A Case Report of the First Nonburn-related Military Trauma Victim Treated with Spray Skin Regenerative Therapy in Combination with a Dermal Regenerate Template

Autologous Skin Cell Suspension for Full-Thickness Skin Defect Reconstruction: Current Evidence and Health Economic Expectations

Despite differing etiologies, acute thermal burn injuries and full-thickness (FT) skin defects are associated with similar therapeutic challenges. When not amenable to primary or secondary closure, the conventional standard of care (SoC) treatment for these wound types is split-thickness skin grafting (STSG). This invasive procedure requires adequate availability of donor skin and is associated with donor site morbidity, high healthcare resource use (HCRU), and costs related to prolonged hospitalization. As such, treatment options that can facilitate effective healing and donor skin sparing have been highly anticipated. The RECELL® Autologous Cell Harvesting Device facilitates preparation of an autologous skin cell suspension (ASCS) for the treatment of acute thermal burns and FT skin defects. In initial clinical trials, the approach showed superior donor skin-sparing benefits and comparable wound healing to SoC STSG among patients with acute thermal burn injuries. These findings led to approval of RECELL for this indication by the US Food and Drug Administration (FDA) in 2018. Subsequent clinical evaluation in non-thermal FT skin wounds showed that RECELL, when used in combination with widely meshed STSG, provides donor skin-sparing advantages and comparable healing outcomes compared with SoC STSG. As a result, the device received FDA approval in June of 2023 for treatment of FT skin defects caused by traumatic avulsion or surgical excision or resection. Given that health economic advantages have been demonstrated for RECELL ± STSG versus STSG alone when used for burn therapy, it is prudent to examine similarities in the burn and FT skin defect treatment pathways to forecast the potential health economic advantages for RECELL when used in FT skin defects. This article discusses the parallels between the two indications, the clinical outcomes reported for RECELL, and the HCRU and cost benefits that may be anticipated with use of the device for non-thermal FT skin defects.

Maximizing wound coverage in full-thickness skin defects: A randomized-controlled trial of autologous skin cell suspension and widely meshed autograft versus standard autografting

BACKGROUND

Traumatic insults, infection, and surgical procedures can leave skin defects that are not amenable to primary closure. Split-thickness skin grafting (STSG) is frequently used to achieve closure of these wounds. Although effective, STSG can be associated with donor site morbidity, compounding the burden of illness in patients undergoing soft tissue reconstruction procedures. With an expansion ratio of 1:80, autologous skin cell suspension (ASCS) has been demonstrated to significantly decrease donor skin requirements compared with traditional STSG in burn injuries. We hypothesized that the clinical performance of ASCS would be similar for soft tissue reconstruction of nonburn wounds.

METHODS

A multicenter, within-patient, evaluator-blinded, randomized-controlled trial was conducted of 65 patients with acute, nonthermal, full-thickness skin defects requiring autografting. For each patient, two treatment areas were randomly assigned to concurrently receive a predefined standard-of-care meshed STSG (control) or ASCS + more widely meshed STSG (ASCS+STSG). Coprimary endpoints were noninferiority of ASCS+STSG for complete treatment area closure by Week 8, and superiority for relative reduction in donor skin area.

RESULTS

At 8 weeks, complete closure was observed for 58% of control areas compared with 65% of ASCS+STSG areas (p = 0.005), establishing noninferiority of ASCS+STSG. On average, 27.4% less donor skin was required with ASCS+ STSG, establishing superiority over control (p < 0.001). Clinical healing (≥95% reepithelialization) was achieved in 87% and 85% of Control and ASCS+STSG areas, respectively, at 8 weeks. The treatment approaches had similar long-term scarring outcomes and safety profiles, with no unanticipated events and no serious ASCS device-related events.

CONCLUSION

ASCS+STSG represents a clinically effective and safe solution to reduce the amount of skin required to achieve definitive closure of full-thickness defects without compromising healing, scarring, or safety outcomes. This can lead to reduced donor site morbidity and potentially decreased cost associated with patient care.Clincaltrials.gov identifier: NCT04091672.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level I.

Addressing Full-Thickness Skin Defects: A Review of Clinically Available Autologous Skin Replacements

Autologous keratinocyte culture, and combinations of scaffolds, different cell types, solutions of macromolecules, or growth factors have contributed to the resurfacing of full-thickness skin defects. Ideally, a treatment for full-thickness skin defects should not merely reestablish continuity of the surface of the skin but should restore its structure to allow skin to function as a dynamic biological factory that can participate in protein synthesis, metabolism, and cell signaling, and form an essential part of the body's immune, nervous, and endocrine systems. This paper provides a review of clinically available autologous skin replacements, highlighting the importance of regenerating an organ that will function physiologically.

Plastic Surgery at War: A Scoping Review of Current Conflicts

INTRODUCTION

The scope of military plastic surgery and location where care is provided has evolved with each major conflict. To help inform plastic surgeon utilization in future conflicts, we conducted a review of military plastic surgery-related studies to characterize plastic surgeon contributions during recent military operations.

MATERIALS AND METHODS

Using a scoping review design, we searched electronic databases to identify articles published since September 1, 2001 related to military plastic surgery according to a defined search criterion. Next, we screened all abstracts for appropriateness based on pre-established inclusion/exclusion criteria. Finally, we reviewed the remaining full-text articles to describe the nature of care provided and the operational level at which care was delivered.

RESULTS

The final sample included 55 studies with most originating in the United States (54.5%) between 2005 and 2019 and were either retrospective cohort studies (81.8%) or case series (10.9%). The breadth of care included management of significant upper/lower extremity injuries (40%), general reconstructive and wound care (36.4%), and craniofacial surgery (16.4%). Microsurgical reconstruction was a primary focus in 40.0% of published articles. When specified, most care was described at Role 3 (25.5%) or Roles 4/5 facilities (62.8%) with temporizing measures more common at Role 3 and definite reconstruction at Roles 4/5. Several lessons learned were identified that held commonality across plastic surgery domain.

CONCLUSIONS

Plastic surgeons continue to play a critical role in the management of wounded service members, particularly for complex extremity reconstruction, craniofacial trauma, and general expertise on wound management. Future efforts should evaluate mechanisms to maintain these skill sets among military plastic surgeons.