Background Determining frequently colonizing microorganisms and typical demographics affected by burns in the West Bank is essential to aid timely and effective injury management. Methods This study included n = 435 patients with burn injuries between January 2018-December 2021 at a tertiary center in Nablus. Eligible medical records were reviewed, and relevant data extracted. Results n = 244 males and n = 191 females, average age 14.5 years were included. n = 227 had wound swab cultures, n = 80 which were positive. Scald injuries were the most common mechanism of injury (n = 314, n = 162 in males (p < 0.001), average age of 10.5 years). The most common organisms isolated were Pseudomonas aeruginosa (n = 17) and Staphylococcus aureus (n = 18). n = 17 multidrug resistant (MDR) organisms were cultured, MRSA most commonly (n = 9), followed by K. pneumoniae (ESBL) (n = 5). Overall length of stay (LOS) was 17.27 days in all patients and 28.2 days in those with MDR, with increasing LOS significantly associated with positive culture and MDR development of MDR (p < 0.001). Conclusions Younger male demographics and longer hospital admission increase the risk of burn wound colonization and MDR development in the Northern West Bank. Pseudomonas aeruginosa and Staphylococcus aureus were prevalent organisms isolated. MDR development represents a significant challenge in the effective management of injuries in an immunologically vulnerable cohort.

Burns are a global issue that can result in lifelong multimorbidities and disproportionately affect people in low-resource settings. Prioritising research of importance to patients and health-care professionals improves evidence-based care. This prioritisation setting partnership was undertaken in global burn care (focusing on thermal non-electrical burns) by establishing a James Lind Alliance research priority setting partnership. Over 2 years, two online multilingual surveys with patients, carers, and clinicians, 16 interviews, and a virtual priority setting workshop were conducted to identify and prioritise questions for research. Survey responses were received from participants in 88 countries (1617 survey one respondents; 630 survey two respondents). A short-list of 19 research priorities were ranked at an online workshop attended by 28 participants (14 health-care professionals, ten burn survivors, and four carers or advocates) from 15 countries to produce the final top ten research priorities. These priorities provide opportunities for researchers, funders, and clinicians to shape the future of burns research and improve burns care globally.

The scarring that occurs following a burn injury can have devastating physical and emotional consequences for the patient. Scar revision surgery can be very effective, but when surgical options are exhausted or the patient declines, camouflage is an alternative. A 43-year-old woman with mid-deep dermal flame burns sustained in a house fire in August 2020, comprising 6% total body surface area, underwent chemical debridement followed by allograft application. One month later, the patient underwent surgical debridement with a split-thickness skin graft to an unhealed area on her left posterior shoulder. This procedure was successful, with 100% graft take. During her follow-up visits, she developed hypertrophic scarring in this region, which shifted the focus of her care to scar management. We developed a custom-made silicone gel prosthesis to camouflage the scar, help the patient regain confidence, and also provide therapeutic benefit by sealing in hydration. The prosthesis was matched to the patient's normal skin tone and texture, featuring a soft and flexible outer surface with a smooth inner surface for adherence. The patient found the prosthesis easy to apply and inconspicuous, yet effective at concealing the scarred area. The prosthesis also offered protection from external sources of irritation. Both the Patient and Observer Scar Assessment Scale and the Modified Vancouver Scar Scale showed marked improvement when the prosthesis was used.

Introduction: Extended reality technologies including augmented reality (AR) and virtual reality (VR) can be used in surgical settings for surgical planning, perioperative visualisation of patient anatomy and simulation of operative steps. This study aimed to ascertain the role of extended reality in perforator-based breast reconstruction. Methods: A systematic search of the literature was performed. Screening was conducted independently by two reviewers, with conflicts resolved through consensus. Results: In total, 4957 articles were identified of which 10 were included, comprising 229 flaps. Overall, localisation of perforator emergence with AR and VR were 4 mm (95% confidence interval [CI] 3.2-4.9) and 14 mm (95% CI 5.5-22.5), respectively, from the correct intraoperatively identified location. Two studies reported a significant reduction in harvesting time (88 min for VR and 19 min for AR). The pooled mean image processing time from four studies was 39±47 min. Preoperative VR was associated with shorter operative times than conventional Doppler ultrasound (478±56.94 vs 606.29 ± 81.94 min, P<0.05). Use of a simulated environment for mapping perforators appeared to reduce complications (wound breakdown, flap revision, flap loss, infection); however, this failed to reach statistical significance (odds ratio 0.6; 95% CI 0.3-1.3; P=0.20). Conclusions: This study suggests that AR and VR offer limited benefit in improving accuracy of perforator identification; however, they may reduce flap harvesting and total operative time. Key limitations include heterogeneity and quality of the included studies. With larger sample sizes and higher quality evidence, definitive benefits and longitudinal outcomes relating to use of extended reality in perforator-based breast reconstruction may be established.

OBJECTIVE:To evaluate the performance and safety of Biatain Fiber Ag (Coloplast A/S, Denmark), a new gelling fibre wound dressing containing silver, based on percentage of wounds healed in partial-thickness burns within two weeks. METHOD:This non-comparative, one-armed, open-labelled, multicentre study, included patients from five different sites in the UK between October 2023 and April 2024. The primary endpoint was whether a wound healed or not. Adverse events were also assessed. RESULTS:In total, 51 patients with a partial-thickness burn wound that was either infected or at risk of infection, and with medium-to-high levels of exudate, were part of the full analysis set. The proportion of wounds healed within two weeks of treatment was 83.7% (95% confidence interval (CI): 69.3, 93.2) of the 43 patients completing the investigation. In a post hoc sensitivity analysis, assuming that missing data on wound healing were either missing at random or corresponded to a non-healed wound, the estimated proportion of wounds healed was 74.8% (95% CI: 60.7, 85.1). In the pre-planned sensitivity analysis, where all missing data on wound healing were assumed to correspond to a non-healed wound, it was 70.6% (95% CI: 56.2, 82.5). A total of seven adverse events were found related to the investigational device; all were non-serious. CONCLUSION:In this study, treatment of partial-thickness burns with the investigational device showed that the percentage of healed wounds within two weeks was comparable to the performance of similar products. In addition, the results revealed no safety concerns. This new gelling fibre wound dressing containing silver may therefore have a notable clinical implication for wound healing in patients with acute wounds that are infected or at risk of infection.

A national observational study of 115 NHS Trusts across England was conducted over a 4-month period from July to October 2023. Each Trust was sent a Freedom of Information (FOI) request, which included a standardised questionnaire on extravasation incidence, incident reporting, and management protocols. 96 NHS Trusts responded to the FOI request, 86% (n=82) provided information on extravasation incidence. Extravasation incidence significantly increased from 2018-2022, with median values increasing from 27.5 to 42 per year (p=<0.0005). Extravasation incident reporting was compulsory in 62.5% of Trusts (n=60), with a median value of 196 incidents between 2018-2022. 106 Extravasation protocols met inclusion criteria. Protocols focussed on initial management, and most commonly described incident documentation (92.5%), limb elevation (88.7%), infusion cessation and cannula aspiration (83%). However, only 58.5% (n=62) were easy to read. Plastic Surgery involvement was low, with 16% (n=17) recommending contacting Plastic Surgery in the event of extravasation, and 47.2% (n=50) in specific clinical circumstances or extravasation severities, and only 11.3% (n=12) before the application of heat or cold packs. A review of the literature highlights inadequacies in evidence quality for extravasation management recommendations and few comparative studies across management options. This study highlights the increasing burden of extravasation, and the need to improve research quality. We urge the establishment of a clear consensus approach on extravasation management to ensure consistent and evidence-based treatment for patients.

Introduction Maggot debridement therapy is an effective and widely used biodebridement method in chronic or non-healing wounds but is infrequently documented in burn injuries. Many burn patients wish to avoid surgical intervention, and in an ageing population with increasing comorbidities surgery may not always be preferable. Here we describe its successful use in an elderly and comorbid patient. Methods The larvae were applied to a 0.5% full thickness burn wound on the thigh using two treatments of BioMonde Biobags, and he achieved healing within eight weeks. Discussion Maggot debridement therapy has been documented to shorten healing time, increase the likelihood of healing, and reduce antibiotics use in other chronic wounds. Maggots may be more selective in debriding wounds than sharp surgical debridement, preserving more healthy tissue. There is evidence to suggest that maggots clear biofilms created by Staphylococcus aureus and Pseudomonas aeruginosa , which are common organisms cultured in burn wounds. The patient was enthusiastic about the therapy and would recommend it to other patients. Conclusions More formal evidence is required to compare outcomes between maggot debridement therapy and surgical intervention in such patient subgroups, as this may become a workhorse therapy for successful burns debridement and treatment. Lay Summary Burn injuries are common and increasingly so in the elderly. Full-thickness injuries are those which involve all the layers of skin and are at risk of becoming long-term wounds if left to heal on their own. These types of wounds will often develop a hard covering layer, called eschar, which protects the regenerating skin underneath but can slow down how fast the wound heals. Often patients with full thickness injuries will need the eschar removed, the wound surgically cleaned (known as debriding) and a skin graft to reduce the healing time. However, in elderly patients with medical issues such as diabetes and heart problems (as in this case), surgery may not be advisable due to the risks of having anaesthetics, as well as the medical problems possibly impacting on how well the skin graft will work. Maggots are immature green-bottle fly larvae which feed on dead tissue and release enzymes to break it down to digest. They have been used in wound care for centuries but are less frequently considered an option for burns. In this case report, an elderly and comorbid patient sustained a deep burn injury to his thigh. He declined surgery and maggots were used instead, which were highly safe and effective. He did not require skin grafting. We suggest more studies are required to compare how effective this treatment is within the elderly population as means of avoiding surgery.

Medical simulation has progressed to using sophisticated computerized systems such as virtual and augmented reality. Despite its widespread adoption across various specialties, its adoption in burn surgery remains limited. Consequently, we wish to report on the "Excision of an Unhealed Burn Wound" module on the Touch Surgery mobile application that simulates the tangential excision and reconstruction of a burn wound with a split-thickness skin graft. To ascertain their knowledge of the surgical management of an unhealed burn wound, 38 regional senior house officer trainees currently on a plastic surgery placement completed a multiple-choice test. The trainees then viewed a full demonstration of the "Excision of an Unhealed Burn Wound" burn surgery module, before repeating the multiple-choice test after 1 hour. The self-assessed knowledge of participants regarding the excision of a burn and skin graft procedure improved in 90% of cases. Similarly, knowledge of the different types of equipment used for burn surgery saw an improvement in 89.5% of cases. Additionally, 84.3% of participants reported improvement in their understanding of the principles of preparing and applying a split-thickness skin graft. All but one participant agreed that simulation is beneficial in teaching surgical procedures, with the lone participant providing no rationale. Despite the relative inability to provide trainees with hands-on experience using surgical instruments and the risk of constraining the user to a single, preferred operating technique, we feel that digital simulation offers a novel tool for educating trainees in burn surgery.

Background Complex upper-limb defects with exposed tendon or bone often require flap reconstruction. Fully synthetic dermal substitutes such as Biodegradable Temporizing Matrix (BTM) may create a vascularized neodermis over poorly perfused structures and enable delayed grafting as an alternative to flaps. Methods We undertook a retrospective review of consecutive patients undergoing upper-limb soft-tissue reconstruction with BTM (January 2020-January 2024). Demographics, wound characteristics, comorbidities, indications, complications, secondary procedures, and functional outcomes were recorded. "Good" function was defined as >75 % active range of motion (AROM) without major complications; "poor" as <50 % AROM with persistent deformity/contracture/limitation. Fisher's exact tests and odds ratios (OR) assessed associations between tendon exposure, anatomical site, and outcome (alpha=0.05). Results Thirty-four patients (mean age 57.0 years; 17 female) were included; median defect approximate to 5 x 5 cm (range 2 x 2 to 20x35 cm). Indications were burns (32.4 %), infection (29.4 %), trauma (14.7 %), extravasation (8.8 %), necrotizing fasciitis (5.9 %), and post-compartment-release (2.9 %). Tendon exposure occurred in 76.5 % and bone in 5.9 %. Complications occurred in 41.2 % (contracture 17.6 %, chronic non-healing 8.8 %, graft failure 5.9 %); 70.6 % proceeded to split-thickness skin grafting and 17.6 % required salvage procedures (scar release, tenolysis, fusion). Functional outcomes were good in 38.2 % and poor in 50.0 %. Tendon exposure was not significantly associated with functional outcome (OR 3.33; p = 0.360). Anatomical site (hand/digits versus other) was not significantly associated with outcome (Fisher's exact test; OR 0.55; p = 0.691). Conclusions BTM is a useful option for upper limb reconstruction when flap coverage is not feasible, particularly in complex wounds with exposed tendon or bone. In this cohort, healing was achieved in all patients, though functional outcomes varied and complications were more frequent with joint involvement or comorbidities. BTM may be especially valuable in high-risk patients or injuries where flap surgery is unsuitable.

A keloid scar is a benign fibroproliferative disorder that is characterized by excessive tissue growth beyond the original wound. The psychosocial and surgical challenges that arise can present potentially devastating long-term consequences for patients, particularly in demographics with a high incidence of keloid scar formation. Considering the high incidence of keloids with an estimated 11 million cases annually, particularly in those of Asian and African backgrounds, an understanding of their exact pathophysiology remains challenging. Piercing-induced keloids of the ear are a common cause of ear keloids, yet the exact mechanism and optimal treatments are of considerable debate. This narrative review aims to evaluate current treatment modalities for ear keloids, focusing on their association with ear piercings and the implications for management. A systematic review of Medline, Embase, and Mendeley identified 26 studies, covering a range of surgical and non-surgical treatment methods, indicating a considerable recurrence rate, with an average of 20.3%. Surgical excision remained the primary treatment modality, which was often accompanied by adjunctive therapies such as steroid injections and radiotherapy. Fractional carbon dioxide laser therapy may also be a useful treatment modality with fewer potential complication risks. Overall, the findings identified significant variability in treatment protocols and outcomes, underscoring the need for personalized approaches based on keloid characteristics and patient preferences. Ultimately, the review highlights the importance of further research to establish standardized treatment protocols for ear keloid scars and to understand the role of piercing-specific pathophysiology in improving patient outcomes.

BACKGROUND:Gaps in research evidence lead to research waste. In burns treatment, there is a paucity of reliable evidence or data. This contributes to inconsistent patient care, especially on a global scale, where low-resource countries often lack access to the latest research advancements. This umbrella review was undertaken as part of the James Lind Alliance Priorities in Global Burns Research Prioritisation Setting Partnership (PSP) and aimed to identify and assess the quality of evidence in thermal burns care. The objective was to map which interventions in thermal burns care are supported by a reliable evidence base and for which the evidence is lacking. METHODS:Systematic reviews of randomised controlled trials in thermal burns were identified and assessed using reliability criteria determined a priori. Multiple systematic review databases were searched in June 2023, including the Cochrane Library, KSR Evidence database and NIHR Journals Library. Summary of findings and, where available, Grading of Recommendations Assessment, Development and Evaluation was used to assess certainty of evidence. Reliable reviews were mapped onto clinical categories identified by patients, carers and healthcare professionals as part of the PSP. RESULTS:232 systematic reviews were identified, of which 83 met reliability criteria and were included. The main reason for not meeting reliability criteria was poorly defined eligibility criteria (n=128). Of the 83 reliable reviews, most were conducted in pain (n=28) or wound management (n=14) and acute care (n=13). Certainty of evidence was mixed. Reviews mapped onto nine of the 17 clinical categories identified by the PSP. CONCLUSION:This review summarises the available high-quality evidence in burns care and identifies evidence gaps, indicating that many important clinical questions remain unanswered. There is a discrepancy between the treatments investigated in high-quality research and the clinical areas considered as most important to stakeholders. These findings provide direction for future research to improve global burns care.

Advances in data processing, motion tracking, and projection technologies have expanded the potential of extended reality (ER) modalities, including augmented reality (AR) and virtual reality (VR), in surgical settings. ER applications in perioperative visualisation, planning, and simulation are promising, but their role in aiding intraoperative perforator identification for breast reconstruction remains unexplored. A systematic review was conducted following PRISMA guidelines, and prospectively registered in PROSPERO (CRD42024564928). Seven databases were searched. Two reviewers independently screened articles and extracted data, resolving conflicts by consensus. The search identified 4957 articles, with 10 meeting inclusion criteria (229 flaps). Overall, localisation of perforator emergence with AR and VR were 4.0mm (95% CI 3.2-4.9) and 14.1mm (95% CI 5.5-22.5) respectively from the actual intraoperatively identified site. AR and VR significantly reduced harvesting time versus doppler ultrasound (19mins and 88mins respectively). Similarly, preoperative VR shortened operative times compared to doppler ultrasound (478±57mins vs 606±82mins, P<0.05). The rate of complications such as flap loss and infections where similar between ER and traditional methods of perforator identification (OR 0.6, 95% CI 0.3–1.3, P=0.20). The results of this study suggest that ER modalities, particular AR, have high rates of accuracy for identifying perforators with reduced harvesting time compared to traditional methods. With larger sample sizes, the longitudinal effects on complications, including flap failure rates, may be determined, and their role and potential in the surgical setting be established.

BACKGROUND:Skin substitutes are routinely used in burn surgery. Increasing numbers of marketed products, regional variation in use, and lack of high-quality research may be contributing to non-standardised care across units. Previous research has also shown that many healthcare professionals in burns care cannot correctly identify the constituents of skin substitute products, with medicolegal implications related to consent. METHODS:A cross-sectional survey of healthcare professionals across all burn units/centres in the UK and Ireland was conducted between 24/04/2022-15/08/2022. The survey was developed and distributed by the Reconstructive Surgery Trials Network using REDCap©. We evaluated current skin substitute use, clinicians' awareness of their constituents, factors influencing product selection, and feasibility of performing future randomised trials in this area. RESULTS:From all burn units and centres in the UK, 306 healthcare professionals responded. Knowledge of product constituents was significantly greater among senior burn surgeons, but <50% respondents correctly identified the constituents of most products. Skin substitutes were used by most units/centres for acute superficial partial burns (16/21, 76%), deep partial/full-thickness burns (18/21, 86%) and secondary reconstruction (20/21, 95%) but not for donor sites (6/21, 29%). Biobrane was the most used for superficial partial burns and Novosorb-BTM for acute deep partial/full-thickness burns and secondary burn reconstruction. Most respondents reported willingness to consider randomising patients to future trials involving skin substitutes. CONCLUSIONS:Skin substitute use is reportedly widespread, but there is significant intra- and inter-unit variability. Better evidence to guide use is required, ideally with randomised controlled trials comparing products. Knowledge of product constituents, particularly by non-senior burn surgeons, requires improvement.

Consistent anatomical terminology is essential to prevent miscommunication between team members in the clinical environment and reduce confusion for those taking important examinations. We aimed to evaluate the disparity between the official anatomical terminology used in surgical textbooks, and that which is used in clinical practice and the literature. The example we chose was the improper usage of the term “peroneal” over “fibular”. A questionnaire was answered by 30 doctors of various training grades at a tertiary plastic surgery hospital, assessing the usage of the term “peroneal” versus “fibular” for structures of the lower leg. Additionally, a systematic search of Medline and Embase analysed the terminology used in major plastic, vascular and orthopaedic journals since 2010. Eighty percent of respondents used the term “peroneal” when describing structures of the lateral lower leg, with only 50% aware of any synonymous terminology. Notably, of those who used “fibular” as the preferred term, 80% graduated from medical school within the last 5 years. Review of the literature revealed 90% of published papers since 2010 to use “peroneal” over “fibular”. There exists a large disparity between the anatomical terminology used in anatomical textbooks, and that which is used in clinical practice and the literature. This holds the potential for confusion and may negatively impact those sitting important examinations. Awareness of new official terms needs to be improved, and the burden of this should be on the Royal Colleges, surgical bodies such as ASiT, journals and examination bodies.

Infections are a major cause of morbidity and mortality in burn patients, and the rise of multidrug-resistant organisms (MDROs) has made it more challenging to manage and prevent infections. This review examines the available treatment options for MDROs in burn patients and anticipates the future challenges posed by their increasing prevalence. The review covers new antibiotics, such as Eravacycline and Plazomicin, as well as non-antibiotic therapies, such as bacteriophages and nanoparticles. Future research should focus on examining the long-term efficacy, cost-effectiveness, and in vivo efficacy of different treatment modalities. The potential of alternative therapies, such as probiotics and low-frequency magnetic fields, should also be explored. Accurate and rapid diagnostic and monitoring tools for detecting MDROs in burn patients should be developed. The emergence of MDROs in burn care is a challenge and a new beginning in infection innovation and novel treatments.

Lower limb reconstruction is performed to replace like with like and achieve tissue durability. Free flaps are a method of reconstruction commonly used to manage cases of lower limb deficits. However, the failure rate is 8.5%, with venous thrombosis and congestion playing a significant role. Despite this, preoperative venous mapping of recipient site before free flap reconstruction is not routinely practiced, often resulting in pathologies remaining unidentified until the intraoperative stage. The aim of the review was to evaluate the existing literature on the topic of lower limb preoperative venous assessment, screening, and its effect on lower limb free flap survival. Five different databases were searched from their inception to August 2021. The search terms and included studies were independently reviewed by two investigators for their eligibility. Eleven articles were eligible for inclusion, with a combined patient population of 99, and 107 flaps were identified to have lower limb pathology at the donor or recipient vein. Venous pathology was detected preoperatively in 69 veins using ultrasound duplex scanning and computed tomography angiography; of them, 3 (4.34%) resulted in failure. In comparison, 38 veins were diagnosed with venous pathology intraoperatively; of them, 5 (13.85%) failed. The studies evaluated in this review demonstrated that preoperative screening for venous pathology showed a higher flap survival rate. It can therefore be inferred that developing a standardized preoperative process for identifying venous issues in lower limb free flap reconstruction may improve outcomes. This can be explored in future research, with a focus on assessing the validity and efficacy of such screening tools, and their role in the management of patients identified with venous pathology.

Background: Laser or light therapy hair removal is commonly used for hair removal in beauty salons and other non-medical practices. The process utilises light energy which is absorbed by the melanin in the hair. The subsequent heat energy damages the hair follicles inhibiting or delaying future hair growth. Burn injuries are a very rare side effect of this procedure and more commonly seen in patients with darker skin pigments. Case presentation: We present a case of a 30 year old female who was a delayed presentation of full thickness burns to her right lower leg around a tattoo following hair removal with an intense pulsed light (IPL) device. Conclusions: Burn wounds as a result of light therapy hair removal procedures are very rare. However the involvement of surrounding tattoos in creating excessive heat transfer to surrounding tissue needs to be highlighted. This potential side effect is not often recognised or explained to customers and therefore important to note for providers as light therapy use becomes increasingly popular.

Deep facial burns present unique challenges due to the risk of scarring and contracture which can negatively impact patients’ cosmesis and function. Enzymatic debridement of burns with bromelain-based agents, such as Nexobrid™, may improve scarring through maximal preservation of viable tissue. However, Nexobrid™ use in facial burns is poorly described in the literature. We conducted a single-centre case series, retrospectively reviewing all patients treated with Nexobrid™ for deep facial burns between January 2016 and July 2022. We identified five female patients aged 27–69 with 1–6