Professor Fiona WoodAn in depth interview with the inventor of 'Spray On Skin'
Professor Fiona Wood is a plastic surgeon specialising in burns. She is the director of the Royal Perth Hospital burns unit and a Clinical Professor at the University of Western Australia. Along with Marie Stoner, Fiona developed the revolutionary ‘spray on skin’ for burns victims, which has changed the way burns victims can be helped across the globe. Following the 2002 Bali bombings, she led a team at Royal Perth that saved the lives of 28 victims who arrived with up to 92% of their bodies burned. She has been awarded the Australian of the Year prize and made a Member of the Order of Australia amongst many other awards for her incredible work.
Interview part of the archive of The Incomplete Map of the Cosmic Genome. Filmed in October 2014. A full transcript of the entire interview is available below.
How can you avoid being interested in science?
On becoming interested in science
When I think about being interested in science it’s just thinking about where to start, where did I first begin thinking about it? And I was one of those kids that was a “why” kind of a kid, why is it working, why does it do that, why, why, why, why? And so, if you look at the world in that kind of way you have to start looking for some answers and the answers are embedded in science so it’s not a, sort of, oh, I started thinking about science when I was twelve and a half and, you know, I saw a comet, or whatever, it’s like, just part of the world. For me, I think science is so part of our everyday life, it’s almost like, how can you avoid it? How can you avoid being interested in science?
On moving into medicine
I went into medical school in 1975, I’d come through schools and I was in the bracket where I was looking for university courses and I thought, maths and science in Cambridge, which was a good plan, and then my elder brother was doing medicine at St Thomas’s in London and I went to visit him and the parties were amazing, and I found myself very rapidly in medical school in the 70s in London and it was a ball. Subsequent to starting medicine, and then you start to get drawn into it, I remember my first day and I thought, oh my goodness, I want to be a surgeon, I want to do anatomy, I want to be able to put people back together and then looking at…well, what kind of surgery, there’s so much scope, and one of the areas of surgery that is really broad in its scope is plastic and reconstructive surgery, it can be an extreme makeover or an extreme rebuild and so there’s a huge spectrum in between. You use the same kind of techniques and the same learnings and you apply it in different ways and it’s a very innovative kind of specialty that certainly sparked my interest, my imagination, and so I was sucked down the anatomy route, the surgical route, plastic and reconstruction surgery and then stood back from that and went, where within that, because again it’s very broad, and I’m a great believer that if you’re lucky enough to get a passion about something and you do it every day you’ll do it better, one would hope.
And so that focus and that dedication to one subject was something that was very much in my personality and so I looked around, and burn injury I was exposed to in the south of England in Queen Victoria Hospital, East Grinstead, where the Guinea Pig Club had been in the Second World War with the air force personnel and I thought, wow. We’ve got to be able to do better than this, we’ve got to be able to understand the whole scarring process in a way that we can really make…I often say we have to understand our subject such that we can drive to make sure that the quality of the scar is worth the pain of survival because there is no two ways about it, it hurts. There’s a lot of pain involved in surviving a burn.
On the body’s response to being burnt
When you have a burn, it can really knock your wheels off. It’s very obvious that if you’ve got a massive burn, and you may see this in a movie or something, is very obvious that that skin is so badly damaged it can no longer function. What we see though is that you don’t have to have a massive burn for your whole body to be knocked out of kilter. Your skin is really interesting, I could talk about skin forever. It’s a receptor, it’s our interface with the world, I think Spike Milligan said, “beautiful skin, it helps to keep your body in”. This is our interface: vitamin D, temperature regulation, a sensory interface. We clearly understand that there’s a psychological component: blushing, eczema’s worse when we’re stressed etcetera. There’s a huge amount of functionality in skin that we take for granted. That’s damaged, the inflammatory response, the drive of our body from our immune system, driving that inflammation to try and heal it, again is associated with collateral damage and we have the injury itself, we have the response to the injury, and we know that it affects all our body’s systems. It affects the heart, the lungs, the liver, the brain, and certainly we’ve become much more interested in how the brain is affected and how the nerves are affected within the skin, because we see that the skin is a receptor, it’s like the eye…the eye does black and white and colour but the skin needs to be considered within that context. Certainly we need a blood supply to heal, certainly we need skin cells to heal, a source of cells, we need the framework. But when we look at self-organisation, what actually makes us our shape? How do we get the feedback from that? How do we actually drive to that shape? How do we take the genetic material in all of these different cells and we come up with all these different shapes?
So I have a hypothesis because I haven’t proven, but we’ve got some chinks in the armour that the nervous system is the key to that, the nervous system is key to driving our construct into a regenerative pattern. But a small burn, you lose your functionality, and if you pare it right back you’re no longer waterproof, you leak fluid and you’re no longer bacteria proof or fungal proof or…any sort of invader can get in. So you’ve lost your protective layer so bugs can get in, water can get out, and that’s a bad combination. So we need to repair that and protect it while it’s repairing as quickly as possible.
On the body’s healing process
We have a mantra in our burns unit that I always shout from the rooftops, “every intervention from the point of injury will influence the scar wall for life”, and I think we should all hold hands and say it. But every intervention starts at the point of injury, so anybody can influence their scar by clean, cool running water, 15 – 18 degrees for 20 minutes within the first hour of injury – you will close down the collateral damage, you will remove the heat away and you will facilitate that healing straight up. It’s a cleaner as well, keeps it clean and reduces the bacteria, reduces the bug population and then it starts you on a healing pattern. Then it’s a complex and challenging road and it’s associated with severe pain. And I know that that pain must be there for a reason, so to protect ourselves and all, but what else is it there for? Is it to drive the cells in our body to that zone, to guide them to that zone to facilitate healing? And so the healing process in burns, we want to be regenerative, we want really, and this is the sort of holy grail, we want the gecko’s tail to grow back again and somewhere along the line of evolution we lost that capacity and so all but very small injuries, the capacity to regenerate like that is overwhelmed and we go down the scar path. What we want to do is understand how we can knock the scar over here to regeneration so we get soft, supple skin that doesn’t lock people in scar. And scar itself isn’t just about the way it looks, a scar actually impacts on your function; temperature control is a very obvious one if it’s a big area, but it impacts on your movement: again a very obvious one, it’s not just about how it looks. It impacts…it’s itchy, you know, if you don’t sleep half the night because it’s itchy, the dominoes start to fall and it impacts on the whole of your life.
On combining mental and physical treatments
I think people’s psychological response to injury is fascinating and extraordinarily varied. I see people that just blow me away they’re so inspirational, they can take on suffering that is beyond imagination and say thank you and come back and really share that growth with others around them. Trying to work out that and trying to drive that direction is a real area of interest. But people do vary a huge amount. You know some people, you think, ooh goodness, that’s a terrible scar, I wonder how they’re managing psychologically, and they’re fine and then you’ll see somebody and think, that’s not much of a scar, and they’re crippled by it. So we absolutely know that that psychological response to burn injury is that person’s, it’s a non-judgemental zone. What we have to do is understand that person’s coping strategies, their personality type, the environment of the injury, the circumstances, all these have a role to play in that recovery phase and we do track the psychological recovery and we treat where appropriate, wherever we can. But it is really fascinating because you can’t just say, OK, you’ve got a burn of the face, so you’re going to go into that treatment path, you know? What you say is, you’re a person who has all your life history, who has this kind of coping strategy, who has this injury, how can we facilitate your best recovery? And we put that all together.
On the Fiona Wood Foundation
Many years ago we started thinking in our research, how can we get funds to do our research? We work in a very small group in a very small niche area and we cross a whole lot of boundaries from population health to cell biology to neural physiology to clinical medicine, we have projects going in cardiology and psychology, we’re “ologies”. And there’s lots of work going on that pertains to somebody that’s injured from burns and it’s all been clinically focused, really driving to solving the clinical problem so it’s very translational and multidisciplinary. We know we’re not very competitive in a lot of the funding arenas, so many years ago Marie and I started in the McComb Research Foundation and people were very generous and it supported our research for a very long time. Mr Harold McComb was a great plastic surgeon, he was the patron and I was the chair. And as we’ve gone along…succession planning, I’ve handled the Fiona Wood Foundation and I’m still obviously involved, very much so with my shoulder to the wheel, but the first thing my colleagues did was they moved from the McComb Foundation to the the Fiona Wood Foundation and I’m the patron and it is our vehicle for people’s generosity to support us.
We have got some great supporters, people like Woodside have supported us for a very long time, Chevron and Western Power, lots of corporate supporters and people like…very generous folks like the Perrin family, the McCuskers, Telethon of course. I’m sure I’m going to forget someone… and Lottery West, so lots of people support us, and lots of individuals support us, far too many to name but they all know who they are, whether they do a run for a reason or just pop that donation in the post or just being helpful and helping us with our research in any way, it’s meant that we’ve been able to get a long way and a help a lot of people. So the Fiona Wood Foundation is the banner we run under that links our research with our clinical work.
On how to treat a burn
When you have a burn, the really important thing is clean cool running water, 15 to 18 degrees for twenty minutes. You can make a massive difference. What you don’t do is put ice on it. Ice will do cold damage as well as the heat damage and it will feel great because it gets numb but you will extend your burn. Things like toothpaste, vinegar, all sorts of interesting things that we’ve seen put on burns, really makes it difficult and contaminates the surface so we’re very much like, there’s no mileage for lots of things. Things like, if you’ve got an acid burn, you put some milk on it, no, clean, cool running water and if it’s a chemical burn, just for longer, just stay longer, longer, longer, prune-like.
So there’s misconception around what you must first do and there’s things that can help in healing in wounds of some [sort], like honey, but honey first up, no, it seals the heat in, so we want that heat away, energy away from the wound and so a lot of things people put on the wound seal it. Things like, I can’t take their clothes off because the skin will come with it and I’ll do damage, if the skin comes with it, no damage, it was always going to. Then your cooling will be effective and stopping that further damage.
The drive was really around trying to understand how we could cover really bad burns which were large surface areas.
Spray-on skin cells is a fascinating story for me because it’s now coming up to 20 years of my life and I can probably encompass it in a few minutes! The drive was really around trying to understand how we could cover really bad burns which were large surface areas. If you’ve got a burn, traditionally – and we still use traditional techniques as well as the cell-based therapies here – we could take an area of your body you’re not injured on, skim a skin graft off the top, allow that area to heal, move that skin graft and put it on the wound. And you can imagine if you’ve got half of your body burnt, well, that’s quite challenging, because how are you going to take the other half? And then now, all of your body is wounded. And so we spent a lot of time over the years, not just here, of course, but globally in the burns arena, trying to expand the donor site, so whether we put it through a machine that meshes it, like a string vest, or all sorts of different strategies and different layers that we can introduce, scaffolds and layers that are coated in biologics or in various molecules.
And so the skin cells of the dermoepidermal junction are the two main layers of skin. You’ve got your waterproof layer and your tough layer, and the layer in between, the dermoepidermal junction, is the engine room where the skin regenerates from. So the idea that came out of MIT in Boston in the 70s is that you can peel those two layers apart, like a bread and butter sandwich. You scrape the butter off, you put it in a favourable environment, and you can grow the cells into sheets. That’s where we started and based on Reinhold and Green’s work growing cells in sheets, because we skin graft in sheets. And before long, Marie Stoner and with a lab funded by Telethon in 1993, and then we realised that the skin cell sheets that did better were the ones that looked like they were a bit moth eaten because they weren’t quite as mature. We thought, this is interesting, and so we did some experiments looking at the cells, and how the surface of the cells changes with the maturity. So when we get a cell, when we split all these cells apart, they’re all dissociated, they’re all apart from each other and they’re looking for a mate. And they connect, and they start to form a sheet and then once they get that sheet they then start to form layers…then those layers eventually become waterproof. That’s the normal sort of way of going.
But, interestingly, then when you take that and put it on the body, it was really hard to get it to stick and it was really fragile and really difficult to use, and took three weeks. So we thought, hmm, this is interesting. The cells when they’re on their own are much stickier, they stick to the wound better. And we looked at how the skin cells grew into a sheet in a box and we looked at how the skin cells on the body like in a soup healed and we thought, hmm, this is interesting. So we started putting the cells in, like, a blister over the wound and that was messy and difficult. Or for a hand, we’d put it in a surgical glove and allow the patient to move their hand and the cells would coat their hand, things like that. And one day we just thought, oh, we should just spray this on. And the two of us looked at each other like, whoa!
And so we tried all sorts of different ways of spraying, went to the art store and the chemist store, the pharmacy, the anaesthetic trolley, that’s a very good source of sprayers, throat spray, hairspray, and we found an Italian mouth freshener that had a nozzle that if we took that nozzle and put it onto a syringe – on a 5ml syringe standard – it would maintain 90% plus viability coming through with no dead space. It was ridiculously simple and so that’s how we started spraying skin cells on.
And then, we were three weeks in the lab to grow a mature sheet. Marie managed to grow really very good quality sheets in ten days. We started using suspension at five days post harvesting and then…that’s still five days you’re waiting, that’s five painful days. And so we stood back and we thought, well, could the body be the tissue culture flask? So the surgery has to be meticulous, you have to be clean, no bleeding, no dead tissue etc. but the answer is yes. So we then put the first steps of the whole lab process in a box and took the box to the patient and that’s what we do now, so it takes about 20 to 30 minutes. So that’s about twenty years of my life!
But now I’m seeing all sorts of interesting utilisation going forward, it’s still in trials in the US with the armed forces using regenerative medicine, there’s colleagues in the UK using it in head and neck reconstruction, for pigment change, for acne scarring, and more recently one of my colleagues was looking at exploring the use of these cells to change radiotherapy scarring, chronic wounds and sorts of things. So when I see what everybody else has done I think, this is really good because I can learn from them and see how it’s sort of growing and moving across the world for basically skin repair, but we need skin repair in all sorts of different ways so it’s good to see the boundaries pushed.