Transcriber: Els De Keyser Reviewer: Capa Girl
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
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)