The "spray-on skin" technique, pioneered by Australian surgeon Fiona Wood, was used to treat Australians who were victims of the Bali bombings in 2002.

WARNING: An image below may offend those who are sensitive to images of pain.

A biopsy of healthy skin tissue is taken from the patient, put in a suspension and cultured for five days, and then sprayed back into the wound. The body responds to the cells, healing with less scarring than skin graft treatments.

Many burns units around the world now use the technique. Doctors at Berlin's Trauma Hospital have developed their own version where the skin cells are ready in one and a half to two hours.

A big difference

Peggy and Reginald Rothbarth were on vacation in Sardinia in June 2009, when a gas leak in their apartment led to a fire. They suffered burns to over 50 per cent of their bodies, including the face, neck, chest, hands, arms and legs. After receiving initial treatment in Italy, they were flown back to Germany, where they received further treatment at Berlin's Trauma Hospital.

But meeting Peggy and Reginald Rothbarth, it's hard to imagine they had suffered burns to their faces.

Reginald Rothbarth remembers going to rehab, where they met other burn victims who were treated at different hospitals and didn't receive the spray on skin treatment.

A burned hand before treatment with the spray-on skin

“Their faces were completely scarred, mostly because they didn't receive this treatment technique at other hospitals in Germany. And that's our biggest luck,” said Reginald Rothbarth.

The Rothbarths were treated by Bernd Hartmann and his team at the Trauma Hospital's Severe Burns and Plastic Surgery Centre. Like most patients suffering severe burns, the Rothbarths were placed in an artificial coma for over three weeks. During this time, their wounds were cleaned, disinfected and dressed, and then the treatment began. Hartmann used the spray-on skin technique for their faces, necks and hands.

Dr Hartmann explained that due to the severity of the burns, the Rothbarths received a combination of different techniques including skin grafts, expended skin grafts and the spray-on skin cells.

After being treated with spray-on skin, the area heals in around 10 days. But the spray-on skin technique can only be used to treat second degree burns - not third- or fourth-degree burns, which are worse.

Light treatment

Professor Matthias Augustin, director of the Institute for Health Services Research in Dermatology in Hamburg, says that the main advantage of the spray-on skin technique is that it's very quick compared to skin grafts or sheets, which take weeks to implement. Another advantage is that because the patient's own skin cells are used in the spray-on skin technique, the body doesn't reject them.

A burned hand afer treatment with the spray-on skin

"The sprayed skin can be used without contact and without active intervention on the wound, so it's a very light treatment which does not lead to more pain than necessary," explained Augustin, who added that another difference is that "this sprayed skin spreads over the surface of the wound very well, so it adapts to the wound surface and the cells can evenly start growing. They are better spread over the whole wound than other technologies.”

This really makes a difference to the healing of facial burns. Minimizing scarring doesn't just look nicer, it also really makes a difference for a patient's psychological health when people can't see the scars.

"With the spray-on skin method, it's really about that fact that you when you look at our faces, you cannot believe what we've just told you. We can still lead a normal life,” said Peggy Rothbarth.

Mrs. Rothbarth has been able to return to work, but unfortunately Reginald's hands were too damaged to continue his work as a precision mechanic. The severity of burns to other parts of their bodies means they do have ongoing health problems.

But Hartmann is still working on improving treatment for burn victims. He has collaborated with the German Institute for Cell and Tissue Replacement on a new device to spray skin cells onto wounds, which was approved this year. And together with the EuroSkinGraft project - a Europe-wide initiative - Hartmann hopes to extend the spray-on skin technique to dark scars and severe burns within the next five years.

Doctors at Berlin's Trauma Hospital developed the cell spray device

Human skin has an extremely complex three-layer structure - deeper layers contain lymph and blood vessels, along with sweat glands, which can be damaged in severe burns.

"We now have the sprayed cells for the dermal and mid-dermal burns, but we want to have products for the deep burns to have better results like normal skin,” says Dr Hartmann.

With his Swiss and Dutch colleagues, Dr Hartmann is working on a 5-year project to develop multi-layer skin techniques.