Late outcomes after grafting of the severely burned face: a quality improvement initiative

A Systematic Review of Quality Improvement Interventions in Burn Care

Quality improvement interventions (QIIs) are intended to improve the care of patients. Unlike most traditional clinical research, these endeavors emphasize the sustainable implementation of scientific evidence rather than the establishment of evidence. Our purpose was to conduct a systematic review of QII publications in the field of burn care. A systematic review was conducted utilizing electronic databases (MEDLINE, Embase, and Cochrane Library) of all studies relating to "quality improvement" in burn care published until March 31, 2020. Studies were excluded if no baseline data were reported, or if no intervention was applied and tested. Studies were scored using a novel 10-point evaluation system for QII. We evaluated 414 studies involving "quality improvement" in burn care. Only 82 studies contained a QII while 332 studies were categorized as traditional research. Several traditional research studies made claims to be QIIs, but few met the criteria. Of the 82 QII references, only 20 (24%) were accessible as full-text manuscripts, the remainder were published as abstracts only. The mean score was 7.95 for full-text studies (range 6-10) and 7.4 for abstract-only studies (range 5.5-9.5). Despite the importance of quality improvement (QI) in burn care, very few studies have been published that employ true QI methodology, and many QII studies never advance beyond publication as abstracts in conference proceedings. Based on this systematic review, we propose guidelines to improve the quality of QII submissions.

Scar Quality of Skin Graft Borders: A Prospective, Randomized, Double-Blinded Evaluation

Prominent scars may remain around the border of a mature skin graft (SG) at the interface of the SG with normal skin. The border of a SG may be constructed by either exactly approximating (A) or slightly overlapping (O) the edge of the SG on the wound margin. The purpose of this study was to evaluate whether A or O affects the quality of the border scar of SGs applied to burn patients. This prospective study was a within-border design in which adult burn patients requiring SGs served as their own control. Half of each study border was fashioned using O and the immediately adjacent other half was made using A. We randomly assigned O or A to the proximal or distal halves of vertical borders and the medial and lateral halves of horizontal borders. Both halves of the study border were identically fixated with staples or sutures and were managed in the same fashion postoperatively. Blinded evaluations at 3, 6, and 12 months of O and A borders were performed using the Vancouver Scar Scale (VSS), the observer component of the Patient and Observer Scar Assessment Scale (POSAS), and a global binary assessment of which half of the study border "looked better." Blinded patients also rated each half of the study border with a 10-point Likert scale. Values are reported as the mean ± SD or median (interquartile range), as appropriate. There were 34 borders studied in 15 subjects (46.7% female, age 29 [22,57], % TBSA burn 9.7 ± 5.3, and no inhalation injuries). Study borders were constructed at 7 (5,11) days postburn, had a total length of 12 (9.3,14.5) cm, and all involved split thickness SGs of thickness 13 (12,14)/1000th of an inch. Sheet grafts were applied in 27% and meshed grafts in 73%. SGs were applied immediately after excision in 75% or after allografting in 25%. Border scars matured between 3 and 12 months with reductions in total VSS from 8 (7,8) to 4 (3,6) for O borders (P < .001) and from 8 (7,9) to 4 (1,6) for A borders (P < .001). However, there were no significant differences between O and A borders in total VSS at 3 months (P = .165), 6 months (P = .602), and 12 months (P = .358) or in total OSAS at 3 months (P = .681), 6 months (P = .890), or 12 months (P = .601). At 12 months, 60% of O borders and 40% of A borders were globally rated as "better" (P = .258). There were no significant differences in the patients' subjective ratings of the O and A borders at 3 months (P = .920), 6 months (P = .960), and 12 months (P = .66). The scar quality at the border of a skin graft does not appear to be affected by the surgical technique used to construct the border at the time of grafting.

Orofacial rehabilitation after severe orofacial and neck burn: Experience in a Brazilian burn reference centre

OBJECTIVE

To quantify the benefits of a functional oral rehabilitation program for impairment caused by full thickness orofacial and neck burns, comparing the effects of early and late intervention.

METHODS

An observational cross-sectional study was conducted in a burn reference center over a two-year period. Patients with full thickness orofacial and neck burns were divided in two groups: Group 1 was composed by 14 patients who began the rehabilitation program 3-12 months after the burn injury; Group 2 was composed by 15 patients who began the rehabilitation program more than 12 months after the burn injury. Treatment was based on current strategies of non-surgical exercises for orofacial contracture management. Outcome measurements included an oral motor clinical evaluation and the assessment of the mandibular range of movement.

RESULTS

The functional rehabilitation program was effective in reestablishing the oral motor functions (i.e deficits reduced to approximately 15% when compared to the optimal possible scores) and in restoring horizontal mouth opening dimensions, with more than 70% of the patients presenting measurements within the expected normal limits at the end of treatment. Our results did not indicate differences in performance between the group of patients in neither set of assessments, i.e. pre and post treatment (p > 0.05).

CONCLUSION

The results of this study indicate that non-invasive orofacial contracture management is effective for patients with orofacial and neck burns, including those with long term sequelae.

Reabilitação motora orofacial em queimaduras em cabeça e pescoço: uma revisão sistemática de literatura

RESUMO Objetivos Investigar estudos sobre o tratamento das queimaduras em cabeça e pescoço, nas diversas áreas da saúde envolvidas na assistência a queimados (médica, enfermagem, fonoaudiologia, fisioterapia e terapia ocupacional), avaliando a eficácia das técnicas empregadas, principalmente no que se refere à reabilitação da funcionalidade da musculatura em cabeça e pescoço. Estratégia de pesquisa Os artigos foram selecionados por meio da base de dados PubMed, utilizando os descritores “burn and face and speech-language pathology”, “burn and face and speech language”, “burn and face and rehabilitation”, “burn and face and myofunctional rehabilitation”, “burn and face and myofunctional therapy”, “nonsurgical and scar and management”, “burn and face and nonsurgical” e “burn and face and scar and management”. Critérios de seleção Foram incluídos artigos que investigaram os tratamentos das queimaduras em cabeça e pescoço, associados à reabilitação da funcionalidade da musculatura em cabeça e pescoço, utilizando exercícios musculares e/ou terapias manuais. Resultados A maioria dos tratamentos descritos apresentou efeitos benéficos para pacientes com queimaduras. Foi observada grande variabilidade da metodologia adotada para a aplicação e verificação dos efeitos dos tratamentos. Conclusão Apesar do crescente número de pesquisas, ainda não existe consenso quanto à melhor técnica terapêutica e ao real benefício de cada uma delas. Existe uma grande diversidade nos protocolos de tratamento, sendo que um número pequeno de estudos de tratamento visa a funcionalidade do sistema miofuncional orofacial. A maioria dos estudos tem, como foco, atividades motoras isoladas, que visam à mobilidade mandibular.

Approaches to cutaneous wound healing: basics and future directions

The skin provides essential functions, such as thermoregulation, hydration, excretion and synthesis of vitamin D. Major disruptions of the skin cause impairment of critical functions, resulting in high morbidity and death, or leave one with life-changing cosmetic damage. Due to the complexity of the skin, diverse approaches are needed, including both traditional and advanced, to improve cutaneous wound healing. Cutaneous wounds undergo four phases of healing. Traditional management, including skin grafts and wound dressings, is still commonly used in current practice but in combination with newer technology, such as using engineered skin substitutes in skin grafts or combining traditional cotton gauze with anti-bacterial nanoparticles. Various upcoming methods, such as vacuum-assisted wound closure, engineered skin substitutes, stem cell therapy, growth factors and cytokine therapy, have emerged in recent years and are being used to assist wound healing, or even to replace traditional methods. However, many of these methods still lack assessment by large-scale studies and/or extensive application. Conceptual changes, for example, precision medicine and the rapid advancement of science and technology, such as RNA interference and 3D printing, offer tremendous potential. In this review, we focus on the basics of wound treatment and summarize recent developments involving both traditional and hi-tech therapeutic methods that lead to both rapid healing and better cosmetic results. Future studies should explore a more cost-effective, convenient and efficient approach to cutaneous wound healing. Graphical abstract Combination of various materials to create advanced wound dressings.

Bold to do - bald to be? Outcomes decades after harvesting the scalp in burned children

BACKGROUND

The scalp is the only hidden donor site for split thickness skin grafts. Nevertheless, it is underappreciated due to fear of iatrogenic scarring alopecia. Long-term data showing whether androgenetic hair loss can reveal previously hidden scarring alopecia is unavailable. We aimed to evaluate results and patient satisfaction up to 30years after skin harvest from the scalp.

METHODS

Burn patients, hospitalized between 1977 and 1987 at the University Children's Hospital Zurich with scalp skin harvest and currently over 30years old, were studied. Medical records and patient satisfaction were analyzed, and a clinical scalp examination was performed.

RESULTS

Thirty-two patients (18 males, 14 females) with a current age of 34.13±3.42years participated. Mean follow-up time was 27.09±3.04years. Fifty-four scalp harvests were performed with 1.69±0.96 sequential harvests. Hair growth was considered normal in 97% patients. Androgenetic alopecia (AGA) type Norwood II-VI was seen in 11 patients. Scalp examination revealed 11 unknown likely harvest-related alopecias with a mean size of 0.7cm².

CONCLUSIONS

Long-term morbidity of scalp skin harvest and the risk of clinically significant alopecia is very low while patient satisfaction is high. AGA is unlikely to reveal harvest damage previously hidden by regrown hair.

Scalp as a donor site in children: Is it really the best option?

BACKGROUND

Since 2003 we have used the scalp as a donor site for split skin grafts (SSGs) in major burns when there was a shortage of conventional donor areas. However, we seen a high incidence of complications, contrary to international experience.

OBJECTIVE

The aim of this study was to analyze the results and complications related to the scalp as a donor site and to determine whether there is an association between our specific patient population and the complications encountered.

METHODS

A retrospective review of our scalp donor site outcomes over a 12-year period was conducted. The cohort included 25 patients, 15 of black African descent, nine of mixed race and one Caucasian. The various hair types were identified based on ethnicity and classified into eight types. Most of our patients had hair types VI-VIII. None of these patients had scalp burns and all received standard burn treatment. The SSGs were taken with an electric dermatome with a standard micrometric setting of 0.2mm. Complications were categorized into short- or long-term, with a mean follow-up time of 1.59years.

RESULTS

The mean age of the 25 children was 5.7years. Nineteen sustained flame burns and 6 sustained hot water burns, with a mean total body surface area of 44.9%. A total of 43 scalp procurements were performed in the 25 patients studied. The group of 15 black African patients (hair types VI-VIII) had a total of 22 procurements, the nine patients of mixed race (hair types III-V) had 18 procurements and the single Caucasian patient (hair types II-III) had two procurements. The median healing time was 15days, 11.8days and 8.5days, respectively, per group. Significant complications were encountered, including folliculitis 44%, non-healing wounds 52%, alopecia 16% and visible, hypopigmented scars 3%. One patient had a hypertrophic scar and no hair transfers to the recipient areas were observed. The various hair types correlated with the complications encountered. Five children, with an average burn size of 65.2% (range: 40-85%) died of sepsis. Due to the small sample size, the only statistically significant findings were related to the total body surface area of the burn and the number of times skin was harvested from the scalp, with a p-value of 0.005. The p-values for the healing times related to the first, second and third croppings, were p=0.022, p=0.00032 and p<0.001 respectively.

CONCLUSION

Our study suggests that in pediatric patients of black African descent (hair types VI-VIII) the scalp is not an ideal donor area, due to the unacceptably high incidence of complications. Hence, every precaution should be taken when it becomes necessary to harvest donor skin from the scalp.

Risk Factors for Ocular Burn Injuries Requiring Surgery

The surgical management of severe ocular burns is challenging and often associated with variable long-term outcome. The aims of this study were to analyze the clinical course of these injuries and determine the factors associated with the need for surgery. A retrospective medical records review was conducted for patients admitted to the Victorian Adult Burns Services, with ocular burns, from January 2000 to January 2010. One hundred and twenty-nine patients were admitted with ocular burns, of which 17 (13.2%) required surgery. The most common indication for surgery was ectropion (n = 9) and the most frequent procedure was full-thickness skin grafts to the eyelids (n = 10). Almost all patients managed surgically developed late ocular complications, the most frequent being visual loss and recurrent ectropion (n = 7 each). Patients undergoing surgery had a longer length of hospital stay (median [interquartile range] 40 [12-90] vs 12 [4-29.5] days; P = .004) and larger TBSA burned (median [interquartile range] 20 [10-60] vs 8 [4-20]; P = .011). Factors associated with the need for surgery included flame burns, periorbital edema, visual loss on presentation, increasing severity of eyelid and facial burns, severe corneal injury, as well as lagophthalmos, ectropion, and microbial keratitis (P < .05). Although only a minority required surgery, these patients often require multiple procedures and develop long-term ocular morbidity.

Ivy Loop Wiring: A Useful Form of Endotracheal Tube Stabilization in Burn Patients

The stabilization of endotracheal tubes in the burn population presents many problems. Access to the face for dressings, debridements, and the use of topical antimicrobials prevent adequate stabilization of the endotracheal tube with commonly used methods. Conventional methods have an increased risk of shifting, which can lead to injury to the friable burned tissue or unplanned extubation. To prevent these complications, alternative methods using the dentition to stabilize the endotracheal tube have been described. Here, we present our technique of using Ivy loops to secure the endotracheal tube. It is a simple method with low complications that provides a strong stabilization of the tube while giving access to the face.

Head and Neck Reconstruction

Management of head and neck burns involves acute and intermediate phases. Acutely, the goals are establish a secure airway and treat life-threatening injuries. Then, optimize nutrition, assess extent of the burn, perform local wound care, and provide eye protection. Management depends on the degree of the head and neck burn. Postinjury splinting and rehabilitation are vital to healing. After the acute inflammation has resolved and the scars have matured, reconstruction begins with the goals of restoring both function and aesthetics. Reconstruction ranges from simple scar release, to skin grafting, and possibly free flap reconstruction.

Surgical treatment algorithms for post-burn contractures

Burn contractures produce restrictions in motion and unacceptable aesthetic results, frequently with persistent wounds. Proper planning and tissue selection are essential to minimize donor site morbidity optimizing outcomes. The principle of burn reconstructive surgery requires that the defects after release should be replaced with donor tissues which have matching texture and color as well as enough pliability. Autologous skin grafting or flap surgeries meet these criteria to replace scar tissues and resurface the subsequent to post-released scar defects. Despite the benefits, the use of flaps is often limited in burn patients for many reasons. If a surgeon intends to release completely and reconstruct in one-stage operation, a large defect may result in large donor site morbidity, necessitating flap surgery including free flap surgery. A lot of different methods and procedures are available for resurfacing the defects, and these are reviewed. In this article, algorithms for the release of burn contractures and reconstructive methods are presented. These treatment algorithms should aid in achieving significant improvement in both joint motions and aesthetic deformities.

The scalp as a donor site for skin grafting in burns: retrospective study on complications

Background

Split skin grafting (SSG) is the cornerstone in the treatment of deep burns and large skin defects. Frequently used donor sites are the thigh, abdomen and buttocks. The scalp is less common while considered as a reliable donor site. Advantages are a large surface area, rapid wound healing, cosmetically favourable results and multiple harvests from the same donor site. Complications include scab formation, chronic folliculitis and alopecia but have been recorded sporadically in previous studies. This article evaluates the complication rate of the scalp donor site in the treatment of deep burns in the Beverwijk Burn Centre.

Methods

A retrospective study was performed of all patients who received a skin graft from the scalp at the Beverwijk Burn Centre between January 2004 and December 2012. Data were collected from medical files of included patients, including gender, age, type of burn (scald, flame, other) and total body surface area (TBSA) burned at the time of first surgery. Postoperative variables were healing time of the donor site and incidence of complications. During follow-up, the incidence of late complications was reviewed.

Results

A total number of 105 grafts were analysed in 93 patients: 58 males (62 %) and 35 females (38 %), with a median age of 2 years and 3 months old. Of the patients, 30 (32 %) had flame burns and 57 (61 %) had scald burns. Eighty-seven percent of patients had a TBSA burned of 5 % or less. All donor sites healed within 14 days. No alopecia or scar hypertrophy developed at the donor sites. Two patients (2.2 %) developed folliculitis; one patient (1.1 %) showed scab formation.

Conclusions

The scalp as a donor site in our Burn Centre shows a comparable short-term complication rate to the previous literature, with quick healing and no long-term complications. Therefore, we propose the consideration of the scalp as a primary donor site, especially in young children, where the scalp offers a larger donor site area than the buttocks or thighs.

Preliminary results in single-step wound closure procedure of full-thickness facial burns in children by using the collagen-elastin matrix and review of pediatric facial burns

BACKGROUND

Management of full-thickness facial burns remains one of the greatest challenges. Controversy exists among surgeons regarding the use of early excision for facial burns. Unfortunately, delayed excision of deeper burns often results in more scarring and subsequent reconstruction becomes more difficult. A collagen-elastin matrix is used to improve the quality of the reconstructed skin, to reduce scarring and to prevent wound contraction. It serves as a foundation for split thickness skin graft and enhances short and long-term results.

AIM

We report the usage of a collagen-elastin matrix during single-step wound closure technique of severe full-thickness facial burns in 15 children with large burned body surface area, and also we review the literature about pediatric facial burns.

RESULTS

There were 15 pediatric patients with severe facial burns, 8 girls and 7 boys ranging in age from 10 months to 12 years, mean age 7 years and 6 months old. The facial burn surface area (FBSA) among the patients includes seven patients with 100%, five with 75%, and three with 50%. The average total body surface area (TBSA) for the patients was 72%, ranging between 50 and 90%. 5 of the patients' admissions were late, more than four days after burns while the rest of the patients were admitted within the first four days (acute admission time). The burns were caused by flame in eight of the patients, bomb blast in four, and scalding in three. All patients were treated by the simultaneous application of the collagen-elastin matrix and an unmeshed split thickness skin graft at Turgut Özal Medical Center, Pediatric Burn Center, Malatya, Turkey. After the treatment only two patients needed a second operation for revision of the grafts. All grafts transplanted to the face survived. The average Vancouver scar scales (VSS) were 2.55±1.42, ranging between one and six, in the first 10 of 15 patients at the end of 6 months postoperatively. VSS measurements of the last 5 patients were not taken since the 6 months postoperative period was not over.

CONCLUSION

In regard to early results, graft quality was close to normal skin in terms of vascularity, elasticity, pliability, texture and color. Esthetic and functional results have been encouraging. This study shows us that the collagen-elastin matrix as a dermal substitute is a useful adjunct, which may result in quick healing with satisfying esthetic and functional results. It also may enhance short and long-term results in after burn facial wound closure in children.

Pediatric scalp burns: hair today, gone tomorrow?

Scalp burns in the pediatric population appear relatively uncommon, with most reported cases occurring in adults secondary to electrical burns. We reviewed our experience with the management of these injuries in children. A retrospective review was conducted at our institution from March 2004 to July 2011. Scalp burns were defined as any burn crossing over the hairline into the scalp region. During the 7-year 4-month study, there were 107 scalp burns, representing 1.8% of the 6074 burns treated at our institution during that time. The cause was scald in 97, contact in 4, flame in 3, friction in 2, and chemical in 1. The majority (n = 93, 87%) appeared superficial to mid-dermal, with an average time to complete healing of 10.3 days. The remaining 14 cases (13%) were mid-dermal to full thickness, with an average time to complete healing of 50.8 days. Grafting was required in 12 cases (11%). The mean time to grafting was 4 weeks (range, 2 weeks to 2.5 months). The main complication of scalp burns was alopecia, which occurred in all grafted sites as well as in 4 patients treated conservatively. There were no other complications after grafting and no cases of graft loss. In our pediatric series, scalp burns were most commonly caused by scald injuries and were superficial to mid-dermal in depth. These generally healed rapidly but occasionally resulted in alopecia. The management of deep dermal and full-thickness scalp burns remains challenging in children, with the decision to graft often delayed.

Management of Hypertrophic Burn Scar: A Comparison between the Efficacy of Exercise-Physiotherapy and Pressure Garment-Silicone on Hypertrophic Scar

Purpose

Our study aims to investigate the effectiveness of other treatment methods for burn related scarring and to determine the possibility of their routine administration in similar clinical settings.

Methods

Through a prospective study, 66 patients were enrolled to receive either the conventional pressure garment therapy (PGT) and Silicone (control group) or exercise and physiotherapy (case group). Patients were visited regularly to be examined for the status of their scars’ regression, limbs’ dysfunction, and joint motion. Then, these two groups were compared to determine the efficacy of exercise and physiotherapy as an alternative to the conventional treatment with PGT.

Results

After about 20 months follow-up, decreased articular range of motion (ROM) was: 16 (51.5%) cases compared to 5 (15%) of controls had mild, 11 (35.5%) of the cases compared to 13 (39.5%) of the controls had moderate; and 4 (13%) of the cases compared to 15 (45.5%) of the controls had severe decreased ROM which revealed statistically significant difference (P<0.01). At the same time, Vancouver Scar Scale score was: 15 (48%) of the cases and 6 (18%) of the controls had mild Scar Scale, 12 (39%) of the cases and 14 (42.5%) of the controls had moderate score and 4 (3%) of the cases and 13 (39.5%) of the controls had severe score which revealed a statistically significant difference (P<0.05).

Conclusion

Our study showed that physical therapy andexercise are more effective than PGT, in management of burn hypertrophic scar, hence could be an alternative in cases that conventional therapy cannot be used for any reason.