Dried irradiated human amniotic membrane as a biological dressing for facial burns—A 7-year case series

Background

Facial burns are common and have a significant impact on patient function and psychosocial well being. Human amnion has been used for many years as a temporary biological wound dressing in the management of partial thickness burns. The observed advantages of human amnion treatment include pain relief, ease of use, prevention of infection and acceleration of wound healing.

Objective

This study evaluated our 7 years of working with dried irradiated human amnion in the treatment of facial burns.

Method

A review of patients, treated with dried human amnion for facial burns between 2001 and 2008. Demographic details collected included age, gender, total facial surface area burned, type of burn and cause of injury. The effectiveness of the treatment was determined by wound infection rate, frequency of dressing reapplication, healing time and resulting scarring.

Results

Thirty-three patients with superficial partial thickness burn were identified (25 males, 8 females). The average age of the patients was 16.5 years (range: 8 months to 64 years). The causes included scalding (n = 15), contact burning (n = 13) and flash burning (n = 5). The mean percent total facial surface area burned was 2.7% (range: 0.5–8.5%). None of the patients developed facial wound infections. Eighty-five percent (n = 28) of the patients needed a single application of the dried amnion. The average healing time was 5.4 days (range: 2–14 days). Thirteen patients (39%) had burns confined to the facial area, of which three were discharged and treated as outpatients. Long-term follow up showed two hypopigmented scars, one hyperpigmented scar and one hypertrophic scar.

Conclusion

Superficial partial thickness facial burns can be effectively treated with dried irradiated human amnion membrane.     

Dermal substitution with Matriderm in burns on the dorsum of the hand

Background

Dermal substitutes are used increasingly in deep partial and full-thickness burn wounds in order to enhance elasticity and pliability. In particular, the dorsum of the hand is an area requiring extraordinary mobility for full range of motion. The aim of this comparative study was to evaluate intra-individual outcomes among patients with full-thickness burns of the dorsum of both hands. One hand was treated with split-thickness skin grafts (STSG) alone, and the other with the dermal substitute Matriderm^® and split-thickness skin grafts.

Material and Methods

In this study 36 burn wounds of the complete dorsum of both hands in 18 patients with severe burns (age 45.1 ± 17.4 years, 43.8 ± 11.8% TBSA) were treated with the simultaneous application of Matriderm^®, a bovine based collagen I, III, V and elastin-hydrolysate based dermal substitute, and split-thickness skin grafting (STSG) in the form of sheets on one hand, and STSG in the form of sheets alone on the other hand. The study was designed as a prospective comparative study. Using both objective and subjective assessments, data were collected at one week and 6 months after surgery. The following parameters were included: After one week all wounds were assessed for autograft survival. Skin quality was measured 6 months postoperatively using the Vancouver Burn Skin Score (VBSS). Range of motion was measured by Finger-Tip-Palmar-Crease-Distance (FPD) and Finger-Nail-Table-Distance (FNTD).

Results

Autograft survival was not altered by simultaneous application of the dermal matrix (p > 0.05). The VBSS demonstrated a significant increase in skin quality in the group with dermal substitutes (p = 0.02) compared to the control group with non-substituted wounds. Range of motion was significantly improved in the group treated with the dermal substitute (p = 0.04).

Conclusion

From our results it can be concluded that simultaneous use of Matriderm^® and STSG is safe and feasible, leading to significantly better results in respect to skin quality of the dorsum of the hand and range of motion of the fingers. Skin elasticity was significantly improved by the collagen/elastin dermal substitute in combination with sheet-autografts.     

Effect of different pressure magnitudes on hypertrophic scar in a Chinese population

Introduction

This study aimed to investigate the effect of different pressure magnitudes on treatment outcomes of hypertrophic scars, and determine pressure loss over time.

Methods

A randomized clinical trial was adopted. 53 hypertrophic scar samples from 17 Chinese participants were recruited and randomly assigned into a high pressure group (20–25 mmHg) and low pressure group (10–15 mmHg) for a five-month intervention program. The scars were assessed objectively before intervention and monthly after intervention for thickness, color (redness, yellowness and lightness) and scar pliability. Pressure magnitude at each assessment was also measured. Two-way repeated ANOVA was used to compare for differences between groups.

Results

The results showed that both levels of pressure produced reduction in scar thickness and redness, but the improvement in the high pressure group was statistically better than that of the counterpart (both p < 0.05). Monthly pressure measurement revealed that pressure loss in the high pressure group was more severe. However, no major changes in other color parameters and pliability were observed for both the groups.

Conclusion

High pressure was demonstrated to be more effective for scar management, but it was also more prone to higher pressure loss. Pressure therapy integrated with regular monitoring of the interface pressure is suggested to improve its therapeutic efficacy.     

Burn scar assessment: A systematic review of objective scar assessment tools

Purpose

All deep second and third degree burns are at risk to develop hypertrophic scars which can severely undermine the quality of survival. To assess the severity of scarring, several technical devices or tools have been introduced to evaluate one or more aspects of the scar, enabling comparison of different treatment protocols and allowing an objective follow-up. The objective of this study was to review which tools can be used in objective burn scar assessment.

Basic procedures

The Systematic literature search involving PubMed, the Web of Science (incl. Science Citation Index).

Main findings

51 articles with burn scar assessment as main topic were found. Several characteristics of the scar can be assessed, such as color, metric features and elasticity, but none of the available tools covers the whole aspect of the scar. Especially subjective factors such as pain and itching cannot be assessed with those tools, in spite of their great impact on the patient's quality of life.

Conclusions

Scar tools enable objective and reproducible evaluation of scars, which is essential for scientific studies and medico-legal purposes, and in selected cases for the clinical follow-up of an individual patient. Further studies to evaluate these tools on scars are nevertheless required.     

A novel rapid and selective enzymatic debridement agent for burn wound management: A multi-center RCT

Objectives

Excisional debridement followed by autografting is the standard of care (SOC) for deep burns, but is associated with serious potential complications. Conservative, non-surgical and current enzymatic debridement methods are inefficiently slow. We determined whether a non-surgical option of rapid enzymatic debridement with the debriding enzyme NexoBrid™ (NXB) would reduce need for surgery while achieving similar esthetic and functional outcomes as SOC.

Methods

We conducted a multi-center, open-label, randomized, controlled clinical trial including patients aged 4-55 years with deep partial and full thickness burns covering 5-30% of their total body surface area (TBSA). Patients were randomly assigned to burn debridement with NXB (applied for 4 h) or SOC, which included surgical excisional or non-surgical debridement.

Results

NXB significantly reduced the time from injury to complete débridement (2.2 vs. 8.7 days, P < 0.0001), need for surgery (24.5% vs. 70.0%, P < 0.0001), the area of burns excised (13.1% vs. 56.7%, P < 0.0001) and the need for autografting (17.9% vs. 34.1%, P = 0.01). Scar quality and quality of life scores were similar in both study groups as were the rates of adverse events.

Conclusions

Enzymatic débridement with NXB resulted in reduced need for and extent of surgery compared with SOC while achieving comparable long-term results in patients with deep burns.

Trial registration

: Clinical Trials.gov NCT00324311.     

The use of Suprathel(®) in deep dermal burns: first results of a prospective study

Introduction

While autologous skin grafting has been the standard for coverage of full-thickness areas, several options for deep-partial-thickness defects exist. With regard to economising donor sites, we compared a copolymer based on dl-lactid acid (Suprathel^®) as temporary wound dressing with autologous skin, and analysed time to healing and scar quality in matched areas of deep-partial-thickness burn.

Methods

We recruited 18 patients with a median age of 45 years (range: 25–83 years), for this prospective, non-blinded controlled non-inferiority study, suffering from deep-partial-thickness burns from November 2009 to July 2010. After early tangential excision, matched deep-partial-thickness areas were covered with 1:1.5 meshed autologous skin grafts and the copolymer for direct intra-individual comparison. Scars were evaluated by means of the Vancouver Scar Scale (VSS), the Patient and Observer Scar Assessment Scale (POSAS) and suction cutometry (MPA 580, Courage and Khazaka Electronic GmbH, Cologne, Germany) on days 30 and 90, postoperatively.

Results

Fifteen days after surgery, complete wound closure was present in 44.4% (8/18) of all areas covered with copolymer and 88.9% (16/18) in the split-thickness skin graft (STSG) area (p = 0.008). Evaluation of the total VSS, POSAS and cutometry satisfied the criterion of non-inferiority for Suprathel^® on day 30. Ninety days after surgery, only the Observer Scar Scale showed that Suprathel is non-inferior to STSG, albeit the mean total VSS and Patient Scar Scale were better in Suprathel^® areas.

Conclusion

Suprathel^® represents a solid, reliable epidermal skin substitute with longer healing times in comparison to skin grafts but comparable results concerning early scar formation. Suprathel^® can serve as a tool in treatment portfolio for adult patients suffering from deep dermal burns. Especially in patients with extensive burns, Suprathel^® can be used to cover the deep dermal burn wounds to save STSGs and its donor sites for the coverage of full-thickness burned areas.     

Prospective study on burns treated with Integra,a cellulose sponge and split thickness skin graft: Comparative clinical and histological study—Randomized controlled trial

Background

The aim of this study was to compare three different methods to cover excised burn wounds in a randomized controlled trial.

Methods

Fascially excised burn wounds, measuring 10 cm × 5 cm, were covered with Integra^®, split thickness skin graft (STSG), and a viscose cellulose sponge Cellonex™ in each of ten adult patients. Integra^® and Cellonex™ treated areas were covered with thin STSG on day 14. Biopsies were taken 3, 7, 14, and 21 days, 3 months, and 12 months after surgery, and samples were subjected to a range of immunohistochemical stains, in addition to hematoxylin and eosin (HE). Scar assessment was performed 3 and 12 months post-operatively with the Vancouver Scar Scale (VSS).

Results

Inflammation was not substantial in any of the study areas, but Cellonex™ had the most neutrophils, histiocytes, and lymphocytes with significant differences on days 7 and 14. Complete vascularization of Integra^® seemed to occur later compared to the other materials. STSG had the most myofibroblasts on day 14 (p = 0.012). In VSS the quality of the scar improved in all materials from 3 to 12 months.

Conclusions

The final results for all treatments after 12 months demonstrate equal clinical appearance, as well as histological and immunohistochemical findings.     

Effectiveness of topical zinc oxide application on hypertrophic scar development in rabbits

Background

The etiology, biology, prevention and effective treatment of hypertrophic scars have not exactly been defined. Topical zinc oxide application was shown to be effective in the treatment of proliferative scars. We studied the effectiveness of topical zinc oxide ointment in the prevention of hypertrophic scar development by using the rabbit ear hypertrophic scar model.

Methods

Circular full-thickness skin excisions were performed on both ears of 10 rabbits. The rabbits were divided into two groups and topical 40% zinc oxide ointment was applied daily to one ear and the ointment base was applied as placebo to the other ear. Scar samples were taken in the 3rd week in group 1 and in the 6th week in group 2. All of the specimens were divided into two halves: one half for histopathologic/histomorphometric examinations and the other half for biochemical studies.

Results

Application of topical zinc oxide ointment decreased clinical scar hypertrophy scores significantly (p = 0.017) at 6th week in comparison with placebo. Topical zinc oxide also reduced nodule formation histopathologically at 6th week in comparison with placebo but this was not significant statistically (p > 0.05).

Conclusion

The findings of this study may have clinical implications on the management of human hypertrophic scars.     

Effect of imiquimod on partial-thickness burns

Background

Burns can result in substantial morbidity through fibroblast proliferation and contracture. Imiquimod (IMQ), an immune response modifier and upregulator of endogenous cytokine expression, has been shown to suppress fibroblast proliferation. It is widely used in the treatment of viral, neoplastic and non-neoplastic skin conditions and has recently been tested in the reduction of hypertrophic scarring and keloids. To our knowledge, no other study has so far evaluated the effect of IMQ on cutaneous burns.

Methods

Partial-thickness burns were produced on the dorsum of 32 Wistar rats. Right-sided wounds received saline and left-sided wounds received 5% IMQ cream three times/week following injury. Photographs taken on post-burn days (PBD) 4, 7, 14 and 21 were evaluated for wound appearance using a clinical assessment scale and a visual analog scale. Scars were measured by digital planimetry. Samples stained with hematoxylin–eosin were submitted to conventional histological analysis. Samples stained with Sirius Red were analyzed under polarized light for collagen morphometry.

Results

Visual scores were higher in the saline group on PBD 21 (p < 0.05). Wound edge migration rates were lower (p < 0.05) and conventional histology showed accentuated inflammation and delayed reepithelialization in the IMQ group. Type-I and type-III collagen deposition increased in the saline group and decreased in the IMQ group. Conversely, the proportion between type-I and type-III collagen differed significantly between treatments on PBD 4 and 21 (p < 0.05 in both cases).

Conclusions

Short-term topical imiquimod treatment of partial-thickness burns in rats did not improve clinical appearance and scarring but rather decreased fibrosis. Significant differences in collagen deposition were observed between the treatments.     

The impact of laser Doppler imaging on the early decision-making process for surgical intervention in adults with indeterminate burns

Objective

We aimed to analyze whether laser Doppler imaging (LDI) can lead to earlier decision-making regarding the need for surgery in adults with indeterminate burns.

Methods

In a retrospective cohort study, we developed a prediction model for surgery in adults with indeterminate burns. Patient data (n = 101) from January 2007 to December 2009 were used for model development, and those (n = 40) from January 2010 to October 2010 for external validation.

Results

Between non-surgical and surgical groups, there were significant differences for mean age (p = 0.009), % total body surface area burn (p = 0.016), site of burn wound (p = 0.033), and mean perfusion units (PU) (p < 0.001). Multiple logistic regression showed that only the mean PU differed significantly between the groups. The area under the curve (AUC) of the equation derived from multiple logistic regression was 0.938, which did not differ from that of the mean PU alone (0.931; p = 0.453). Using a cut-off point of 154.7PU, the sensitivity of LDI was 78.3% and the specificity was 92.7%. This cut-off point also yielded a sensitivity of 77.8% and specificity of 95.5% in the external validation dataset.

Conclusion

LDI can help make a decision for surgery in the early stages of care for adults with indeterminate burns.     

Burns to the head and neck: Epidemiology and predictors of surgery

Background

The face is a frequent site of burn, but prevalence rates vary and reports are often limited to one healthcare setting. We examined the incidence of facial burns in the Netherlands in Emergency Departments (ED), hospitals and burn centres. Additionally, we identified which patient, injury and burn-related characteristics were predictors of facial burns, facial surgery and facial reconstruction in burn centres.

Methods

A retrospective, observational study was conducted including data from the Dutch Injury Surveillance System, the National Hospital Discharge Register and burn centres in a 5-year period (2003–2007).

Results

Facial burn incidences per 100,000 were 15.1 for ED visits, 1.3 for hospital admissions and 1.4 for burn centre admissions. A total of 2691 patients were admitted to Dutch burn centres; 47.5% (n = 1277) had facial burns of which 20.5% received primary facial surgery and 5.3% received facial reconstruction in follow-up. Predictors of facial burns and facial surgery were identified. Predictors of facial reconstructive surgery were burns to the neck (ventral), fire/flame burns and number of facial surgeries in the acute phase of the burn.

Conclusions

One in five patients with facial burns admitted to a Dutch burn centre received primary facial surgery and 1 in 20 received facial reconstructive surgery within a follow-up of minimum 2 years.     

An objective long-term evaluation of Integra (a dermal skin substitute) and split thickness skin grafts,in acute burns and reconstructive surgery

Introduction

The field of wound healing and tissue repair has advanced rapidly in the last decade, with this there is an increasing emphasis on the importance of the functional and cosmetic outcomes following injury. Integra artificial skin is the most widely used synthetic skin substitute and is reported to have better outcomes in relation to the appearance and elasticity when compared to split thickness skin grafting (SSG). A review of the literature reveals very few trials that are based on an objective evaluation of Integra treated scars as compared to SSGs. This research aimed to provide objective data on the long-term outcome of Integra.

Method

All adult patients from the Welsh Burns Centre who had been successfully treated with Integra ± SSG were invited to attend a clinic for a follow up provided they had been healed for greater than one year. The hypothesis that Integra scars are more pliable than skin grafts was tested objectively using the Cutometer, a suction device which measures skin elasticity.

Results

Of the 13 patients eligible, six were available for assessment. The results of this study suggest that Integra treated sites correlate well with normal skin as measured by the Cutometer. This was statistically significant for the parameters Ur/Ue (elastic function) and Ur/Uf (gross elasticity). On the other hand there was no correlation seen between the patients SSG sites and the patient's normal skin.

Conclusion

With advances in medicine we are increasingly able to modulate wound healing and the resultant scars. In order to assess new and often costly treatments the need for objective scar measurement tools have become apparent. Integra has been advocated to improve scarring from injury. However, there have been few studies to evaluate the long-term outcome of Integra as compared to traditional methods such as SSG. In the past scar evaluation has been based on subjective scores by patients and clinicians. Now the mechanical properties of the skin can be evaluated using simple bioengineering methods such as the Cutometer Suction Device. Using this device our study has objectively demonstrated that the elastic properties of areas treated with Integra is comparable to normal skin.     

Percutaneous collagen induction therapy: An alternative treatment for burn scars

Objective

This study aims to evaluate percutaneous collagen induction (PCI) in post-burn scarring.

Background

Patients with scarring after burn frequently request help in improving the aesthetic appearance of their residual cicatricial deformity. Their scars are generally treated by tissue transfer, W- and Z-plasties, flaps, cortisone injections or ablative procedures that injure or destroy the epidermis and its basement membrane and subsequently lead to fibrosis of the papillary dermis. The ideal treatment would be to preserve the epidermis and promote normal collagen and elastin formation in the dermis.

Patients

A total of 16 consecutive patients (average age: 37 ± 15.5 years, average body mass index (BMI): 25.7) in Germany with post-burn scarring.

Intervention

PCI using the Medical Roll-CIT (Vivida, Cape Town, South Africa). This device was designed to multiply-puncture the skin to the level of the dermal scar to institute remodelling. Patients were prepared with topical vitamin A and C cosmetic creams for a minimum of 4 weeks preoperatively to maximise collagen stimulation.

Outcome measures

The outcome was measured rating (visual analogue scale (VAS) and Vancouver Scar Scale (VSS)), histological specimen 12 months after intervention.

Results

On average, patients rated their improvement as a mean of 80% better (±15.5) than before treatment. Histologic examination revealed considerable increase in collagen and elastin deposition 12 months postoperatively. The epidermis demonstrated 45% thickening of stratum spinosum and normal rete ridges as well as the normalisation of the collagen/elastin matrix in the reticular dermis at 1 year postoperatively.

Conclusions

This pilot study shows that PCI appears to be a safe method for treating post-burn scarring without destroying the epidermis. The procedure can be repeated safely and is also applicable in regions where laser treatments and deep peels are of limited use. However, it is necessary to initiate an efficacy trial to prove the data of this pilot study.     

Enhancing the clinical utility of the Burn Specific Health Scale-Brief: Not just for major burns

Introduction

Like many other Western burn services, the proportion of major to minor burns managed at Royal Perth Hospital (RPH) is in the order of 1:10. The Burn Specific Health Scale-Brief (BSHS-B) is an established measure of recovery after major burn, however its performance and validity in a population with a high volume of minor burns is uncertain. Utilizing the tool across burns of all sizes would be useful in service wide clinical practice.

Aim

This study was designed to examine the reliability and validity of the BSHS-B across a sample of mostly minor burn patients.

Method

BSHS-B scores of patients, obtained between January 2006 and February 2013 and stored on a secure hospital database were collated and analyzedCronbach's alpha, factor analysis, logistic regression and longitudinal regression were used to examine reliability and validity of the BSHS-B.

Results

Data from 927 burn patients (2031 surveys) with a mean % total burn surface area (TBSA) of 6.7 (SD 10.0) were available for analysis. The BSHS-B demonstrated excellent reliability with a Cronbach's alpha of 0.95. First and second order factor analyses reduced the 40 item scale to four domains: Work; Affect and Relations; Physical Function; Skin Involvement, as per the established construct. TBSA, length of stay and burn surgery all predicted burn specific health in the first three months of injury (p < 0.001, p < 0.001, p = 0.03). BSHS-B whole scale and domain scores showed significant improvement over 24 months from burn (p < 0.001).

Discussion

The results from this study show that the structure and performance of the BSHS-B in a burn population consisting of 90% minor burns is consistent with that demonstrated in major burns.

Conclusion

The BSHS-B can be employed to track and predict recovery after burns of all sizes to assist the provision of targeted burn care.     

Acute burn induced coagulopathy

Background

Acute traumatic coagulopathy is well described in the trauma population. Major burns are characterised by a similar endothelial injury and cellular hypoperfusion. These features could be a driver for an acute burn induced coagulopathy (ABIC).

Methods

Patients admitted to a regional burn centre over a 71 months period with a total body surface area burn of 30% or more were identified. The metavision electronic patient database was scrutinised for a predetermined list of demographics, interventions and admission investigations to identify any clinically significant ABIC.

Results

On admission 39.3% of the 117 patients analysed met our criteria for a coagulopathy. Of the patients with a coagulopathy, 71.7% had an elevated Prothrombin Time (PT), 2.2% had an elevated Activated Partial Thromboplastin time (APPT) and 26.1% had an elevation of both. Patients with a coagulopathy received a similar volume of fluid (p = 0.08). There was a statistically significant correlation between the PT and the abbreviated burn severity index (p = 0.0013, r = 0.292) and serum lactate (p = 0.0013, r = 0.292). ABIC was an independent predictor of 28 day mortality, OR 3.42(1.11–10.56).

Conclusion

In patients with major thermal injuries a clinically significant ABIC exists. Early diagnosis and treatment of ABIC should be considered particularly in those undergoing total burn wound excision.     

Population pharmacokinetics of a propofol bolus administered in patients with major burns

Objective

In operating theaters and burn units, propofol is commonly used for sedation and anesthesia in patients with major burns. This study determined the population pharmacokinetics of propofol in burns and identified clinically significant covariates.

Method

Seventeen adults, age 42 ± 10 (mean ± SD) years, with 41 ± 19% total body surface area burns, were enrolled at 16 ± 14 days after-burn. Non-burn adults (n = 19) served as controls. After an intravenous bolus of 2 mg/kg propofol, the plasma concentration was determined at designated times for up to 4.5 h. Concentration–time profiles were analyzed using nonlinear mixed-effect modeling.

Results

A three-compartment model gave the best fit. The volume of distribution of the central compartment (V₁) was considerably greater in the burned than non-burned group (48.4 L vs. 27.6 L, respectively). The clearances of the central (CL₁) and slow peripheral (CL₃) compartments were higher in burn patients (4.2 L/min vs. 1.7 L/min and 3.6 L/min vs. 1.1 L/min, respectively). Adding the covariates BURN to V₁, CL₁, and CL₃ and WT (weight) to CL₁ significantly improved the model performance.

Conclusion

The pharmacokinetic characteristics of a propofol bolus administered in patients with major burns were enhanced clearance and expanded volume of distribution. BURN and WT were the important covariates. For sedation or anesthesia induction, a higher than recommended dose of propofol may be required to maintain therapeutic plasma drug concentrations in patients with severe burns. Vigilance regarding the burned individual and careful titration of hypnotics to the desired effect cannot be overemphasized.     

Differential expression of growth differentiation factor-9 in keloids

Objective

The mechanisms of keloid invasion are largely unknown. This study aims to analyze the differentially expressed genes between keloid peripheral and central areas and thus to define the molecule that might be responsible for keloid invasion.

Methods

The gene chip of transforming growth factor-β (TGF-β) superfamily signaling pathway was used to analyze differentially expressed genes of the fibroblasts derived from peripheral area and central area of 3 keloids. The differential expression of growth differentiation factor-9 (GDF-9) was also confirmed by quantitative PCR and Western-blot. Moreover, GDF-9 expression levels were compared among the fibroblasts derived from 3 keloids, hypertrophic scars and normal skin with quantitative PCR and immunofluorescent staining.

Results

GDF-9 expression level was significantly higher in the peripheral area than in the central area (p < 0.05) and was significantly higher in keloid than in hypertrophic scar and normal skin (p < 0.05).

Conclusion

Up-regulated GDF-9 expression in keloid peripheral area may play a role in keloid invasive behavior.     

Ankle dorsiflexion postburn scar contractures: anatomy and reconstructive techniques

Background

Postburn ankle scar contractures cause functional limitations of all lower extremities and create a serious cosmetic defect, not allowing patients to use normal foot wear, and, therefore, needing surgical reconstruction. The anatomic features of ankle dorsiflexion contractures and their treatment have been covered in the literature far less than other joint contractures, and their treatment is still a challenge for many surgeons. A common treatment method is incisional release of the contracture and defect resurfacing with skin graft. Rarely, distally based sural or free flaps and Ilizarov fixator are used.

Methods

Anatomy of postburn ankle scar contractures in 55 patients was studied and contractures were surgically treated using a specific approach and technique. Follow-up results were observed from 6 months to 16 years.

Results

According to the anatomic features, dorsiflexion scar contractures were divided into three types: edge, medial, and total. Edge contractures were caused by burns and scars located on the lateral or medial ankle surface and were characterized by the presence of the fold along the anterior edge ankle; the skin of the anterior ankle surface was not injured. Medial contractures were caused by scars located on the anterior ankle surface and were characterized by the presence of the fold along the medial ankle line. Total contractures were caused by scars tightly surrounding the ankle. In fold's sheets of edge and medial contractures there is a trapeze-shaped surface deficit in length (cause of contracture) and a surface surplus in width which allows contracture release with local trapezoid flaps. For total contractures, wide scar excision and skin grafting were indicated.

Conclusion

Three anatomic types of ankle dorsiflexion scar contractures were identified: edge, medial, and total. An anatomically justified technique for edge and medial contractures is trapeze-flap plasty; total contractures are effectively eliminated with scar excision and skin grafting.     

The use of neoprene as a scar management modality

Purpose

Scar formation is one of the most functionally and cosmetically debilitating results of thermal injuries. Burn team members continuously search for new, cost effective, ways to prevent and treat hypertrophic scar formation. This study is a retrospective review of one facility's use of neoprene based products as an adjunct to, or in place of, traditional scar management techniques.

Methods

Records of all patients treated with neoprene patches or neoprene splints from March 2008 through April 2011 were retrospectively reviewed. Vancouver Scar Scores (VSS) were collected, photographs were reviewed and any documented problems reported by the patients were noted.

Results

Mean VSS scores were significantly lower at follow-up (5.3, SD 2.8) than at initial appointment (11.7, SD 1.4) with an estimated mean difference of 6.3 (P = 0.0001). A 95% confidence interval for this mean difference is 3.9–8.7.

Conclusions

In the reviewed cases, the use of neoprene inserts or splints resulted in a statistically significant reduction in hypertrophic scars with no secondary complications.     

Patient-reported body image and cosmesis outcomes following kidney surgery: comparison of laparoendoscopic single-site, laparoscopic, and open surgery

Background

Laparoendoscopic single-site surgery (LESS) is reported to result in superior cosmesis versus alternative surgical approaches, based solely on surgeon assessment or anecdotal evidence.

Objective

Evaluate patient-reported body image and cosmesis outcomes following kidney surgery.

Design, setting, and participants

We conducted a prospective and retrospective observational cohort study involving patients who underwent kidney surgery (n = 114) via LESS (n = 35), laparoscopic (n = 52), or open (n = 27) approaches. Cosmesis was evaluated using a comprehensive survey administered ≥3 mo postoperatively.

Measurements

Survey components were a body image questionnaire (BIQ) consisting of body image and cosmesis subscales, a photo-series questionnaire (PSQ) assessing scar preferences after knowledge of scar outcomes for alternative surgical approaches, and query of preference for future surgical approach using a trade-off method. Body image, cosmesis, and PSQ scales ranged from 5 to 20, 3 to 24, and 1 to 10, respectively.

Results and limitations

Median BIQ component scores did not significantly differ across surgical approaches. Median ratings for the LESS, laparoscopy, and open scar photographs were 8, 5, and 5, respectively (p = 0.0001). Before viewing photographs, median self-scar ratings for LESS, laparoscopy, and open approaches were 9, 5, and 6.5, respectively (p = 0.02); after photographs, ratings were 9, 7, and 7, respectively (p = 0.008). Assuming equivalent surgical risk among the approaches, overall preference for future LESS, laparoscopy, or open surgery was 39%, 33%, or 4%, respectively. As theoretical risk of LESS was raised, preference for LESS decreased, whereas preference for laparoscopy and open surgery increased. Study limitations are a nonrandomized design and the use of a nonvalidated scale.

Conclusions

Urologic patients favor LESS cosmesis outcomes over those for laparoscopy or open surgery. Considering the superior scar satisfaction among LESS patients, who were younger and more likely to be undergoing surgery for benign disease, we infer that this demographic most values the cosmetic advantages of LESS.