January 26, 2009

Tega Cay burn victim begins skin graft procedure

Within days of the outdoor fireplace accident in which Connor McKemey was burned last month, grafts of his skin were growing in a laboratory to replace burned tissue.

Now, surgeons are beginning the long process of placing those grafts over his body to form new skin.

Surgeons at the Joseph M. Still Burn Center in Augusta, Ga., recently spent four hours placing 72 of the grafts -- called Cultured Epidermal Autografts, or CEAs -- on Connor's neck, back, chest and sides, his mother, Karin McKemey, said.

It was the first in a series of surgeries that 13-year-old Connor will undergo in coming weeks to cover his wounds with skin, Karin said. So far, she said, the grafts are "looking good."

Connor was burned just days before Christmas at his parent's Tega Cay home when their backyard fireplace erupted. Karin, who was burned trying to help Connor, was released from the center last month.

Connor -- with burns on more than 85 percent of his body -- doesn't have enough healthy skin to cover the wounds. So, a combination of cultured grafts and his own was used, Karin said.

She said Connor, who has been in a medically induced coma, had enough healthy skin for his face. The natural skin was used for his face because the color will match more closely, she said.

On Monday, she said, doctors plan another surgery to place 96 more grafts of the cultured skin on Connor's arms, legs, hands and feet.

The grafts were grown from a sample of healthy skin -- about the size of a postage stamp -- that surgeons clipped from Connor's body after his arrival at the burn center, Karin said.

While the new skin grew in a Cambridge, Mass., lab, surgeons at the Augusta center worked almost daily for more than three weeks cutting burned skin, one area at a time, from Connor's face, arms, legs, back and chest.

Then, they temporarily covered the areas with cadaver skin in preparation for grafts.

After sending the lab a skin biopsy, surgeons measure a patient's wounds and calculate how many cultured grafts will be needed, said Dr. Robert Mullins, a surgeon at the burn center.

At the laboratory, technicians spend about five days preparing a skin sample to be grown into cultured grafts, said Gail Pituck, clinical specialist for Epicel Genzyme Biosurgery, which produces the grafts.

Skin cells are separated from the sample and placed in a flask so they can reproduce. The cells in one flask produce enough skin for one graft, Pituck said.

In the laboratory, skin cells reproduce faster than in the body because they are in an ideal setting -- in an incubator at body temperature, 98.6 degrees Fahrenheit, where they are fed a high-nutrient food called a media, she said.

"It's like running a newborn nursery. They have to be fed and kept warm," Pituck said.

Every day, lab technicians inspect each flask containing the duplicating cells, change the nutrient media and calculate how much growth has occurred, she said.

After about two weeks in the lab, the skin cells replicate to form a cultured graft the size of a playing card. Then they are ready to be transported to the burn center, Pituck said.

The cultured grafts consist of only the top layer of skin, called the epidermis, so they are very thin -- between two and eight cell layers thick, Pituck said. Normal skin consists of three layers.

Because of the delicacy of the cultured grafts, as many as 25 technicians are required to remove each graft from the flask it grew in, she said. Then, it is clipped to a piece of petrolatum gauze and placed in a carrier dish.

Up to 48 dishes are placed in one transport box, which is kept cool to slow the reproduction of the cells, she said. The box is sealed and hand-delivered to the burn center.

A surgeon places the skin side of the graft onto the wound bed, and the petrolatum backing is left on facing upward, Pituck said. The graft is stapled in place. Enough grafts are placed to cover an area of wound and then, a netted dressing is applied, Pituck said.

It takes about a week for the grafts to attach to the body. Seven to 10 days after placement, the dressings, staples and petrolatum gauze backings are removed, Mullins said.

Pituck said cultured grafts might look different from natural skin because fragile melanocyte cells, which gives skin its color, might not reproduce in the same quantity as in natural skin. Cultured skin does not have hair follicles, which gives it a smoother look, Pituck said.

The fragile grafts require special care. A bili light is shined on them periodically during the first few days to dry them, which might reduce the risk of infection, Mullins said.

After his first grafting surgery, Connor has been kept highly sedated and turned every two hours so that pressure does not harm the grafts, said Karin.

Once wounds are grafted, they take about a year to heal, Mullins said. But the skin usually grows enough to close the wound in a few weeks.

In a week, if Connor's second grafting surgery goes well, Karin said doctors will allow Connor to come out of the medical induced coma for a few minutes.

"I can't tell you how much I want to see his eyes and hear his voice again," Karin said. "Every day, we get closer to that moment, and I truly believe that faith, prayer and the sheer will of this community is what is getting us there."

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