1. 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 Origin
Alloderm® Human cadaveric skin
GraftJacket® Human cadaveric skin
Dermagraft® Human neonatal foreskin
Apligraf® Human neonatal foreskin
Oasis® 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