Functional and Cosmetic Outcome of Full- Versus Split-Thickness Skin Grafts in Pediatric Palmar Surface Burns: A Prospective, Independent Evaluation

Use of lateral femoral cutaneous nerve blocks by landmark technique is ineffective in decreasing narcotic usage after skin grafts: A retrospective case-control study

INTRODUCTION

Cutaneous burns are commonly treated with autologous skin grafts. Following skin grafting, many patients complain of pain at the donor site. Donor sites are taken most commonly from the lateral thigh, which is innervated by the lateral femoral cutaneous nerve (LFCN). Use of a LFCN blocks should decrease nociception from the donor site.

METHODS

Our group began utilizing LFCN blocks in 2019. Utilizing anatomic landmarks, LFCN blocks were performed on all patients who received autologous skin grafts to reduce perioperative pain. A retrospective cohort study was performed on all patients with 10% or less total body surface areas burns who received an autologous skin graft. A similar cohort from 2016, prior to use of any local or regional analgesia, was used as a historical control. Post-operative enteral and parenteral narcotic analgesics were collected for each post-operative day up to day 5 or discharge (whichever came first) and converted to morphine milligram equivalents (MME) to quantify analgesia after surgery.

RESULTS

Chart review identified 55 patients in the 2020 cohort. Fifty-five patients from the 2016 cohort were matched based upon size of skin graft, total body surface area (TBSA) burned, gender, and age. There were no statistically significant differences between the two groups in terms of size of graft, TBSA burned, age, gender, or type of burn. When examining narcotics usage in the immediate perioperative period (days 0-2), we found no difference between the two groups for total MME (113 vs 133, p = 0.28) or IV MME (38 vs 33, p = 0.45). Similar relationships existed in the extended post-operative period (days 1-5) for total MME (149 vs. 188, t = 0.22) or IV MME (37 vs. 50, t = 0.25). Examining daily narcotic usage also yielded no statistically different values.

CONCLUSION

Our data shows that use of LFCN block by landmark technique did not reduce narcotic usage in patients that undergo skin grafting procedures. Future studies should consider ultrasound-guided LFCN blocks.

A prospective analysis of the efficacy of phase II autologous skin grafting on deep second‑degree burns on the dorsum of the hand

The aim of the present study was to investigate the possibility of reducing the damage to the donor site while preserving the functional recovery of the dorsum of the hand following burn injury. An attempt was made to analyze the effect of a phased surgery approach on inflammatory indicators. A two-phase treatment was administered on a total of 64 patients with deep second-degree burns on the dorsum of the hand who were admitted to Guangzhou Red Cross Hospital between January 2020 and March 2023. During phase I treatment, the wounds were covered with xenogeneic (porcine) skin, followed by the application of autologous thin intermediate thickness skin grafts for wound repair in phase II treatment 1 week later. The surgical results, complications, patient satisfaction and inflammatory response indicators were then analyzed. The mean wound healing time of these patients was found to be 21.94 days without complications. The mean survival rate was 98.66%, and the overall satisfaction score of the patients was high. Finally, the white blood cell, C-reactive protein and IL-6 levels of these patients were continuously decreased 2 days preoperatively and 2 days postoperatively in phase I, and 2 days preoperatively and 2 days postoperatively in phase II. In combination, the effect of phased autologous skin grafting in patients with severe second-degree burns on the dorsum of the hand was ideal, as it significantly reduced inflammatory response and was beneficial to the functional recovery of the hand. Therefore, phased autologous skin grafting is worthy of wider application.

First do no harm: A patient-reported survey of split skin graft donor site morbidities following thin and super-thin graft harvest

The split-thickness skin graft (STSG) donor site is the commonest used during burn surgery which has its own complications and as such the focus should be on minimizing it. Modifications to practice in our unit which we believe aid this include limiting the amount of STSG taken and the harvest of super-thin STSGs, with 0.003-0.005 in. (0.08-0.13 mm) being the commonest dermatome settings used. A patient-reported survey via a mobile phone link to a questionnaire was sent to 250 patients who had a STSG for an acute burn between 1st August 2020 and 31st July 2021. Patient demographics were collected from electronic records including the thickness of the FTSG taken when recorded. Patient responses were statistically analyzed and logistic regression with backwards elimination was performed to explore which contributing factors led to an improved experience of the donor site. Questionnaire responses were obtained from 107 patients (43%). These were between one and two and a half years after the injury. Concerning early donor site issues, itch was a problem for 52% of patients, pain was a problem for 48% of patients. Less common problems (fewer than 25% of patients) were leaking donor sites, wound breakdown, and over-granulation. Regarding long-term outcomes, increased, decreased or mixed pigmentation at the donor site was reported by 32% patients at the time of the survey. Hyper-vascular donor sites were reported by 24% patients. Raised or uneven feeling donor sites were reported by 19% patients, firm or stiff donor sites by 13% patients, and altered sensation by 10% patients. At the time of the survey, 70% responders reported their donor site looked "the same or about the same as my normal skin". Of these, 62 reported how long it took for this to happen, and it equates to a third looking normal at 6 months and half looking normal at a year. For the 32 patients who reported their donor site looking abnormal, 72% were "not bothered" by it. Patients with super-thin grafts (0.003-0.005 in.) were significantly more likely to have normal sensation, normal stiffness, and be less raised at their donor sites than those who had thin grafts (0.006-0.008 in.). This survey gives important information on patients' experiences of donor site morbidity that may form part of an informed consent process and allow tailored advice. Furthermore, it suggests that super-thin grafts may provide a superior donor site experience for patients.

A Comparative Analysis of the Outcomes of Various Graft Types in Burn Reconstruction Over the Past 24 Years: A Systematic Review

Burn injuries, a major global health concern, result in an estimated 180,000 fatalities annually. Despite tremendous progress in treatment methods over the years, the morbidity and mortality associated with burns remain significant. Autologous skin grafting, particularly split-thickness skin grafting (STSG), has been a cornerstone in burn reconstruction, and it has facilitated survival and functional recovery for total body surface area (TBSA) significantly. However, the requirement for primary closure at the donor site due to the constraints of full-thickness donor harvesting continues to pose challenges. The introduction of dermal regenerative templates (DRT) in the late 1970s marked a substantial step forward in tissue engineering, addressing the inadequacy of dermal replacement with STSGs. This systematic review aimed to compare the outcomes of different graft types - bioengineered, autografts, allografts, and xenografts - in burn reconstruction over the last 24 years. The review focused on the pros and cons of each graft type, offering clinical insights grounded in experience and evidence. The approach involved a systematic review of studies published in English from January 2000 to January 2024, covering randomized controlled trials (RCTs), cohort studies, case-control studies, and case series. The participants comprised individuals of all ages who underwent burn reconstruction with skin grafts, specifically split-thickness grafts, full-thickness grafts, composite grafts, and epidermal grafts (autografts, allografts, and xenografts) and bioengineered grafts. The primary outcomes were functional and cosmetic results, patient satisfaction, graft survival, and complications. The risk of bias was evaluated using the Cochrane risk-of-bias tool for randomized trials version 2 (RoB 2), the Newcastle-Ottawa Scale (NOS) for non-randomized studies, and the Canada Institute for Health Economics (IHE) quality appraisal tool for case series. Our initial search yielded a total of 1,995 articles, out of which 10 studies were selected for final analysis. Among the four clinical trials assessed, 75% showed a high risk of bias. The studies reviewed involved various graft types, with six studies (60%) concentrating on allografts, three (30%) on autografts, and one (10%) on bioengineered skin grafts. The outcomes were varied, underlining the intricate nature of burn wound management. Our evaluation revealed promising results for autologous-engineered skin substitutes and allografts but also highlighted methodological disparities among the studies included. The dominance of observational studies and the diversity of outcome measures present obstacles to direct comparisons. Future research should address these limitations, employing well-structured RCTs, standardized outcome measures, and exploring long-term outcomes and patient-specific factors. The rapidly evolving field of regenerative medicine offers great potential for novel grafting methods. This systematic review provides valuable insights into the diverse outcomes of burn reconstruction using different graft types. Autologous-engineered skin substitutes and allografts seem to hold significant promise, suggesting a possible shift in grafting techniques. However, methodological inconsistencies and the lack of high-quality evidence underscore the necessity for further research to fine-tune burn care approaches.

Prevention and Treatment of Burn Scar Contracture: A Practical Review

Burn contracture affects close to one-third of all burn patients, leading to significant functional impairment and costs. Effective prevention and treatment strategies are necessary to decrease morbidity and unnecessary costs. This scoping review aimed to summarize prevention and treatment strategies used for management of burn scar contractures published in the literature since 2000. A comprehensive PubMed review was performed in October 2022 to identify methods of burn contracture prevention and treatments. Non-English, duplicate, and unavailable articles were excluded. Data were extracted including publication year, techniques, and outcomes. A total of 327 publications met criteria for inclusion. Most articles were published in 2011 (n = 22). Treatment strategies were discussed in 82.9% of studies, prevention in 16.5%, and both in 0.6%. The most common areas discussed included the upper extremity (n = 127) and neck (n = 102). Flaps were the most frequently used method (n = 208), followed by autografts (n = 89). Most preventative therapies were still in early stages of development. Burn contracture management requires a highly individualized approach with many available reconstructive techniques available. Further research is needed to improve prevention techniques and decrease morbidity and cost to patients.

Full-Thickness Skin Graft Versus Split-Thickness Skin Graft for Radial Forearm Free Flap Transfer in Oral Cavity Reconstruction: A Systematic Review and Meta-Analysis

The radial forearm free flap (RFFF) is a surgical technique for addressing intraoral reconstruction. However, with the limitation of an unavoidable defect at the RFFF donor site, split-thickness skin grafts (STSGs) have been a solution for repairing these defects, but they are not without challenges. This study aimed to evaluate an approach using full-thickness skin grafts (FTSGs), comparing their effectiveness in terms of aesthetics, pain, complications, and scarring. A systematic review and meta-analysis were conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies comparing FTSG with STSG for RFFF donor site repair in head and neck cancer patients were included. Primary outcomes measured were appearance and pain at the RFFF site, and secondary outcomes were infection, tendon exposure, graft loss, and scar assessment. A meta-analysis and systematic review of eight studies demonstrated that FTSG provided a superior aesthetic appearance at the RFFF donor site compared to STSG (p = 0.001), with low heterogeneity among the studies. The analysis found no significant difference in donor site pain between techniques. There were no significant differences in infection, tendon exposure, or skin graft loss between the two graft methods. This study suggests that FTSG is comparable to STSG in terms of donor site pain, scarring, and infection while offering superior aesthetic outcomes.

Functional and aesthetic outcomes of abdominal full-thickness skin grafts in paediatric postburn digital and palmar flexion contractures

The study aimed to assess the functional and aesthetic outcomes of abdominal full-thickness skin grafts (FTSGs) in paediatric postburn digital and palmar flexion contractures. The digital and palmar functions and aesthetics of 50 children who met the criteria were evaluated at pre-operation, the 3rd- and 12th-month post-operation, respectively. In the evaluation, the Vancouver Scar Scale (VSS), total active movement (TAM), and Jebsen-Taylor Hand Function Test (JHFT) were used. The contralateral, unaffected hand served as the criteria for functional recovery. The complications of donor sites were observed, and the take rate of skin grafts was calculated. The VSS scores at the 3rd and 12th months post-operation were lower than those before the operation. The TAM of each finger was improved at the 3rd and 12th months post-operation, compared with that before the operation. There was a significant difference in the time to complete the JHFT between the affected hand and the unaffected at the 3rd month post-operation, but no significant difference between them at the 12th month post-operation. The excellent and good take rate of the skin grafts was 90.00%.No donor site complications were observed. The abdominal FTSGs are effective in repairing paediatric digital and palmar scar contractures, with satisfying functional and aesthetic results, especially in large defects after scar release and resection.

A Single Institution's Recent Experience With Pediatric Hand Burns

Children are at risk for sustaining hand burns due to their innate curiosity, slow withdrawal reflexes, and thin palmar epidermis. We sought to summarize our recent experience managing pediatric hand burns, focusing on injuries that required surgical management. This was a retrospective review of children with burn-injured hands managed at a quaternary referral children's hospital between 2016 and 2020. Demographics and mechanisms of injury were collected for all patients. Initial management of all wounds included pain control, deflation of blisters, and mechanical debridement. Wounds were then dressed, and a plaster-backed soft cast was applied for positioning if the swelling was controlled. Wounds were reassessed in 4-7 days, at which time a nonadherent dressing with antifungal ointment or a bismuth dressing was applied to partial-thickness wounds, vs an active silver dressing for deep partial-thickness burns. For patients who underwent split-thickness or full-thickness skin grafting, additional wound care, operative, and short-term outcomes data were collected. A total of 3715 children were seen for burn injuries during the study period, of which 2100 (56.5%) were seen for hand burns. In total, 123 (5.8%) required a skin graft an average of 11.7 days from the date of their burn injury. Surgical complications were minimal with 5 (4.1%) incomplete graft takes, though none required reoperation, and 1 (0.8%) experiencing a postoperative wound infection. Pediatric hand burns are common. A multidisciplinary treatment approach, including standardized wound care and adept therapeutic interventions, will lead to spontaneous healing in approximately 95% of patients.

Reporting of scar outcomes in the hand and wrist; a state-of-the-art literature review

OBJECTIVES

The aim of this literature review was to synthesise and report current practice in evaluation and reporting of scar outcomes in hand and wrist clinical research.

METHODS

A systematic search from inception to 2022 was conducted using three electronic databases. English language randomized controlled trials and observational cohort studies reporting standardised scar outcome measures and/or scar symptoms, appearance, impairment, function, or mental health outcomes in patients with hand and wrist scars were included. Two independent reviewers determined study eligibility and performed data extraction of a priori identified scar outcome domains. Data analysis included descriptive statistics and identification of discordance in taxonomy.

RESULTS

Fifty-nine studies were included. Elective surgery cohorts were the most frequently included clinical population (n = 28; 47%) followed by burns (n = 16; 27%). Six different standardised scar outcome measures were reported by 25% of studies however only 7% of studies utilised a patient-reported measure. Scar symptoms were the most frequently reported outcome domain (81%); but taxonomy was incongruous, constructs lacked working definitions required for generalisability and outcome measurement was variable and unreported. Nineteen different measures of scar appearance and structure were reported by 30 (51%) of studies however only nine (23%) were patient-reported. Seven different hand function PROMs were reported by 25 (43%) studies. Person-centred domains including scar acceptability (12%), mental health impact (5%), and social participation (4%) were rarely reported.

CONCLUSIONS

This review highlights that evaluation and reporting of hand and wrist scar outcomes is not standardised, assessment methods and measures are under-reported and there is discordance in taxonomy. Evaluation is not person-centred, rather it is dependent on clinician assessment. Domains including scar acceptability, mental health, and social participation are rarely addressed. A stakeholder consensus derived hand and wrist scar core outcome measurement set will promote standardisation and underpin improvements in clinical research quality, transparency, and rigour.

Flexible application of scar tissue flaps in scar contracture release surgery: A retrospective study

BACKGROUND

Complete release of scar contracture often relies on surgery, but if the surgery injures normal skin tissue triggers new wounds and scarring, which adds insult to injury for the patient.

OBJECTIVE

To explore a method that uses scar tissue to repair the defect after the release of scars and try to avoid damage to normal skin tissue.

MATERIALS AND METHODS

Forty-eight scar contracture patients admitted to our hospital from October 2014 to October 2019 were treated with scar tissue flaps (including Subcutaneous pedicle rhomboid flap, Z-plasty flap, 5-flap, and their combination model) and minor defects in combination with little scattered skin grafts. Medical and demographic data were collected on each patient. Assessed the joint range of motion (ROM) preoperatively and postoperatively, and complication was recorded. The rate of scar contracture recurrence was recorded at a follow-up of 6-24 months.

RESULTS

Twenty-eight cases of scar contracture located in the joint sites, 20 in the trunk. All the surgical outcomes were satisfied, with significant improvement in contracture scarring and joint status. Postoperative joint range of motion (ROM) showed a significant improvement in comparison with preoperative mobility, whereas the difference was statistically significant (p < 0.05). After 24 months of follow-up, five joints showed recontraction, with a recurrence rate of 10.42%.

CONCLUSION

Scar contracture could be efficiently treated by properly designing incisions and making the most of the scar tissue flap, to minimize and avoid damage to the normal skin.

Reliability of a novel technique to assess palmar contracture in young children with unilateral hand injuries

BACKGROUND

Palmar contracture in young children can have significant developmental consequences. Despite this, objective techniques to measure palmar range of movement and quantify contracture in young children are limited.

PURPOSE

The purpose of this study was to determine the reliability of hand span and hand length measures in young children and to establish whether there is any association with age, sex and presence of a palmar burn injury in the reliability of these measures. The study also sought to determine the normative difference and establish a cut off value for the between-hand difference to identify loss of movement in 1 hand.

STUDY DESIGN

Cross sectional METHODS: Forty-four children aged 0 to <5 years were recruited. Twenty-two children had a unilateral palmar burn injury and 22 did not have a palmar burn injury. Each child's hand span and hand length were measured 3 times. This was performed twice by the first assessor and once by the second assessor. Intraclass correlation coefficients were calculated to determine the intra-rater and inter-rater reliability. The largest of the 3 values for both hand span and hand length from the first assessor's first assessment were used to determine the normative between-hand difference. Outliers were removed prior to determining the normative difference. Children were considered outliers if their between-hand difference in hand span and/or hand length was in the top 5% of values.

RESULTS

Excellent reliability was established for hand span and hand length measures for the whole group (intra-rater ICC_2,1 ≥0.95, inter-rater ICC_2,1 ≥0.94). The mean normative between-hand difference for both measures was 2 mm. The cut-off for the normative difference in hand span was <9 mm and hand length was <6 mm.

CONCLUSION

This measurement technique has excellent reliability and could be a useful method to quantify palmar range of movement and identify contracture in young children with unilateral hand injuries.

Use of Autologous Skin Cell Suspension for the Treatment of Hand Burns: A Pilot Study

Purpose

Autologous skin cell suspension (ASCS) is a valid alternative and adjunct to split-thickness skin grafting (STSG) for treating burns. Limited data exists regarding the use of ASCS for hand burns. We hypothesized that using ASCS in hand burns shortens healing time with no difference in complications and less donor site morbidity.

Methods

This was a retrospective chart review of second- and third-degree hand burns treated at a level 1 Trauma and Burn Center from 2017 to 2019. Study groups included patients with hand burns treated with ASCS in combination with STSG and those treated with STSG alone. Outcomes included time to re-epithelialization, return to work, length of hospital stay, and complications including reoperation, graft failure, and infection.

Results

Fifty-nine patients aged 14 to 85 years (mean age 39 ± 15 years) met inclusion criteria. The ASCS treatment group comprised 37 patients; STSG comprised 22 patients. Mean follow-up time was 14 ± 7 months. The ASCS treatment group had a larger mean percent total body surface area (TBSA) (22% ± 14% vs 6% ± 8%; P < .05). There was no difference in time to wound re-epithelialization between both groups (ASCS, 11 ± 4 days vs STSG, 11 ± 5 days). Mean length-of-stay was 23 ± 13 days compared to 10 ± 13 days (P < .05) between the ASCS and STSG groups, respectively. No patients in the ASCS group required reoperation, whereas 2 patients in the STSG group required such for an infection-related graft loss and a web space contracture release. On multivariable analysis adjusting for TBSA, ASCS was associated with an earlier return to work (P < .05).

Conclusions

ASCS is safe and effective in treating hand burns. ASCS was associated with similar rates of re-epithelialization, earlier return to work, and no difference in complications compared with STSG.

Type of study/level of evidence: Therapeutic IV.

Historical Evolution of Skin Grafting-A Journey through Time

Autologous skin grafting was developed more than 3500 years ago. Several approaches and techniques have been discovered and established in burn care since then. Great achievements were made during the 19th and 20th century. Many of these techniques are still part of the surgical burn care. Today, autologous skin grafting is still considered to be the gold standard for burn wound coverage. The present paper gives an overview about the evolution of skin grafting and its usage in burn care nowadays.

Surgical Management of Post Burn Hand Deformities

Objective

To evaluate the efficacy of different surgical procedures on post burn contracture of hand.

Methods

A quasi-experimental study design was conducted at the Department of Plastics and Reconstructive Surgery, Dow University of Health Science, DR. Ruth KM Pfau, Civil Hospital, Karachi, Pakistan from 1^st June 2019 to 30^th November 2019. Ninety-three participants of burned hand contracture of either gender, aged between 6- 60 years were included in the study. Resurfacing surgery with skin graft and loco-regional flaps were done according to type of contracture with individualization for each patient. All patients were kept under follow up for ninety days to assess efficacy of contracture release for each surgical procedure was noted. SPSS version 23 was used to analyse data.

Results

Full thickness skin graft (FTSG) was performed in 60.2% cases, 17.2% with split thickness skin graft (STSG) and 12.9% with cross finger flaps. About 25% of recurrence was observed in cross finger flaps, whereas no recurrence was seen in Z-plasties and posterior interosseous flap. The significant association was between recurrence and surgical procedures (p<0.05).

Conclusion

Z-plasty followed by FTSG was effective in the management of post burn contractures of hand.

Thin and Ultra-Thin Split-Thickness Skin Grafts Are Safe and Efficacious in the Burn Population

Split-thickness skin-grafts are a mainstay of burn management. Studies suggest no benefit to using thick (0.025 inch) over standard (0.012-0.020 inch) grafts, and some support the use of thin (0.008 inch) over standard thickness. Data on the use of even thinner grafts is scarce. This study reviewed outcomes of burn patients treated with thin (0.008-0.011 inch) and ultra-thin (≤0.007 inch) grafts. Retrospective review of records from July 2012 to June 2016 included patients who sustained operative burns treated by a single surgeon. Patients were excluded for nonoperative injuries, inhalational injuries, or prolonged hospitalizations. Outcome measures were compared between thin and ultra-thin groups. One-hundred twenty-eight patients met inclusion criteria; 35 received thin split-thickness skin-grafts while 93 received ultra-thin. Cohort analysis demonstrated equivalent graft-take, time to reepithelialization, and functional outcomes. Time to donor-site healing was significantly faster in the ultra-thin cohort (P = .04). Of those with functional outcomes recorded, 88.1% had good-excellent function and 11.9% retained a limitation in function as designated in physical therapy notes. There were fewer complications overall (P = .004) and a lower incidence of hypertrophic scarring (P = .025) in the ultra-thin cohort. This study presents a single-surgeon experience with thin and ultra-thin split-thickness skin-grafts. These grafts are exhibit excellent graft-take and few complications. There was no correlation between thickness and functional outcome at the time of physical therapy discharge. Donor-site reepithelialization was faster with ultra-thin grafts, which may be important in patients with large burns and limited donor sites.

Contact Hand Burns in Children: Still a Major Prevention Need

Since toddlers explore with their hands, contact burns continue to be a major pediatric problem. The purpose of this report is to review our 8-year experience with contact burns of the hand. After institutional review board approval, a review of pediatric contact hand burns that occurred between 2006 and 2014 was performed. In the 8-year span, 536 children had contact hand burns. The majority suffered burns from an oven or stove (120). The other etiologies included burns from a fireplace (76), clothing iron (65), curling or straightening iron (50), and firepit or campfire (46). The mean age was 2.62 years, with a range of 2 months to 18 years. Male children (339) burned their hands more than females (197). Most children burned the palmar aspect of their hand (384) compared to the dorsum (61). These burns typically cover small TBSAs (mean 1.08% TBSA), with only 2% of burns comprising &gt;5% TBSA. Approximately, 84% of these patients did not need surgery, but 86 (16%) had skin grafting (usually full thickness) and roughly 26% of those needed reconstructive surgery. Contact burns to the hand continue to be a major problem for toddlers. Children are most likely to burn themselves on an oven or stove, fireplace, clothing iron or curling/straightening iron. The palmar surface of the hand is the most likely site. While most children do not require surgery, approximately 16% require grafting. A significant number of those patients need reconstructive surgery. Clearly, current prevention efforts have failed to reduce these injuries.

Reconstruction of postburn contractures due to tandir oven

The aim of the study was to evaluate postburn contracture reconstructions caused by high temperature such as tandir. The records of our 58 patients who were operated for burn contracture between 2008 and 2018 were retrospectively reviewed. Duration elapsed after the burn, localization of contracture, surgery applied, and the recurrence rates were recorded. McCauley classification was used to evaluate the severity of hand contractures. One hundred and thirty-seven contracture release operations were performed in 45 hands in 40 cases. Five patients had bilateral hand contractures. One hundred and sixty-three (84.9%) surgeries out of total 192 contracture release surgery were applied to the hand and foot region. FTSG alone was the most common method of treatment. Z-plasty was used the most frequently by our team as the flap surgery. Tissue damage is more severe due to very high temperature of the tandir and as a result, more frequent and heavier burn contracture occurs on hands and feet than other burn etiologies develops, and reconstructive operations are needed more frequently.

Skin grafting after paediatric palmar burns: an analysis of 82 patients

Contact burn injuries to the palm are common in toddlers. We report a case series of 82 paediatric patients (age 7-48 months) with contact burn injury of the palm. We share our experience and outcomes of using plantar split-thickness skin grafts for resurfacing of the paediatric palm. We found that despite the excellent colour and texture match, split-thickness skin grafts from glabrous skin during growth are prone to motion-limiting scare contracture. From this series, we conclude that full-thickness skin grafts remain the reference standard of care in paediatric patients' hands. We recommend that children with burn scars should have regular check-up examinations until they are fully grown. Level of evidence: IV.

Combined multiphoton imaging and biaxial tissue extension for quantitative analysis of geometric fiber organization in human reticular dermis

The geometric organization of collagen fibers in human reticular dermis and its relationship to that of elastic fibers remain unclear. The tight packing and complex intertwining of dermal collagen fibers hinder accurate analysis of fiber orientation. We hypothesized that combined multiphoton microscopy and biaxial extension could overcome this issue. Continuous observation of fresh dermal sheets under biaxial extension revealed that the geometry of the elastic fiber network is maintained during expansion. Full-thickness human thigh skin samples were biaxially extended and cleared to visualize the entire reticular dermis. Throughout the dermis, collagen fibers straightened with increased inter-fiber spaces, making them more clearly identifiable after extension. The distribution of collagen fibers was evaluated with compilation of local orientation data. Two or three modes were confirmed in all superficial reticular layer samples. A high degree of local similarities in the direction of collagen and elastic fibers was observed. More than 80% of fibers had directional differences of ≤15°, regardless of layer. Understanding the geometric organization of fibers in the reticular dermis improves the understanding of mechanisms underlying the pliability of human skin. Combined multiphoton imaging and biaxial extension provides a research tool for studying the fibrous microarchitecture of the skin.

The role of two-sided splinting for recalcitrant paediatric post-burn hand flexion contracture: a case report

A 2-year-old boy presented to the plastic and reconstructive surgery outpatient clinic with bilateral post-burn hand flexion contracture. The contracture had been released twice elsewhere. The third surgical repair on one hand at a time was conducted by the author (TOHP). However, inadeq.uate compliance to the postoperative splinting and exercise led to the recurrence of the contracture in the following year. A customised two-sided splint was therefore created to ensure proper placement and compliance. Reinforcement to the parents to encourage the boy to practise active exercise on demand was also an integral part of the management. Good functional and cosmetic outcome were presented at 1-year follow-up. This case highlights the value of a two-sided splint for the management of post-burn hand flexion contracture in children whose compliance is inevitably cannot be guaranteed.

Reconstruction of the Adult and Pediatric Burned Hand

Thermal injuries of the hand can have a great impact on function. Initial treatment should focus on the prevention of contracture through the use of tissue-sparing techniques and optimized occupational therapy. Surgical intervention should follow the standard reconstructive ladder and can involve several techniques from simple to complex including minimally invasive techniques, such as laser and steroid injection, contracture release and skin grafting, and local tissue rearrangement and regional flaps as well as distant pedicled and free flaps. Reconstructive surgery of the hand, when performed well, can lead to meaningful functional improvement in severe burns.

Is there any place for spontaneous healing in deep palmar burn of the child?

Child palm burns arise by contact and are often deep. The singular difficulty of such a disease comes from the necessity of the child growth and from the potential occurrence of constricted scars. In order to avoid sequelae, the actual gold standard is to practice an early excision of the burn, followed by a skin graft. The aim of this study is to evaluate the results of spontaneous healing combined with rehabilitation versus early skin grafting and rehabilitation concerning the apparition of sequelae. We performed a retrospective study in two burn centers and one rehabilitation hospital between 1995 and 2010. Eighty-seven hands have been included in two groups: one group for spontaneous healing and the other group for excision and skin grafting. Every child benefited from a specific rehabilitation protocol. The two main evaluation criteria were the duration of permanent splint wearing and the number of reconstructive surgery for each child. The median follow-up duration is about four years. The two groups were comparable. For the early skin grafting group, the splint wearing duration was 1/3 longer than for the spontaneous healing group. Concerning the reconstructive surgery, half of the grafted hands needed at least one procedure versus 1/5 of spontaneous healing hands. Our results show the interest of spontaneous healing in palmar burn in child, this observation requires a specific and intense rehabilitation protocol.

Effectiveness of basic fibroblast growth factor for pediatric hand burns

AIM OF THE STUDY

Pediatric hand deep dermal and deep burns may lead to serious hand deformity with functional impairment and result in an esthetically unfavorable outcome. Since there is no guideline regarding the use of growth factors for pediatric hand burns, we sought to investigate the effectiveness of an angiogenic and regenerative growth factor, basic fibroblast growth factor (bFGF).

METHODS

Consecutive series of second degree or third degree palmer burns at less than 3 years of age seen from January 2010 to June 2014 were included for evaluation at 6 months post-wound healing. The bFGF treatment started from just after injury and continued up to 21 days. Each patient had their scars scored using the Vancouver Scar Scale (VSS) at 6 months after wound healing.

RESULTS

There were 34 children with 49 acute palmar burns. The mean healing period was 13.5 ± 4.3 days (7-44 days) and 43 wounds healed within 21 days. There was no need of additional surgery in the 43 wounds, healed within 21 days. In comparison to the wounds for which healing took more than 21 days, the wounds that healed within 21 days demonstrated significantly better pigmentation, pliability, and height according to the VSS (p < 0.05), as well as no scar contracture or hypertrophic scars.

CONCLUSION

bFGF treatment was effective in cases that healed within 21 days, avoiding scar contractures and hypertrophic scars. Our methods using bFGF to complete wound healing are less invasive and produce better results in pediatric palmer burns.

Retroauricular full-thickness skin grafts in syndactyly repair: outcome and comparison with inguinal full-thickness skin grafts: retrospective (cross-sectional) study

OBJECTIVE

Most surgeons recommend the use of full-thickness skin grafts for syndactyly repair. Common donor sites include the groin and elbow, but only one publication has previously mentioned retroauricular skin. No publication has compared the results for full-thickness skin grafts between retroauricular and other donor sites. This study aims at comparing functional and aesthetic outcomes and parents' satisfaction with retroauricular vs inguinal full-thickness skin grafts.

METHODS

Eleven children with retroauricular and 15 with inguinal full-thickness skin grafts were included in this retrospective study. Examination included the Patient and Observer Scar Assessment Scale, parent satisfaction, and a colour match measurement.

RESULTS

Both pigmentation match and parents' overall impression of the donor site were significantly better for retroauricular than for inguinal full-thickness skin grafts.

CONCLUSION

Due to the excellent pigmentation match and the inconspicuousness of the donor site, this study recommends the use of retroauricular full-thickness skin grafts for syndactyly repair.

The Importance of Hand Appearance as a Patient-Reported Outcome in Hand Surgery

Hand appearance is meaningful to patients because hands are an essential part of human interactions, communication, and social integration. Recent literature indicates that hand aesthetics is an important, measurable patient-reported outcome. In hand surgery, several outcome instruments exist that accurately measure functional outcomes, but aesthetics is often overlooked or imprecisely measured. This makes comparison of disease burden and effectiveness of therapies, as they pertain to aesthetics, difficult. This special topic article outlines the aesthetic features of the hand, how literature is evaluating the appearance of the hand in outcomes research, and proposes a novel approach to assessing hand aesthetics.

The use of split-thickness versus full-thickness skin graft to resurface volar aspect of pediatric burned hands: A systematic review

OBJECTIVE

The aim of this systematic review was to discuss the comparison of split-thickness skin graft (STSG) and full-thickness skin graft (FTSG) use as the treatment for volar digital and palmar burns in children.

METHODS

We conducted PubMed and Cochrane Library searches using keywords "hand injuries", "contracture" and "skin transplantation". The search was limited to studies published from 1st January 1980 until 31st December 2013 and used English language. We selected the studies based on specific inclusion and exclusion criteria. We assessed the quality of the studies by using Newcastle-Ottawa Scale (NOS) for cohort studies.

RESULTS

We included eight articles in our systematic review. One of those studies is a prospective cohort study and the others are retrospective cohort studies. Based on combined range of motion (ROM) evaluation in three studies, STSG group yielded poorer functional outcomes than FTSG group. However, there is no study which can fairly show that FTSG was significantly superior to STSG to achieve good functional outcomes.

CONCLUSION

Currently, there is no strong, high-quality evidence to prove that FTSG is superior to STSG to cover pediatric palmar burns. Either FTSG or STSG can be utilized with consideration of several influential factors especially splinting and physiotherapy.

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.

Nonmicrosurgical options for soft tissue reconstruction of the hand

There are many options for nonmicrosurgical soft tissue coverage of hand wounds, ranging from split thickness skin grafting to pedicled soft tissue transfer, depending on the size, location, blood supply, and depth of the wound. Although many of these techniques have been available for decades, recent advancements in wound management include synthetic dermal substitution, new dressing materials, and variations on previously described or novel pedicled flaps.The goals of coverage include maximizing healing, function, aesthetic appearance, and patient satisfaction, while minimizing donor site morbidity. Optimal management often relies on an individual surgeon's assessment and judgment, as hand wounds can vary greatly and pose unique challenges, and multiple coverage options often exist for each wound. Here, we aim to present useful and up-to-date information on nonmicrosurgical soft tissue coverage for hand reconstruction focusing on recent findings of interest to provide an update on areas with evolving evidence.