective Control ◽

Partial Thickness ◽

Thickness Skin ◽

Graft Donor ◽

Partial Thickness Burns ◽

Control Study

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Use of a biosynthetic wound dressing to treat burns: a systematic review

Journal of Wound Care ◽

10.12968/jowc.2020.29.sup12.s16 ◽

2020 ◽

Vol 29 (Sup12) ◽

pp. S16-S22

Author(s):

Farimah Rahimi ◽

Reza Rezayatmand

Keyword(s):

Systematic Review ◽

Wound Dressing ◽

Large Scale ◽

Scientific Evidence ◽

Ease Of Use ◽

Wound Dressings ◽

Split Thickness Skin Graft ◽

Burn Treatment ◽

Partial Thickness ◽

Partial Thickness Burns

Objective: Accelerating the process of wound healing, reducing infection risks, and decreasing pain and discomfort in the burn area are important goals of burn treatment. To achieve these goals, the use of biosynthetic wound dressings has increased in recent years. Suprathel (PolyMedics Innovations, Germany) is a biosynthetic wound dressing used to treat both partial-thickness burns and split-thickness skin graft (STSG) donor sites, full-thickness wounds, large-scale abrasions, and scar revisions. Method: This study is a systematic review of empirical evidence reported on the application of the biosynthetic wound dressing in burns up to 2017. Keywords such as ‘Suprathel’, ‘effectiveness’, ‘safety’, and ‘cost’ were searched in PubMed, Cochrane, Scopus and Embase databases. Results: A total of 14 publications were identified, based on the inclusion and exclusion criteria. The findings reported in the literature reviewed were classified in terms of safety, effectiveness and cost-effectiveness of use of the biosynthetic wound dressing. Regarding safety and effectiveness, the dressing was found to yield desirable results, particularly for partial thickness burns and STSG donor sites. As of 2017 no health economics assessments have been carried out. Conclusion: Despite the desirable advantages of the biosynthetic wound dressing with respect to its effectiveness, safety and ease of use, its major limitation was found to be its cost. However, in the absence of comprehensive studies on the quantification of all factors, there is scant scientific evidence for making reliable conclusions from this systematic review.

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The Role of Autologous PRP on Deep Partial-Thickness Burn Wound Healing in Bama Pigs

Journal of Burn Care & Research ◽

10.1093/jbcr/iraa012 ◽

2020 ◽

Vol 41 (3) ◽

pp. 657-662 ◽

Cited By ~ 2

Author(s):

Yanwei Sun ◽

Yongqian Cao ◽

Ran Zhao ◽

Famei Xu ◽

Dan Wu ◽

...

Keyword(s):

Wound Healing ◽

Growth Factors ◽

Growth Factor ◽

Healing Process ◽

Control Group ◽

Therapeutic Effects ◽

Partial Thickness ◽

Partial Thickness Burn ◽

The Mean ◽

Partial Thickness Burns

Abstract In this study, we aimed to evaluate the therapeutic effects of autologous platelet-rich plasma (PRP) on deep partial-thickness burns in Bama pigs. Deep partial-thickness burn wounds were created on the back of Bama pigs. The reepithelialization time was compared between the PRP and control groups. The mean score of Ki67 (+) cells and α-SMA (+) vessels, the mean thickness of epidermis and dermis of the healing wounds were determined via H&E staining and immunohistochemical assay. The levels of the growth factors epidermal growth factor (EGF), basic fibroblast growth factor (bFGF), and vascular endothelial growth factor (VEGF) were examined by ELISA. Our data showed that the time to wound reepithelialization was shorter in the PRP group compared with the control group. The thickness of the epidermis was larger in the PRP group compared with the control group. On the 7th and 14th days after the treatment, the mean score of Ki67 (+) cells and α-SMA (+) vessels were higher in the PRP group compared with the control group. The PRP group showed higher levels of growth factors (EGF, bFGF, and VEGF) compared with the control group by ELISA. The results indicated that PRP could improve wound healing process of deep partial-thickness burns in Bama pigs. The PRP increased the thickness of epidermis of the healed wounds, cell proliferation, and angiogenesis. We demonstrated that applying PRP had a greater potential for the treatment of deep partial-thickness burns.

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CICAFAST: comparison of a biological dressing composed of fetal fibroblasts and keratinocytes on a split-thickness skin graft donor site versus a traditional dressing: a randomized controlled trial

Trials ◽

10.1186/s13063-019-3718-4 ◽

2019 ◽

Vol 20 (1) ◽

Cited By ~ 1

Author(s):

Alexandra Poinas ◽

Pierre Perrot ◽

Judith Lorant ◽

Olivier Nerrière ◽

Jean-Michel Nguyen ◽

...

Keyword(s):

Wound Healing ◽

Growth Factors ◽

Skin Graft ◽

Donor Site ◽

Split Thickness Skin Graft ◽

Skin Grafts ◽

Thickness Skin ◽

Fetal Fibroblasts ◽

Biological Dressing ◽

Graft Donor

Abstract Background Wound repair is one of the most complex biological processes of human life. Allogeneic cell-based engineered skin substitutes provide off-the-shelf temporary wound coverage and act as biologically active dressings, releasing growth factors, cytokines and extracellular matrix components essential for proper wound healing. However, they are susceptible to immune rejection and this is their major weakness. Thanks to their low immunogenicity and high effectiveness in regeneration, fetal skin cells represent an attractive alternative to the commonly used autologous and allogeneic skin grafts. Methods/design We developed a new dressing comprising a collagen matrix seeded with a specific ratio of active fetal fibroblasts and keratinocytes. These produce a variety of healing growth factors and cytokines which will increase the speed of wound healing and induce an immunotolerant state, with a slight inflammatory reaction and a reduction in pain. The objective of this study is to demonstrate that the use of this biological dressing for wound healing at the split-thickness skin graft (STSG) donor site, reduces the time to healing, decreases other co-morbidities, such as pain, and improves the appearance of the scar. This investigation will be conducted as part of a randomized study comparing our new biological dressing with a conventional treatment in a single patient, thus avoiding the factors that may influence the healing of a graft donor site. Discussion This clinical trial should enable the development of a new strategy for STSG donor-wound healing based on a regenerative dressing. The pain experienced in the first few days of STSG healing is well known due to the exposure of sensory nerve endings. Reducing this pain will also reduce analgesic drug intake and the duration of sick leave. Our biological dressing will meet the essential need of surgeons to “re-crop” from existing donor sites, e.g., for thermal-burn patients. By accelerating healing, improving the appearance of the scar and reducing pain, we hope to improve the conditions of treatment for skin grafts. Trial registration ClinicalTrials.gov, ID: NCT03334656. Registered on 7 November 2017.

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