The helpful twin: Skin graft donation in a challenging burn case

OBJECTIVES: This is the first report of a successful skin grafting between monozygotic twins in the United Kingdom (UK). We discuss the process of assessing the suitability of the patients for the procedure, gaining approval and extraordinary funding from the relevant bodies, developing a new protocol within the trust and the logistics of carrying out the procedure safely. METHODS: We describe the case of a 61-year-old paraplegic woman with insensate legs who presented with a 5-week old 2% TBSA deep dermal to full-thickness scald burn which was sustained accidentally in the shower. In view of the prolonged healing time and the risk of burn wound infection, skin grafting of the wound was the recommended treatment. However, given the high risk of impaired wound healing in denervated skin of quadriplegic individuals, the patient was warned of potential donor site wound healing problems. This, along with concerns over the donor site area interfering with the use of her mobility aids prompted her homozygotic twin sister to donate the necessary skin. The process was risk assessed and approval was sought from the Trust's Caldicott Guardian, NHS Specialist Commissioners and the Trust's Human Tissue Authority (HTA) Designated Individual (DI). A new protocol for the pathway in line with HTA guidance was developed. Specific patient information documents were written, psychological assessments performed and specific consent for skin donation undertaken. One week prior to and again on the day of the procedure, the donor was serologically screened for communicable diseases. A donor medical and social history assessment was also carried out. RESULTS: There was 100% graft take at day 5 post-surgery. The sister's donor site healed well by day 13. At 3 months, there were no signs of hypertrophic scarring. No additional outpatient or dressing clinic appointment were required. DISCUSSION: This is the first case of successful skin homografting between monozygotic twins in the United Kingdom. Donation of skin grafts between such patients, however, requires clinical justification, twin zygosity DNA testing, approval from the HTA and NHS commissioners with appropriate protocols and procedures in place to ensure patient safety. Liaising with the local Tissue Bank can facilitate this process. CONCLUSION: Skin grafting between identical twins is a feasible and successful procedure and offers an alternative treatment modality when wound healing in the recipient twin is suboptimal or when severely burnt. This principle should also be considered, in appropriate cases, for composite tissue transfer in situations where complex reconstructions are required.