Rapid enzymatic burn debridement: A review of the paediatric clinical trial experience.

NexoBrid (NXB) has been proven to be an effective selective enzymatic debridement agent in adults. This manuscript presents the combined clinical trial experience with NXB in children. Hundred and ten children aged 0.5 to 18 years suffering from deep thermal burns of up to 67% total body surface area were treated with NXB in three clinical trials. Seventy-seven children were treated with NXB in a phase I/II study, where 92.7% of the areas treated achieved complete eschar removal within 0.9 days from admission. Thirty-three children (17 NXB, 16 standard of care [SOC]) participated in a phase III randomized controlled trial. All wounds treated with NXB achieved complete eschar removal. Time to complete eschar removal (from informed consent) was 0.9 days for NXB vs 6.5 days for SOC (P < .001). The incidence of surgical excision was 7.9% for NXB vs 73.3% for SOC (P < .001). Seventeen of these children participated in a phase III-b follow-up study (9 NXB and 8 SOC). The average long-term modified Vancouver Scar Scale scores were 3.4 for NXB-treated wounds vs 4.4 for SOC-treated wounds (NS). There were no significant treatment-related adverse events. Additional studies are needed to strengthen these results.

Survival of human cadaver skin on severe combined immune deficiency pigs: Proof of concept.

Transplantation of human xenografts onto immunocompromised mice is a powerful research tool for studying wound healing. However, differences in healing between humans and mice and their small size limit this model. We determined whether human cadaver skin xenografts transplanted onto pigs with severe combined immune deficiency (SCID) would survive and not be rejected. Meshed (1:1.5), cryopreserved human cadaver skin was transplanted onto 10 partial thickness dermatome wounds in each of two normal domestic pigs and two SCID pigs. Autografts (n = 2/animal) from the four animals were used as controls. In normal pigs, all autografts were engrafted and healed with a minimal, if any, inflammation and scarring. All human xenografts were rejected by the normal pigs within 5-11 days and associated with an intense T-cell inflammatory response. In contrast, both autografts and xenografts were engrafted and survived the 28-day study in the SCID pigs with a minimal inflammation and no gross scarring.

Bromelain-based enzymatic debridement of chronic wounds: A preliminary report.

Sharp debridement is currently considered most effective for debridement of chronic wounds; however, some patients do not have access to or cannot be treated by surgical methods. This study was designed to provide a first impression of the safety and efficacy of bromelain-based enzymatic debridement of chronic wounds. Two consecutive single-arm studies assessing the enzymatic debridement efficacy of a concentrate of proteolytic enzymes enriched in bromelain in chronic wounds was conducted in 2 medical centres. Patients were treated with up to 11 consecutive 4-hour enzymatic debridement sessions and then treated until wound closure. Twenty-four patients with chronic wounds of different aetiologies were enrolled. All wounds achieved an average of 68% ± 30% debridement in an average of 3.5 ± 2.8 enzymatic debridement 4-hour sessions. Seventeen responding wounds (venous, diabetic, pressure, and post-traumatic aetiologies) achieved an average 85% ± 12% debridement in 3.2 ± 2.5 applications. Seven non-responding wounds (arterial and post-surgical aetiologies) achieved an average 26% ± 13% debridement in 4.3 ± 3.5 applications. No treatment-related serious adverse events were observed, and the only adverse event attributed to the enzymatic debridement was pain. These preliminary results indicate the potential safety and efficacy of bromelain-based enzymatic debridement in chronic wounds. Larger controlled studies are needed to further investigate this indication.

Bone Healing Promotion by Negatively Charged Polysterene Microspheres.

Bone healing under optimal conditions is fairly predictable. Yet when the healing process is disturbed by inadequate immobilization, inadequate blood supply, or scar tissue, little therapeutic alternatives to surgery exist.It appears that redistribution of electric charges along the bone during a callus consolidation promotes bone healing. It has been shown in the past that negatively charged polysterene spheres promote bone growth in animal models.In this preliminary report, we tested weather or not a commercial device of negatively charged polysterene spheres promotes bone healing in a porcine model.This preliminary study seems to suggest that the negatively charged polystyrene microspheres may have a potential in promoting bone healing, either alone or as an adjunct to other bone graft materials. These speculations should be further validated by large-scale studies in animal models and clinical trials.

[DEMOGRAPHIC AND ANATOMIC CHARACTERISTICS AND SURGERY RESULTS IN CHILDREN WHO WERE TREATED IN SOROKA FOR CRANIOSYNOSTOSIS].

BACKGROUND: Craniosynostosis, the premature fusion of one or more of the cranial sutures, can occur as a part of a syndrome or as an isolated deformity. When not treated properly it may have major physical and social implications. STUDY HYPOTHESIS: We assumed that our center's results are similar to those reported in the literature, in terms of gender and anatomic characteristics, and different in terms of the number of syndromic cases. We also assume that only a few patients needed a second surgery and that this medical problem effects quality of life in term of cognitive impairment and aesthetic results. METHODS: A retrospective chart review was conducted of patients who were treated for craniosynostosis in Soroka University Medical Center between the years 1991-2005. RESULTS: A total of 63 patients were treated in Soroka during those years: 30 (47.6%) were females and 33 (50.8%) were males; 27 (42.9%) had coronal synostosis, 20 (31.8%) had sagital synostosis, 10 (15.8%) had metopic synostosis, 5 (7.9%) had lambdoid synostosis. A total of 5 (7.9%) cases were syndromic and the rest were isolated; 6 patients (9.5%) needed a second surgery for correction of the defect; 8 out of 30 patients (26.7%) 6 years or older at the present time suffer from attention deficit disorder. Parents' satisfaction from aesthetic results on a scale of 1-5 was 4.77 with SD of 0.504, while the doctors' score was 3.93 with SD 0.980 (p = 0.01). CONCLUSIONS: Craniosynostosis is a complex surgical problem, however with prompt treatment it may attain high levels of satisfaction among parents and patients. We found high rates 26.7% vs 10% (in the general population) of ADD in children affected by the disease.

[REVIEW OF 30 YEARS OF RESEARCH AND DEVELOPMENT OF AN ENZYMATIC DEBRIDEMENT AGENT FOR BURNS].

INTRODUCTION: Early removal of burn eschar is a cornerstone of burn care. The most commonly practiced eschar removal technique for deep burns in modern burn care is surgical debridement but this technique is associated with surgical burden and leads to unnecessary excision of viable tissue. GOALS: To review 30 years of research and development of an enzymatic debridement agent for burns. METHODS: Studies performed during the last 30 years are reviewed in this manuscript. RESULTS: Patients who underwent enzymatic debridement had a significantly shorter time to complete debridement, the surgical burden was significantly lower, hand burns did not necessitate escharotomy, and the long term results were favorable. DISCUSSION: Early enzymatic debridement leads to an efficient debridement, preservation of viable tissue, a reduction in surgical burden and favorable long term results. CONCLUSION: We believe early enzymatic debridement will lead to better care for burn victims and perhaps, even to a paradigm shift in the treatment of burns.

Early Enzymatic Burn Debridement: Results of the DETECT Multicenter Randomized Controlled Trial.

Since 1970 surgeons have managed deep burns by surgical debridement and autografting. We tested the hypothesis that enzymatic debridement with NexoBrid would remove the eschar reducing surgery and achieve comparable long-term outcomes as standard of care (SOC). In this Phase 3 trial, we randomly assigned adults with deep burns (covering 3-30% of total body surface area [TBSA]) to NexoBrid, surgical or nonsurgical SOC, or placebo Gel Vehicle (GV) in a 3:3:1 ratio. The primary endpoint was complete eschar removal (ER) at the end of the debridement phase. Secondary outcomes were need for surgery, time to complete ER, and blood loss. Safety endpoints included wound closure and 12 and 24-months cosmesis on the Modified Vancouver Scar Scale. Patients were randomized to NexoBrid (n = 75), SOC (n = 75), and GV (n = 25). Complete ER was higher in the NexoBrid versus the GV group (93% vs 4%; P < .001). Surgical excision was lower in the NexoBrid vs the SOC group (4% vs 72%; P < .001). Median time to ER was 1.0 and 3.8 days for the NexoBrid and SOC respectively (P < .001). ER blood loss was lower in the NexoBrid than the SOC group (14 ± 512 mL vs 814 ± 1020 mL, respectively; P < .0001). MVSS scores at 12 and 24 months were noninferior in the NexoBrid versus SOC groups (3.7 ± 2.1 vs 5.0 ± 3.1 for the 12 months and 3.04 ± 2.2 vs 3.30 ± 2.76 for the 24 months). NexoBrid resulted in early complete ER in >90% of burn patients, reduced surgery and blood loss. NexoBrid was safe and well tolerated without deleterious effects on wound closure and scarring.

Proliferating cell nuclear antigen is a novel inhibitory ligand for the natural cytotoxicity receptor NKp44.

NK cells play an important role in the early immune response to cancer. The NKp44 activating receptor is the only natural cytotoxicity receptor that is expressed exclusively by primate NK cells, yet its cellular ligands remain largely unknown. Proliferating cell nuclear Ag (PCNA) is overexpressed in cancer cells. In this study, we show that the NKp44 receptor recognizes PCNA. Their interaction inhibits NK cell function through NKp44/ITIM. The physical interaction of NKp44 and PCNA is enabled by recruitment of target cell PCNA to the NK immunological synapse. We demonstrate that PCNA promotes cancer survival by immune evasion through inhibition of NKp44-mediated NK cell attack.

Objective estimates of the risk factors for death and length of hospitalization following burn injuries, Soroka University Medical Center, 2001-2002.

BACKGROUND: Burn injuries are extremely common and may impose a serious load on public health around the world. OBJECTIVES: To compare mortality rates and length of hospitalization according to the identified risk factors, extent of burn, gender and age. METHODS: In this retrospective study, data from 558 archive files of hospitalization due to burns as the diagnosis in patients of all ages, between the years 2001 and 2002, were analyzed to identify the risk factors for mortality and length of hospitalization. RESULTS: Males comprised 62.4% of the hospitalized burn patients. The mortality rate was 3.2% (n = 18) and among them 55.6% were women. Fifty percent of the fatality cases were over 48 years old, with statistically significant correlation of mortality rate and age. Most of the fatality cases (66.7%) had burns with total burn surface area (TBSA) larger than 40%. The multiple logistic regression model showed that leukocyte count on admission, TBSA, and age are the most important predictors of mortality. Smoke inhalation was not found to be an independent risk factor. CONCLUSIONS: Using a statistical model for estimating the mortality rate, this study found that white blood cell count at admission, TBSA, and age were the most significant predictors of mortality.

An open-label, proof-of-concept study assessing the effects of bromelain-based enzymatic debridement on biofilm and microbial loads in patients with venous leg ulcers and diabetic foot ulcers.

BACKGROUND: Most chronic wounds contain biofilm, and debridement remains the centerpiece of treatment. Enzymatic debridement is an effective tool in removing nonviable tissue, however, there is little evidence supporting its effect on planktonic and biofilm bacteria. OBJECTIVE: This study evaluated the effects of a novel BBD agent on removal of nonviable tissue, biofilm, and microbial loads in patients with chronic ulcers. MATERIALS AND METHODS: Twelve patients with DFU or VLU were treated with up to 8 once-daily applications of BBD and then followed for an additional 2 weeks. Punch biopsy specimens were collected and analyzed for biofilm, and fluorescence imaging was used to measure bacterial load. RESULTS: Ten patients completed treatment, and 7 achieved complete debridement within a median of 2 applications (range, 2-8). By the end of the 2-week follow-up period, the mean ± SD reduction in wound area was 35% ± 38. In all 6 patients who were positive for biofilm at baseline, the biofilm was reduced to single individual or no detected microorganisms by the end of treatment. Red fluorescence for Staphylococcus aureus decreased from a mean of 1.09 cm² ± 0.58 before treatment to 0.39 cm² ± 0.25 after treatment. BBD was safe and well tolerated. CONCLUSION: Preliminary data suggest that BBD is safe and that it can be used to effectively debride DFU and VLU, reduce biofilm and planktonic bacterial load, and promote reduction in wound size.

Comparison of purified olive oil and silver sulfadiazine in the treatment of partial thickness porcine burns.

INTRODUCTION: Burns are widespread in the developed world, and expensive burn dressings are not universally available. Most burn patients suffer from a partial thickness burn that can be treated conservatively. Nevertheless, the ideal dressing for the burn wound has not been identified. We performed an animal experiment to compare the healing of partial thickness burns treated with silver sulfadiazine (SSD) and olive oil. METHODS: A randomized controlled animal experiment was conducted on 3 anesthetized domestic pigs in which 51 partial thickness burns were created using a metal bar heated to 400°C and applied to the dorsum of the animals for 20 seconds. The burns were treated every other day with SSD cream (n = 16), purified olive oil (n = 20), or no topical therapy at all (n = 15). Assessment of wound healing was done by drawing and scanning the margins of the wound at the endpoint of the experiment. The remaining open wound area was then calculated using Scion Image version beta 4.0.2 (Scion, Frederick, Md), and the results were analyzed using a 1-way ANOVA test. RESULTS: Burns treated with SSD healed faster than control burns (P < .05). There were no differences in the healing rates of wounds treated with olive oil versus controls or SSD. There were no wound infections in any of the 3 study groups. CONCLUSIONS: Treatment of partial thickness burns with purified olive oil did not result in faster healing when compared with SSD or dry gauze in a porcine model.

Epidemiology of cleft lip and palate among Jews and Bedouins in the Negev.

BACKGROUND: Clefts of the lip and palate are the most common significant congenital birth anomaly of the orofacial region. The condition may vary from a minor easily correctable cleft to a significant functional and cosmetic incapacitation. This is the first epidemiological study of orofacial clefts in the Negev region in Israel. OBJECTIVES: To establish the frequency of cleft lip and palate in the population of the Negev, characterize the demographic features of affected individuals and find possible risk factors, compare the risk in two major population groups: Bedouin and Jewish in a well-defined geographic area, and determine whether there is a change overtime in the birth of babies with facial clefts. METHODS: We conducted a retrospective survey of the Soroka Medical Center archives. The sample population comprised all 131,218 babies born at Soroka during the 11 year period 1 January 1996 to 31 December 2006. Statistical tests used Pearson's chi-square test, Student's t-test and Spearman's correlation coefficient test according to the type of parameter tested. RESULTS: During the study period 140 babies were born with orofacial cleft. The overall incidence of cleft lip and palate was 1.067/1000. The incidence of facial clefts was 1.54/1000 among Bedouins and 0.48/1000 among Jews (P < 0.001). Cleft palate was significantly more frequent in female than male babies (P = 0.002). Over the study years we found a significant decrease in the incidence of facial clefts in the Bedouin population, with Spearman's correlation coefficient rank -0.9 (P < 0.01). CONCLUSIONS: A significant decrease occurred in the incidence of facial clefts among Bedouin. This change may be attributed to prenatal care in the Bedouin Negev population as part of social and health-related behavior changes. The reduction in rates of congenital malformations, however, does not mean a reduction in the number of cases in a growing population. Also, with a modern western lifestyle, the expectancy and demand for reconstructive facial surgery and comprehensive care for these children are on the rise.

NKp44 receptor mediates interaction of the envelope glycoproteins from the West Nile and dengue viruses with NK cells.

Dengue virus (DV) and West Nile virus (WNV) have become a global concern due to their widespread distribution and their ability to cause a variety of human diseases. Antiviral immune defenses involve NK cells. In the present study, we investigated the interaction between NK cells and these two flaviviruses. We show that the NK-activating receptor NKp44 is involved in virally mediated NK activation through direct interaction with the flavivirus envelope protein. Recombinant NKp44 directly binds to purified DV and WNV envelope proteins and specifically to domain III of WNV envelope protein; it also binds to WNV virus-like particles. These WNV-virus-like particles and WNV-domain III of WNV envelope protein directly bind NK cells expressing high levels of NKp44. Functionally, interaction of NK cells with infective and inactivated WNV results in NKp44-mediated NK degranulation. Finally, WNV infection of cells results in increased binding of rNKp44 that is specifically inhibited by anti-WNV serum. WNV-infected target cells induce IFN-gamma secretion and augmented lysis by NKp44-expressing primary NK cells that are blocked by anti-NKp44 Abs. Our findings show that triggering of NK cells by flavivirus is mediated by interaction of NKp44 with the flavivirus envelope protein.

[Description of differential optical spectropolarimetric imaging system (DOSI) for non-invasive detection of skin tumors].

BACKGROUND: Most physicians diagnose skin malignancy using theoretical criteria and clinical experience. Apart from dermatoscopy, noninvasive means for skin tumors' diagnosis are highly expensive and are not in daily use. We developed a simple, handy and relatively inexpensive tool for non-invasive diagnosis of skin tumors. The Differential Optical Spectropolarimetric Imaging system (DOSI) is based on collecting information from the surface and depth of skin tumors, using the advantage of liquid crystal devices (LCDs]. OBJECTIVE: DOSI feasibility study in order to diagnose skin tumors non-invasively. METHOD: Skin tumor optical data was collected in order to create image indicators for specific skin tumors. Spectral images of skin tumors are captured before the lesion that was scheduled for removal was surgically excised. Repeating features of images of each tumor type (which was histologically diagnosed) that characterize the specific tumor and show distinction from the features of other tumors are recorded. RESULTS: The feasibility of DOSI has been demonstrated for research, but it is not yet mature for clinical use. Specific images, indicating specific skin tumors could not yet be reliably concluded. One relatively obvious characteristic for malignancy seems to be crescent-like and finger-like growth patterns. In the non-malignant lesions: crescent and finger-like structures are of less pronounced orders of magnitude. Crescents are more open and radius of curvature are of larger orders of magnitude than in malignant specimen. DISCUSSION: The advantage of using LCD is the ability to manipulate light electronically, without any movable components. LCDs are the building blocks of optical filters and polarization controllers. Using optical filters and polarization controllers, we are able to electronically manipulate the polarization and wavelength of our light source without any movable components. The light source emits different wavelengths (colors) that penetrate the tissue at different depths. The camera (CCD) captures the diffused reflected light from a skin lesion as a sequence of images for each polarization stage. By applying our novel method for each polarization stage we are able to overcome the noise of the diffused reflection and emphasize the scattering areas. Emphasizing the scattering areas provided images that may indicate malignancy. CONCLUSIONS: The feasibility of DOSI has been demonstrated. In order to obtain reliable diagnostic image indicators for specific skin tumors, more clinical tests are necessary.

[The burn array in Israel].

Circa 2700 burn victims require hospitalization in Israel each year. Most of these burns happen as household accidents, caused by hot liquids and involve less than 20% of the total body surface area. Treatment is dictated by the burn severity. Patients with severe burns are referred to one of the five dedicated burn services complying with the ABA & EBA criteria, located at the tertiary trauma centers which are situated in accordance with Israel's geographic, demographic and security needs. In most centers, the joint treatment of the most severe cases, provided by plastic surgeons and intensive care specialists allows the use of advanced techniques and treatment protocols, improving outcome. In order to further improve the quality of care for the burn patients, to allow improved national capability to contend with scenarios of disaster and mass casualty, to provide a sound database for future planning and billing, and also to produce appropriate intervention plans, Israel should have a system similar to the US's National Burn Repository.

The role of frozen section histological analysis in the treatment of head and neck skin basal and squamous cell carcinomas.

BACKGROUND: Skin basal and squamous cell carcinomas together account for over half of all newly diagnosed cancer cases. Frozen section control of surgical margins is often required in the head and neck region. A paraffin permanent section does not always confirm the results of a frozen section. OBJECTIVES: To test the diagnostic accuracy of frozen section histopathological analysis in determining the free margins of excised tumors. METHODS: This was a retrospective study of 169 cutaneous basal and squamous cell carcinomas excised with surgical margins diagnosed by frozen section and confirmed by permanent paraffin sections. The data included patients' age, gender, clinical and histopathological diagnosis, as well as characteristics of the lesions. RESULTS: There were 149 (88%) basal cell carcinomas and 20 (12%) squamous cell carcinomas. False negative margins were found in 19 cases (11.2%) and false positive margins in 11 (6.6%). We did not find any correlation between false positive or false negative margins and patients' age, gender, tumor size, tumor location, or the presence of sun-damaged skin. A significantly lower rate of false negative results was found in the residual tumor group. CONCLUSIONS: Our findings support the use of frozen section margin control in selected patients suffering from non-melanoma skin cancer of the head and neck.

The effects of platelet rich plasma on healing of full thickness burns in swine.

INTRODUCTION: Platelet rich plasma (PRP) is rich in growth factors and has been shown to improve healing in a variety of wounds. We determined the effects of PRP on healing and scarring in full thickness porcine burns with and without tangential excision and grafting (TEG). METHODS: Standardized full thickness 5cm by 5cm burns were created on each of the backs and flanks of 10 anesthetized female pigs (25kg) using a validated model. The burns were created with a heating device that emits heat at a temperature of 400°C for a period of 30s. The burns were randomized to one of six treatments: no TEG or PRP, no TEG+PRP, early (day 2) TEG and no PRP, early TEG+PRP, late (day 14) TEG and no PRP, and late TEG+PRP. Tangential excision was performed down to viable tissue and autografts were 0.2mm thick. When used, a thin layer of autologous PRP was applied below the graft. All wounds were then treated with a topical antibiotic ointment 3 times weekly for 42 days. Digital images and full thickness biopsies were taken at 9, 11, 14, 18, 21, 28, 35 and 42days after injury to determine percentage reepithelialization, scar depth, and scar contraction. Tissue sections were stained with H&E and viewed by a dermatopathologist masked to treatment assignment. RESULTS: There was no reduction in platelet and white blood cell concentrations in PRP and blood samples for the first 14days after-full thickness burns. A total of 120 burns were created on 10 animals evenly distributed between the six treatment groups. Burns undergoing early TEG reepithelialized fastest and with the thinnest scars followed by late TEG. Burns that did not undergo TEG had the slowest reepithelialization and greatest amount of scarring. Application of PRP had no additional effects on reepithelialization, scar depth, or scar contraction in any of the treatment groups. CONCLUSIONS: Addition of PRP had similar effects on reepithelialization and scarring of full thickness porcine burns as standard topical antibiotic ointment regardless of whether the burns underwent excision or grafting or the timing of excision and grafting.

Development of a contaminated ischemic porcine wound model and the evaluation of bromelain based enzymatic debridement.

OBJECTIVES: There are no well accepted animal models of chronic wounds, limiting advances in understanding and treatment of chronic ulcers. We developed a porcine wound model which combines multiple factors involved in chronic wounds to create a contaminated necrotic eschar and evaluated the debriding efficacy of a novel bromelain based enzymatic debriding agent (EscharEx). METHODS: Contaminated ischemic wounds were created on the flanks of domestic pigs by 'sandwiching' the skin between 2 'O' rings (1 placed on the surface of the skin and the other underneath the skin) for 24h prior to dermatomal excision of the necrotic eschar and its contamination with Staphylococcus aureus and Candida albicans. After confirming the development of infected eschars, additional animals were used to compare the effects of daily application of topical EscharEx or its hydrating vehicle on eschar debridement as a control. RESULTS: In all cases, application of the 'O' rings resulted in full thickness necrotic ecshars with invasive infections, which did not reepithelialize and sloughed off spontaneously within 14-21 days. All wounds reepithelialized within 28-42 days forming contracted scars. All EscharEx treated eschars were completely debrided within 7-9 days, while no debridement was evident in eschars treated with the control gel. CONCLUSIONS: Our model simulates the initial phase of chronic wounds characterized by a contaminated necrotic eschar allowing evaluation of wound debriding agents, and that a bromelain-based debriding agent completely debrides the contaminated necrotic eschars within one week in this model.

The effect of Lactobacillus bacteria supplement on sepsis and its complications in patients with acute burns.

Sepsis as a result of bacterial translocation from the gastrointestinal tract (GIT) is a known associate of morbidity and mortality in patients with severe burns. This translocation is influenced by the GIT flora. Oral consumption of Lactobacillus bacteria was previously shown to reduce translocation. We conducted a retrospective cohort study on a series of 56 patients with burns admitted to Soroka University Medical Center in Beer-Sheva, Israel. Those 56 patients included 28 who were given lactobacillus supplements and 28 who were not. The parameters that were compared between the groups evaluated the level of sepsis and its complications. The parameters of morbidity during hospitalization were significantly higher in the treatment group; however, their mortality was lower. That difference in mortality between the groups was not significant as a whole (p=0.071), but it was significant in the subgroup analysis of 41-70% total body surface area burned. In that subgroup there were zero cases of death in the treatment group versus five cases in the control group (p=0.005). Our findings suggest that in acute burns, lactobacillus bacteria food additives may be clinically beneficial in patients with total burned body surface area of 41-70%.

Enzymatic debridement of deeply burned faces: Healing and early scarring based on tissue preservation compared to traditional surgical debridement.

INTRODUCTION: Facial burns occur frequently and depending on the injured skin layers often heal with scars which may cause permanent functional and cosmetic sequelae. Preservation of the sensitive facial skin layers, especially of the dermis is essential for scarless epithelialisation. Enzymatic debridement of deep thermal burns has already been shown to assist with preserving viable dermis. However, up to date, there are no published reports on wound healing and in the long term aesthetic outcome after enzymatic debridement of facial burns. METHODS: Therefore we performed a-single centre clinical trial that included 26 subjects aged 18-78 years with facial burns clinically evaluated as deep dermal or deeper. Burns were treated either with enzymatic debridement or excisional surgical debridement. Then we compared both groups regarding debridement selectivity, wound closure and scar quality after more than 12 months. RESULTS: Enzymatic debridement significantly reduced time to complete wound closure after admission (19.85 days versus 42.23 days, p=0.002), and after enzymatic eschar removal (18.92 days versus 35.62 days, p=0.042). The number of procedures to complete debridement were significantly lower in the enzymatic debridement group (1.00 versus 1.77, p=0.003). 77% of facial burns that had been debrided enzymatically were found to be more superficially burned than initially estimated. Wounds undergoing autografting of any size were significantly reduced by enzymatic debridement (15% versus 77%, p=0.002). Scar quality after enzymatic debridement was superior compared to surgical debridement after 12 months regarding pigmentation (p=0.016), thickness (p=0.16), relief (p=0.10), pliability (p=0.01), surface area (p=0.004), stiffness (p=0.023), thickness (0.011) and scar irregularity (p=0.011). Regarding erythema and melanin, viscoelasticity and pliability, trans-epidermal water loss or laser tissue oxygen saturation, haemoglobin level and microcirculation we found no significant differences for treated and untreated skin in the EDNX group. CONCLUSION: In our current study we found Bromelain based enzymatic debridement better in some aspects of tissue preservation in deep dermal facial burn.