Abstract
Introduction
Burns of the head and neck are particularly devastating, commonly occurring due to accidental flame or scald injury. Autologous grafting has traditionally been used for ...reconstruction in this area. Recently the use of dermal matrices as a reconstructive alternative has increased. This study compares annual trends, outcomes, and hospital costs between head and neck burn patients who underwent reconstruction with dermal matrix or autologous grafting.
Methods
The U.S Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project Nationwide Inpatient Sample database was queried from 2012 to 2016. Patients with head and neck burns treated with dermal matrix or autologous graft were identified using International Classification of Disease Ninth and Tenth Revision diagnosis and procedure codes. Demographic, clinical characteristics, and outcome measures were reported. χ 2 and Student’s t-tests were used for univariate survey-adjusted comparisons between groups. Multivariate survey-adjusted linear regressions were used to identify associations between surgical intervention, length of stay and cost of hospitalization. Analyses were conducted with RStudio (1.4.1717).
Results
A total of 6,730 patients met inclusion criteria; 2,855 underwent reconstruction dermal matrix and 3,875 with autologous graft. There was an increasing number of patients undergoing dermal matrix reconstruction each year, peak in 2016 (1,450, 50.8%). The dermal matrix group was younger (33.7 vs 39.9, p< 0.001) had fewer females (27.3% vs 38.2%, p=0.003) and fewer inhalation injury (4.0% vs 11.0%, p< 0.001). The dermal matrix group had a shorter length of stay (11.2 vs 27.8, p< 0.001) and more home discharges (80.4% vs 53.4%, p< 0.001); they had lower Elixhauser Comorbidity Index score for readmission (6.57 vs 11.92, p< 0.001) and in hospital mortality (4.76 vs 9.69, p< 0.001). Median cost of care was lower for the dermal matrix group ($17,858 vs $59,860, p< 0.001). Multivariable regression demonstrated that reconstruction with dermal matrix was independently associated with decreased length of stay (11.01 7.95 - 14.07, p< 0.001) and decreased cost ($38,297 23,813, p< 0.001).
Conclusions
Operative management of head and neck burns with dermal matrix is associated with a shorter hospital stay, greater likelihood of home discharge, and decreased hospital costs. Patients with autologous grafting had higher rates of inhalation injury, which may account for longer hospital stays and increased discharges to nursing facilities. A limit of this study is the inability to differentiate patients undergoing staged procedures. Further study is needed to evaluate factors contributing to faster discharges home in the head and neck burn population.
Abstract
Introduction
While complications from fractional ablative CO2 laser treatment for burn hypertrophic scar (HTS) are relatively rare, the risk of surgical site infection (SSI) after laser ...treatment exists. When infection occurs, it has been linked to further morbidity, such as scar development in previously unaffected skin. Hypochlorous acid is a non-flammable and colorless antiseptic solution that has been used to treat wounds and is believed to be a less cytotoxic alternative to other agents such as betadine and chlorhexidine. This study aims to investigate the use of hypochlorous acid solution as a skin prep for patients undergoing laser scar revision for HTS and determine its efficacy in preventing SSI.
Methods
All patients undergoing fractional ablative CO2 laser revision of HTS at a single center from September 2016 through September 2021 were retrospectively reviewed. Data pertaining to patient demographics, skin characteristics, treatment sessions, and post-treatment complications were recorded. All patients underwent topical skin preparation with hypochlorous acid-soaked laparotomy pads for 10 minutes before laser treatment. No perioperative oral or topical antibiotics were given to any included patient. Patients were excluded from analysis if they were not treated with a fractional ablative CO2 laser, were treated for a scar etiology outside of burn injury, or if insufficient follow-up was documented.
Results
A total of 208 patients undergoing a total of 758 laser treatments were identified. Average patient age was 45 years (SD 16), with 112 (53.8%) patients being female and 96 (46.2%) being male. Median number of laser treatments was 3 (IQR: 1-5). Patients from all Fitzpatrick skin types were treated, with the most common type being type 5 (n=54, 26.0%). None (n=0, 0.0%) of the 208 patients experienced a surgical site infection after any of the laser treatments received.
Conclusions
Hypochlorous acid is a safe and effective skin preparation for patients undergoing laser burn-scar revision to prevent SSI. Moreover it is non-flammable, colorless and does not need to dry prior to procedure.
Abstract
Introduction
Carbon dioxide ablative fractional laser (CO2-AFL) therapy has become standard of care for adult burn hypertrophic scars (HTS). This therapy option has not been widely adopted ...in pediatric burn care and no established guidelines for treatment protocols have been published. We sought to modify our American Burn Associated Adult Verified Burn Centers laser protocol at our Children’s Hospital with hopes to provide optimal care to our pediatric burn population. We present our protocol and early experience of CO2-AFL therapy for pediatric burn HTS.
Methods
We conducted a retrospective chart review of pediatric burn patients undergoing CO2-AFL treatment of HTS during the study period of Jan 2021-Oct 2021. Pediatric burn patients were offered laser treatment if their scars were symptomatic with patient complaints of HTS, pruritis, neuropathic pain, and scar contractures. 37 pediatric patients ≤13 years of age were included in our review.
Results
We treated 13 pediatric patients for a total of 40 laser sessions with each patient averaging 3 sessions. Of the 13 patients that were treated with laser, 62% (8 of the 13 patients) had split-thickness skin grafting with 38% (3 of the 8 patients) of those having a staged grafting procedure with dermal substitute. 15% (2 of the 13 patients) healed primarily and 15% (2 of the 13 patients) required excision and closure. Only 1 patient treated with ASCS alone required laser therapy. Our protocol requires patients to receive pre-operative Tylenol, Benadryl, Pepcid, and Oxycodone. The patients then received MAC anesthesia with Toradol, Dexamethasone, Ketamine or Propofol, and Zofran. Patients with extensive HTS on the face or neck were intubated for the procedures. Oxycodone and/or Dilaudid were provided if needed in the post-operative phase. All patients were discharged with Tylenol or Motrin and Triamcinolone 0.1% ointment to be applied daily for 48 hours and then 3-4x/day until the follow-up clinic appointment at one week. Patients were able to resume normal activities the day following the procedure.
Conclusions
Patients and their parents have reported improvements in pigment, pliability, thickness, and pruritis following laser treatments. We created a protocol that allows on average 8 pediatric patients per day to receive laser treatment without it over burdening the pre-operative and post-operative recovery room nursing staff. We are currently tracking outliers of patients requiring increased post-operative analgesia and/or greater than 1 hour in the recovery phase. With the implementation of a laser protocol, we have successfully introduced laser therapy as a viable option for our pediatric burn survivors.
Abstract
Introduction
The first dorsal metacarpal artery perforator (DMCAP) flap is frequently used to cover exposed bone, tendon and neurovascular structures in the hand after trauma and burns. The ...size and width of DMCAP flap is limited and rotation arc generally lets to cover defects up to middle phalanx. Expansion of the DMCAP flap has not been reported in the literature and this technique might be solution to increase flap viability and size in order to cover defects up to distal phalanx. In this study, we will describe utilization of tissue expander to first DMCAP and present a case of electric burns in with flexor contracture.
Methods
A nine-year-old male patient applied to our clinic with the complaint of inability to extend the second finger of the left hand after an electrical burn. Physical examination revealed flexor contracture in the distal interphalangeal (DIP) and proximal interphalangeal (PIP) joints. Reconstruction was planned for the patient with a two-session expanded first DMCAP flap.
In the first session, a 16 cc 5x3 cm tissue expander placed through a 3 cm vertical incision at the fifth metacarpal level. From the second postoperative week, the tissue expander was inflated with 1 ml of isotonic three days a week. Six weeks later, the DMCAP area was enlarged by giving 45 cc saline.
Results
In the second session, contractures at the level of the left hand 2nd finger DIP and PIP were excised.. Left hand 2nd finger was fixated in extension with K-wire. 9x3 cm DMCAP flap was elevated by dissection over the paratenon and the pedicle was preserved. The flap was adapted to the defect area on the volar face with 180-degree rotation angle. The flap donor site was closed primarily.
There were no complications in the post-operative period. K-wire was removed at 6 weeks postoperatively. The patient was referred to the physical therapy.
Conclusions
In cases where the tissue defect cannot be closed with loco regional flaps, extra tissue can be provided by free flaps or using tissue expanders. Primary closure of the donor area, appropriate flap thickness for the finger, and aesthetically pleasing results are among the advantages of the expanded DMCA flap.. However, in tissue expander applications in the upper extremity, the patient should be followed closely, and pain and finger circulation should be constantly questioned.
Abstract
Introduction
Trochanteric region is one of the most frequent site for pressure ulcer development. High-voltage electric injuries with neurovascular damage is an important reason of ...paraplegia. These patients have prolonged hospitalization period and develop cachexia by time. Grade 3-4 sores with thoracanter major of femur exposition generally need flap reconstruction. Musculocutaneous flaps are preferred to cover exposed bone and fill the dead space. Although loco regional flaps such as tensor fasia lata, gluteus Maximus muscle flap have been used for thoracanteric ulcers, these flaps have mandatory muscles for ambulation in the following rehabilitation period. Another disadvantage of these flaps are the possible donor site problems due to pressure loading. Thus, we aimed to used vastus lateralis- anterolateral thigh(VL-ALT) flap for decreasing donor-site morbidity and tension.
Methods
Between 2019 and 2021 we have operated 6 trochanteric pressure ulcers in 5 patients. All patients had history of electric injury related paraplegia. The mean age of the patients was 33 (24-50) The defect size were ranging between 5x4cm and 10x12 cm. Flap size were planned according to exact size of the defect. VL muscle were harvested according to the size of dead space. The donor site was closed primarily in 3 patients. Split thickness skin graft were needed in 2 patients. Patients were hospitalized in lateral decubitus or supine position during follow –up.
Results
Mean follow up time was 10 months (6-18). All flaps were survived. Hematoma development were seen in 1 patient in the donor site which were treated with bedside debridement. No recurrence was seen during follow-up period. No restriction or morbidity were encountered during ambulation.
Conclusions
VL-ALT musculocutaneous flap provides the required tissue for dead space filling and defect closing simultaneously. The advantages of this flap are; lower donor site morbidity, perfect match in terms of skin quality and bulk, protecting the major muscles such as gluteus maximus and tensor fascia lata. The technique needs knowledge of quadratus femoris anatomy which has a short learning curve.
Abstract
Introduction
Facial burns are a common occurrence with a small percentage causing injury to the periocular region. Although the eye itself is often spared, madarosis may occur from deep burn ...injury to the eyelid. Reconstruction of the eyelid margin is technically difficult due to the challenging aesthetic region, as well as specific characteristics of eyelashes. Although there are several options for eyelash grafting there is no established gold standard, and there is little to no-literature related to procedures involving burn madarosis.
Methods
Here we describe a case of unilateral eyelash grafting utilizing a composite strip graft in a 20-year-old female who sustained a 70% flame injury at the age of two.
Results
The presented results show the efficacy of this technique at restoring function and providing a good aesthetic result which is maintained at 1 year follow up.
Conclusions
Utilization of a composite strip graft to recreate the eyelid margin is a viable choice for reconstruction of burned upper eyelids in the appropriate patient. Further exploration regarding procedure timing and choice of donor site are warranted.
Abstract
Introduction
The ear is one of the most highly visible structures on the face. One or both ears are frequently involved in panfacial burns. Because they are bilateral structures, asymmetries ...are clearly visible. Reconstruction of burned ear deformity often requires replacement or modification of skin and/or cartilage. Even these are successfully replaced, scar contractile forces can cause deformation of the ear. One of these deformities is lop or cup ear, in which the helical rim is either folded over, wrinkled or tight. We describe the necessity of applying otoplasty techniques to address this problem.
Methods
A retrospective chart review analysis was performed to assess demographic variables, procedural indications and procedural outcomes in pediatric patients treated at our hospital for complex ear reconstruction for ear deformities after her surgery. Inclusion criteria were pediatric patients aged 0 to 21 years admitted to Shriners Hospital for Children-Boston from January 1, 2010 to January 1, 2021 for burn injury, who subsequently required follow-up complex ear reconstruction for ear deformities after burn injury. Of these patients, those with lop ear deformities who required construction were examined. Using the Trauma Registry of the American College of Surgeons (TRACS) and Shriners Hospital for Children Information Source (SHCIS) databases, we identified 12 eligible patients. Surgical procedure data was obtained from the SHCIS electronic medical records. Surgical photographs were obtained with patient informed consent. Those patients who required Medpor or cartilage frame reconstructions were excluded.
Results
12 patients required an otoplasty-type procedure to obtain desired results or symmetry with the contralateral ear. This technique involved a posterior incision in the auriculomastoidmastoid sulcus, are you a year and cartilage modification with sutures to to re-create the antihelical fold an superior crus as well as conchal setback sutures.
Conclusions
Because ears are bilateral structures, symmetry is extremely poor. Because of multiple contractile forces on the external ear from secondary healing or contraction of skin grafts, the ear is often displaced anteriorly and the upper portions become folded. Treatment requires reconstruction of the natural folds of the ear and shortening of the helical rim to mastoid distance. this requires an otoplasty approach with a posterior incision,, exposure of the cartilaginous framework and modification of the cartilage with incisions and sutures. This technique however requires adequate soft tissue coverage of the ear.
Working the Systemoffers key insights into the politics of the everyday in twenty-first-century dominant party and neo-authoritarian regimes in Africa and elsewhere. Detailing the many ways ordinary ...Angolans fashion their relationships with the system-an emic notion of their current political and socioeconomic environment-Jon Schubert explores what it means and how it feels to be part of the contemporary Angolan polity.
Schubert finds that for many ordinary Angolans, the benefits of the post-conflict "New Angola," flush with oil wealth and in the midst of a construction boom, are few. The majority of the inhabitants of the capital, Luanda, struggle to make ends meet and live on under $2.00 per day. The "New Angola" as promoted by the ruling MPLA, Schubert contends, is an essentially urban, upwardly mobile, and aspirational project, premised on the acceptance of the regime's political and economic dominance by its citizens. In the first ethnography of Angola to be published since the end of that country's twenty-seven years of intermittent violent internal conflict in 2002, Schubert traces how Angolans may question and resist the system within an atmosphere of apparent compliance. Working the System will appeal to anthropologists and political scientists, urban sociologists, and scholars of African studies.
In the aftermath of a civil war, former enemies are left living side by side-and often the enemy is a son-in-law, a godfather, an old schoolmate, or the community that lies just across the valley. ...Though the internal conflict in Peru at the end of the twentieth century was incited and organized by insurgent Senderistas, the violence and destruction were carried out not only by Peruvian armed forces but also by civilians. In the wake of war, any given Peruvian community may consist of ex-Senderistas, current sympathizers, widows, orphans, army veterans-a volatile social landscape. These survivors, though fully aware of the potential danger posed by their neighbors, must nonetheless endeavor to live and labor alongside their intimate enemies. Drawing on years of research with communities in the highlands of Ayacucho, Kimberly Theidon explores how Peruvians are rebuilding both individual lives and collective existence following twenty years of armed conflict.Intimate Enemiesrecounts the stories and dialogues of Peruvian peasants and Theidon's own experiences to encompass the broad and varied range of conciliatory practices: customary law before and after the war, the practice ofarrepentimiento(publicly confessing one's actions and requesting pardon from one's peers), a differentiation between forgiveness and reconciliation, and the importance of storytelling to make sense of the past and recreate moral order. The micropolitics of reconciliation in these communities present an example of postwar coexistence that deeply complicates the way we understand transitional justice, moral sensibilities, and social life in the aftermath of war. Any effort to understand postconflict reconstruction must be attuned to devastation as well as to human tenacity for life.
The learning-based super-resolution reconstruction method inputs a low-resolution image into a network, and learns a non-linear mapping relationship between low-resolution and high-resolution through ...the network. In this study, the multi-scale super-resolution reconstruction network is used to fuse the effective features of different scale images, and the non-linear mapping between low resolution and high resolution is studied from coarse to fine to realise the end-to-end super-resolution reconstruction task. The loss of some features of the low-resolution image will negatively affect the quality of the reconstructed image. To solve the problem of incomplete image features in low-resolution, this study adopts the multi-scale super-resolution reconstruction method based on guided image filtering. The high-resolution image reconstructed by the multi-scale super-resolution network and the real high-resolution image are merged by the guide image filter to generate a new image, and the newly generated image is used for secondary training of the multi-scale super-resolution reconstruction network. The newly generated image effectively compensates for the details and texture information lost in the low-resolution image, thereby improving the effect of the super-resolution reconstructed image.Compared with the existing super-resolution reconstruction scheme, the accuracy and speed of super-resolution reconstruction are improved.
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