Experience with a synthetic bilayer Biodegradable Temporising Matrix in significant burn injury  John E. Greenwood, Bradley J. Schmitt, Marcus J.D. Wagstaff  Burns Open  Volume 2, Issue 1, Pages 17-34 (January 2018) DOI: 10.1016/j.burnso.2017.08.001 Copyright © 2017 The Author(s) Terms and Conditions

Fig. 1 (a) The right upper limb of Subject 1 sustained full-thickness burn injury requiring tangential excision. (b) After haemostasis with bipolar diathermy and adrenaline-soaked packs, the BTM is cut to shape and applied with staples. (c) Close up of the right hand application. (d) By Day 22, the ‘foam’ structure of the BTM is obscured by tissue ingrowth into the polyurethane matrix. Vascularisation is ongoing. (e) At Day 30, the white foam structure is almost completely filled with vascularised tissue and three days later the upper limb BTM demonstrates full integration (f). Donor site was, however, unavailable at that stage. (g) At Day 39, the non-biodegradable seal has been removed to reveal the pink ‘neo-dermis’ below. Graft was applied at this time. (h) Long term outcome. (i) Long term outcome of the burn to the dorsum of the right hand. Note – the hand received sheet autograft. Burns Open 2018 2, 17-34DOI: (10.1016/j.burnso.2017.08.001) Copyright © 2017 The Author(s) Terms and Conditions

Fig. 2 (a) The left upper limb of Subject 1 was similarly burned and again underwent tangential excision. (b) No residual dermal element was left including the dorsum of the left hand. (c,d) BTM cut to shape and applied with staples. (e) Vascular invasion and collagen deposition complete by Day 30 and consolidated by Day 33 (f). (g) The autograft appearance 4days after application over the integrated BTM neo-dermis’. (h) Result at 1year. (i,j) Longer term results. Burns Open 2018 2, 17-34DOI: (10.1016/j.burnso.2017.08.001) Copyright © 2017 The Author(s) Terms and Conditions

Fig. 3 (a) Subject 2’s left upper limb burn before and after (b,c) immediate tangential excision. (d) Two days later, further debridement of non-viable fat to fascia completed the pre-BTM preparation. (e) BTM shaped, cut and fixed. (f) Day 25 appearance. (g) Ready for delamination on Day 33. (h) Post-delamination neo-dermis ready for graft. (i) Meshed graft applied. (j) 4days later at first graft check. (k) At 2weeks post-graft application. (l) Result at 1year. Burns Open 2018 2, 17-34DOI: (10.1016/j.burnso.2017.08.001) Copyright © 2017 The Author(s) Terms and Conditions

Fig. 3 (a) Subject 2’s left upper limb burn before and after (b,c) immediate tangential excision. (d) Two days later, further debridement of non-viable fat to fascia completed the pre-BTM preparation. (e) BTM shaped, cut and fixed. (f) Day 25 appearance. (g) Ready for delamination on Day 33. (h) Post-delamination neo-dermis ready for graft. (i) Meshed graft applied. (j) 4days later at first graft check. (k) At 2weeks post-graft application. (l) Result at 1year. Burns Open 2018 2, 17-34DOI: (10.1016/j.burnso.2017.08.001) Copyright © 2017 The Author(s) Terms and Conditions

Fig. 4 (a) Subject 2’s right upper limb before and after (b,c) tangential burn excision. (d) After refreshing 2days later (fascial bed). (e) BTM shaped, cut and fixed. (f) Appearance at 25days. (g) At 33days, ready for delamination and grafting. (h) Following delamination, demonstrating the neo-dermis. (i) Meshed autograft applied. (j) Graft at Day 4 check. (k) Graft at 2weeks. (l) Graft at 1year. Burns Open 2018 2, 17-34DOI: (10.1016/j.burnso.2017.08.001) Copyright © 2017 The Author(s) Terms and Conditions

Fig. 4 (a) Subject 2’s right upper limb before and after (b,c) tangential burn excision. (d) After refreshing 2days later (fascial bed). (e) BTM shaped, cut and fixed. (f) Appearance at 25days. (g) At 33days, ready for delamination and grafting. (h) Following delamination, demonstrating the neo-dermis. (i) Meshed autograft applied. (j) Graft at Day 4 check. (k) Graft at 2weeks. (l) Graft at 1year. Burns Open 2018 2, 17-34DOI: (10.1016/j.burnso.2017.08.001) Copyright © 2017 The Author(s) Terms and Conditions

Fig. 5 (a) Tangential excision full thickness burn (fascia exposed) in Indigenous Australian subject (Subject 3). (b) BTM applied (note unburned skin over antecubital fossa). (c) Fully integrated at Day 39 and delaminated arm (d). (e) Delaminated forearm BTM. f. Meshed autograft applied. (g) Graft appearance at 1week. (h) Graft appearance at 3weeks (good interstitial pigmentation). (i) 6month appearance. (j) 9months. (k) 10months (note, adjacent to the BTM graft, the hairs growing on the unburned area mentioned in b). Burns Open 2018 2, 17-34DOI: (10.1016/j.burnso.2017.08.001) Copyright © 2017 The Author(s) Terms and Conditions

Fig. 5 (a) Tangential excision full thickness burn (fascia exposed) in Indigenous Australian subject (Subject 3). (b) BTM applied (note unburned skin over antecubital fossa). (c) Fully integrated at Day 39 and delaminated arm (d). (e) Delaminated forearm BTM. f. Meshed autograft applied. (g) Graft appearance at 1week. (h) Graft appearance at 3weeks (good interstitial pigmentation). (i) 6month appearance. (j) 9months. (k) 10months (note, adjacent to the BTM graft, the hairs growing on the unburned area mentioned in b). Burns Open 2018 2, 17-34DOI: (10.1016/j.burnso.2017.08.001) Copyright © 2017 The Author(s) Terms and Conditions

Fig. 6 (a) On Subject 3, a piece of BTM was applied to the upper abdomen when insufficient graft was available to complete coverage of the anterior trunk. (b) Subsequently, most of the trunk graft was lost to Stenotrophomonas infection. The BTM section had failed to integrate and was removed. Burns Open 2018 2, 17-34DOI: (10.1016/j.burnso.2017.08.001) Copyright © 2017 The Author(s) Terms and Conditions

Fig. 7 (a) Fourth degree flame burns to right upper limb, axilla and right chest/flank in Subject 4. (b) Close up of the forearm/arm injury. (c) After debridement of the chest/flank burns. (d) After debridement of the axilla and arm burns. (e) After debridement of the forearm burns. (f) BTM application to the chest and upper limb (g) at Day 5 post injury. (h) Early progress at 1week. (i) A haematoma secondary dialysis and anticoagulation necessitated replacement of some BTM at Day 9. (j) The replaced sections of BTM lagged behind in their appearance at Day 19. although the upper limb BTM was integrating without issue (k). (l) Day 33 appearance and passive physiotherapy to the axilla (m). (n) Delamination at Day 38 was followed by meshed graft application (o–q). (r) Good graft take generally was marred by failure over the exposed medial epicondyle and ulnar nerve. (s) A new BTM piece was applied over the medial elbow. (t,u) Similarly, rib exposure was treated by cortical drilling and BTM application. (v,w) At 6months. (z) At 18months (most recent appointment). Burns Open 2018 2, 17-34DOI: (10.1016/j.burnso.2017.08.001) Copyright © 2017 The Author(s) Terms and Conditions

Fig. 7 (a) Fourth degree flame burns to right upper limb, axilla and right chest/flank in Subject 4. (b) Close up of the forearm/arm injury. (c) After debridement of the chest/flank burns. (d) After debridement of the axilla and arm burns. (e) After debridement of the forearm burns. (f) BTM application to the chest and upper limb (g) at Day 5 post injury. (h) Early progress at 1week. (i) A haematoma secondary dialysis and anticoagulation necessitated replacement of some BTM at Day 9. (j) The replaced sections of BTM lagged behind in their appearance at Day 19. although the upper limb BTM was integrating without issue (k). (l) Day 33 appearance and passive physiotherapy to the axilla (m). (n) Delamination at Day 38 was followed by meshed graft application (o–q). (r) Good graft take generally was marred by failure over the exposed medial epicondyle and ulnar nerve. (s) A new BTM piece was applied over the medial elbow. (t,u) Similarly, rib exposure was treated by cortical drilling and BTM application. (v,w) At 6months. (z) At 18months (most recent appointment). Burns Open 2018 2, 17-34DOI: (10.1016/j.burnso.2017.08.001) Copyright © 2017 The Author(s) Terms and Conditions

Fig. 7 (a) Fourth degree flame burns to right upper limb, axilla and right chest/flank in Subject 4. (b) Close up of the forearm/arm injury. (c) After debridement of the chest/flank burns. (d) After debridement of the axilla and arm burns. (e) After debridement of the forearm burns. (f) BTM application to the chest and upper limb (g) at Day 5 post injury. (h) Early progress at 1week. (i) A haematoma secondary dialysis and anticoagulation necessitated replacement of some BTM at Day 9. (j) The replaced sections of BTM lagged behind in their appearance at Day 19. although the upper limb BTM was integrating without issue (k). (l) Day 33 appearance and passive physiotherapy to the axilla (m). (n) Delamination at Day 38 was followed by meshed graft application (o–q). (r) Good graft take generally was marred by failure over the exposed medial epicondyle and ulnar nerve. (s) A new BTM piece was applied over the medial elbow. (t,u) Similarly, rib exposure was treated by cortical drilling and BTM application. (v,w) At 6months. (z) At 18months (most recent appointment). Burns Open 2018 2, 17-34DOI: (10.1016/j.burnso.2017.08.001) Copyright © 2017 The Author(s) Terms and Conditions

Fig. 7 (a) Fourth degree flame burns to right upper limb, axilla and right chest/flank in Subject 4. (b) Close up of the forearm/arm injury. (c) After debridement of the chest/flank burns. (d) After debridement of the axilla and arm burns. (e) After debridement of the forearm burns. (f) BTM application to the chest and upper limb (g) at Day 5 post injury. (h) Early progress at 1week. (i) A haematoma secondary dialysis and anticoagulation necessitated replacement of some BTM at Day 9. (j) The replaced sections of BTM lagged behind in their appearance at Day 19. although the upper limb BTM was integrating without issue (k). (l) Day 33 appearance and passive physiotherapy to the axilla (m). (n) Delamination at Day 38 was followed by meshed graft application (o–q). (r) Good graft take generally was marred by failure over the exposed medial epicondyle and ulnar nerve. (s) A new BTM piece was applied over the medial elbow. (t,u) Similarly, rib exposure was treated by cortical drilling and BTM application. (v,w) At 6months. (z) At 18months (most recent appointment). Burns Open 2018 2, 17-34DOI: (10.1016/j.burnso.2017.08.001) Copyright © 2017 The Author(s) Terms and Conditions

Fig. 8 (a) The scald injury sustained by Subject 5 after a seizure in the bath declared as deep dermal by Day 8 (b). (b) Tangential excision and BTM application (d). (e,f) Despite lying on the BTM on the Intensive Care Unit, the BTM integrated as usual. (g) By Day 39, some graft was available and a section of the back BTM was delaminated revealing the neo-dermis. (h) Meshed graft was applied. The remaining BTM seal was left in situ. (i) On Day 46, the remaining BTM was delaminated and graft applied (j,k). (l) Graft appearance at 4days. (m) At Day 72. (n) By Day 92, the graft mesh pattern was indistinct. (o) Result at 1year. Burns Open 2018 2, 17-34DOI: (10.1016/j.burnso.2017.08.001) Copyright © 2017 The Author(s) Terms and Conditions

Fig. 8 (a) The scald injury sustained by Subject 5 after a seizure in the bath declared as deep dermal by Day 8 (b). (b) Tangential excision and BTM application (d). (e,f) Despite lying on the BTM on the Intensive Care Unit, the BTM integrated as usual. (g) By Day 39, some graft was available and a section of the back BTM was delaminated revealing the neo-dermis. (h) Meshed graft was applied. The remaining BTM seal was left in situ. (i) On Day 46, the remaining BTM was delaminated and graft applied (j,k). (l) Graft appearance at 4days. (m) At Day 72. (n) By Day 92, the graft mesh pattern was indistinct. (o) Result at 1year. Burns Open 2018 2, 17-34DOI: (10.1016/j.burnso.2017.08.001) Copyright © 2017 The Author(s) Terms and Conditions

Fig. 9 (a) Infection presenting in the right arm BTM of Subject 5 as a sub-seal collection at Day 15. Additional fenestrations were created in the BTM seal and the collected fluid expressed. Pseudomonas aeruginosa was isolated and antibiotics commenced. (b) By Day 25, the infection was eradicated and the affected BTM has begun to integrate. (c) On Day 37, the BTM seal was removed to reveal a healthy neo-dermis within the BTM foam and the bed was grafted (d). (e) On Day 67, the graft is completely healed. f. The result at 12months. Burns Open 2018 2, 17-34DOI: (10.1016/j.burnso.2017.08.001) Copyright © 2017 The Author(s) Terms and Conditions

Fig. 10 The junction of meshed graft on fat (shoulder) and meshed graft on BTM (arm) in Subject 3 at 6months. Burns Open 2018 2, 17-34DOI: (10.1016/j.burnso.2017.08.001) Copyright © 2017 The Author(s) Terms and Conditions