Repairing burn wounds through skin regeneration: Fiona Wood at TEDxFlanders

Fiona Wood's journey of 3 decades treating burn injury, bringing basic science to the bedside focusing on helping people whose lives have changed in an instant, making sure the quality of the outcome is worth the pain of survival.

Thank you, that's right.
I'm Fiona Wood.

I'm a plastic and reconstructive
surgeon,

and for the last 30 years --

I've spent my whole
professional life focused on

and trying to treat people
with burn injuries.

I think as a plastic surgeon
I see suffering on a daily basis.

I see people's lives
that have changed in an instant.

When I look back and sort of introspect,
I guess, over those 30 years,

where did I start ? Where did I start
to think that we could do better ?

And I've traced that back
to seeing a young child,

a young child in 1985.

A cup of coffee had gone down
the front of that chest.

There had been a period
of time for painful dressings,

the cries that would probably
never leave the mother and father.

All those weeks for healing,

and I was working
in a plastic surgery center

in the South of England
at that time

and this child turned up
at our plastic surgery center.

"The burns are healed now,
he needs plastic surgery."

It hit me straight between the eyes,

that this boy would never move
properly again,

he would never move
his neck or his arm,

that the scars that had been left
from a very simple situation

would be with him for life.

And so as I moved forward through
my education and my training as a surgeon,

I became increasingly focused
on how to make sure

that the quality of the outcome
was worth the pain of survival.

Many of you may have burnt
yourselves on the arm,

just done a bit of a splash of oil
when it's cooking.

Just bear one second,
a fraction of a second,

for half your body being burnt.

Ten years ago,
this month,

was a tragedy that touched
many people across the world

but in particular touched Australia,

it was the Bali bombings.

It was at the ten year review,

when I was talking to
one of these young men,

the captain of the football team,

who found himself in
that nightclub that night,

and he described
how he fell into the flames,

he broke his back,
he lost all his teeth,

he had multiple fractures,
and 70% of his body was burnt.

He went on to survive

and he described on this occasion
two weeks ago,

the pain of that injury.

But he also went on to describe
the pain of the healing,

week in, week out,

and the recovery,
the rehabilitation

and making sure
that when he first left,

and he couldn't clean his teeth
or brush his hair,

how he drove over
that first 3-4 years,

to the point where he had
a full range of movement.

The scars will never leave him.

So, as a surgeon, when I say
I've come to talk to you today about

"How can we do it better?"

You know that it is what we live,
what we breathe, on a daily basis.

We see sufferings, we see lives changed
in an instant, and it can happen to anyone.

So, what do we do?

When someone has
a burnwound, the skin --

I could talk about skin forever,

it's a fascinating organ,
that's well and truly underrated.

Now, what a beautiful thing is skin.

It helps to keep your body in,
how amazing. (Laughter)

It does all sorts of things,
it's your interface to the world.

We look at a baby
and we smell that baby,

and we smell that skin,
and how exquisite it is.

How could we get back to
that when it's damaged ?

Only it takes very little,

our skin is turning over
all the time,

it takes very little
to overwhelm that capacity,

so it can't repair itself.

It can't return to the functions

of temperature control,
bacterial control, etcetera.

So many functions I couldn't even begin
in 18 minutes to talk about.

So, what do we do then?

Look around
and take your blinkers off.

I think anybody in science these days
has got to seriously have their blinkers off.

They've got to look and see where else
they can find information.

And certainly in embryology
and in biological sciences,

in genetics we can see
all sorts of things happening.

I can see a gecko can grow a tail,

yet I can't repair
a wound without scarring.

Now we may step back
from this and think,

"Wow, what is it that we do? "

So, I'd like to take you
to the last 20 years

of work in the area
of skin grafting.

When you treat somebody with burns
it's a massive juggling exercise.

We have the pain, we still have infection
as the biggest killer,

we have to seal the skin over as the waves
of infection relentlessly come

and weaken that body,
weaken it,

weaken the ability
of the bone marrow to respond.

And we try to seal that surface,

so once we got that surface sealed,
we're safe.

And then the healing goes on,
as I've described.

But it gives us an opportunity for life,
if we can seal that surface,

we are safe and we can have
that opportunity to live again,

to then rebuild
the skin underneath.

So how do we create that surface,

if 50% of your body surface is gone,

there's only 50% to get skin from.

And so traditionally,
many years ago --

the first skin graft done
was in the 1800's,

that's a serious little time ago.

And so traditionally, when I started,
over 30 years ago,

we would take the surface of the skin,
just skim that surface

with a very large tool,
very sharp knife,

and still skim that surface,
so we'd got a split thickness skin graft.

We can change that
split thickness skin graft

to mesh it and make it larger.

So if I take a piece from a leg,
I can cover maybe 2/3 of an arm.

Maybe just less.
By meshing it out.

But that scar then look like a mesh.

So how, when we get bigger
and bigger burns,

we're in a situation
where technologies are advancing,

we know the people
can survive major burns.

And I recently had coffee
with a patient I met in 1991,

1st of October in 1991,

as I'd not long been director
of the Burns Service in Western Australia.

He had 92% body surface area burns,

and I was expected to walk away.

And I said, "We don't walk away,
because we have now the technology

to move forward
to ensure his survival."

And 20 years later
I was having coffee with him.

So, how did we achieve that?

When he only had 8%
of his body left?

Where could we get
the skin from?

Well, clearly we can't.

So many years ago,
in that famous institution

in Boston, the MIT,
they started growing skin cells

because we're into sheets,
we're into skin grafts,

we understand how the blood vessels
can come into that sheet

and establishes connections
with the surface.

We can change the skin from here to here,

we understand that.
So we grew skin cells into sheets.

By this time, these skins cells
were 10 cells thick,

we knew which way was up
and which way was down,

10 cells thick, you can imagine,
that's quite challenging.

But certainly, back in 1992,
at that stage,

there were one place in Australia
that was growing skin,

there was one other place in the world
that was growing skin commercially,

and that was Boston.

And so we could send a piece of skin from
-- I live in Western Australia.

We sent that skin
overnight to Melbourne

they grew it into sheets
that came back.

We put these sheets on
and we'd got an element of cure,

we'd got an element of closure,

we were able to save a life.

But that skin was over
in that laboratory for three weeks.

Every day in a burns unit
is a day too long.

How could we stop that?
How could we shorten that three weeks?

That's where my story started,

engaging the whole concept
of tissue engineering,

tissue expansion.

Myself and Marie Stone,
the scientist I worked with,

we raised money,
we started our own laboratory.

If you heal a burn within 10 days,
you get a 4% risk of scarring,

if you heal a burn within 21 days,
78% will have scarring.

Why wait 3 weeks?
Time matters.

People die waiting.

And so we started
in the skin lab in 1993,

and our first sheets
we grew in 10 days.

But before long we realised,
by observation,

by taking basic signs
to the bed side,

we saw that the more immature
those skin cells were,

paradoxically,
the better they did.

And so we started doing
experiments around this.

Trying to understand
what was going on.

And then we started seeing that if we take
the cells after 5 days in the laboratory,

and remove them
from the flask into a soup,

that they did even better.

And the operating theaters we work in,
are round about 44 degrees -- that's C[elsius],

because if a patient gets cold,

they no longer clot their blood,

and so we can't operate.

So I came out of the sweat box,

I walked into the lab to see Marie
in the beautiful air conditioned lab,

it was all clean,

and in the operating room
we debride,

we remove the burn tissue until such point
that we get pin point bleeding

and then we know it's alive.
Somewhat less than subtle.

But our advances in that area are
another 18 minutes at another time.

And so there we were,
and I shook my head and said,

"Wow, we just should just
spread this stuff on."

The time taken to make sure
those cells were on the right way up,

fixing each patch onto the body
so they didn't sheer or move.

Taking it from there, putting in a soup,
trying to keep the soup under the dressings.

At that stage, you gain a whole raft
of more experiments to do.

How can we actually deliver cells

to the surface
of this burned wound, such

that they are alive and functional?

We took, became I guess,
amateur physicists,

looking at the vortex in,
and apertures, in various nozzles,

we found a nozzle,
in a chemist shop in Perth,

that was from an Italian
mouth freshener.

And when you put that nozzle
on a 5 ml standard hospital seringue,

the cells coming through that system
with no dead space,

were viable,
90% plus cells were viable.

It was a eureka moment.

In the program you'll see
fine dots behind my name.

Just off screen is the seringue
as we're spraying those cells on.

So what we do, we take the skin cells
from you, to you.

It avoids all the issues of rejection,

it allows tissue expansion.

Each little cell can cover
much greater area

than when we coalesce them into a sheet,
and then grow them

and the next step in the whole process
was to look back,

and say, "We can do this in 5 days."

But 5 days is a long time.

I've said already one day in a burns unit
is a day too long.

How can we actually move quicker?

We notice that our smaller burns
by this stage,

we were looking at these technologies
in our smaller wounds,

how where we were still doing
our traditional skin grafting,

they had scars that were worse
than larger burns

where we were doing
more advanced technology,

where we were mixing the technologies,

where we were using this traditional,
and the cells spray.

And so we then moved to say,

"How can we do it
in less than 5 days?"

So we took the absolutely
key essential components

of the laboratory,
we minutarised them.

We put them in a box,
a box just this big.

The box that heats the enzyme
up to the required temperature,

such that the skin
that we harvest,

we take a split thickness skin graft,
a small postage stamp.

We put that in the enzyme,

takes few --
a matter of minutes, 10 to 15,

20 if the skin is a little thick.

And we take that out,
it's like a bread and butter sandwich,

and we could peel those slices
of the skin apart,

like we'd peel the sandwich apart,

and the butter is all those
actively growing cells.

Those cells under normal conditions
will keep us whole.

They will keep replenishing the surface
against the knocks

and the scrapes of everyday life.

We harvest those cells,
filter them through,

make them into a suspension,
and deliver them to the wound.

The whole process now
takes 30 minutes.

(Applause)

So, I'm a great believer in
learning from today's experience

to make tomorrow a better place.

That tomorrow, every morning,
when you get up,

it's the start of a new journey.

So, where to now?

Where to when we stand back and look
at 20 years of our work --

Where to next?

I had this idea that when I was
chasing scar-less healing,

having seen that boy in 1985.

I would get to the top of the mountain,

20 years more no trouble,

we plant the flag
at the top of the mountain,

but my goodness,
I was wrong.

Because as we've changed
the goalpost,

people survive more and more
and more massive injuries.

And we're chasing that illusive goal
for more complex situations.

And so I put it to you:
yes, we've got the cells in the right place,

but where to next?

What create, what self-organizing
systems makes me this shape?

Recognizable through life,

a little bit bigger,
a little bit smaller.

But essentially recognizable
through life.

From the embryo to death?

What self-organizes this systems?
Well, we started looking.

We understand
that if you are burnt here,

the nerve density
in the nerves of the scar

and on the non-scarred
matched area are the same.

They're both decreased.

I know that if you have a burn,

in your right upper limb, the patterning
of your left brain has changed.

So where to next?

We've got the cells in the place.

We've got the architectural frameworks,

as I work with colleagues in nanotechnology
looking at self-assembly,

a framework such that the cells
can express themselves

through an appropriate phenotype.

Such as not only can we seal
the surface, giving life,

but that we can develop
the underlayers of the skin,

which give the quality of life.

Then we can organize,

we can self-organize
back to the original shape

And is the 3-dimensional spacial information
for that original shape

actually housed in
the homunculus in the brain?

I know also,
from personal experience,

when I was being scanned,
the day after I had a tooth out

that the pain blunts
and changes the neuro-plasticity

such that the patterning
is lost temporarily.

How can we with visualization,

with active stimulation,

think ourselves whole?

We put the cells in place,

the framework in place,

but there are so many things
we need to do.

But that's an 18-minutes in the future.

Thank you very much indeed.

(Applause)