European Burn Journal

Introduction: The indication for a free flap in acute burn reconstruction is very specific. It should avoid several complications that are more common in the burned patient population. We propose an anterolateral thigh (ALT) flap as a first option for primary burn reconstruction in microvascular free flap reconstruction in burned patients. Patients and Methods: A retrospective review of all acutely burned patients treated with microvascular ALT free flap reconstruction between the years 2005 and 2022 in the Vall d’Hebron Barcelona Hospital Campus Burn Centre was conducted. Results: We performed 30 ALT flaps for primary burn reconstruction. The majority of patients were male (87.5%), with a mean age of 36.7 years, and 37% of patients were smokers. High-voltage electrical burns were the most common etiology. The mean time between burn injury and microsurgery was 22 days. The main recipient site was the lower limb. The flap survival rate was 96.6%. One patient required a meshed skin graft to cover a defect in the proximal third due to peripheral flap necrosis. One flap experienced mild congestion, which resolved spontaneously. Another flap had a local infection, which resolved with antibiotic therapy and surgical debridement. Conclusions: An ALT flap offers several advantages to a burned patient, provided that the surgical technique and postoperative management described in this study are followed. We propose it as the first option for primary burn reconstruction using free flaps in a burned patient. Full article

Substantial research interest has been shown over the past ten years in the management of burn injuries. This bibliometric analysis aims to identify and evaluate the most cited articles that have significantly advanced the field of burn injury management. The 100 most cited articles published from January 2014 to September 2024 were collated using the Web of Science database. The full text of each article was meticulously analyzed for descriptive parameters including subject matter, journal of publication, authorship, institutional affiliation, country of origin, and year of publication. The 100 most cited articles had an average of 203 citations, with the most cited article reaching 754 citations and the least cited article cited 105 times. The subjects ranged from enhancing wound care outcomes to metabolic support, fluid management, and infection prevention and management. These articles were distributed across 59 source journals, with 44% of articles having been published in just ten prominent journals. While bibliometric analyses do not accurately gauge scientific merit, this study illuminates the significant contributions to burn management over the past decade and provides valuable insights into research trends in the field. Full article

Fibrin sealants have been implemented in the management of burn wounds. They can be used either in combination with skin grafts for full-thickness burns or alone for treating superficial and deep dermal burns. The aim of this review was to provide critical insights regarding the efficacy of fibrin sealants in enhancing wound healing, improving graft adherence, and reducing complications. Therefore, evidence from experimental models and clinical trials was synthesized, underscoring the transformative role of fibrin sealants in modern burn care. This comprehensive review includes recent evidence on the potential benefits of fibrin sealants in the management of superficial and deep dermal or full-thickness burn injuries. Clinical and experimental evidence underscores some benefits in utilizing fibrin sealants in the management of superficial and deep dermal burn injuries, or in combination with skin grafts in full-thickness burns. Furthermore, fibrin sealants diminish postoperative pain and facilitate quick recovery for daily activities; however, controversy regarding their cost still remains. This review concludes that fibrin sealants could serve as a safe and effective therapeutic option for burn wound management. The safety and efficacy of their utilization, along with their wide availability and easiness to use, could make them an alternative treatment choice when a specialized plastic surgery service is not available, or in the emergency setting across different healthcare systems. Full article

Firework-related injuries remain a serious public health issue in Germany, especially during New Year’s Eve. While many injuries are minor, the misuse of illegal or homemade fireworks can cause severe trauma resembling military combat injuries and can heavily burden emergency services. Notably, injury rates declined during the COVID-19 firework bans, underscoring the impact of preventive measures. We report two cases of young males with severe injuries from illicit fireworks. The first is a case of a 16-year-old that detonated an illegal Polish firework ball bomb, sustaining 9% total body surface area (TBSA) burns (second- to third-degree), hand fractures, compartment syndrome of the hand, and soft-tissue trauma. He underwent multiple surgeries, including fasciotomy, osteosynthesis, and skin grafting. The other case presented is a 19-year-old man who was injured by a homemade device made of bundled firecrackers, suffering deep facial and bilateral hand burns. He required prolonged ventilation, surgical debridement, and treatment with Kerecis^® fish skin and Epicite^® dressings. Both required intensive ICU care, interdisciplinary management, and lengthy rehabilitation. Total hospital costs amounted to €58,459.52 and €94,230.23, respectively, as calculated according to the standardized German DRG. These cases illustrate the devastating impact of illegal fireworks. The devastating consequences of explosive trauma are often difficult to treat and may lead to long-term functional and psychological impairments. Prevention through public education, stricter regulations, and preparedness is essential. Pandemic-era injury reductions support sustained policy efforts. Full article

Autologous skin substitutes represent a promising advancement in the treatment of burn injuries, offering personalized solutions for patients with extensive skin loss. This white paper synthesizes the current knowledge on laboratory-generated autologous skin substitutes in Europe, incorporating expert opinions and legal considerations. The white paper examines the scientific principles underlying autologous skin substitute development, including cell sourcing, bioengineering techniques, and clinical applications. The regulatory framework governing the production and use of these advanced therapies in Europe is also examined, highlighting challenges in standardization, safety, and approval pathways. The text features expert insights that offer a real-world perspective on the clinical viability and translational hurdles of autologous skin substitutes. The findings highlight the potential of autologous skin substitutes to improve burn treatment outcomes while emphasizing the need for harmonized regulations to facilitate clinical implementation. Despite technological advancements, significant challenges persist, including production costs, scalability, and long-term efficacy. Another focus of this white paper are the legal changes, which have significantly impacted the production and availability of these technologies. The review concludes that while autologous skin substitutes hold great promise, further research, regulatory refinement, and interdisciplinary collaboration are essential to optimize their integration into clinical practice. Full article

Cultured epidermal autografts (CEAs) serve as an alternative permanent skin replacement, though high costs often limit their use in resource-constrained settings and to life-saving cases. This case report presents the first documented cosmetic application of a modified CEA technique in a bodybuilder, demonstrating favorable aesthetic outcomes. A 28-year-old Black male with a 20% total body surface area burn sustained in a domestic fire exhibited superficial and deep partial-thickness burns to the face, arms, torso, and feet. Refusing grafts from visible donor sites, treatment using a low-cost modified CEA approach was employed to minimize donor site morbidity. Keratinocytes harvested from a groin biopsy were cultured on Cutimed Sorbact^® (Essity AB, BSN Medical (Pty) Ltd., Pinetown, RSA) dressings with autogenous plasma and hydrogel supplementation and incubated at 37 °C for two weeks. Xenografts provided temporary coverage before CEA transplantation. Graft take was 85%, with minor (15%) loss at 21 days, requiring small autograft coverage. At two months, the Vancouver Scar Scale score was 4, indicating optimal pigmentation, smoother texture, and minimal scarring. These findings align with limited studies on CEAs for cosmetic applications, suggesting this cost-effective technique may broaden the scope of CEAs beyond life-saving interventions to include aesthetic reconstruction, reducing both donor site morbidity and scarring. Full article

(1) Burn injuries demand multidisciplinary, evidence-based care, yet the extensive literature complicates timely decision making. Retrieval-augmented generation (RAG) synthesizes research while addressing inaccuracies in pretrained models. However, citation bias in sourcing for RAG often prioritizes highly cited studies, overlooking less-cited but valuable research. This study examines RAG’s performance in burn management, comparing citation levels to enhance evidence synthesis, reduce selection bias, and guide decisions. (2) Two burn management datasets were assembled: 30 highly cited (mean: 303) and 30 less-cited (mean: 21). The Gemini-1.0-Pro-002 RAG model addressed 30 questions, ranging from foundational principles to advanced surgical approaches. Responses were evaluated for accuracy (5-point scale), readability (Flesch–Kincaid metrics), and response time with Wilcoxon rank sum tests (p < 0.05). (3) RAG achieved comparable accuracy (4.6 vs. 4.2, p = 0.49), readability (Flesch Reading Ease: 42.8 vs. 46.5, p = 0.26; Grade Level: 9.9 vs. 9.5, p = 0.29), and response time (2.8 vs. 2.5 s, p = 0.39) for the highly and less-cited datasets. (4) Less-cited research performed similarly to highly cited sources. This equivalence broadens clinicians’ access to novel, diverse insights without sacrificing quality. As plastic surgery evolves, RAG’s inclusive approach fosters innovation, improves patient care, and reduces cognitive burden by integrating underutilized studies. Embracing RAG could propel the field toward dynamic, forward-thinking care. Full article

Face and neck burns present significant clinical challenges due to their proximity to the airway, predisposing patients to inhalation injuries and subsequent respiratory complications. In our cohort of 206 patients, facial and neck burns were associated with a markedly higher incidence of inhalation injury (34.8% vs. 2.8%), necessitating more frequent endotracheal intubation (51.9% vs. 14.1%). Furthermore, respiratory infections were significantly more common in patients with facial and neck burns (26.7% vs. 7%, p < 0.001), with respiratory secretion cultures revealing a predominance of Pseudomonas aeruginosa (39.58%), Acinetobacter baumanii (18.75%), and Klebsiella pneumoniae (6.25%). In contrast, patients without facial and neck burns primarily exhibited Pseudomonas aeruginosa (50%) in their cultures. These complications translated into a significantly increased mortality rate in patients with facial and neck burns (31.1% vs. 12.7%), with a reduced mean survival period (66.7 days vs. 84.3 days) and a 2.8-fold increase in the hazard of mortality. Additionally, older age emerged as a significant determinant for the development of respiratory infections. Multivariable model regression analysis revealed that only TBSA remained a consistent and independent predictor for adverse respiratory outcomes and increased mortality, while face and neck burns are more causally associated with TBSA. Full article

Mesh grafting and Meek micrografting are split-thickness skin graft expansion techniques. This study aimed to compare the effectiveness of Meek and Mesh expansion ratios 1:2 and 1:3 in smaller wounds. An intra-patient randomized controlled trial was conducted at two burn centers (the Netherlands and Belgium). Wound outcomes, e.g., take rate, re-epithelialization rate, and donor site size, were measured. At 3 months post-surgery, patient preference and scar quality were evaluated with the Patient and Observer Scar Assessment Scale (POSAS), cutometer and dermaspectrometer. Seventy patients with a TBSA of 10 ± 10% (mean ± SD) were included. The take rate was 79 ± 25% vs. 87 ± 19% (p = 0.003), Meek vs. Mesh, respectively. At follow-up, a majority of observer and patient POSAS items were statistically significantly lower, corresponding with better scar quality for Mesh grafting compared to Meek micrografting. The scar elasticity was 0.37 ± 0.20 vs. 0.42 ± 0.21 (p = 0.013) and mean melanin 13.3 ± 8.3 vs. 12.1 ± 7.7 (p = 0.019) for Meek vs. Mesh, respectively, and the patient preference was 32%, 49%, and 19% for Meek, Mesh, and no preference. Other outcomes showed no statistically significant difference. In patients with smaller wounds, Mesh showed superiority on most wound and short-term scar results. Nevertheless, patient preference within the 1:3 expansion ratio group and donor site size were in favor of Meek. Full article

Burn injuries lead to significant physical and psychological consequences, including chronic pain, post-traumatic stress, depression, and social isolation. Mindfulness-based interventions (MBIs) have been proposed as a holistic approach to address these challenges in burn rehabilitation. This systematic review evaluates the efficacy of dispositional mindfulness and MBIs, including mindfulness meditation, yoga, and self-compassion training, in managing pain, emotional distress, and psychosocial adaptation in burn survivors. A comprehensive literature search was conducted through MEDLINE and Web of Science, covering studies up to February 2025, with additional papers retrieved from Google Scholar and Semantic Scholar. Studies were included if they reported quantitative data on the effects of MBIs in burn patients and/or their families, excluding opinion pieces, editorials, reviews, and qualitative studies. After screening 91 studies retrieved from the databases and adding a compelling paper retrieved from the other sources explored, 12 studies were included in the final pool, categorized into cross-sectional studies (n = 6), and intervention studies (n = 6). The extracted data included publication year, research design, sample characteristics, intervention details, main findings, and data for quality assessment. The synthesis of the results suggests that mindfulness is associated with reduced psychological symptoms, improved emotional regulation, and enhanced self-compassion, leading to better coping strategies and social reintegration. However, the long-term efficacy of MBIs remains inconclusive, and further research is needed to differentiate mindfulness-specific effects from those of general physical exercise. Evidence also suggests that mindfulness interventions may reduce anxiety and secondary trauma in children with burns and their caregivers. This review highlights the potential of MBIs as adjuncts to conventional burn rehabilitation programs, but further high-quality trials are needed to establish their sustained efficacy and to understand the specific benefits of mindfulness. Full article

Background and Objectives: Traditionally, full-thickness skin defects (FTSDs) are covered with split-thickness skin grafts (STSGs). This usually provides an epidermal coverage but entails a high risk of hypertrophic scarring mainly due to the absence of the dermal layer. The Novosorb^® Biodegradable Temporising Matrix (BTM) is a novel synthetic dermal substitute that has been used for the reconstruction of various complex and/or large defects in our center. The aim of this article is to evaluate the clinical performance of the BTM as a synthetic dermal substitute for complex FTSD reconstruction in a European context. Materials and methods: This case series focused on the treatment of complex FTSDs with the BTM. After wound debridement, the BTM was applied according to a defined protocol. Once adequate vascularization was observed, the sealing membrane was removed and the neo-dermis was covered with STSGs. Patient demographics, comorbidities, wound defect localization and etiology, wound bed preparations, time of BTM application and removal, time to complete wound healing after STSG, complications, and HTS formation were recorded. Results: The BTM was used to treat FTSDs in six patients with complex wounds from degloving (3), burns (1), ulcerations (1), and necrotizing fasciitis (1). Successful integration occurred in five cases (83%), with one partial integration. The BTM remained in situ for an average of 20.7 days before delamination and STSG coverage. No major complications occurred, though one case had hypergranulation with secondary STSG infection. Two patients were lost to follow-up, while the remaining four had excellent aesthetic and functional outcomes with good-quality scars. Conclusions: Within the limits of this small and heterogeneous case series, the BTM appears to be a promising option for the reconstruction of complex FTSDs of varying etiologies. Its successful integration in most cases and limited complication rate support its clinical potential. However, given this study’s retrospective design and limited sample size, further prospective studies are required to validate these findings and assess long-term outcomes. Full article

The Life Impact Burn Recovery Evaluation (LIBRE) Profile was developed to assess long-term social participation outcomes for adult burn survivors. Traditional clinical burn recovery outcomes focus on early physical complications and psychosocial issues, but there is a growing need for quantitative measures of long-term recovery that assess experiences deemed relevant to burn survivors. The LIBRE Profile, co-produced with input from burn survivors and clinicians and grounded in the World Health Organization’s International Classification of Functioning, Disability and Health (WHO-ICF) conceptual framework, addresses the measurement gap by focusing on six domains of social participation: social interactions, social activities, family and friends, work and employment, romantic relationships, and sexual relationships. The LIBRE Profile uses Item Response Theory (IRT) and computer adaptive tests (CAT) to minimize respondent burden while maintaining accuracy. Psychometric evaluations have validated the LIBRE Profile as a reliable and clinically useful tool that can help clinicians and burn survivors monitor recovery and inform personalized care. Future work includes LIBRE Profile development for pediatric populations, further international language translations, and the development of an APP for broader personal and clinical use. This paper provides a comprehensive overview of the LIBRE Profile’s development, psychometric foundations, and future directions, advocating for its adoption in clinical practice and burn survivor communities. Full article

A PROM is a measure of patient needs and therapeutic progress. This paper outlines the validation of the CARe Burn Scale: Parent/Caregiver Form, a PROM that measures quality of life in parents/caregivers supporting a child with a burn injury. A literature review and interviews with sixteen parents and six burns health professionals informed the development of the PROM conceptual framework/draft form. Cognitive debriefing interviews with five parents and seven burns-specialist health professionals provided feedback to ascertain content validity, and two-hundred and four parents/caregivers took part in the field testing. Rasch measurement theory (RMT) analyses and internal consistency tests were conducted to create a shortened version and for psychometric validation. The final conceptual framework included eight domains/individual scales: Physical Well-being, Confidence with Managing Burn Wound/Scar Treatments, Social Situations, Partner Relationship, Self-worth, Negative Mood, Parent Concerns about the Appearance of their Child’s Burn Wounds/Scars, and Positive Growth. Seven scales had solutions from RMT analyses and passed internal consistency criteria. Confidence with Managing Burn Wound/Scar Treatments did not fit the Rasch model but was retained as a checklist based on theoretical insight. The CARe Burn Scale: Parent/Caregiver Form is the first and only burn-specific PROM that assesses parents’ own health needs when caring for a child with a burn. Full article

Prolonged healing time of acute burn wounds is associated with increased pain, infection, risk of scarring, poorer mobility and higher financial and emotional burden. Electrical stimulation (ES) reduces healing time in chronic wounds; however, its reported use on acute burn wounds is limited. This systematic review (SR) aimed to evaluate the relative benefit of ES compared to routine wound care on the healing time of acute burn wounds in adults. The online databases queried included Cochrane Database of SR’s, MEDLINE, EMBASE, PUBMED and CINAHL. The search criteria included RCTs involving the application of ES of varying voltage, duration and modality in acute burn patients aged ≥18 years. The primary outcome investigated was days to burn wound closure, while the secondary outcomes included edema and infection. Four RCTs were discovered, involving a total of 143 participants with a mean age 35.5 years. Two RCTs demonstrated (a) 36% (2.6 days) reduction in time to wound closure with ES (p < 0.001); and (b) significant reduction in wound area with ES (11.2 ± 3.2 cm², p < 0.001) compared to controls at 21 days. Two RCTs found ES promoted better wound-healing environments, reducing edema, bacterial infection, and biofilm. This review highlighted low-risk wound-healing benefits with ES as a feasible adjunct to routine burn care. Full article

The effective treatment of severe burns in pediatric patients is essential for minimizing complications and promoting optimal recovery. This study investigates the use of non-thermal atmospheric pressure plasma (NTAPP) as an adjuvant therapy in combination with Epifast^® for the experimental group, compared to standard care involving early excisions and Epifast^® for the control group. A randomized controlled trial was conducted with 40 pediatric patients suffering from superficial partial-thickness and deep dermal burns. The experimental group that received NTAPP daily demonstrated a significant reduction in the need for skin grafts, requiring only 10% compared to 40% in the control group (p = 0.02). Although there were no statistically significant differences in the length of hospital stay, the experimental group showed a trend toward shorter stays (9.85 days vs. 11.65 days; p = 0.38) and lower analgesic consumption (13.01 doses vs. 21.15 doses; p = 0.09). Additionally, the infection rate in the NTAPP-treated group was significantly lower at 25%, compared to 37.95% in the control group (p < 0.05). These findings suggest that NTAPP enhances wound healing while reducing surgical morbidity and the risk of infections. In conclusion, this study highlights the transformative potential of NTAPP as an innovative strategy in pediatric burn management. It combines clinical efficacy with a less invasive approach, representing a significant advance in regenerative medicine and opening new avenues for research into advanced therapies. Full article

Background: Burns represent one of the most severe injuries encountered in the pre-hospital and ED environment, with essential features and an often negatively powerful impact on patients’ quality of life. Preventive measures can significantly reduce the number of cases presenting to medical facilities; knowledge and the correct application of first aid measures in the pre-hospital stage have a significant role in reducing the risk of complications and in obtaining optimal outcomes. Methods: This retrospective one-year single-center study analyzed 399 adult burn patients treated at the Clinical Emergency Hospital of Bucharest (CEHB) in 2023. Information concerning the main characteristics of the patients (age, sex, and residence), etiology and severity of burns, and pre-hospital management of patients was analyzed. Results: Most patients (63.41%) resided in urban areas, with a higher prevalence of males (55.89%). Thermal burns accounted for 77.69% of cases, primarily caused by water, food, oil, or flames. Burns covered ≤10% TBSA in 77.19% of cases, while 6.52% extended beyond 50% TBSA. First aid was provided to 52.63% of patients at the accident site, often by non-specialized individuals. The mean time to presentation was 34.90 h, with significant correlations between time, age, burned body surface area, and burn depth. Conclusions: There is a real need for improvements in first-aid training and health initiatives to enhance pre-hospital burn care. Better documentation of the care provided to patients before being admitted to specialized centers, as well as further studies in this field, are absolutely necessary for improving prevention programs and burn management in the acute stage. Full article

Background: The wound healing process presents notable challenges for nursing teams, requiring extensive knowledge of wound care materials. A nanoparticle-free, bioabsorbable pol-yvinyl alcohol (PVA) with citric acid (CA) dressing produced by simple electrospin-ning was evaluated to treat acute wound healing in rats. This PVA-CA combination promotes crosslinking, increases the dressing capacity of absorption and confers heal-ing properties due to the citric acid antioxidant action. Methods: The dressing was tested in a quantitative experiment on 1.9 cm acute dermatological lesions in rats (n = 12), com-paring the PVA-CA-treated group with the untreated control group (CG). Samples were collected at 3, 7 and 14 days after lesion induction to evaluate the inflammatory process and tissue healing. Results: The macroscopic and histological data on the third day showed similar characteristics in both groups; however, after fourteen days, the PVA-CA group exhibited complete healing, accompanied by recomposition of the skin layers, whereas the wounds in the CG did not close completely. Conclusions: The results highlight that electrospun PVA-AC dressings improve healing outcomes and constitute a prom-ising and affordable solution, providing a suitable environment for tissue repair, re-ducing inflammatory cell infiltration, blood vessel formation, and restoration of epi-thelial tissue, reducing the time of the healing process of acute wounds. Full article

Background: Burn injuries constitute a significant global health challenge, especially in pediatric populations, where they are a leading cause of morbidity and mortality. Pediatric burns require particular attention due to their unique pathophysiology, long-term consequences on growth and development, and psychological impacts. Methods: We propose a comprehensive review of recent advancements in understanding the key aspects of hormonal and metabolic changes in burned children, aiming to guide therapeutic interventions, improve outcomes, and reduce the global burden of these injuries. Results: Effective management of the physiological stress response in pediatric burn patients necessitates a multidisciplinary approach integrating medical, nutritional, and rehabilitative strategies. Timely nutritional support and individualized plans preserve muscle mass, promote wound healing, and reduce complications and organ dysfunction risk. Advances in pharmacological interventions, such as beta-blockers, anabolic agents, and hormonal treatment, offer promising pathways to improve recovery and mitigate long-term complications. Early mobilization and physiotherapy are essential for preventing complications of prolonged immobility, including muscle wasting, joint contractures, and functional decline; their effectiveness is closely tied to advancements in minimally invasive procedures, regenerative medicine, and reconstructive techniques, particularly for pediatric patients. Conclusions: While current strategies have significantly improved survival and outcomes for pediatric burn patients, ongoing research is critical to refine these new care strategies. Full article