2. What is ReCell? A unique device enabling to produce an autologous skin regeneration suspension - in a simple 30 minute procedure The suspension comprises of the patient’s cells, together with the signalling factors they express for wound healing In the treatment of Burns, Plastics, Maxillo-Facial & Trauma Procedures

3. How the technology works The cells harvested from the epidermal dermal junction include: Fibroblasts Melanocytes Langerhans Cells Keratinocytes Important wound healing factors These cells: Are not yet terminally differentiated Are highly proliferative M igrate evenly across the wound bed In this technique we use the Wound bed as culture media The Autologous Cell Suspension

4. PRE-TREATMENT PREPARATION MATERIALS REQUIRED Sterile drapes, gowns, gloves Protective eyewear (if applicable) Skin biopsy instrument (e.g. dermatome) Appropriate anaesthesia Wound bed preparation tool Fine Forceps Primary and Secondary Dressings

5. PRE-TREATMENT PREPARATION PATIENT SELECTION Stable condition, no infection Expect improvement not perfection No history of keloids or scar going into dermal area

6. CONTRA-INDICATIONS FORMAL CONTRA-INDICATIONS Clinical infection (no contamination) Active auto-immune disease (e.g. non-stable Vitiligo) Absence of vascularised wound bed (atonic or fibrotic tissue) RELATIVE CONTRA-INDICATIONS Co-morbidities impacting healing (e.g. diabetes) Patient non-compliance

7. PRE-TREATMENT PREPARATION WOUND BED PREPARATION Sterile fields Clean – no necrotic tissue Infection free Pinpoint bleeding

8. PRE-TREATMENT PREPARATION DRESSINGS Primary dressing – small pore, low absorbent, non-adherent, non- toxic to cells Secondary dressing – moderately absorbent, minimal adherence, low shear, readily removable

9. SET UP STAGE SET UP CARD

10. SET UP STAGE SELF TEST AND ENZYME PREPARATION

11. SET UP STAGE BUFFER PREPARATION AND DELIVERY SET PREPARATION

12. STAGE 1: RECELL SKIN PROCESSING

13. STAGE 1 1. TAKE SKIN SAMPLE Take a thin, split-thickness shave biopsy (0.15-0.2 mm in depth) Skin Sample SizeTreatment Area 1 cm x 1 cm up to 80 cm 2 2 cm x 2 cm up to 320 cm 2 Site match biopsy Take two passes. Use second biopsy only Take biopsy only from neck or head. Recommended body donor sites: axial, medial thigh, hip

14. INSTRUMENTS FOR HARVESTING SKIN SAMPLE Silvers Knife Electric Dermatome Air Powered Dermatome SKIN SAMPLE 0.15 – 0.2 mm in depth Sterile conditions Appropriate Anaesthesia STAGE 1

15. Correct thickness Almost transparent appearance Will leave pinpoint bleeding xToo thick White dermis Curling of edges SKIN SAMPLE

16. 2. HEAT ENZYME Run test again by pressing (?) When shows, press play button to heat the Enzyme 3. INCUBATE SKIN SAMPLE When orange light changes to insert skin sample into incubator well for 15 minutes STAGE 1

17. 4. DRAW UP BUFFER SOLUTION Using a 5 mL syringe and blunt needle draw up appropriate volume of Buffer Solution from well B STAGE 1 Treatment AreaBuffer Solution Volume Up to 80 cm 2 1.5 mL 80cm 2 – 160 cm 2 2.5 mL 160 cm 2 – 320 cm 2 4.5 mL

18. WOUND BED PREPARATION Preparing the wound bed Clean, well vascularised wound bed Careful debridement to viable dermis Pin-point bleeding should be visible Choice of instruments Mechanical Burr Lasers; Erbium YAG, CO2, Fractional Skin needling i.e. Medical rollers Hydro surgery - Versajet Surgical debridement – i.e. dermatome, Humby knife Keep the prepared wound site moist with saline soaked gauze

19. STAGE 2: RECELL SUSPENSION PREPARATION

20. 5. TEST SCRAPE Remove skin sample from incubator and place on tray Gently scrape to test if the cells disaggregate, DO NOT complete scraping If cells do not come away – incubate for a further 5-10 minutes and repeat step 6. DEACTIVATE RECELL ENZYME Rinse skin sample briefly in well B STAGE 2

21. 7. SCRAPE CELLS Place skin sample on the tray dermal side down Using Buffer Solution in the 5 mL syringe, place a few drops onto the skin sample Scrape thoroughly to disaggregate the cells STAGE 2

22. 8. RINSE AND ASPIRATE Add remaining Buffer Solution from the 5 mL syringe onto the tray, using the solution to rinse the scalpel and tray into one corner Using the 5 mL syringe and blunt needle, aspirate the cell suspension and again rinse the tray into one corner STAGE 2

23. STAGE 3: RECELL SUSPENSION DELIVERY

24. 9. FILTER CELLS Filter cell suspension through well C Remove cell strainer Tip: Tap cell strainer over well 10. DRAW UP RECELL SUSPENSION Use a new sterile 5 mL syringe with blunt needle to draw up ReCell suspension from well C STAGE 3

25. 11. DRESSINGS Ensure the dressings are cut and prepared for immediate application once the cell suspension is applied STAGE 3

26. AIMS OF PRIMARY DRESSINGS Surface protection Minimise infection Haemostasis PRIMARY DRESSING SELECTION CRITERIA Small pore Low absorbent Minimal adherence / readily removed Low shear Non-toxic to Keratinocytes (no silver or chlorhexidine) PRIMARY DRESSINGS

27. AIMS OF SECONDARY DRESSINGS Hold excess exudate Keep primary dressing intact Protect the wound from trauma Minimise infection SECONDARY DRESSING SELECTION CRITERIA Moderately absorbent Minimal adherence Low shear Readily removed SECONDARY DRESSINGS

28. 12. APPLY RECELL SUSPENSION TO WOUND BED If spraying, connect spray nozzle to the syringe If dripping, leave blunt needle in place N.B. Spraying of less that 2 mL suspension is not recommended Ensure haemostasis is achieved (adrenaline soaked gauze) at recipient site as blood flow will wash away the sprayed on cells Start applying cells to the most elevated part of the recipient site STAGE 3 Cell VolumeRecommended Application Method 1.5 mLDrip 2.5 mLSpray or Drip 4.5 mLSpray

29. Post Treatment Guidelines

30. PATIENT FOLLOW UP Infection control is key to allow cells to develop well. Prophylactic antibiotics are recommended for 1 week. Antiviral should be considered in case of history of herpes. The use of cytotoxic medications e.g. silver sulfadiazine is contraindicated During the healing process the wound may be itchy, for this reason anti- histamines are recommended. No vigorous or strenuous activity should be undertaken during the first week following the procedure.

31. POST OPERATIVE CARE Outer dressings should be debulked on Day 2. Be careful when removing do not dislodge the primary dressing. Secondary dressing can be changed if soiled. Primary dressing will eventually peel off and shed once the new epidermis has formed. Do not removed primary dress before day 5. Ensure primary dressing removal is atraumatic. Do not just pull away if it has stuck to the wound. Never forcibly remove the primary dressing

32. POST OPERATIVE CARE If the primary dressing sticks to the wound: Trim the edges as the primary dressing loosens Soak remaining dressing in aqueous (saline solution) or oil based solution from day 5 to facilitate atraumatic removal Cover to protect with a retention dressing (e.g. Hypafix or Mefix) Do not remove unless there are clear signs of infection Never forcibly remove the primary dressing Need to add extra cautions to this area

33. PATIENT FOLLOW UP The newly healed skin is fragile and needs protecting. Protective dressings must be worn on extremity wounds for two weeks following initial healing Leave the wound open if dry but use a protective dressing if there are shear forces (e.g. foot) until the new epithelium looks resistant enough to withstand such forces. Regular applications of moisturiser should be applied, 2-3 times a day. This should be gently massaged into the newly formed skin. Avoid direct sun exposure at least 4 weeks following treatment. New skin should have protected sun exposure by either sun cream 30+ or clothes for at least 3 months. Patient should not use any stimulating products (retinol or glycolics) until the skin has matured.

34. SUMMARY REMEMBER Every indication is different Every patient is different Manage patient expectations If there are any signs of infection treat the infection first Keep the dressings dry after the procedure Do not forcibly remove the dressings Keep the newly formed skin moist once the dressings have been removed by gently massaging moisturiser into the area Protect the newly formed skin from the sun

35. CLINICAL SUPPORT MATERIAL Set Up Card Appointment card Quick Guide Stickers After ReCell

36. Take skin further with ReCell ReCell can help take skin further in the treatment of burns when used: In Combination Deep burns with meshed autografts Large TBSA burns where insufficient donor skin exists allowing wider mesh ratio Alone Partial thickness burns and paediatric scald injuries in particular At Donor Site Stimulate regeneration of donor skin for re-harvesting

37. Case Studies Date37

38. MID DERMAL FACIAL FLAME BURN Day 9 – ReCell application 18 weeks post treatment Courtesy of Isabel Jones, MBBS MD FRCS Plastics C&W Hospital, London 18 weeks post treatment

39. MIXED DEPTH PAEDIATRIC SCALD Before treatment 3 weeks post treatment 10 weeks post treatment 10 months post treatment Courtesy of Jeremy M Rawlins FRCS(Plast) 10 months post treatment Before treatment

40. ReCell Benefits: Burns Date40 CLINICAL BENEFITS: BURNS Smaller donor site area requirement Maximises the use of available healthy skin Immediately available for use at a single procedure Donor skin can be meshed wider to cover a greater area Donor sites may be treated for re- harvesting Viable melanocytes for normal pigmentation Less pain management CLINICAL NEED: BURNS Conventional skin grafting is burdensome to patients, requiring large amounts of painful donor harvesting, and leaving undesirable scaring CEA is time consuming, costly, requires multiple surgeries only produces keratinocytes

41. THANK YOU