A rapidly moving bushfire passing across 85,000 hectares (210,000 acres) destroyed a small town, claimed 2 lives and injured 13. Five of those injured sustained significant burns and were admitted to the Adult Burns Service at the Royal Adelaide Hospital. The most significant burn injury, 75% TBSA full-thickness burns, in a 66-year-old male patient was complicated by smoke inhalation injury and renal failure. The burns included the head and neck, anterior and posterior trunk, both arms, and both lower legs. The feet, buttocks, perineum, parts of both thighs, midface, and left axilla were spared.
The patient arrived to the emergency department and was intubated and ventilated. He underwent escharotomies to all limbs and trunk during his trauma clearance, before attending the operating theatre. Within 6 hours of his injury, his burns to both upper limbs had been excised to fascia, revealing death of the right distal forearm muscle compartments both on the volar side and dorsally and at-risk viability of the digits of the left hand. Deep burns of the chest and abdomen were also excised to fascia as were circumferential burns of both lower limbs. Although head burns were obvious, these were cleaned and left at this first operation and, due to falling core temperature and physiological lability, deep burns on his back also had to be left. His wounds were dressed, and he was admitted on to the intensive care unit (ICU).
Two days later, he returned to operating theatre where a below-elbow amputation was performed on the right. The remaining deep burn was removed from the posterior trunk and, under the Australian Therapeutic Goods Administration (TGA) Special Access Scheme, a biodegradable polyurethane dermal matrix (NovoSorb BTM; PolyNovo Biomaterials Pty Ltd, Port Melbourne, Victoria, Australia) was implanted into all debrided burn wounds (anterior and posterior trunk, both arms and legs). This concluded the majority of his early burn surgery until the BTM was integrated and ready to graft at day 40 postimplantation.
On day 6 postinjury, however, his head and neck burns began to declare and degrade, necessitating excision of the scalp and dead periosteum to the level of the skull over the entire calvarium (Fig 1). It took until day 40, with meticulous small debridements designed to retain as much viable head tissue as possible before the wounds were clean around the exposed calvarium (Fig 2). In the intervening period, further necrosis was evident on the right upper limb, revealing an open elbow joint, and the amputation was converted to above-elbow. In addition, the BTM on both lower limbs and left upper limb had failed to integrate and been removed, the underlying wounds cleaned, and negative pressure wound therapy (VAC) dressings applied.
At this stage, he was still resident on the ICU with a tracheostomy in situ. The BTM over the chest, abdomen, back, and residual right upper limb had completely integrated. The lower limb and left upper limb wounds were clean and lightly granulating. Thus, on day 43, he underwent his third major surgery. Fresh BTMs were implanted into the lower limbs. The integrated BTMs were delaminated (the outer seal peeled off) and the neodermis refreshed by light dermabrasion with a diamond-tipped cylindrical burr. Meshed split skin autograft (1:3) was applied to the integrated BTM over the chest, abdomen, back, right arm stump, and both shoulders as well as into the left arm wounds (where BTM had previously failed). Finally, our attention turned to the head.