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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. Integra Flowable Wound Matrix (IFWM) was recently introduced to the South African market by Baroque Medical in 2018. Objectives. To investigate the published literature on the role of IFWM, and illustrate our experience using a case report. Methods. A Pubmed/Medline literature review of the use of IFWM to evaluate the published experience of clinicians and identify any useful information for improvements of was done. We also present a case report using the IFWM for an axillary defect after contracture release. Results. There were 31 hits for ‘Integra Flowable’, of which we selected 7 articles for full review. Only 1 article specifically focused on Integra Flowable (Suchyta et al.), in 2018. There was no article that focused on the use of IFWM for axillary contractures. The IFWM was used successfully in the patient. Conclusion. We used IFWM successfully in a patient with an axillary defect after contracture release. Despite our success, there are certain wound conditions that are not favourable for collagen products.

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 . An observation was made in 2004 by Holtan et al. by dermoscopic examination that skin tumours coincide with arterial blood supply. In 2006 the author proposed the hypothesis that these areas often coincide with areas where arteries join from multiple different directions, called arterial converging points (ACP), or with sharp S-curves in arteries. Methods. The anatomical vascular observations were made through a prospective study dissecting 30 cadavers and comparing 60 hemi-foreheads. The arteries were filled with latex and then dissected meticulously to expose them. Results. In all the foreheads there were anastomoses between arteries joining from different directions. These junctions are called ACP. There were also many sharp angled S-curves in the course of the arteries, which assisted in formulating a skin tumour pathogenesis. Based on the clinical knowledge of basal cell carcinoma growth sites in the face, an anatomical vascular hypothesis was developed. This may also play a role in migraine pathogenesis because of the relationship of the cutaneous nerves to the blood supply. Conclusion. An association between ACP and certain skin tumours may be relevant in tumour pathogenesis, and further study of the vascular phenomena of ACP will provide more answers

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.

In our burn unit, we used Glubran cyanoacrylate glue until 2017, but thereafter had problems obtaining it. Since 2018, we have gained some experience using a new glue called INDERMIL flexifuze. It is supplied as a sterile liquid topical tissue adhesive. It is composed of an octyl blend cyanoacrylate formulation that is not associated with perceptible heat release upon application. It acts as a physical barrier to microbial penetration as long as the adhesive film remains intact. The skin graft must be set in position before the glue is opened. Meticulous haemostasis before graft application is needed. In addition, the surrounding areas must be cleaned and dried. The glue is then applied at 1 - 2 cm intervals. The skin graft can then be dressed in a standard fashion. We have used it in 30 cases, with 100% graft take. We have found INDERMIL flexifuze to be a very effective glue for atraumatic skin graft fixation, and recommend its use.

Background. Biofilms in hospital environments provide the ideal conditions for pathogenic bacteria to thrive. Hospital hygiene practices such as cleaning and disinfection do not affect bacteria ‘hiding’ in the biofilm. Using a cleaning product containing environmentally friendly probiotic bacteria to eliminate biofilm may reduce the risk of hospital-acquired infection. A prospective controlled study was designed to investigate this. Objective. The primary objective of the study was to document the effect of a probiotic cleaning protocol on environmental flora. The secondary objective was to determine the cost-effectiveness and cost reductions of its use. Methods. Our Burn Unit was divided into different areas, and a number assigned to each test zone and comparative normal cleaning treatment control zone in different rooms. We informed the cleaning staff that they should use only the probiotic product in each of the designated test areas. A baseline surface swab for culture was done in each area. Swabs were taken again for culture weekly. Results. The total number of pathogenic organisms counted was 17 in the test area, and 9 in the control area. In the test area the predominant organism was Acinetobacter baumanii , and in the control area it was Streptococcus species. The highest concentrations of organisms were on the floors, where they accounted for 59% in the test area and 67% in the control area. The other test areas had mostly single organisms. Conclusion. Based on the results, further investigations as to the application of probiotics are indicated, and a prospective study looking at the effects on wound cleaning should assist in answering the question of their effectiveness on wounds.

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.

Cutimed Sorbact is a unique wound dressing that uses no antibiotics but has antibacterial effects. It is a hydrophobic dressing that acts by irreversibly binding to the hydrophobic extracellular surfaces of bacteria and fungi, thereby deactivating them. The active component in the dressing is a fatty acid derivative, dialkylcarbamoylchloride. The dressing has been used in many clinical scenarios, including on infected wounds, in prevention of infection on wounds and on central blood line puncture sites, as skin substitute in burn wounds, on donor sites and as a cell culture matrix. The optimal wound environment for the dressing is a relatively dry environment to enhance the hydrophobic mechanism of action, and secondary dressings should be selected accordingly. The dressing should be removed when saturated by fluids, including blood, and dressing-to-wound-bed contact is essential for good outcomes. It is not to be used on the upper eyelids, because it will inhibit eyelid closure. The dressing can be used as a first-line choice in wound-dressing antibacterial stewardship. Once the use of the dressing has been mastered in the different scenarios, it becomes an integral part of daily wound care.

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 mechanism of action of the Drawtex dressing is described as having three components: capillary, hydroconductive and electrostatic. Objective. To find a more complete explanation of Drawtex’s mechanism of action, from in vitro research and clinical observations. Method. Ten 1 A~ 1 cm sections of Drawtex dressing were cut off, and some trypan blue was dripped onto one side of each using a pipette. The pieces were then examined macroscopically and under a light microscope (LM), on all sides and surfaces (superficial and deep surfaces, as well as the edges), to assess fluid movement. Results. Three fibres (cotton, viscose and polyester) of different diameters and different directions were visible under the LM. Fluid could also be seen surrounding the fibres in which the trypan blue was absorbed. Macroscopic examination of Drawtex removed from sloughy wounds showed that slough was stuck to the dressing, and mechanical action also played a role. Conclusion. Based on our observations, the following explanation of the mechanism of action of the dressing seemed easier to grasp: ( i ) absorption within the fibres; ( ii ) absorption between the fibres resulting from the Venturi effect, diffusion gradient and buoyant forces; ( iii ) the effect of the diffusion gradient; ( iv ) evaporation; ( v ) dehydration; and ( vi ) adsorption and mechanical slough removal. The physics of fluid movement is complex, and likely not fully understood.

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.

A wound assessment acronym, BE ME SIC SOS, was developed to aid consistent record keeping of wound healing and assist in teaching dressing selections: B = biofilm; E = exudate/(o)edema; m = moistness; E = epithelialisation; S = slough; I = infection; c = colour; S = size; O = odour; S = swab need.