Severe burn injuries are the most traumatic and physically debilitating injuries affecting nearly every organ system and leading to significant morbidity and mortality. Early burn wound excision and ...skin grafting are common clinical practices that have significantly improved the outcomes for severe burn injured patients by reducing mortality rate and days of hospital stay. However, slow wound healing, infection, pain, and hypertrophic scarring continue to remain a major challenge in burn research and management. In the present article, we review and discuss issues in the current treatment of burn injuries; the advances and novel strategies developed in the past decade that have improved burn management; and also, pioneer ideas and studies in burn research which aims to enhance burn wound care with a focus on burn wound infection, pain management, treatments for scarring and skin tissue engineering.
Display omitted
Burn scars are a major clinical sequelae of severe burn wound healing. To effectively establish a successful treatment plan and achieve durable results, understanding the pathophysiology of scar ...development is of utmost importance.
A narrative review of the principles of the kinematic chain of movement and the hypothesised effect on burn scar development based on properties of burn scars was performed. An examination of the literature supporting these concepts is presented in conjunction with illustrative cases, with a particular focus on the effect of combination treatments that include ablative fractional resurfacing with surgical contracture releases.
Ablative fractional resurfacing combined with the surgical release of contractures are an effective treatment modality for burn scar reconstruction. This treatment approach seems particularly effective because it is one of the only approaches where the principles of functional kinematics can be addressed when tailoring a reconstructive approach to an individual burn patient. The presented cases illustrate the importance of recognising and including the principles of functional kinematic chains in any reconstructive treatment approach for burn scars. Further, epifascial contracture bands are cord like structures which can be found underneath the subcutaneous fat of scar contractures which follow the principles of functional kinematics. Contractures can be more efficiently released if these structures are divided as well.
Ablative fractional resurfacing combined with local tissue re-arrangements is a promising approach to address the underlying forces leading to hypertrophic burn scarring. To achieve an optimal outcome, it is essential to recognise and address the origin of the pathology when treating burn scars. Ablative fractional laser resurfacing allows a different scar approach as it is not limited to one surgical site and thus enables for effective treatment at the cause of the pathology.
•Burn scar features may be explained by the kinetic chain of movement•Description of functional kinetics in burn scar development•Epifascial contracture bands: A newly identified structure in burn scars•Release of epifascial contracture bands effectively releases contractures•Ablative fractional laser of entire scar group connected by functional kinematics
In this review, the authors discuss the use of laser photothermolysis and laser resurfacing in the management of hypertrophic burn scars. They provide details regarding preoperative selection, ...intraoperative decision making, and postoperative care.
The COVID-19 pandemic has significantly impacted the clinical presentations of burns and the provision of services. This study aims to describe and analyse patterns and trends in adult burns across ...New South Wales (NSW) and the Australian Capital Territory.
A NSW statewide retrospective review was conducted from 2017 to 2022 for adult patients with burns. A comparative analysis was performed for the COVID-19 group (2020–2022) and control group between 2017 and 2019.
We found a total of 11,433 patients (7102 non-COVID vs 4331 COVID-19). The average age in the COVID-19 group was 1.4 years older than counterparts (40.6 vs 42.0, p < 0.001). The 18 – 25 and 36 – 45 age groups experienced significantly lower proportions of presentations, whereas, the 76–85 years experienced significantly higher proportions. There was a significantly higher proportion of pressure injuries (0.1% vs 0.4%, p < 0.001) and contact burns (17.2% vs 18.7%), but lower explosions (1.3% vs 0.2%) for the COVID-19 group compared to their counterparts. The mean TBSA% was 0.4% greater in the COVID-19 group compared to their counterparts (2.4 vs 2.8, p < 0.001). There were significantly more operating sessions (0.2 vs 0.3, p < 0.001). The mean length of stay was significantly greater by 0.8 days for the COVID-19 group compared to their counterparts (1.5 vs 2.3, p < 0.001).
Epidemiological changes were not greatly different to previous years from the impact of COVID-19. The shift in elderly presentations and operative interventions reflects the holistic care of burns units working in a new landscape with an invigorated focus on telehealth and outpatient care.
•There was a significant decrease in burn presentations during the COVID-19 period compared to the pre-COVID-19 period.•An older population with greater severity and depth of burns were experienced.•Telehealth and outpatient care shaped the provision of services.
Early retrospective data identify that dysphagia is common in older persons with burn injury, suggesting a rate of 47 %, and that it is associated with medical, burn, and nutritional outcomes.
To ...prospectively (1) explore the incidence, (2) describe associations, and (3) evaluate risk factors for dysphagia in patients ≥ 75 years old hospitalised with burn injury.
All patients > 75 years old admitted to Concord-Repatriation-General-Hospital with burn injury over 4 years (2019–2023) were assessed for dysphagia on presentation and were continually monitored throughout their admission. Burn injury, demographic, and nutritional data were prospectively captured and analysed for association with dysphagia.
Sixty-two patients (33 male) aged 75–95 years (median=83 years) were recruited. Dysphagia was identified in 50 %. Dysphagia was associated with burn size (p = 0.002), pre-existing cognitive impairment (p = 0.000), hospital length of stay (p = 0.001), in-hospital complications (p = 0.000), feeding dependence (p = 0.002), nutritional status (p = 0.013) and enteral feeding duration (p = 0.030). Cognitive impairment was the most sensitive predictor for dysphagia at 100 % (specificity=29 %, NPV=100 %, PPV=59 %). Development of secondary comorbidities was less sensitive at 52 % (NPV 65 %), but was associated with high specificity (90 %) and PPV (84 %).
One in every two patients ≥ 75 years admitted with burn injury will demonstrate dysphagia during their hospital admission. Those with pre-existing cognitive impairment are most at risk.
•Dysphagia incidence in the older person with burn injury is confirmed to be high.•Dysphagia in the older person with burn injury is confirmed to be associated with increased morbidity and mortality.•Those with pre-existing cognitive impairment are most at risk for dysphagia.
Ablative fractional resurfacing is clinically an efficient treatment for burn scar management. The aim of this pilot study was to investigate the poorly understood mechanisms underlying ablative ...fractional CO2 laser (AFL-CO2) therapy in relation to biomarkers S100 and 11β-hydroxysteroid dehydrogenase type 1 (11β-HSD1). S100 stains for Langerhans cells and neuronal cells, potentially representing the pruritus experienced. 11β-HSD1 catalyses the interconversion of cortisol and cortisone in cells, promoting tissue remodelling. Immunohistochemical analysis of S100 and 11β-HSD1 protein expression in the dermis and epidermis of the skin was performed on normal skin, before and after AFL-CO2 therapy. Data assessing outcome parameters was collected concurrently with the skin biopsies. 13 patients were treated with AFL-CO2 therapy. Langerhans cells decreased by 39% after 2nd treatment. Neuronal cells were overexpressed before treatment in the scar tissue by 91% but levels returned to that resembling normal skin. 11β-HSD1 expression in keratinocytes was significantly higher after laser treatment compared to before in scar tissue (p <0.01). No clear correlation was found in dermal fibroblast numbers throughout the treatment course. Whilst the role of the explored mechanisms and their association with clinical outcomes cannot conclusively be stated, this pilot study demonstrates promising trends that encourages investigation into this relationship.
•Mechanisms of fractional laser resurfacing of scar healing is not well understood.•Two biomarkers, S100 and 11β-HSD1, investigated in relation to laser therapy.•The data from this pilot study shows promising trends for further investigation
Highlights • Extensive analysis of subjective and objectives outcomes of burn scars treated with ablative fractional laser resurfacing. • Evaluation of pruritus and neuropathic pain before and 6 ...weeks after treatment with ablative fractional CO2 laser. • First analysis of burns specific quality of life following treatment with ablative fractional CO2 laser.
•167 patients treated with the AFL-CO2 were compared with 20 patients receiving standard scar management in a nested case-control study. Regardless of scar maturation status, the AFL-CO2 treatment ...group showed significant improvement in scar thickness and scar associated symptoms.•Burn specific quality of life increased significantly in the AFL-CO2 group, but worsened at the follow up of the patients receiving standard care.•Complications only occurred in 5 patients (2.9%) treated with AFL-CO2 and were generally mild in nature.•Burn scars can be effectively and safely treated with the AFL-CO2 and this treatment induces profound improvements in relevant burn patient outcomes.
Burn scars are a major clinical challenge. The aim of this study was to determine the effectiveness and safety of one treatment with the ablative fractional CO2 laser (AFL-CO2) compared to standard burn scar treatment.
From December 2014 to October 2018 patients were prospectively recruited and treatment effects analyzed by assessing various outcome parameters from the date of first consultation and after treatment. A case control study was conducted looking at the impact of one AFL-CO2 treatment compared to a cohort subjected to conventional conservative treatment. Adverse effects were noted at follow up.
187 patients were included, with 167 in the AFL-CO2, and 20 in the control cohort. Baseline demographics and scar characteristics showed no significant differences. Ultrasound measured scar thickness as well as the Vancouver Scar Scale (VSS) revealed a significant reduction in the treatment cohort, but no significant improvement in the control group. The POSAS-O was significantly improved in both cohorts. Subjective parameters (POSAS-P, DN4-Pain, and modified D4Pruritus scores) decreased significantly in the AFL-CO2 cohort but remained unchanged in the control group. The BSHS-B quality of life score increased significantly in the AFL-CO2 group, but worsened at the follow up of the untreated patients. Sub-domain analyses found the biggest differences in Affect, Body Image, Heat Sensitivity, Treatment and Work. Complications occurred in 5 patients (2.9%).
This study demonstrates that AFL-CO2 is an effective and safe treatment modality for burn scars improving thickness, symptoms and quality of life of burn survivors when compared to conventional scar treatment.
•Burn reconstructive procedure types before and after ablative fractional CO2 laser introduction.•Significant reduction in conventional and complex reconstructive operations.•Significant reduction in ...anaesthetic times following ablative fractional CO2 laser implementation.•Significant reduction in hospital admissions and hospital length of stay following ablative fractional laser introduction.
Reconstructive surgery remains the main approach to address burn scar contractures. Ablative fractional resurfacing is an increasingly popular tool for severe burn scar management, but its effect on overall burns reconstructive case-mix, operating time and patterns of hospital admission have not been reported.
Retrospective analysis of hospital administrative data from September 2013 to June 2017 was performed evaluating these effects of ablative fractional CO2 laser (CO2-AFL).
The total number of acute burn patients treated at CRGH increased substantially over this timeframe, resulting in 412 elective procedures including 82 before and 330 after introducing CO2-AFL. The proportion of traditional non-laser reconstructive procedures dropped considerably to 23.9% in about 2.5 years following CO2-AFL introduction. This change in approach had a profound effect on LOS with average LOS being 1.96days for non-laser and 0.36days for CO2-AFL-procedures (p<0.001). Anaesthetic times also decreased significantly, with median durations at 90min pre-laser and 64min post-laser introduction (p<0.001), and median anaesthetic times at 87min (non-AFL) and 57min (AFL procedures) (p<0.001).
AFL profoundly affects elective reconstructive burn case mix with a replacement of conventional reconstructive operations in favour of AFL-procedures. This results in reductions of average LOS and anaesthetic times. Consequently, increased use of AFL in burn scar management could potentially reduce overall costs associated with burn scar reconstruction.
