Hello, everyone. Thank you for joining us in this first in class course that is set to revolutionise your approach to veterinary wound healing, learning how to utilise groundbreaking fish skin grafts for tissue regeneration. But before we begin, please note that all the mics will be muted during the class.
We invite you to write your comments and questions in the chat so we can address them after the presentation. I am Mark Hines, veterinary Business Development Manager at CARESS, and your moderator. Conducting the class is Doctor Elizabeth Maxwell, assistant professor in surgical oncology at the University of Florida.
Doctor Maxwell is a Miami native that graduated from Ross University School of Veterinary Medicine in 2012. Doctor Maxwell went on to complete a rotating internship at Louisiana State University, a surgical internship at Ridge Animal Hospital in Colorado, and a surgical fellowship at Lauderdale Veterinary Specialist in Florida. Doctor Maxwell then completed a three-year small animal surgical residency at the University of Illinois.
Where she also obtained a Master of Science degree in Veterinary Clinical Sciences. Following residency, Doctor Maxwell completed a 1-year surgical oncology fellowship at the University of Florida and became one of less than 60 veterinary surgical oncologists in the United States recognised by the American College of Veterinary Surgeons. Doctor Maxwell is a certified veterinary pain practitioner and a fear-free certified professional.
She serves as past president of the Veterinary Wound Management Society and is current president for the collaborative Care Coalition. Welcome, Doctor Maxwell. It's a pleasure to have the opportunity to introduce you and to learn from you about fish skin grafts and their application to veterinary wound management and tissue regeneration.
Thank you, Martha. Hello, everyone, and welcome to today's webinar, Fishing for Solutions. I'm excited to have you join us as we explore this innovative use of Kera's fish skin grafts in veterinary medicine.
Biological graphs have gained a lot of attention for their ability to enhance wound healing and tissue regeneration, and among these, the fish skin grafts have stood out for their unique properties and benefits. We'll look at this today. So throughout this webinar, we'll delve into the science behind Keri's fish skin graphs.
We'll discuss their clinical applications, and then I'll share some real world case studies that highlight their effectiveness in treating various wounds and companion animals. We will also finish off with some commonly asked questions. So thank you for being here.
Let's get started. Keris's vet fish skin grafts are made from intact fish skin, specifically sourced from Atlantic cod, caught off the northwest coast of Iceland. These graphs can be used in veterinary medicine to manage wounds in small, large, and exotic species.
These fish skin grafts are indicated for management of wounds, including partial and full thickness wounds, traumatic wounds such as abrasions and lacerations, and superficial and partial thickness burns. Unlike mammalian tissues, Keraus products are minimally processed. This is possible because there's no known risk of viral disease transfer from fish to other mammals.
So gentle processing via osmotic mechanisms will leave a non-cellular proteins and lipids, as well as the native microstructure of the graft. This process is also sustainable as it's made from a byproduct of Iceland fisheries. There are several different formats of the graph that can be selected based on your wound bed.
There's the kerais solid, which is seen in the right-hand image. This can be used for partial or full thickness wounds, which are ideal when the wound topography is flat. The meshed option seen in the middle image is ideal for partial thickness wounds such as burns, also with a flat or level topography, but with moderate to heavy drainage.
And finally, a new option available to veterinarians is micro, seen on the left hand image, which is great for wounds that are uneven or have an irregular topography. The micro is essentially fish skin that's fragmented into smaller bits, which allows you to feel the wounds that have uneven surface. The rehydration of the graft is performed within the pouch itself before placing it into the wound.
Now let's dive deep into the science behind fish skin grafts and understand why they are becoming a valuable tool in veterinary medicine. Most skin substitute products are based on tissues of human and porcine origin. These are not ideal substitutes because the heavy processing that's needed to eliminate the risk of disease transmission.
In a study looking at the microscopic cell ingrowth capabilities of Keras's fish skin, it was found that the microstructure of the fish skin graft is highly porous and has superior ability to support three dimensional ingrowth of cells compared to mammalian skin. So what does that mean exactly? That the porosity, both the size and arrangement, leads to improved cell migration, proliferation, differentiation, and adhesion.
You can use the QR codes in the upper right hand corner of the slide if you'd like to read more about the study. This was also further supported by a second in vitro study comparing the porosity of fish skin to human amnion chorion membrane. Human amnion chorion membrane is a tissue derived from the placenta that's used to promote tissue regeneration and wound healing.
In this study, the microstructure of acellular fish skin was again found to be highly porous, while the microstructure of the dehydrated human amnion chorion membrane was mostly non-porous. It was also noted that the fish skin provided a bacterial barrier for 24 to 48 hours. To further support the antibacterial properties of Kerius fish skin grafts, Kerases and other competitive products were tested for the ability to resist bacterial invasion.
In this study, Kerois was shown to have a longer acting bacterial barrier than the other graphs shown here, including the human amnion chorion membrane, and ovine poresine and bovine collagen matrixes. In a clinical study comparing Keri's fish skin to bovine collagen skin grafts in burn patients that underwent skin grafting on donor sites, there was faster healing seen in the Kerasis treatment group than the bovine collagen group, presumably due to the unique structure and bioactive components of the fish skin that was minimal to absent in the bovine collagen group. A pre-clinical trial compared keesis to foetal bovine dermis on deep partial thickness burn wounds on Yorkshire pigs.
These wounds were treated with kerais or prematrix on day 1 and day 7. Results showed that by day 14, there was 50% greater reepithelization, reduced wound size, faster incorporation, and better blood perfusion. By day 60, there was mature healing without contracture in the kerais group.
And finally, Kera's fish skin maintains strong mechanical properties. Cells recognise stiffness and are activated in a natural environment. Thus, cells may be mechanically activated in the fish dermis due to the homogeneity of the tissues.
OK, so we've discussed a lot of the science behind the Kerais fish skin, and we looked at some in vitro and preclinical data demonstrating why it works. Now, let's look at some clinical data to support its use. Here we have a selection of published articles in the human literature.
You can see that Kerius fish skin has been used widely in in various prospective clinical trials and studies demonstrating its use in burn wounds and difficult or chronic wounds. So what do we have in the veterinary literature? It's slowly growing, as it's only been available to veterinary, in veterinary medicine for about 5 years.
But here are 3 publications that I will review in a little bit more detail. One is a case study, one is a retrospective study, and one is a prospective case series. Let's start by looking at the retrospective study.
In this study, case details were collected from 10 different veterinary hospitals between 2019 and 2021. 17 animals, both dogs and cats, with a variety of wounds were included in this study. The most common wounds were related to trauma, burns, or attacked by dog.
At least 1 fish skin graft was used in the management of the wounds. The number of graft applications ranged from 1 to 4 in dogs and 1 to 2 applications in cats, with the time in between applications ranging from 4 to 21 days. There were no adverse events and most wounds were healed by second intention.
In this prospective study, the objective was to evaluate the use of kerais fish skin grafts for the management of wound healing by second intention following wide surgical excision of skin tumours in dogs. 5 dogs were enrolled in this study. And fish skin grafts were applied to the surgical bed following wide excision and changed weekly with additional grafts placed when integration of the previous graft was complete.
All masses were excised with 2 centimetre margins and 1 fascial plane deep. The median number of graphs placed was 5, and complete epithelialization occurred within 7 to 9 weeks for uncomplicated wounds, and 12 to 15 weeks for complicated wounds. No adverse events were reported, and local recurrence was not seen over the follow-up period, even in cases of incomplete excision.
Finally, here's a case report of a 3 year old female spayed American bulldog that suffered severe burn injuries and had burns over 50% of total body surface area. A variety of techniques were applied including surgery, maggot debridement, and fish skin grafting with autologous skin cell suspension. You can see here an example of the meshed fish skin being used in this dog in the image, in the middle.
And on the image in the lower right, you can see the eventual complete healing of the injured areas. So now that we've discussed the science behind why it works, and we looked at the evidence to show that it works in both humans and animals, let's talk about the logistics of application, indications for using it, and how to use it. OK, so indications and application techniques.
We've talked about some of the properties and benefits of fish skin grafts, but how does that play into each stage of wound healing? So for the topic of this conversation, I've included the main three stages of healing inflammatory stage, proliferative stage, and maturation stage. But I've also included hemostasis, which is sometimes incorporated into the inflammatory stage.
So in the hemostatic stage, fish skin grafts facilitate faster coagulation rates when compared to whole blood and thrombin. In the inflammatory phase, there is the bacterial barrier when compared to mammalian grafts. Also, there is a high content of omega 3 fatty acids, which are known to have anti-inflammatory properties.
In the proliferative stage, there's rapid cellular ingrowth, which means it recruits and supports the migration and proliferation of fibroblasts, as well as host stem cells. And finally, in the remodelling and maturation phase, there is faster incorporation and greater epithelization, which maintains pliability and function. Now, while we can see benefits of Keraus fish skin at any stage of wound healing, when we look at the three main phases of wound healing, which again are inflammation, proliferation, and maturation, my personal favourite time frame to use Kerais grafts are during the proliferative and maturation phases.
I find that it really ramps up the body's natural healing processes, and this is when I see the most activity. So once you place your fish skin graft, what do you cover it with? Well, that's gonna be based on how much exudate the wound is producing.
In early wounds, it will likely be highly exudative, in which case you might want to reach for something like a calcium alginate product that's markedly absorptive. For a later wound that might be dry, you will want to use a moisture retentive dressing like a hydrogel. And for mature wounds that have minimal exudate, you will want to consider a moisture retentive dressing like a foam, for example.
Allogenates have a high absorptive capability and are therefore most useful for wounds with heavy exudate. This product is made out of seaweed and is sometimes infused with honey or silver. It can stay on for several days, and when calcium alginate comes into contact with the wound fluid, the fibres in the dressing will swell and form a gel.
This gel-like substance helps to maintain a moist wound environment and supports healing. This dressing can promote rapid granulation tissue formation. So keep that in mind that when you remove this dressing, there might be an odour to it, it might even look like purulent exudate, but once you lavage the wound, it'll reveal a a healthy granulation bed beneath it.
Foams are great for mature granulation beds that you want to retain moisture. In these cases, you're essentially happy with the amount of granulation tissue you have that's developed, and now you're looking more to promote epithelization. So these dressings may also stay on for several days, which minimises the frequency of bandage changes.
Hydrogels are great for dry wounds or wounds that you want to provide moisture to. These come in the form of a gel that you can squeeze into the wound or even as a disc that you can cut and secure to the wound edges. When it comes to non-adherent bandages, these can be placed over your fish skin grafts.
I particularly like to apply an adaptic over top of my fish skin graft before my secondary dressing is actually placed. Adaptics are a petroleum impregnated gauze, and I place these over my fish skin to ensure that whatever I place to absorb the exudate won't stick to my graft if it dries out. As the wound gets smaller and is no longer highly exudative, I will often switch to the silicone adhesive pads that you can see in the lower left hand side.
They're great for small wounds that you don't necessarily want a full limb bandage on the animal, and since they're adhesive, it sticks around the wound. I will also sometimes reinforce these with hyperfix tape. A telfa pad can be used over your graft as well, but I find that when if the wound dries out, the telfa tends to stick and it might pull your graft off.
OK, so we've talked about why fish skin works, how to use it, and what to cover it with. Now we will look at clinical examples of incorporating fish skin into wound management. We will start by going over the actual application of the graph, and then we'll dive into several cases to demonstrate its use.
So, once the graft is removed from the package sterilely, It's placed in warm sterile saline and allowed to rehydrate for 60 seconds. Once the graft is rehydrated, it can be trimmed to size, or the size of your wound, and then secured in place with sutures or skin staples. I do prefer to use skin staples for securing my graft, but skin sutures, sorry, but staples work as well.
So here we have an application example of a dog following a mass excision on the dorsal aspect of the left hind limb. So after the mass was excised and the wound was prepared, the fish skin graft is removed from the pouch using aseptic technique, and allowed to rehydrate and warm saline for approximately one minute. The graft is then cut to fit the size of the wound and applied directly to the wound with the scale pattern up and then compressed until the bleeding of the wound bed stops.
The graft is fixed in place using skin sutures or staples along the margin. This graph may be bolstered to ensure that there's good contact with the wound bed and can include negative pressure, the calcium alginates, the foam dressings, or moist gauze. The graft is covered with a dressing again, that's going to ensure optimal exudate management, and then wrapped is needed to secure and protect the dressing.
The graph typically integrates within 7 to 10 days. So depending on the size and location of the wound, as well as the rate of healing, repeated graft applications may be indicated. So here are some specific case examples.
So, here we have a 3 year old female spayed Dalmatian that presented for evaluation following exposure to a brush fire. Approximately 40% of the patient's body had 3rd degree burns, with most over the left lateral trunk and the left hind limb. The wounds were initially managed with surgical debridement, silver alginate dressings, and a modified Robert Jones bandage of the limb and chest wrap of the trunk.
16 days after presentation, fish skin grafts were applied. The graft was covered with secondary layer of extraso, cotton roll and bat wrap. 7 days after the initial graph placement, a second grafting was applied.
The wound was allowed to heal by second intention, and wound closure was eventually achieved after 127 days. This is an eight year old female spayed mixed breed dog that underwent a wide tumour excision of the soft tissue sarcoma, and then immediate and weekly placements of fish skin grafts. In image C, this is 2 weeks post-op with a healthy bed of granulation tissue.
Image D is 5 weeks post-op, and you can see epithelization along the wound margin and a healthy granulation bed. Image E is 12 weeks postoperatively with complete epithelization of the surgical wound. And then in image F, this is 12 months postoperatively with mature epithelial tissue present and no hair growth at the centre of the where the wound was.
That's something you do need to prep owners for. Sometimes we'll have areas of, no hair regrowth. In this case, we used 5 graphs for this wound, and they were replaced every 7 to 14 days once the previous graft was fully incorporated.
So in this example, we have a 2 year old spayed female goldendoodle that presented for evaluation of a degloving injury of the left front limb after being struck by a vehicle. The dog had a 15 by 27 centimetre wound that extended from the distal scapula to carpus of the left front limb. The wound was initially managed with surgical debridement, aqua cell silver bandage, and modified Robert Jones bandage of the limb.
It was about 23 days after presentation that Kera's fish skin graphs were applied. The graphs were covered with a secondary layer of telop pads and a modified Robert Jones bandage. A total of 4 graph applications were performed with 1421, and 21 days between graph placements respectively.
The wound was allowed to heal by second intention, and additionally punch autographs were used to aid in the continued epithelialization. Wound closure was achieved after about 168 days. In this case, we have a 4 year old spayed female domestic short-haired cat that presented for evaluation of a traumatic wound suspected to be a dog attack.
The wound was 7.6 by 10 centimetres over the right caudal dorsum thigh region. The wound was initially managed with surgical debridement and wet to dry bandages.
This is a wound just prior to application of a single fish skin graft. This was 32 days following the initial presentation. Here you can see progression of wound healing just 10 days after the fish skin graft was placed.
The wound healed completely by 2 intention in 12 weeks with no complications or additional interventions required. This is a good example of a situation in which the wound bed had plateaued and wasn't making any progress, and the fish skin sort of helped to kickstart the healing process again. This case is a seven year old male castrated mixed breed jaw that initially had a wide resection of a masal tumour and an autograph placed at the same time as surgery, with the use of vacuum assisted closure device over the right antibraum.
Unfortunately, the autograph failed. So this is at 10 days post-op when Keri's fish skin grafts were placed. In this case, we used a total of 6 graphs placed every 7 to 14 days, and we eventually had complete wound closure at around 65 days.
This is a case of an adult male castrated mixed breed dog that had a soft tissue sarcoma excised from his right caudal thigh. He's a very, very active dog and the owners were unable to keep him calm, and in his incision was, you know, in an area of high tension. And so around 5 days postoperatively, there was dehiscence of the incision.
And there also appeared to be a secondary infection, and so we did opt to do open wound management with incorporation of Kerais vet micro. We decided to use the micro in this case, because you can see the topography of the wound bed is pretty deep and uneven, and there were some areas of pocketing as well. So, following wound debridement and lavage, we rehydrated the Keraus micro by adding warm saline into the pouch.
Usually this is gonna be about 1 to 2 mLs. After the 1 minute, we applied Kerais micro to the wound, and we packed it into some of the deeper areas as well. We probably could have used a second pack of micro based on the size of the wound, but we generally had good coverage when we were done.
I did like using the Debay forceps. I think those worked well for transferring the Kerais micro into the wound bed, in my experience. Because the wound was markedly exudative, we covered the wound bed with calcium alginate.
And then we put laps and we placed a tie over bandage and covered it with an Ayaand for protection. A tie over bandage is great for difficult areas to bandage, or when you want to relax the skin around the wound margins. So because this is an area of high tension and also very difficult to bandage being so far up on the leg, we opted for use of the tie over bandage.
When he came back in the following week, the remainder of the incision had actually deistsed, but we had made good progress on our granulation bed. So we placed more kerosus micro and covered again with calcium alginate because it was still very, very exudative. This time we placed split shot sutures to gradually bring the skin edges closer together.
With this technique, we can essentially tighten the sutures gradually every couple of days, and this will help decrease the tension on the skin margins. You can see after an additional week of tightening and wound care, our granulation bed is looking beautiful and ready for closure. So you can see at each time that we tightened it, we added additional split shots.
There are different types of split shots that can be used. Some you can open and close to retighten, and some you just place new ones. And so there's different ways that this can be done.
And so in the upper right hand image, you can see that we have used the split shots to bring the wound edges together, and then the lower right hand image is a week after closing the incision. And lastly, I'll throw in a horse example for all you equine lovers out there. This is a horse that presented for a laceration he had sustained about 2 months prior that the owner had been managing at home with little progress.
We were able to do a standing sedation with a little local block around the wound, and then we just quickly stapled the fish skin to the wound edges and placed a soft padded bandage. Only a single fish skin graft was used to essentially kick start the healing, and then alternative dressings were placed until complete healing had occurred. So this is the wound after one week with the Kerius fish skin graft in place.
And then here is an image of the wound once it was completely healed. OK, so now that we've gone through why Kerosus fish skin works, we've talked about how to apply it, and we saw a variety of clinical examples. Let's go over some of the commonly asked questions.
So one of the most commonly asked questions I get is, what is the difference between Kerius and tilapia skin. So a lot of people have heard of using tilapia for burns in both humans and animals, but what's the difference? So from a geographic standpoint, North Atlantic cod is a cold water fish.
Well, tilapia is a warm water fish. Tilapia skin is used as a biologic dressing, so the dressing remains in place while the patient is healing and then it's removed after 7 to 14 days. During the healing process, the skin underneath is allowed to heal by second intention and is not incorporated into the fish skin.
On the other hand, paresis essentially turns into living tissue. It slowly becomes incorporated into the wound bed as new granulation tissue develops. Kerosis is also FDA approved and commercially available for the treatment of wounds, while tilapia is not.
How is the graph stored? So the graph can be stored at room temperature, and it has a shelf life of 5 years, which is great because you can store it along with all of your other bandage materials and primary dressings. And it comes in a variety of sizes from as small as 3 by 3.5 to 7 by 20 centimetres.
I find the 7 by 20 centimetres to be the most useful for our larger wounds, and I tend to reach for that size more frequently. Does it have scales? No, all of the scales have been removed as part of that gentle processing that retains the fish skin's fatty acid structure.
This fatty acid structure has that added benefit of retaining the EPA and DHA omega 3 fatty acids, which are known again for their anti-inflammatory properties. You will, however, see sort of an imprint of the scales, which helps to direct placement when you put it in the wound, since you're supposed to put it in with your scale pattern facing outward. So while there are no actual scales on the graft, you can see the pattern of the scales.
Can the graft be placed over exposed bone and or tendons? Sometimes we get these really terrible wounds in our companion animals, in which case, a lot of the tissue trauma results in bone exposure. Even with some of these decubital ulcers that dogs get, sometimes we have bone and tendon exposure.
So this is a very common and a great question. And the answer is yes. You can definitely place it over bone and tendons, and it will aid in the development of granulation tissue development over those structures.
In a new study evaluating Keraus fishkin grafts for the treatment of diabetic foot ulcers in people with exposed bone and tendons, they found that by 16 weeks, 44% of wounds were healed compared to the 26% of wounds that were healed in the standard of care group. OK, so let's go over again now, some of the key concepts that I want you to take away from this webinar. We talked a lot about the science, we talked about how to apply it, we talked about what to cover it with, and went through a lot of case studies looking at its incorporation in wound management.
And so now we're gonna essentially look at a summary of all of those things, but the real take home messages of what I want you to to gain from this webinar. OK, so first things first, the kerais that fish skin grafts are derived from North Atlantic cod. What's remarkable about the graft is that because of the gentle processing, they maintain their natural biological components, including the collagens, elastins, proteoglycans, and omega 3 fatty acids.
This ensures that the biological benefits of the fish skin are preserved and can contribute to effective wound healing. It is FDA approved for use in human medical treatments for a variety of wounds. So this speaks volume about its safety and efficacy in wound management.
These intact fish skin grafts are very practical as well, because they can be stored at room temperature and have an impressive shelf life of 5 years, making them pretty convenient for veterinary practises. When it comes to application, the process is straightforward. The grafts are rehydrated in saline, trimmed to fit the wound, and then secured to the wound using sutures or staples.
Notably, it can be used at any stage of wound healing, whether it's an initial injury or in a chronic wound. Integration of the graft into the tissues occurs relatively quickly, typically within 7 to 10 days. Additional graphs can be applied as necessary throughout the healing process to ensure optimal support for tissue regeneration.
Moreover, to address the practical aspects of the wound care, secondary dressings can be used based on the amount of wound drainage observed, which allows for you to tailor your patient care. As we mentioned, a variety of things can be used to bolster this, so many of the common secondary dressings that you already have in practise can be used overtop your fish skin grafts. These characteristics make fish skin grafts very versatile and a great option for a variety of wounds and companion animals.
OK, so as we come to the end of today's webinar, I want to say a big thank you to all of you for being here and joining us in our talk about fish skin grafts and companion animals. I hope you found the information insightful and useful, and you're excited to try out this innovative treatment in your own practise. We may have.
I'm sorry. Yeah, go ahead, go ahead. I, I was looking for.
Yeah, we may have some time now for additional questions and thoughts that you might have. So please feel free to ask. So, while we wait for some questions, Doctor Maxwell, I wanted to ask you some of the questions that I encounter, many a times, talking to some veterinarians or when I'm working in shows.
And I think something that people wants to know a lot is if only applicable to dogs and cats, what other species or what species can take the fish skin grafts. So any species really. So dogs and cats are often the, you know, we see encounter them a lot in in small animal practise, but I gave an example here of use in a horse, and so there are a couple case studies of its use in horses, and we've even seen some exotic species use as well.
I know on your website you have sea turtle demonstrated on the, on the website, so it can be applied to any species. I think the one caveat is if the animal has any allergy to fish, that would be the one instance where you might want to avoid using fish skin grafts, but really it can be used in any species. So, we have a question come in.
Do you apply new graphs directly on top of graphs already placed? Yeah, that's a great question. So, we generally will want to wait for the graft to fully incorporate into the wound before you place a new one.
And so, for example, I change my graphs on a weekly basis. And so if I place a graph and I change the bandage the next week, if the graph is still present, then I don't replace it with a new one. I just replace the secondary dressings, and then I will do another bandage change the week after, and once that graft has fully incorporated, then I might consider placing another graft.
So how long do you wait before your first checkup or first dressing change? How do you go about that? Yeah, so I will usually do about a week or so in between bandage changes, so 5 to 7 days in the beginning, just because sometimes when it's highly exudated, you need to see them back to change the secondary dressings.
But if the graft is still present, then I will leave the graft in place and just change those secondary dressings, and essentially see them back every 5 to 7 days in the beginning, and as the wound matures, I might go every 7 to 10 days, . To check, change that bandage. OK, we have a question come in.
Let me see. Is there a preferred suture material or size? So I will generally, so for dogs and cats, I will generally reach for a 3ot monofilament non-absorbable suture, so something like nylon or proline.
In cats you can go to 4 ot, depends a little bit on the location of the body, but I would say in general, most of the time I'm gonna reach for a 3 ot nylon or some non-absorbable suture. OK. We have, I understand that we have some other questions in the chat, but I don't see them.
Don, if you can please. Hi Martha, it's, it's in the Q and A box. Can you see the Q&A at the bottom?
Yes, I, I, I have it open, . If not, I'll just read them out to you, Elizabeth, if you don't mind. OK, so the first one is, do you cover the dogs with antibiotics and anti-inflammatories during the healing stages while with the grafts?
Yeah, that's also a great question. So if there is evidence of wound infection, so if there's an active infection present, then I will put, place the animal on systemic antibiotics. If we have been Managing the wound for some time.
They've completed a course of antibiotics. The wound bed is happy, and, you know, healing well, then I, I won't necessarily continue it unless a culture indicates that there's an active infection. OK.
In terms of, I'm sorry, in terms of anti-inflammatories, I will manage the, the patient as, you know, as I would with any wound. So pain management as needed based on, on how uncomfortable they are. OK.
The next one is, do you know if this is used or available in the EU? Yes, that is, it is available, it's being used and it is available in the EU and for more information, I wrote in the chat, you can email that BET@ cares.com.
We will be happy to provide information. Amazing. We'll pop that into the email tomorrow as well, so keep a look out for that one.
How often do you perform dressing changes? So, the dressing changes are done on a weekly basis, so in the beginning of the wound every 5 to 7 days, and as the wound matures, maybe every 7 to 10 days, and sometimes I might just be changing that secondary layer, to help with absorption of the exudate and sometimes I'll be replacing the fish skin graft also. So it just depends on how the wound is progressing.
OK. Thank you. Can I use Kerasis after Stelfonte treatments?
Mhm. That's a very interesting question. Has, has not come up before.
I, I don't know. I think that would be a very interesting study. Maybe someone should look into that.
Yeah. I see another really interesting question in here. It says, have you ever experienced hypergranulation tissue?
And if so, what do you do to handle that? Yeah, so for hypergranulation tissue, the kind of main two options, I'll either do kind of manual debridement with a with a blade, especially if it's kind of growing over my skin margin and then my skin won't be able to, to grow over the granulation bed. So sometimes I'll just cut it back with a, with a scalpel.
If it's, if it's just within the wound bed that seems to be very, excessive, I will actually use, like a hypertonic saline, dressing for a for a day or a couple or a day or two on the wound bed directly, and it sort of just draws out some of that excessive, moisture in the granulation bed and kind of flattens it out. And so those are my two favourite ways to manage excessive granulation tissue. So, I'm looking at one that kind of like follows that one, and it says that fish skin grafts reduce the colloid formation in the horses.
Yeah, I don't have that much horse experience. I just had the, the one case, that we used it in a horse, but, I don't know if Martha has any knowledge on the answer to that. Yeah, we have managed several cases with horses and up to this point in time that we have had some very good results, with very minimal, minimal scarring and so if The person that is interested in reading some of the cases that we have available for courses that we have published, please send us an email and we will be happy to provide them to you.
So I'm looking at in here and it says, what does the graph look like once integrated into the wound bed? How do you know when to place another graph? That's a great question.
I love that question. I love that. Essentially the graph is gone.
It disappears. You take your bandage off and you're like, there's no graph to be found. It's incorporated.
If it's, if there's still residual graph present, it'll sometimes be red red tinge to green or grey in colour and, and very much adhered within the granulation bed. So it seems really, really stuck in there, if there's residual graph present, but, when it's fully incorporated, you won't see anything at all. OK.
Here, I'm looking at, this is interesting. It says, how is this a graft when tilapia is not considered a graft? You have stated that this graph, quote unquote, was replaced up to 5 times in some cases to support healing.
Calling this a graph is not accurate or realistic. Well, the, we can take that up with the company, I suppose, but in terms of the tilapia, the tilapia is used as a biologic dressing, so you're essentially using it to cover your wound while your wound is healing beneath it, and then you remove it, you know, after a week or so. In this case, this is considered a xenograft.
It's a, a graph from a different species, even though it's being fully incorporated, into the wound bed, it, it's essentially dermal tissue from a fish, in which case I would say it could be classified as a graft in that sense, even though it's being incorporated, in a different way than we're used to with other graph incorporations. Yes, and I would think also that with tilapia, this is something that you actually buy I we don't know where to buy it rather than the market, and then you have to prepare and go through a disinfection protocol, so it's nothing that is going to granulate into the wound. I think that's what I heard you say, Doctor Maxwell.
It's not going to granulate into the wound, so it's more like a dressing. You're gonna have to change it where care is fully granulates into the wound and there's nothing to take out. Right.
OK. Here it says any comments about using in exotic mammals or birds. I can answer that question.
We've had several cases, and exotic species. We worked, we have a case really nice on a koi fish. You mentioned we have a sea turtle.
We have also worked, with turkeys and, seals, also, we just finished working. With a bald eagle, and we have had fabulous results, in all those different species. So it is very suitable for exotic, species and other mammals.
Let me see. So, how flexible is the application? Is the graft suitable for application using wound management protocols or does it have to be a surgical application?
Yeah, so the, the graft itself is very flexible once it's rehydrated, flexible and pretty strong. It does need to apply be applied with aseptic technique. It doesn't necessarily need to be applied in a surgical setting.
And so some of my examples were in a surgical setting because we were placing them after mass excision. But in other settings where it was a bandage change, we prepared the wound as we would for any wound management or wound care where we clean around the wound, we flush it out, and then we lay towels down, you know, to keep the area clean. We do use sterile gloves when.
Placing them in sterile instruments, but it would be similar for, you know, if you were doing a, a biopsy or, or something, a small wound closure. So aseptic technique, but doesn't need to be in an OR or or in a surgical setup. OK.
So, here's another nice question. Can it be applied to actively infected wounds or should open wound management be done for a few days to get the infection under control before applying the graft? Yeah, so, even though you can apply it, it's any stage of wound healing.
I would, just from personal preferences, if we had an overly active infection, with unhealthy tissue, I would want to consider maybe some sharp debridement or, or non-selective mechanical debridement, maybe for a day or two, before placing a fish skin graft, but that's just a sort of a, a personal preference. So, this one is nice one to follow. The previous one, does this graph also require the administration of immunosuppressants like other graphs?
No, it does not, and we don't use immunosuppressants, with, you know, autographs or, you know, if we're using graphs from, from the patient, which are the more common types of grafts that we would use in companion animals. We don't tend to use, You know, xenographs of mammalian, you know, in inner companion animals, that's not decellularized essentially, but in this case example, we, we do not need to use any type of immunosuppressants. So, can you combine the fish skin graft plus laser therapy?
I don't see why not. I haven't done that personally, but, you know, laser therapy is used to enhance wound healing, so, I, I could imagine a world in which you would do those, could do those together. So I, I'm not, I haven't seen it personally, but I have worked with veterinarians that actually have combined the two techniques together.
As a matter of fact, I was just looking at two cases like those this week, with some very good results. So that's what I can contribute to that. How important is it to trim the graph to fit the wound bed?
Is it OK if the graph overhangs onto intact skin? Yeah, so, it's OK if it overhangs a little bit. What you'll find is that as the graft is incorporating, when you do your bandage change, you'll have sort of a dried margin of graft that's stuck to your skin, or that's sutured into your skin because it's over intact skin.
And so that's not going to incorporate into anything. I do, I do. Go over it just a little bit by a couple millimetres, just to help with suturing it in place, because of how flexible it is.
I don't want it to be too small, in which case the animal moves and it tears from the skin sutures, but you don't want it overhanging by too much, but you'll just have a lot of excess, you know, skin graft that is kind of dried around the margin. Before this product, what would you do to treat this wounds with just wet to dry dressings? Yeah, so wet to dries can be used in the early stages of of the wound when there is an active infection or you need non-selective mechanical debridement.
But once you have a wound under control and you're looking to grow your granulation bed or, you know, or you're looking for further epithelialization, you're gonna be reaching for those secondary dressings, essentially, so your calcium allogenates or foams, or hydrogels, like those are all things that we would normally put on top of the wound bed. That in this case, we can put on top of the graft. So we're getting a similar, almost like an additive benefit of using those secondary dressings that we would have put on top of the, on top of the wound itself, but now we have the graft in place and we're using them to manage with the exudate.
Any instance that you have where you have to remove, the integrated graft, does it get infected? What do you do something like that to have that. I've not had to remove any graphs that have been partially integrated.
Once they're integrated, you won't see it at all. But I have not had any, any scenarios where the graft caused an adverse event or a reaction. In which case I had to, to remove it.
So, it does have antibacterial properties, so, you're not usually gonna have to worry about it getting infected, you know, especially if you have, a healthy bit of granulation tissue and you don't have an active infection that you're working with, so. Mhm. So do you need to debride the wound bed at the graft change or just apply the new graph if the granulation bed is good?
Yeah. So I will stimulate the, the wound bed. So I might take like a 4x4, rough 4x4, and rub the granulation bed to get it bleeding.
Sometimes maybe with a blade, I'll stimulate the granulation bed. Because we want that blood to sort of soak into the graft and for that graft to, to help stick it down. And it also stimulates that healing process and so I don't do any major debridement if I'm happy with the granulation bed, but I might stimulate it so that I get a little bit of bleeding.
Can it be used if a surgical flap has failed? Yeah, yeah, absolutely, I had one example here where an autograph failed, and we placed a graph after that. And so, so definitely if you have a, a flap or a graph that fails, you know, an auto autograph or a a flap that that, you know, doesn't take, then you can do second intention healing with the use of fish skin grafts.
So, I'm gonna combine two questions here. So have you had any adverse reactions or have you had any rejection from rejection from the receptor? No, no rejection, no reactions.
I did have one patient that was always very interested and I don't know if he could smell the graft or if it had a fishy smell to him. He was always interested in his bandage, but, you know, sometimes dogs are that way in general, so I don't know if it was related to the graft or not, but no adverse reactions or ever having to remove them. So we're almost on time, but I do want to ask you a couple of more questions.
Did you combine the graft with PRP? I haven't personally, but, there was that case report where they had combined it with a self suspension, so, I, I think that's potentially a reasonable approach if if you wanted to try that. OK.
Does it need to be covered with the bandage or dressing until the end of the healing? Yeah, I, I do keep it covered until until it's healed. So, you want to always maintain a moist wound environment and as the wound matures, it tends to get more dry.
And so, that's why sometimes you might need to reach for, you know, like a hydrogel or or this or even just the silicone adhesive, . Might be good enough, over top. And usually, once we get toward the end, I don't need the fish skin grafts.
And so I use them to get to a place in which I'm very happy that the dog has been progressing and it's a small wound. And then I just let the wound heal, on its own, and you can just cover it with whatever you think would be fitting for the size of the wound and, and, you know, how the wound looks. OK.
And this is gonna be the last question because we are right on the time for those who want to know about graph sizes and pricing, please do send us an email. We will be happy to provide information for you. .
And do you sedate or anaesthetize for dressing changes? Yeah, that is another great question. So it depends on the wound and the patient.
And so when I'm using it in a situation where I need to do significant debridement, I will sedate the animal. As the wound matures and is not very painful and I'm having to do less and less debridement, sometimes I will do it with the dog awake, as long as they're comfortable, and, you know, some, there are even cases where I don't, place the sutures or, your skin staples, if it's very small, and I can place the adhesive pad and that's gonna hold it in place, and those dogs don't get sedated, . You know, if, if they're very reactive and they're not, they're not gonna hold still, then you want to sedate them so that they're comfortable during the process.
But, so it just, yeah, it just depends on, on how tolerant the patient is of bandage changes and, and how much debridement you have to do. All righty. So we're out of time for those that didn't get their questions answered.
Please feel free to send us an email at [email protected]. Thank you for spending your time with us and Dr.
Maxwell, thank you so much for presenting this class for us. And we hope to see everyone sometime again very soon. Thank you.
