Donated skin is being processed into cosmetic-surgery products. Meanwhile, shortages can leave burn victims at lethal risk.
Burn victims lie waiting in hospitals as nurses scour the country for skin to cover their wounds, even though skin is in plentiful supply for plastic surgeons, an Orange County Register investigation found. The skin they need to save their lives is being used instead for procedures that could wait: supporting bladders, erasing laugh lines and enlarging penises. Donated bodies and tissue such as bones and veins are used in ways most people would never imagine, and profits are made with little oversight.
Tight federal regulations ensure that kidneys, hearts and other internal organs are funneled to patients in the greatest need. But skin, the body's largest organ, isn't covered in the law. Instead, it has become a commodity. Of 139 burn centers nationwide, 11 have their own skin banks. Even they, at times, have difficulty finding enough skin for their patients. The rest of the hospitals must call banks nationwide when they need skin and pay whatever price tissue banks are charging that day.
Hospitals say they can't compete. Increasingly, the skin they need goes to two companies that have contracts with more than 20 of the largest tissue banks. The companies buy all the skin the banks harvest and turn it into plastic-surgery products.
In Kansas City, doctors have delayed surgeries for lack of skin. Last summer in Syracuse, N.Y., the shortage became so severe that a hospital sent a burn patient 570 miles west to Cincinnati. Coast to coast, doctors are stretching what little skin they find -- putting patients at risk of infection, burn doctors say.
In places like St. Louis and Phoenix, tissue banks harvest skin in the same hospital where burn patients lie waiting for skin -- but they ship it to companies for plastic-surgery products.
In January, the shortage alarmed enough members of the Skin Council of the American Association of Tissue Banks that they organized a conference call to discuss ways to change the system, a move many felt was urgently needed. So far, they have not reached an agreement on creating a priority list for skin.
"I'd rather save lives with skin," said Judy Perkins, a Skin Council member who runs the University of San Diego Tissue Bank. "It's a big moral dilemma for tissue banks. Anyone who is supporting a burn unit like I am, you can't fathom why you wouldn't take skin for burn victims first."
People such as Dana Christmas are caught in the tug of war between compassion and commerce. The 21-year-old prelaw student was taken to University Hospital in Newark, N.J., with burns covering 60 percent of her body. She was the most seriously injured og 62 students to survive a January dormitory fire at Seton Hall University -- a blaze that killed three.
Hospital staff called six tissue banks looking for skin to cover Christmas' wounds. They finally found just enough at Perkins' skin bank, 2,400 miles away in San Diego. The first call went to the country's largest tissue bank, the Musculoskeletal Transplant Foundation, just 20 minutes south of Christmas' hospital room. It couldn't help. All of the tissue bank's skin is committed to a Massachusetts firm, Collagenesis Inc., that markets a new product for plastic surgeries. Collagenesis and LifeCell Corp., in New Jersey, are the country's two main corporate skin buyers. "It shocks me," said Jonathan Walker, the hospital's materials manager. "A hospital should have first choice, and then they can take care of the companies. It should go in order of importance."
Foundation president Bruce Stroever said his firm couldn't have helped Christmas even if it had skin available. "First of all, we're not a skin bank," Stroever said. "We don't process skin for burns. We don't know how to process skin for burns."
The crux of the controversy is just that: Skin is going to places that don't make burn grafts. Every year, about 70,000 people are admitted to hospitals for burn injuries. About 10,000 of them die, typically from a collision of causes: infection on the exposed tissues, internal organ failure, smoke inhalation.
No one tracks the amount of skin used every year on burn patients, but one patient can require more than 10 square feet of skin. There are alternatives, but donated skin remains the preferred treatment, leading burn experts say. It fights infection and dehydration while helping the body regrow its own skin. The body gradually rejects the skin, but, as with any transplant, a patient can take drugs to suppress the immune system and allow some of the skin to become permanent.
"When you have a great big burn, skin is absolutely essential to close the wound and start healing," said Bruce Zawacki, former director of the Los Angeles County-USC Medical Center burn unit. "Without skin, you are completely at the mercy of the environment. And none of the substitutes are quite as good as the real thing."
In February, skin was in such short supply at the Grossman Burn Center in Sherman Oaks that doctors had to stretch skin grafts beyond their normal size to cover Benancio Lopez, who was severely burned in an industrial accident. Lopez said he was grateful the hospital could find any skin at all. "When I first got to the hospital it felt like I was still burning," Lopez said. "After they covered me in skin, I felt a lot less pain."
A similar situation played out last November at the Grossman Burn Center in Anaheim. Staff there called more than 15 banks seeking skin for a burn victim and didn't find enough. They had to leave some burned areas open, said nurse Jeannette Ochs. The patient later died from complications unrelated to the lack of skin.
The Anaheim burn-center staff never called the Orange County Eye and Tissue Bank, 10 miles to the south. The hospital staff didn't know the bank harvested skin, even though it had done so in another part of that very hospital. Not that it mattered. The tissue bank sells its skin to LifeCell Corp. near Houston, which makes it into its trademark plastic-surgery product, AlloDerm.
LifeCell now has about 20 tissue banks regularly sending it skin. The company developed AlloDerm in 1992 to help reconstruct burn victims' skin weeks or months after they have had skin grafts. They can use it later to smooth out scars.
A few years ago, though, plastic surgery began to power the company's sales. The numbers show why. LifeCell estimates the potential revenue from AlloDerm in reconstructive and cosmetic surgeries at $200 million annually, 10 times what the company could hope to make on burns.
A strip of AlloDerm can be a sling under a weak bladder. Or fill a hole left by a tumor. Or fatten lips. Or thicken a penis. "The burn market is clearly less attractive," LifeCell President Paul Thomas said. "With plastic (surgery), it's just a much bigger marketplace, a bigger opportunity and better reimbursement."
The reason is simple. Companies charge plastic surgeons more for skin products than they do burn centers. And, in the past decade, the number of cosmetic surgery procedures soared more than 150 percent. Burn centers pay about $6 for a square centimeter of AlloDerm. Plastic surgeons pay up to four times as much for a slightly thicker slice. "The price is a reflection not only of sort of what our costs are but also what the market will support," Thomas said.
Collagenesis Inc. in Massachusetts can make $36,000 on skin from one body by turning it into a gel that is injected to smooth wrinkles and inflate lips. Although New Jersey's Musculoskeletal Transplant Foundation didn't have skin for Dana Christmas, Collagenesis co-founder Dale DeVore said his company has no trouble getting skin from the foundation or filling orders. "There seem to be more donors all the time and certainly as many as we need," he said.
Similarly, when the Grossman Burn Center called LifeCell looking for skin to help Lopez, the company told them it didn't have any skin. It had all been made into AlloDerm. On the other hand, the company says AlloDerm customers have never been forced to wait. "We're one of the biggest AlloDerm practices around, and we never seem to have a problem getting it," said Dr. Daniel Shapiro, a cosmetic surgeon in Scottsdale, Ariz.
Both LifeCell and the Musculoskeletal Transplant Foundation said they are not depleting the pool of available skin. In fact, they say they have increased donor numbers by enlisting and training more tissue banks in skin recovery. They also say the products made from that skin have a wide range of benefits. "For the amount of skin that I could use to help half a burn victim, I can now help 200 people with bladder incontinence or reconstruct eyelids for 200 people," LifeCell vice president John Harper said. "If I crash my Harley, and I know I can help 200 people with my skin, that's a pretty good deal in my book." Harper said the majority of procedures using AlloDerm are reconstructive rather than cosmetic.
Hospitals say burn victims' needs are more pressing. In New York City, for example, burn center staff say they can't find enough skin. To the north, Albany's Center for Donation and Transplant sends 250 square feet annually across the state border to the Musculoskeletal Transplant Foundation, which, in turn, sends it to Collagenesis. "We weren't procuring skin prior to being contacted by MTF," said Bill McTague, development supervisor for the Albany bank.
Both LifeCell and the Musculoskeletal Transplant Foundation emphasized that they either work with banks like McTague's that weren't harvesting skin before or they only take skin that hospitals don't need. The Register found that wasn't always the case. Life Alaska in Anchorage, for example, used to send its skin to the Intermountain Tissue Center in Salt Lake City, which prepares skin for burn centers. It now sends all of its skin to LifeCell, partly because the company pays twice as much. "I'd like to say that the price didn't enter into it, but it was a factor," said director Jens Saakvitne. "I didn't want to chase the dollar, but with the better service we were getting from LifeCell it was better all around."
Until last year, the Donor Network of Arizona sent all skin to the University of Texas Southwestern, where it was made into grafts for burn victims. Now, three-fourths of its skin goes to the Musculoskeletal Transplant Foundation. The Arizona tissue bank harvests skin from a Phoenix hospital with a burn center, and it says local burn patients' needs are being met. But burn center staff said skin remains scarce and that it usually takes calls to several banks to get what they need. "We've always had trouble getting skin since we closed our own skin bank," said clinical director David Ulate at the Arizona Burn Center. "That's never changed."
A quarter of the country's tissue banks dedicated to skin have closed over the past decade because of financial trouble. Burn centers buy sporadically. They might have seven burns one week and none for the next three months. Larry Hierholzer, the executive director of the Orange County Eye and Tissue Bank in Santa Ana, worked for a skin bank in Torrance that folded because spotty sales couldn't cover its costs. With LifeCell, the Orange County bank always has a customer. "As a nationwide program, they have a much greater ability to maintain some consistency," Hierholzer said, adding that local hospitals benefit by having LifeCell's products.
The companies would not exist without the tissue banks. Tissue banks ask for the donation at the time of death. Banks tell families that the donor's skin is going to help burn victims and that the bank is a nonprofit operation. The tissue banks don't mention cosmetic uses in their consent forms. Nor do they mention their alliances with the private companies making plastic- surgery products. "We don't want to give them the impression that their loved one's skin is going into (an actress's) lips," Collagenesis' DeVore said, adding that "he'd be in another business" without his tissue-bank partners.
Last week, the Orange County Eye and Tissue Bank's parent company, Baltimore-based Tissue Banks International, said it was planning to change its consent forms in Southern California. Spokeswoman Toby Bernstein said the pilot program will give people the option of donating skin for cosmetic surgery.
Situations like the one that left Dana Christmas clinging to life while the hospital searched for skin have some skin banks and burn centers calling for much-broader change. They suggest that hospitals get top priority for skin, and the companies get the leftovers. Tissue banks like Orange County's, which don't process skin but merely harvest it, can still send skin to companies like LifeCell, members of the Skin Council for the American Association of Tissue Banks said, but they should also send some to places that make grafts for burn victims. "In places where we might have gotten skin for burn victims before, it's being sent someplace else," said Jan Pierce, director of the Intermountain Tissue Center in Salt Lake City and a member of the skin council. "There is a need for collagen for plastic surgery and urinary incontinence, but ... for burn victims, it's a life-saving procedure."
The American Red Cross, the country's largest skin supplier, has had 534 skin donors since July, but still routinely has a dozen hospitals on a waiting list. In 1999, LifeCell and Collagenesis had about 2,500 donors. The Red Cross always has put burn victims first, said Dr. Duke Kasprisin, the medical director for the Red Cross National Tissue Services. "Even if we had twice as much skin, we wouldn't be able to supply all the need out there, but perhaps we would start to catch up," Kasprisin said.
To make burns a priority for skin would take federal legislation at most and a recommendation by the tissue-bank assocation at least, Pierce said.
Some cosmetic surgeons, too, are troubled by the trend. Dr. Hugh Bailey in Newport Beach has used Dermalogen to puff up lips for several years, but news of a skin shortage gave him pause. "Obviously, a cosmetic lip augmentation should be a secondary use for skin if saving someone's life is the other use," Bailey said. "If this is in fact a problem, the burn- treatment community needs to be more vocal within the scientific literature and peer-reviewed journals of plastic surgery."
Jennifer Borders has lived both sides of the issue. The 31-year-old Lake Forest woman had breast-reduction surgery last year, partly because she was "tired of not being able to find a shirt that fit." She knows that cosmetic surgery can be a mental and emotional salve. But she also has a 5-year-old daughter who burned her hand when she stuck a nail in an electrical outlet. Doctors repaired her hand with donated skin. "My body's not perfect, either. If I could drop six grand and redo my lips or my nose, I might do it," Borders said. "But at the same time, if you're going to be using skin, emergencies should come first."
*Copyright 1999 The Orange County Register
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