CLINICAL UPDATE
Quest for scarless healing in burn injury
The burn-injured patient has complex evolving pathophysiology that impacts on all body systems . Improving burn healing requires both a broad understanding and a subspecialist focus on treatment . Debilitating scarring limits the life of survivors so a vision of scarless healing aims to improve outcomes for life . It has led to the exploration of regeneration .
By Winthrop Prof Fiona Wood ,
Director of the Burns Service WA & UWA Burn Injury
Research Unit
Focus both wide and narrow
The 2005 MJA-published future vision of clinical care , points to a number of disciplines :
“ Assessment is key to understanding the extent of injury . Debridement is focused on tissue salvage . Reconstruction balances repair with regeneration .
�� �������������������������������������� scale characterisation , including confocal microscopy and synchrotron technology will quantify assessment .
�� ����������������������������������������� control techniques with image guided physical methods will ensure the vital tissue frameworks are retained .
�� ��������������������������������������� self-assembly nano-particles will provide the framework to guide cells to express the appropriate phenotype in reconstruction .
To solve the clinical problem a multidisciplinary scientific approach is needed to ensure the quality of the scar is worth the pain of survival .”
Currently , many of these highlighted technologies are available and innovative research can move them towards safe implementation if they are matched with clinical observations , those that result from close working relationships between research and service delivery . The clinical research framework brings together basic science , population health and clinical research .
We know that every intervention from the time of injury impacts on the scar worn for life : first aid and pre-hospital care ; disaster response ; wound and scar assessment ; oedema management focused on tissue salvage ; cell-based therapies to guide healing , in particular the impact of the nano chemistry and architecture ; rehabilitation that begins at the time of injury and is measured by function for life ; the influences of genetics and epigenetics ; the neurological and psychological response to injury ; and population data linkage that reports on the lifelong impact of burn injury .
Incorporating innovation into practice requires education that includes telehealth , and is subject to audit .
Many options to explore
In burns , the repair of injured skin is essential to protect underlying tissues and re-establish an intact barrier with all related functions . Whether this can be achieved using conservative or surgical methods depends on the extent of injury in terms of surface area and depth . Frequently , to ensure survival , rapid wound cover is essential and for many years , split thickness skin graft ( SSG ) has been considered the gold standard . A SSG , taken from a non-injured site , creates an additional wound and retains the characteristics of the site of origin . The result is always a scar . Therefore , fundamental to the quest for scarless healing is the exploration of techniques of tissue salvage and therapy that make up a new gold standard .
Traditionally , the fundamental requirements for skin healing were considered to be :
�� ������������������������������� differentiation into the tissue lost , and
�� �������������������������������� cells to migrate into and express the appropriate phenotype .
However , just as complex tissues have self-organised into the adult body , there are parallels with tissue repair after burns . Although the drivers to self-organisation are not fully understood , they require :
�� ���������������������������������� damage and the relationship to the intact surrounding tissues , and
�� ������������������������������������ � organisation .
In our quest for scarless healing within the framework of this working hypothesis , key pieces of the jigsaw have been uncovered .
We now know that the skin at a contralateral site , which has not been injured , has long term changes of the nerve fibres within the skin construct . We postulate that the changes are related to alterations in the CNS homunculus . Acute changes related to neural plasticity become established long-term , as seen in phantom limb syndromes .
Burn injury is related to an aggressive and prolonged inflammatory response that results in the development of a scar with an abnormal extracellular matrix ( ECM ). The ongoing abnormal ECM ( in shape and chemistry ) is permitted by the immune system for which we now ask :
�� ������������������������������������ lead to an increased lifetime risk related to an alteration in the immune response e . g . cancer ? Conversely , will a recovered immune system mitigate against this risk ?
� Burns telehealth flyer
�� ������������������������������������� the homunculus be used to drive regenerative nerve repair within the skin ?
�� ������������������������������������������� tissue level facilitate a regenerative healing pattern ?
�� �������������������������������� structure be associated with normal phenotypic expression of skin cells ?
�� �������������������������������������������� or even dependent upon systemic recovery of the immune system ?
Although we are living in a time where science and technology are advancing exponentially , harnessing this knowledge to clinical practice is a challenge . Meanwhile , maybe our greatest challenge is translating what we know now into routine practice , such as the impact of first aid education in the community on the scar someone will wear for life ( see image ).
Declaration : Author competing interests : No relevant disclosures .
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