Microsurgery in burn care

Peter Dziewulski FFICM FRCS FRCS(Plast)1

1Clinical Director, Consultant Plastic and Reconstructive Surgeon, St Andrews Centre for Plastic Surgery and Burns, Chelmsford, Essex CM1 7ET

Free tissue transfer can be useful in reconstruction of regions of the body where large tissue deficits exist and in selected cases, play a pivotal part in optimising patient outcomes. The use of microsurgical free tissue transfer within burn care was initially limited to secondary reconstruction however technical improvements and experience allowed microsurgical reconstruction to become more widespread is now used to provide cover for complex deep burns in the acute phase. Currently, free tissue transfer is often the preferred option to provide primary cover in complex deep burn wounds with exposure of bone, nerves, tendons and vessels. Primary indications for the technique have now become more common than for secondary reconstructive procedures. Microsurgical free tissue transfer in such situations offers a number of distinct advantages including ability to harvest uninjured tissue from a different site on the body, transfer well vascularized tissues to bridge deficits in  compromised areas as well as the ability to transfer vascularized bone, skin, muscle and nerves as composite flaps in necessary quantities to the site of the defect. Furthermore, free tissue transfer offers a one stage solution to these complex injuries and enables early mobilization as well as potentially reducing hospital stay. The talk will delineate the indications, timing, pitfalls and failure rates for free flaps in both acute and secondary reconstructive situations will provide an algorithm for the use of free flaps in burn care.

Total burn wound excision in major burn injury; Two decades experience at St Andrew’s

Peter Dziewulski FFICM FRCS FRCS(Plast)1

1Clinical Director, Consultant Plastic and Reconstructive Surgeon, St Andrews Centre for Plastic Surgery and Burns, Chelmsford, Essex CM1 7ET

There remains worldwide variation in the surgical management of major deep or full thickness burns in both adult and paediatric patients.  In our burn service over the past two decades the standard of care has been to perform total or near-total excision of full thickness burns in all patients within 24 hours of the patient’s injury or admission to the Burns Service.

Early wound excision improves survival, decreases burn wound sepsis, shortens length of stay and provides better aesthetic and functional outcomes when compared to serial excision and grafting or conservative non-surgical debridement using topical agents.  Retrospective studies, comparative randomised controlled trials and meta-analysis studies have confirmed the benefits of this approach.

Data was presented on this approach to major burn injury in our service at ANZBA in 2009.   We have continued to collect data and analyse the effect of early total or near total surgical excision in major burn injury over the past two decades.

Early total excision of major burns can be safely performed within a regional burns centre. It requires the participation of an extensive multi-disciplinary team and specialised facilities. Such improvements in acute care are reflected in improvements in survival rates and functional discharge outcomes.

The talk will describe our approach, experience and outcomes and will update ANZBA on data previously presented.


From Knowledge Presentation to Interactive Transformational Learning

Allan Carrington1

1University of Adelaide

The Internet and educational technology have given teachers powerful new ways to interact with students. Participants will be introduced to some of the latest tools for online collaboration, interactive teaching and student feedback. The Internet has shifted from just publishing webpages and content (pull technology) to more self publishing aka social media and collaboration. (push technology). Three major educational methodologies have emerged and when used effectively, give teachers powerful new ways to present content, engage and interact with students.  Student feedback can be easily managed which makes more effective formative assessment possible.

Teachers often use the terms  “podcast” “webcast” and “webinar” interchangeably and yes there is some overlap, but each of these online teaching methods has particular strengths and when used effectively can improve learning outcomes. We will identify the strengths of a:

    • Podcast: a digital audio file made available online for downloading, typically in a series of instalments.
    • Webcast: a media presentation distributed over the Internet using streaming media technology to distribute a single content source to many simultaneous listeners/viewers.
    • Webinar: a seminar or other presentation that takes place on the Internet, allowing participants in different locations to ask questions and make comments

Video content use is increasing. By 2019, video will be responsible for 80 percent of internet traffic around the world. Expect users to share almost one million minutes of video content every second by 2019. Thus, it’s no surprise Facebook’s Mark Zuckerberg projects that video will be the most shared content on Facebook within in the next five years. We will introduce some of the latest video creation, editing and streaming technologies which give teachers powerful tools to help learning.

Burn Wound Management, Tissue Engineering and Regenerative Medicine

Steven Boyce, PhD

Department of Surgery, University of Cincinnati, and, Shriners Hospitals for Children, Cincinnati, Ohio, USA

Skin wounds from burns vary widely in area, depth, and etiology.  The majority of burns in the USA are treated in outpatient facilities, and typically do not require grafting to obtain rapid closure with minimal scar.  Burns requiring hospital admission may also require grafting with autologous, split-thickness skin grafts, subject to availability.  After wounds are closed, management of scar in the grafted wounds and donor sites contributes importantly to functional and cosmetic outcomes.  Two adaptations to conventional management of burn wounds include negative pressure wound therapy to facilitate wound closure, and laser treatment of hypertrophic scars to improve color and pliability.

In addition to the traditional approaches to burn wound care, a variety of alternative materials has been developed during the past three decades.  With origins in polymer chemistry and cell biology, most of these alternatives are considered ‘engineered tissue substitutes’ for repair of dermal and/or epidermal compartments of the skin.  These alternatives respond to the need for greater availability of skin substitutes for earlier wound closure, or definitive closure of extensive, full-thickness wounds.  Dermal substitutes include biologic or synthetic polymers for recruitment of autologous fibro-vascular tissue, while epidermal substitutes consist of epidermal keratinocytes either distributed as sprays, or expanded in culture to form partially-stratified cell sheets.  Autologous dermal-epidermal skin substitutes have been reported to simultaneously replace the fibro-vascular and epithelial components of the skin.  Collectively, these materials have provided important advancements for wound closure, but result in scar that lacks epidermal appendages (hair, glands), complete sensory nerve, and/or native anatomy of dermal matrix.

Continuing research into engineered skin substitutes has demonstrated examples of hair, sebaceous glands, sweat glands, stimulation of innervation, and promotion of vascular development.  These studies have regulated the cellular pathways of developmental biology to regenerate partial or complete anatomy and physiology of the skin by pre-natal mechanisms.  Stem cells (e.g., pre-natal, induced Pluripotent Stem Cells) that express specific genetic programs can restore the structures and functions found in healthy, uninjured skin, and promise to provide full recovery of cutaneous properties without scar.  These distinctions of regenerative medicine suggest that it may deliver both greater availability and elimination of scar in future management of burn wounds.

New approaches for the treatment of burns

Allison Cowin

Future Industries Institute, University of South Australia

The development of new technologies and therapeutic approaches for the treatment of burn injuries and scarring is of great importance. Globally burns affect 11 million people each year and are a significant cost to health care systems. Despite all best endeavours there are still limited wound care products on the market which actively stimulate the healing process and lead to perfect regeneration of the skin after injury.  Our current research is aimed at investigating novel targets for new therapeutic approaches, developing new dressings, and identifying new methods to combat infection and microbial resistance. In this presentation some of these new approaches for the treatment of burn injuries will be outlined including the development of new dressings to deliver stem cells to wounds which improve healing responses, the use of nanoparticles to deliver antibodies to burns and new antibody-based approaches aimed at reducing inflammation in burns.

Development of new antibody therapies for the treatment of burn injuries and hypertrophic scars

Alexander Cameron1,2, Damian Adams1, Jessica Jackson1, Peter Anderson2, Allison Cowin1

1Future Industries Institute, University of South Australia

2Paediatrics and Reproductive Health, University of Adelaide

Hypertrophic scarring has a severe impact on the quality of life for millions around the world.  Occurring after burns, trauma or elective surgery it carries a large burden of disease, which includes disfigurement, pain, disability and psychological co-morbidity.  Current techniques for preventing or treating hypertrophic scarring remain limited and there is, as yet, no medical treatment to reduce or prevent hypertrophic scar development. Our studies have identified Flii as a potential target whose manipulation could improve burn injury repair and reduce scar formation. Our studies have shown that Flii is increased in human burns and hypertrophic scars and that when Flii is present at high levels in mouse models of burn injury healing is delayed and scarring is severe. In contrast, mice with low levels of Flii have reduced scarring, with decreased dermal thickness, smaller cross sectional scar area, fewer myofibroblasts and a decreased ratio of collagen-I to collagen-III. Consequently we have generated and screened a panel of affinity purified antibodies which can neutralize the activity of Flii in burns and have tested these antibodies in murine burns and hypertrophic scarring models and shown that they improve healing responses. These studies suggest that Flii affects the fibroproliferative process underlying hypertrophic scarring and confirms Flii as a potential target for the development of burns.

Fear the burn: The learning and extinction of fear, anxiety, and pain

Dr Daniel Harvie

Assistant Professor, Faculty of Health Sciences and Medicine, Bond University

Contributing to the development of both ongoing pain and stress disorders after trauma, are brain-based adaptations that can be described in-terms of learning mechanisms. Understanding the influence of learning mechanisms—such as classical and operant conditioning—on the expression of fear, anxiety and pain can assist in not only reducing acute pain and distress, but also preventing chronic pain and anxiety disorders.

The advantages of immediate burn excision and active temporisation of the burn wound – Part II: The Advantages of Active Wound Temporisation

Dr John Greenwood

Royal Adelaide Hospital

Once the burn eschar has been excised, thoughts turn to definitive closure. In the patient with extensive burns, this usually means early commencement of serial skin grafting. An alternative strategy is wound ‘temporisation’. This can be ‘active’, where the temporising agent not only buys time for the surgeon but also improves the wound bed by neo-dermal creation. The application of such temporisers reduces the early iatrogenic trauma and physiological insult inflicted on burns patients by early donor site creation at the time when the patient is already maximally traumatised, especially in view of the closing ‘windows’ mentioned earlier. Active temporisation facilitates the development of additional donor sites, as superficial areas of burn heal. A neo-dermis changes the way that meshed graft takes, since interstitial healing by secondary intention is unnecessary and, if skin graft is required, ‘converts’ split grafts to full thickness grafts, affording heightened suppleness and elasticity. Finally, allowing time for the growth and production of cultured composite skin equivalents can negate the need for the skin graft, and its donor wounds and subsequent scars, altogether; this is aided by improvement of the wound bed to better accept graft/composite cultured skin as definitive closure. Active temporisation, thus, opens a logical door to cultured composite skin technology.

The advantages of immediate burn excision and active temporisation of the burn wound – Part I: The Advantages of Immediate Burn Excision

Dr John Greenwood

Royal Adelaide Hospital

Immediate burn excision (within 24 hours of injury) confers an extensive range of advantages to both patient and surgeon. In order to ensure early survival, facilitate the surgical course and deliver an optimal outcome, it is essential to exploit several ‘physiological windows’. These windows are open early after injury, but briefly. They include wound, anaesthetic, haemodynamic and cellular/serum health windows. The timely exploitation of these brief physiological hiatuses is synergistically coupled with the significant benefits of immediate eschar removal, which include the abolition of the Allgöwer effects, a reduction in resuscitation fluid requirements, negating the need for escharotomy and decontaminating the wound surface. Additionally, an “early start means an early finish”. At daily costs incurred on a Specialist Burns Unit approaching $3,000, any reduction in the duration of inpatient stay can save thousands of dollars. This fact is lost on neither administrators, nor governments.

“I Don’t Like the Way I Look”: What can Burn Teams do to Promote Positive Body Image in their Patients?

Professor Nichola Rumsey

Co-Director, Centre for Appearance Research

The changes to appearance in the aftermath of burn injury can result in a range of significant psychological and social challenges, however, individual differences in wellbeing and adjustment in people with visible differences are considerable, and are not well predicted by the severity, extent or site of the subsequent scarring.  Recent research has highlighted the potential for all burn team members to contribute to efforts to promote psychological resilience in their patients. In this talk, key factors in positive adjustment to disfigurement will be discussed and a stepped approach to the provision of appropriate advice, support and intervention involving all members of the team outlined.



ANZBA is a not for profit organisation and the peak body for health professionals responsible for the care of the burn injured in Australia and New Zealand. ANZBA encourages higher standards of care through education, performance monitoring and research.

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