September - October 2022
The Application of Omega3 Fish Skin Graft in Nutritional Skin Failure Syndrome: Two Case Studies
Editorial Summary
Certain conditions can cause the nutritional system to be suppressed, thereby compromising the wound healing process for those subgroups of patients. This article provides a review of two of these types of patients, the application of the Omega3 fish skin graft and subsequent wound closure.
Introduction
Skin, the largest organ of the body is also one of the most important. Comprising of many layers of skin cells, in distinct layers, in a constant renewal cycle. Within the layers of the skin cells in the epidermis and dermis are a network of blood vessels providing nourishment to the skin cells and the skin’s finely tuned nervous system with temperature, pressure and pain sensors, and oil and sweat secreting glands. Healing of the skin occurs from the deepest layer up, and from the edges inward. Initial stages of healing occur when basic connective tissue cells of the skin start the cycle for production of collagen, which nests in the wound area, thus building the framework to support the rebuilding of the skin. Once this collagen construct framework is in place, the expanding leash of blood vessels migrates to it. Enhancement of the blood supply enables the skin and nerve cells to follow. If the vital structures residing in the skin survive the trauma then hair pigment and the sweat glands may regenerate. Otherwise, the new ‘healed’ skin is deficient in these features. Human skin is a vital part of the body’s immune system, forming a physical barrier between external and internal environments. Adequate nutrition is required for this active immune organ to perform its physical barrier function. The growing incidence of chronic nonhealing wounds in aging and indigenous populations may result from a culture of poor nutrition, in what can be referred to as ‘nutritional skin failure syndrome’. Most wounds are partial thickness, i.e. involve only partial layers of skin. If the skin has a full thickness defect it may need to be addressed with an additional reconstructive option.
Additional factors can affect the healing of large wounds such as infection, which can slow the
healing process. Wound healing in a normal state involves a delicate balance between nutritional intake and the body’s metabolism. A deficiency of nutrients (or an excess) can cause a disruption to this balance. A nutritional deficiency is most often encountered in patients from a lower socio-economic background, or sometimes the deficiency has a medical cause involving malabsorption, or for example, patients recovering from bariatic surgery. Psychiatric conditions such as eating disorders are a cause of insufficient nutrition, as are drug and alcohol addiction. A state of insufficient nutrition can be identifiable in symptoms of disorders of the skin.1
Challenging wounds, such as diabetic foot ulcers and venous leg ulcers, have a significant economic impact on healthcare and are associated with elevated patient morbidity. The added nutritional deficit adds an additional layer of challenge for the surgeon.
Dermal and surgical application of minimally intact fish skin graft allows for the deposition of collagen and Omega3 fatty acids to the wound, aiding in reducing inflammatory response as well as providing nourishment to the skin, allowing for improvement in the environment that led to the chronic wound in the first place.
70 Wound Masterclass - Vol 1 - September 2022
Dr Naz Wahab
Wahab Consulting and Research Las Vegas NV, United States
The Application of Fish Skin Graft in Nutritional Skin Failure Syndrome: Two Case Studies
Patient One
A 71 year old man with a long history of peripheral arterial disease presented with a long-standing hard-to-heal wound on the dorsal aspect of his right foot. Initial treatment
commenced with basic dressings, and the progression through the reconstructive ladder included amniotic products and a course of hyperbaric oxygen therapy, which was unfortunately poorly tolerated by the patient. The wound was eventually debrided surgically, prior to application of Omega3 fish skin grafts.
Day 1: Initial presentation Day 7 Day 14
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Figure 1: 71-year-old male patient received weekly applications of the Omega3 fish skin grafts to a wound on the right foot. The oxygenation of the skin and the wound bed improves with each application of the fish skin as seen on laser speckle imaging. Day 14 shows a detectable improvement in the blood flow to the wound.
Case Two
A 92 year old woman had a hard-to-heal wound following multiple attempted endovascular revascularization procedures. She presented to our clinic with a right great toe wound and an Achilles’ tendon wound. She had an aggressive surgical debridement undertaken and initial treatment with amniotic products and other skin substitutes, prior to the application of Omega3 fish skin grafts which were applied weekly.
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The Application of Fish Skin Graft in Nutritional Skin Failure Syndrome: Two Case Studies
Figure 2b: T Representative laser speckle imaging of the wound. The image shows the oxygen saturation as components of hemoglobin present near or at the wound site.
Day 7 Day 14
Figure 2a: 92-year-old female patient received weekly applications of the fish skin graft to left achilles tendon ankle wound. Patient previously received multiple applications of amniotic tissue after aggressive debridement. The oxygenation of the skin and the wound bed improves with each application of the fish skin as seen on laser speckle imaging. At Day 14 there is a detectable improvement in the blood flow to the wound.
Day 1: Initial presentation
The Application of Fish Skin Graft in Nutritional Skin Failure Syndrome:
Results
The oxygenation of the wound had improved by day seven post Omega3 fish skin graft application and continued to improve at day twenty one, in both cases. Wounds showed improved blood flow and delivery of oxygenrich nutrients to the skin, which aided in wound healing processes.
Conclusion
The population most often experiencing chronic wounds is the same population that socioeconomically can least tolerate them. Treating the nutritional depletion of these wounds may be useful both topically and systemically, and further study of nutrition as both treatment and prophylaxis should be performed.
To conclude by summarising the benefits of Omega3 fish skin technology: it confers the advantage of no cultural or religious barriers to clinician/ patient acceptance. It is easier to use, with larger, thicker sheets which negates the need for multi-layer grafts. The product is nonallergenic and is bio-compatible, with no known risk of disease transfer, and improved infection control; and in an advantage particularly relevant in patient groups with nutritional skin failure syndromes, the rate of absorption into the surrounding tissue is adjustable.
References
1. Jen M. Syndrome is associated with nutritional deficiency and access.Clin dermatology.2010 Nov-Dec;28(6):669-85)
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Two Case Studies
Figure 3: Images of Omega3 fish skin graft.