Bridging the gap between health and wellness

Fiona Wood reflects on her career choice as a plastic surgeon, combining this with clinical research and the challenges involved in improving clinical outcomes of burns patients.

ALS: How did you become interested in medicine and becoming a surgeon?

Professor Fiona Wood: It was a combination I think of natural interest, aptitude and environment. At school I found myself in an environment with great teachers, particularly chemistry, physics and math - to the point that everything else fell away.

I was initially interested in doing physics and math at university but with a bit of coercion - my brother was a couple of years ahead of me in medicine and my mother thought it would be a really good idea - I went to medical school. I enjoyed the whole atmosphere, the whole concept of being at university in London - it was brilliant.

During med it became very clear to me that I was going to be a surgeon. In my second year I was plastic surgery junior at Great Ormond Street Hospital for Children in London. I continued surgical jobs all the way through from there.

Increasingly, I focused on plastic surgery and I found myself in East Grinstead at the Queen Victoria Hospital in 1985. This was the home of the Guinea Pig Club in the Second World War - a famous burns unit where air force personnel who were severely damaged on their hands and faces underwent reconstructive plastic surgery.

I spent a year there and that was when I was hooked into the burns area, as well as trying to work out how I could develop a research career around improving the outcomes of burn injury.

ALS: Were there challenges in choosing surgery?

FW: Being female was perceived to be a bit of a negative on the ledger. I was one of 12 women, and I was from Yorkshire. I was different going in and there were two choices: be different coming out or be a sausage coming out. And I wasn’t going to be jumping in the sausage machine!

I did have to bite my tongue a lot. Working hard and being respectful of everybody’s contribution has been the way I have worked. You work hard and show that you can do it and people will support you.

It’s not really rocket science, the way you approach people. One of my mother’s sayings is “more flies are caught with treacle rather than vinegar”. And I thought, well that’s the approach. Clearly I didn’t fit the mould, but I needed support to realise my aims. So if I could get support and I could give back then I would make more progress. It’s a lesson I learnt early.

ALS: What led you into research?

FW: I set the scene with research because it gave me the opportunity to step outside and do things differently, do things that were interesting. That was partly motivated to make sure that I was making progress but also because I wasn’t good at marking time. I wanted to be doing things that were more progressive.

I did a Bachelor of Medical Science with a focus on neuroanatomy and at the end of that year I ended up in a field trip in East Africa, in Kenya and Tanzania. I looked at the impact of locomotion on the brain and brain development, various locomotor patterns and comparative neurobiology. That was really interesting and set the pattern with what I am interested in now.

As I moved into my clinical years I was very keen on surgery and a bit slack on everything else. Rather than doing the standard 12 weeks of obs and gynae, I went to a government hospital in India and did a research project on maternal malnutrition, morphology and anatomy.

By the time I arrived in Australia, I had connected the enquiry aspect of my head with the clinical and surgical practice - linking how to answer a question I was asking with how I could use that information to improve clinical care with a drive to improve patient outcome.

It was about embedding that in my day-to-day work. I worked on cleft lip and palate as well as general plastic surgery, and burns was included in that. I did research into how the airway changes with the palate repair and how that influences the drive to breath. My first publication in 1989 was investigating the nerve supply in tissue-expanded skin as a plastic surgeon.

I try to learn something from every person I treat. But do I achieve that? No.

ALS: Can you describe your team’s involvement in the aftermath of the Bali bombing?

FW: That was a set of certain circumstances driven by where we are geographically and I was part of the Australian response.

I was working as head of the burns unit at the Royal Perth Hospital and how we responded came off the back of work we’d done previously. We know that every intervention from the point of injury influences the scar formed for life - that’s one of our mantras.

Clearly we don’t have a multidisciplinary dedicated burns team in every hospital in Western Australia (WA) - we only have a 10-bed burn unit at the Royal Perth and a 10-bed burn unit at the Princess Margaret Hospital for Children (PMH).

And when you are in a low incidence but intensive care area, you’ve got to understand how you can outreach so that when a person is burnt, the burn team - the person included - has the knowledge and we have the ability to talk to people to optimise every step of care.

We spent a lot of time understanding how to ensure we had that information on the ground and the level of communication needed. We work on telehealth and we work with an outreach education program that’s been going since 1994.

The Health Department was approached in the late 1990s by Woodside to discuss the disaster response around the north-west gas shelf. With the help of the Health Department and stakeholders across Australia we developed a disaster plan, the draft of which we ran through with an exercise funded by Woodside called Exercise Icarus.

We learnt an enormous amount from that exercise. We then put that to the burns community across Australia and finalised the plan that we put to the Australian Health Ministers’ Advisory Council in June-July 2002. It was approved in August 2002 that we should run exercises and work out how to actually iron out the rough spots.

But we never got to it because, of course, Bali happened in October 2002 - so we did it for real.

Geographically, we were the closet burn unit and that’s why we ended up with just under half of the patients from Bali. The other half were distributed between Adelaide, Melbourne, Sydney, Brisbane and Darwin, of course, which is our national triage centre where everyone did an amazing job.

That’s why it unfolded the way it did - geography kind of drove it from a historical perspective and from a response perspective.

ALS: And that’s when the spray-on skin captured people’s attention. How did that technology develop?

FW: Basically, in 1985 I saw people growing skin cells into sheets in East Grinstead. It was very early days. The first people to use the cells of a person’s skin grown into a sheet were in the US in 1982.

In 1990 there was a patient here in Perth who was very compromised. I was a registrar at the time and had heard on the radio that Joanne Paddle-Ledinek and Professor John Masterton had established a skin lab in Melbourne. To cut a long story short, I sent the skin from this patient to Melbourne, they grew it and John Masterton brought it back to Perth where we operated on the patient. She healed but she died with a secondary infection because by the time we did the operation it was five months post-burn - that’s a long time to have open wounds with no skin. She had a fungal infection that was well established in her heart and we couldn’t eradicate it.

Not long after that I became head of the burns unit. I was Director of the Burns Service of WA from January 1991 and I was obsessed with time. If I’d heard that radio program at 5 weeks post-burn rather than 5 months, would the outcome have been different?

Absolutely, categorically, I can say yes now because that patient has changed lives for many people who have come subsequently.

So I started working with the team from Monash - it was costly and difficult and challenging. The skin would come back from Melbourne, arrive in Perth in the night and I would work on it in the lab through the night to have it ready for surgery in the morning.

During that time I met Marie Stoner, a bone marrow scientist who was equally as crazy working through the night to get bone marrows ready. At the beginning of 1993 we received a Telethon grant to establish a skin lab at the PMH.

We noticed that when the skin cell sheets were fragile and less developed, paradoxically they appeared to work better on the wound. Marie and I were working very closely together to iron out the problems and one day we just looked at each other and said: “We should just spray this stuff on - well there’s a thought!”

So we collected everything we could find that had a nozzle on it - throat spray, hair spray, nose spray, air brushing, we went to the art shop, the pharmacy, the anaesthetic trolley, and found all these different spray techniques and put cells through the spray nozzle system.

We found the delivering nozzle on the top of a mouth freshener from Italy that, when clipped on a standard 5 mL syringe, enabled us to maintain 90+% viability of the cells coming through the system. It had to be a 5 mL syringe because it couldn’t generate the pressure - a 2 mL syringe could kill the cells by generating too much pressure. We had a lot of mouth freshener that we pulled the lids off.

We were spraying skin onto wounds by 1995. Normally it takes three weeks for sheet of skin cells to graft. We were spraying skin cells that we grew in the lab onto wounds and getting results in 10 days, then in 5 days. For smaller wounds we developed a kit, putting elements of the tissue engineering process into a box, which harvests the cells in a 30-minute turnaround.

ALS: So you don’t culture cells in the lab anymore?

FW: No, we don’t use the lab as much at all now. For research and innovation driving forward we do, but from a practical point of view we can harvest skin cells from the dermal-epidermal junction and seed wounds with those cells using the ReCell kit.

We use the body as the tissue culture environment - it’s cheaper, easier, more convenient, etcetera. If the wounds are prepared well then that is a better environment for the cells to grow in. They respond better and we get more rapid epithelial cover because the wound environment has appropriate signals for healing.

Cell therapies have been an established aspect of our standard of care as far back as 1993 when we started using cell sheets and by 1995 we were using an aerosol-based system. We use cell-based therapies as part of our regime - it’s not an exclusive way we operate by any means, but we use it as part of our tool box.

ALS: There was a lot of discussion about clinical trials in 2002 or the lack of them. Did you have to go back and conduct trials?

FW: Yes. There were people who said there was no evidence base to support the work. This really fascinates me because for somebody to stand back and say there is no evidence and no prospective randomised trials to validate the technique is true in part but is a bit misleading. The work is based on basic science investigation and tested in animal models.

We work in an environment which is really challenging to do prospective randomised trials due to uniqueness of each individual and the injury characteristics. How do we correct for all those things?

We have published work using the skin graft donor site as a control wound with cells and no cells demonstrating a positive effect. We have also published a comparison of treatments randomised in scald injuries with positive outcomes. The treatment with cell therapies is one aspect of a complex series on interventions and we, and many others have now, have published the impact of the use in major burn injuries.

In the US, an FDA trial is underway, supported by the US Armed Forces Institute of Regenerative Medicine - it is currently well progressed. Each patient is acting as their own control with small wounds that are very rigorously analysed in the face of a larger wound.

From our point of view we have been working towards not only demonstrating that it’s effective and influences healing, but also trying to understand why. We are still in the thick of it; we’re still doing a lot of research to try and understand the mechanism of action.

ALS: Have you been involved in commercialising the technology?

FW: Marie and I established a company, Clinical Cell Culture, which has now gone on to become AvitaMedical, to commercialise the spray-on skin technology.

At the outset Marie and I signed the intellectual property into the Foundation [the Fiona Wood Foundation] with the aim of supporting the ongoing research.

It is now at the stage we are just starting to get momentum. In Munich earlier this year, AvitaMedical held a meeting with all the people internationally who use the technology and wanted to present their work. It was fascinating and stimulated further work. So 20 years on, people are using the technology in ways I hadn’t thought about, which is exciting.

I’m still involved as a director, but my involvement is all around teaching new users and research protocols; but less and less as the interest is growing.

ALS: What do you think about the progress being made in Australian life science and innovation?

FW: Australia has got a lot of innovation, a lot of people thinking smart and a lot of great people, but how do we get to support them such that we can really accelerate this innovation pathway? I’ve lived this for 30 years, and that’s a challenge.

If only we could work out how to support on all fronts from funding and the NHMRC, to working out how we can boost peoples’ interest in life science research because it’s the tomorrow. Our future lifestyles will be based on science and research.

One of the things I’ve realised is that a lot of decisions that people make with respect to their lifestyle - obesity, diabetes, drugs, alcohol - means that we are running a health system that is creaking at the seams. I think our health system is constrained by funding, and that’s appropriate - otherwise it’s a black hole and where do we draw a line?

How we collectively think smarter and support innovation is the key question. When it comes to innovation, driving innovation forward, I think we should stand back and say well done for anything that goes forward when we look at the sheer workload involved.

Somehow we have got to bridge the gap between health and wellness and actually drive wellness so that when we do need healthcare we get not only the best in the world, we drive what is the best in the world. And I think that’s possible because I see some great work being done here - but a lot of it won’t see the light of day if we don’t change the balance.

ALS: Finally, what’s in store for the future?

FW: That brings me right back to the beginning - the neuroanatomy of the nervous system. I still want to understand the changes in the nervous system as a result of burn injury and how we can use that to heal to the pre-injury shape - that’s the aspirational goal.

Will we be able to change the way we heal by neural stimulation? I don’t know whether that will be achieved in my lifetime but I do know we will contribute to the body of knowledge - understanding how we can manipulate the nervous system such that we can change the whole process and use it positively so that we get scarless healing, regenerative repair.

We will be driving to see whether maybe at some point maybe we will change the way people consider healing and rather than a local thing it’s a systemic thing that can be influenced by neural control. And that will be exciting.