Skin Allograft Donors can be

1. Living 
2.Cadaver

1 .Living Donor:-For procurement of Skin grafts, the living donor needs to undergo a battery of investigations for preoperative evaluation followed by a surgical procedure under suitable anesthesia, hospitalization for atleast 2-3 days, donor site healing time of about 10 days and postoperative wound site pain.  Maximum body surface area that can be safety utilized for harvesting of skin grafts is 15 to 20% at a time. The other alternative is to procure split thickness skin grafts from a cadaver donor and preserve them for use in future.

2 .Cadaver Donor:-The concept of skin donation after death is not new and the first skin bank was established in USA around 1950. The chief benefits of use of allografts on excised full thickness burn wounds are,

Ø  Effective control of protein and fluid loss from wounds.

Ø  Reversal of hypermetabolic state with improvement in nutritional status.

Ø  Augmentation of immunological response.

Ø  Control of wound infection and improvement in the wound bed making it ready for acceptance of precious skin autografts.

Ø  Immediate pain relief and general feeling of well being.

Ø  Excellent biological wound cover till the autograft donor sites become ready for reharvesting.

The skin allograft transplant differs from organ transplantation as the skin grafts are used to provide temporary long term protection and are not expected to survive in the recipient permanently as transplanted organ. This means that neither ABO blood group nor HLA matching is required for allograft skin transplantation. So, literally any human being can be a donor for anyone else.

The decision to start a skin bank with the capability to procure skin donation after death was taken and several activities were initiated. Besides my colleagues from department of surgery, faculty of department of Microbiology especially Dr Daksha Pandit (then Associate professor) contributed significantly to the process of establishing protocols and standardizing the procedures. The department of Microbiology continues to be the integral part of the skin bank team. The actions involved the following:

·        Approval from authorities:- The state appropriate authority established by Government of Maharashtra was approached to seek its approval for procuring cadaver skin homografts with consent of next of kin.  This request was supported by Bombay Anatomy Act of 1949 that makes body donation after death possible.  Though the concept was completely now, the official captured the significance and the need for skin bank.  The formalities were completed and the consent letter was obtained within a period of 6 months.  This was really encouraging.

·        Preparation of Documents :- Late Dr. Pritam Phatnani – then Professor and Head of Department Forensic Medicine was of great help in drafting the consent form in appropriate words.  Other forms  for maintenance of records such as donor details, graft processing, recipient details, etc were prepared using UTMB tissue bank documents as prototypes.

·        Preparation of Protocols:-

The following protocols were prepared after review of references and discussion with all the team members.

- Defining eligibility criteria.
- Communication and response details.
- Readiness of equipment.
- Procurement protocol.
- Transport equipment & protocol.
- Deposition and information routine.
- Homograft and serological processing protocol.
- Storage method and quality control.
- Procedure  for requisition and disbursement of homograft.
- Record keeping.

·        Space allocation and procurement of equipment While all the above preparation was in progress, a room was identified in the department of surgery and after appropriate approval from administrative authority, the area was made ready for installation of equipment.  Some items such as incubator, hot air oven were acquired from MCGM funds.  Most of the main storage equipment was received in donation from “Sunday Friends” -   a voluntary organization that has been associated with our burn unit for several years.

·        Work distribution: Awareness, Counseling , procurement and utilization –  Department of Surgery. Processing , banking, disbursement – Department of Microbiology. Funding – Donation from Voluntary organization, M.C.G.M.

·        Equipment : The details regarding equipment and personnel may be of help to an institution interested in setting up a skin bank. Depending on the choice of preservation technique, the required    equipment would vary in certain details.

a) Instruments for skin graft procurement   -   Rs.   50,000 – 00
b) Dermatome ( optional )  -  Rs.  5,00,000 - 00
c) Refrigerator -  Rs  10,000 – 00
d) Incubator  -  Rs.  20,000 – 00
e) Ultra-cool refrigerator for -70 o C temperature -  Rs.  7,00,000 - 00
f)  Laminar flow cabinet -  Rs. 2,00,000 - 00
g) Air conditioners -  Rs. 3,00,000 - 00
h) Universal power supply   Rs  1,00,000 - 00
i)  Laboratory articles, reagents, chemicals, furniture – 1,00,000 – 00

The total initial expenditure to equip the skin bank is about Rs. 20,00,000 – 00

The cost of consumables needed for procuring skin donation from one donor is about Rs. 2000 – 00 and this includes the cost of serological testing.

The institutional infrastructure has to contribute to activities such as central sterile supply, serology and microbiological testing, graft antibiotic treatment and sterility testing. A stand alone skin bank will have to arrange these provisions.

·        Personnel :The functioning of skin bank depends on the dedication and commitment of personnel in the skin bank team. From available persons we need to identify counselor, contact person, response team including surgeon, assistant, helper and supervising consultant. The laboratory processing has to be entrusted to identified microbiologist or biochemist. A record keeper is of great assistant in maintaining documents and record of purchases. Each member of the team needs to be briefed about his/ her responsibility as well as that of others.

·        Records :Donor record  with all lab reports, graft record, recipient record, communication with donor’s family, filing of donor declaration forms with registration number, answers to questions regarding skin bank – all need to be attended to by identified person.

All the above actions were completed ( preparation time about 6 months) before declaring the Skin Bank open.

Donor : It was decided that any person above the age of 16 years will be accepted as skin donor after death if behavioral and medical history and serological testing of the deceased ruled out the following conditions.

- Hepatitis B or C, HIV I / II, Transmissible diseases.
- Skin cancer, skin infections, damaged skin.
- Systemic sepsis.

Consent : Consent for skin donation is obtained from the closest prioritized relative after explaining the procedure.

Skin graft procurement : This should be done with shortest delay after death, though it can be procured upto 24 hours after death if the body is preserved in cold storage. Prolonged delay causes bacterial and fungal colonization of the donor skin. The procurement should be conducted with aseptic precautions in operation theater when possible. If this is impractical, the procedure can be carried out in the side  room of ward, hospital bed , morgue or home of the deceased. The procedure takes about one hour and involves removal of epidermis along with superficial  layers of dermis from both thighs and back of the donor. There is no bleeding as blood circulation stops at death. The thighs are covered with dressing before handing over the body to relatives. About 10 ccs of blood  of the deceased  is collected at the same time for serological testing The grafts are transported to the skin bank in Phosphate buffered saline in glass containers placed in ice box along-with blood sample for serology. The microbiologi t is informed and the processing is initiated. Process details can be provided to interested personnel.

Graft storage : If serology  and microbiology reports are satisfactory, the grafts are shifted to -70 0 C. with 98% Glycerol as  cryo-protectant. The grafts can be preserved  upto 6 months at this temperature. Liquid Nitrogen technology permits preservation upto 3 years. But the present mismatch between availability and requirement does not necessitate the need for methods for prolonged storage. The grafts are thawed to room temperature before use and once thawed, restorage is not recommended.

The response :From April 2011 to 30 th September 2019, skin donation after death has been received from 900 donors. Grafts  from 17 donors had to be discarded due to positive serology. The donation was procured from  478 men and 422 women. The procurement was within 6 hours of death of majority of donors. Till date the skin allografts have been used for 869 patients all with burn extent of more than 40% total body surface area. The greatest burn size of the survivor amongst the recipients was 85 % TBSA.

The future :The awareness in the medical fraternity needs to be augmented so that the relatives of the deceased would be counselled. More efforts are called for in stimulating participation of teaching institutions, peripheral hospitals and private hospitals for counseling of relatives after death of a patient in respective institutions.Participation of voluntary organization needs to be co-ordinated. The facility for skin banking should ideally be available in every medical college hospital as maximum numbers of burnt patients seek treatment at these institutions. Several collection centers can be affiliated to each skin bank facility. Training in standardized graft procurement protocol can be provided to available personnel.

It is essential to ensure the quality in functioning of skin bank. Establishment of Tissue bank Association of India would be the logical step in right direction. This will provide guidelines and assistance in quality control.

Appeal : Work of this magnitude cannot be done single-handed. Department of Surgery , LTM Medical College has made a beginning and our experience shows that Indian society has accepted the concept. Now we seek active support and participation of all medical professionals and alert citizens in promoting the concept and in saving lives of several young and productive members of our society.