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Background. We carried out a literature review to evaluate the status of the scalp as a donor site and examine claims that the scalp donor site in black patients was less suitable than in other races. Objectives. To ascertain whether the finding that using the scalp as a donor site was less successful in black patients than in other races was credible. Methods. A Pubmed search was done for ‘scalp as donor site in burns’. There were 91 hits for the period 1977 - 2020. Results. Twenty-three articles were included for the final review. Of the 23 articles identified, 13 included ≥28 patients. Of these 13 larger articles, the number presumed to have a multiracial population of patients was 7. Of the 7 studies, only 1 study found a noticeable difference in hair growth in all their white patients but none in the black patients. Conclusion. We did an extensive literature review of the scalp as a donor site and found that most authors found it to be an excellent donor site irrespective of race. The report that complications of scalp grafting are related to racial issues such as hair structure by a burn centre in South Africa is not supported by the literature or by another burn centre in the same city.

Background. If a circumferential limb deep partial or full-thickness burn occurs, compartment syndrome can develop. Although several factors affect the outcome of patients who develop compartment syndrome, the most important salvage treatment is an early release of the compartment under pressure by a fasciotomy. However, COVID-19-related fear from doctors may cause some hesitancy to enter a hospital, and hesitancy to interact with patients. Objectives. To provide a literature review of the urgency of burn victim escharotomy and fasciotomy, and to provide a practical algorithm for use during the COVID-19 pandemic. Methods. We used a literature review to search the following key words as search phrases: compartment syndrome; burns; fasciotomy and escharotomy; COVID-19. We searched with the following search engines: Pubmed and Medline. We limited the articles searched to the period 2015 - 2020. We decided not to include abdominal compartment syndrome in the search, but rather to focus on limb compartment syndrome. Results. We included 8 of 14 screened articles, which were relevant to our search. We found no articles discussing the effect of the COVID-19 pandemic and compartment syndrome on burns. Most authors suggest early escharotomy and early fasciotomy. Conclusion. Based on the literature review, it is our recommendation to do a fasciotomy immediately once the diagnosis is made. From the onset of compartment syndrome until fasciotomy, there should be no more than 3 hours’ delay. In patients with circumferential burns that are deep or are converting to full-thickness, it is necessary to do escharotomies where necessary. Hourly monitoring of limbs with escharotomies is essential, and it is important to communicate this clearly to nursing staff. It is important in the environment of the fear related to the COVID-19 global pandemic that the urgency of escharotomy and fasciotomy is not delayed.

Background. A retrospective analysis was done to correlate recorded clinical infections with laboratory cultures to report on the incidence of hospital-acquired infections (HAIs) and the impact of probiotics for environmental cleaning in our burn centre. Objectives. To assess the effect of probiotics for environmental cleaning in a tertiary burn unit on HAIs. Methods. We used the electronic content management system of the hospital to access patient files for 2017 and February 2018. All patients with clinical records showing a new infection after admission for ≥48 hours and who required antibiotics were recorded as HAIs. Results. The total number of HAIs for 2017 was 167. If the two test months (TM) when probiotics were used are excluded for 2017, then the HAIs numbered 151 for the remaining control months (CM). Thus during 2017 there were 16 HAIs in the TMs. The percentage difference of the monthly average of HAIs for the TM and the CM is a 55.89% reduction, with a statistically significant p-value

Background . Breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL) is a newly defined clinical entity. However, much of the research around this topic is based on prognostic studies with low levels of evidence. Objective. To conduct a literature review on the pathogenesis of BIA-ALCL. Methods. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Based on the grading system for levels of evidence for prognostic studies suggested by Burns et al., each article was graded between 3 and 4. Results. After articles were removed based on exclusion criteria, 55 remained for review. These included level 5 expert-opinion and bench-research articles ( n =39), level 4 case series reports ( n =4) and level 3 case control studies and systematic reviews of case control articles ( n =12). No level 1 or 2 research articles were found in our search. Conclusion. Our study describes potential BIA-ALCL risk factors, and provides the level of evidence for the interpretation of recommendations for clinical practice and further study.

Background. Breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL) is a newly defined clinical entity. However, much of the research around this topic is based on low levels of evidence prognostic studies. Part 2 follows on our part 1 article discussion on potential BIA-ALCL risk factors, and provides clinically relevant suggestions for further study. Recommendations. From the available research, we were able to identify several potential strategies to reduce BIA-ALCL risk. These recommendations were graded according to the grade practice recommendations suggested by Burns et al. These strategies include: avoiding Allergan BIOCELL textured implants; using sterile surgical technique; patient screening; use of anti-inflammatory drugs; and the avoidance of implants in genetically susceptible individuals. Conclusion. Owing to the lack of studies with a high level of evidence on BIA-ALCL prevention, few strong recommendations for clinical application can be made at this point. However, our article identifies areas in need of further study.

Background. The MolecuLight i:X device is intended to assist healthcare practitioners managing patients with wounds by enabling real-time visualisation of potentially harmful bacteria. Healthcare practitioners are provided with a visual indication of bacterial presence, load and location within and around wounds. Objectives. We decided to use the device in a cohort of burns patients in an attempt to test its effectiveness and applicability in an adult burn centre. Methods. We were given permission by our hospital to use the MolecuLight i:X device for a test period of 1 month, and elected to do a pilot observational study to test its application on burn wounds. A total of 10 patients were assessed for presence of infection (red or green flare). Results . Seven patients showed either cyan or red fluorescence. Pseudomonas aeruginosa was confirmed on wound swabs in the 4 patients with cyan fluorescence. The red fluorescence in 3 patients showed on wound swabs as either MRSA, Streptococcus pyogenes or Proteus mirabilis . The remaining 3 patients did not show any fluorescence, and there was no growth on wound swabs. Conclusion . The MolecuLight i:X is a new device for identifying Gram-positive and Gram-negative bacteria on an open wound. It is of great practical benefit to the surgeon in making decisions about the adequacy of debridement before subsequent skin grafts, and it also identifies target areas for antiseptics.

Electrical burns to the scalp are rare, and owing to hair coverage and the low index of suspicion, they are easy to miss. The main objective of this article is to highlight the presentation, management options and complications of the condition. A 46-year-old man with no known comorbidities had a delayed presentation with electrical burns to the scalp, legs and feet following an incident of assault. He was admitted to the Burn Unit, and supportive wound care commenced. He underwent several debridements, skin grafts of the legs and feet and left foot amputation, with improvement of the limb wounds. Despite grafting and repeated scalp wound debridement, the wound repeatedly became infected, with necrotic tissue and pus discharge. Successive tissue and wound swabs showed a varying range of bacteria that were treated with antibiotics. A computed tomography brain scan eventually showed osteomyelitis of the calvarium with sagittal sinus thrombosis. Scalp debridement and craniectomy were eventually performed in conjunction with neurosurgeons, with subsequent resolution of the wound. He was subsequently discharged with a protective helmet, with no further complications. A thorough evaluation of patients is invaluable for clinicians, and is advised in every clinical encounter. This case illustrates the challenges encountered in the management of these injuries. Thorough evaluation, repeated debridements, appropriate investigations and multidisciplinary teamwork helped to improve the outcome.

We used adipocyte-derived stem cells in combination with previously used methods (platelet-rich plasma and cell seeding) to create a 3D bioprint of skin on a hydrophobic matrix dressing. The patient was a 16-year-old girl with 65% total body surface area burns who had had multiple previous operations, and required additional skin with minimal donor sites. The patient had a Pseudomonas aeruginosa wound infection that compromised graft take. The overall graft take at 2 weeks was between 20 and 60%. The results were satisfactory in this patient, but there is plenty of room for improvement to achieve 100% graft take. Further technical refinements in the technique and postoperative management could improve results.

Background . The standard of care for slough and exudative burn wounds in our unit is a combination of Intrasite gel and Flamazine. Objective. To analyse our standard of care method in comparison with Drawtex hydroconductive dressings. Methods. A retrospective record review was done of a 3-month period in 2016 during which we had a large amount of the hydroconductive dressing available. The inclusion criteria were the use of Drawtex on the wounds of patients who were not operated on within 48 hours of dressing application, where there was another wound of the same depth on an opposite limb, on which a control dressing was used. The exclusion criteria were skin-grafted areas and patients who had had operations within 48 hours. Results . There were 100 patients with acute burn wounds admitted in the period from February to April 2016. A limited quantity of Drawtex had been donated. The total number of patients with complete clinical documentation available was 39. Of these, 36 met the inclusion criteria, with 48 wounds treated. Eleven patients had wounds that could be assessed with controls, but only 8 had adequate follow-up data for study. Of the eligible 36 patients, 28 were treated with Drawtex without the use of control areas. Eight patients were found who had good control areas for comparison. Drawtex was clearly better than control areas by such a large margin that during the application period in 2016, the control treatment areas were abandoned for Drawtex, hence the low number of controls. Drawtex was also found to be less expensive when a cost comparison was done. Conclusion. The study found that Drawtex delivered better results than the control method, and was more cost-effective than our standard operating procedure. Therefore, we recommend Drawtex for burns with moderate to highly exuding wounds with slough.

Background. A detailed study of the blood supply of the forehead has led to precise landmarks for midline forehead flap planning, similar to the old Indian rhinoplasty landmarks described by Daver and Antia. Further investigation into pedicle rotations has shown that the best technique for one-stage pedicle inset was to use an inverted-kite pedicle base modification of the midline forehead flap. Objective. To carry out a retrospective review of all the cases using the one-stage inverted-kite midline forehead flap (OSIKMFF) operated on by the author between January 2006 and September 2018. Methods. The retrospective review gathered information on patients’ age, pathology, flap design and complications. Results. Twenty patients were included in the study. Most data for 2008 were, unfortunately, lost, but patients whose data were retrievable were included. The average age of the patients was 57 years (range 21 - 84). The male-to-female ratio was 1:1 (10 v. 10). The most common pathology was basal cell carcinoma, which was present in 18/20 (90%) cases, and the remaining 2 (10%) patients had melanoma. Only in two (10%) cases was tissue expansion used before the OSIKMFF. All the flaps survived, and the blood supply was very robust. Complications were minor. Conclusion. The one-stage forehead flap using the inverted-kite pedicle base modification is a useful technique, based on meticulously identified safe landmarks, the robust blood supply, meticulous cadaver dissections and clinical experience over many years.