B. Costa

12-Year within-wound study of the effectiveness of custom pressure garment therapy.

Pressure garment therapy is standard of care for prevention and treatment of hypertrophic scarring after burn injury. Nevertheless there is little objective data that confirms effectiveness. The purpose of this study was to determine the effectiveness of pressure garment therapy with objective data obtained with a randomized within-wound comparison. We enrolled consecutive patients with forearm injuries over a 12-year period. The subjects wore custom garments with normal and low compression randomized to either the proximal or distal zones. Hardness, color and thickness of wounds were objectively measured using appropriate devices; clinical appearance was measured by a panel masked to the identity of the pressure treated area. Wounds treated with normal compression were significantly softer, thinner, and had improved clinical appearance. There was no interaction of any effect with patient ethnicity. However, these findings were clinically evident only with moderate to severe scarring. We conclude that pressure garment therapy is effective, but that the clinical benefit is restricted to those patients with moderate or severe scarring.

Improved burn scar assessment with use of a new scar-rating scale.

The subjective assessment of scar appearance is a widely used method in the evaluation of burn outcomes and the efficacy of treatment methods. The purpose of this study is to design a numeric scar-rating scale with better interrater reliability than has previously been reported. The rating scale assesses scar surface, thickness, border height, and color differences between a scar and the adjacent normal skin. Eight raters were trained with use of a standardized set of photographs that provide examples of the scores to be assigned to each level of severity of each scar characteristic. The raters then rated 10 photographs of different scars, referring to the teaching set of pictures for comparison. The intraclass correlation (interrater reliability) was 0.94, 0.95, 0.90, and 0.85 for scar surface, border height, thickness, and color, respectively. This rating system has proved to be a useful tool for the evaluation of scar surface, thickness, border height, and color.

Early excision and grafting of face and neck burns in patients over 20 years

&NA; Although excision and grafting of burns has become common and standard, many surgeons have been reluctant to excise and graft face burns. In fact, we could find photographic results at 1 year after grafting of only eight patients in the English literature. We began excision and grafting of face burns in 1979 and presented our first 16 patients in 1986 in this journal. With encouragement from Janzěkovič and Jackson, we continued and have now used essentially the same procedure for more than 20 years in approximately 100 patients and, from this large series, are able to present outcomes. From January of 1979 to May of 1999, we performed excision and grafting on 91 patients with deep face burns. Data were recorded and 35‐mm photographs were obtained throughout the 20‐year period. We reviewed that database and the slide files of these patients. We found 45 patients with complete photographic sets including 1‐year follow‐up. Since, in our opinion, there is no useful, objective measure of appearance, we decided to simply publish all 45 sets of complete photographs, permitting the reader to subjectively form an opinion of the outcome of this procedure. The results are all shown as “full” face burns and two “partial” face burns. We continue to believe that early excision and grafting is indicated for face burns that will not heal within 3 weeks and that the procedure yields results that permit the burn victims to return to society and minimizes the time off work or out of school. (Plast. Reconstr. Surg. 109: 1266, 2002.)

Impairment after burns: a two-center, prospective report

Impairment rating is regularly reported for trauma and other conditions but rarely for burns. The purposes of this study were: (1) to report impairment collected prospectively at our burn center, (2) to relate this impairment to measures of psychosocial and functional outcome, and (3) to compare these data to similar data from another burn center to verify that rating impairment is standardized and that the impairments are similar. We studied 139 patients from the University of Washington (UW) Burn Center and 100 patients from the University of Texas (UT) Southwestern Burn Center. The average whole person impairment (WPI) ratings at the University of Washington were 17% and this correlated with total body surface area burned and days off work. It did not correlate with Brief Symptom Inventory (BSI), Functional Independence Measure (FIM), Short-Form 36-Item Health Survey (SF-36), Satisfaction With Life Scale (SWLS), and the Community Integration Questionnaire (CIQ). Average whole person impairment ratings at UT Southwestern were similar at 19%. Several components of the impairment rating, however, differed at the two institutions. To minimize this variation, we recommend: (1) use the skin impairment definitions of the fifth edition of the Guides to the Evaluation of Permanent Impairment (or the most recent published versions of the Guide), and (2) include sensory impairment in healed burns and skin grafts in the skin impairment.

Pediatric palm contact burns: a ten-year review.

Management and proper approach to pediatric palm burns remains unclear. Our burn center’s approach includes early, aggressive range of motion therapy, combined with a period of watchful waiting, reserving grafting only for those palms that do not heal in a timely manner. We reviewed our experience using this approach over a 10-year period. We performed a retrospective review of all pediatric patients with palm burns admitted to our burn center from 1994 to 2004. A total of 168 patients (194 palms) were included in the study. The average patient was 1.3 years old. A total of 168 of the injured palms (87%) healed without need for surgery. The average time to healing was 13 days (range 5–34). The 19 patients (26 palms, 13.4%) who underwent excision and grafting were managed with thick split thickness skin grafts. Of these, four patients (five palms, 19.2%) underwent secondary reconstruction, at an average of 166 days after the initial surgery. Of the 168 (87%) palms managed without surgery, only three patients (four palms) required late reconstruction (2.4%). Reconstructive procedures consisted of full-thickness skin grafts (n = 7) and z-plasty (n = 2). We have found that the majority of patients in this study healed without need for acute or reconstructive surgery. We therefore recommend aggressive hand therapy and conservative surgical management of palm burns in children.

Incidence of the concrete scalp deformity associated with deep scalp donor sites and management with the Unna cap.

The scalp has become a popular donor site for split-thickness skin grafts. This donor site does, however, have complications, including the concrete scalp deformity, which consists of hairs embedded in a thick, desiccated, exudative crust. This article presents our burn units experience with this complication. Fifty-six patients underwent scalp skin graft harvesting between 1984 and 1996. All grafts were quite thick and were used for resurfacing facial burns. Thirty-eight donor sites were treated with medicated gauze, and 18 were treated with the Unna cap, which is an Unna dressing applied over Aquaphor gauze (Beiersdorf, Norwalk, Conn). Eighteen of the 38 patients (32%) treated with medicated gauze developed the concrete scalp deformity. None of the patients treated with the Unna cap developed the deformity. Although useful, the deep scalp donor site has complications, including the concrete scalp deformity. However, with use of the Unna cap dressing, we have had no occurrences of this problem.

Dexter: a tool to facilitate impairment ratings.

Calculating impairment in burn patients is crucial to understanding outcome. However, it is rarely reported after burns, presumably because the process of calculating impairment ratings is complicated and tedious. Computerized systems have been developed that facilitate the process, but it has not been established in burn patients that these systems reduce the time required to calculate impairment. We evaluated the Dexter Evaluation and Therapy System by Cedaron Medical Inc (Davis, CA). A sample of 10 manually recorded ratings was compared with 10 performed on the Dexter. Mean time for the manual technique was 65 +/- 35 minutes versus 37 +/- 13 minutes for the Dexter (P < .05, Mann-Whitney). The time taken to perform impairment ratings in burn survivors is significantly reduced by the use of the Dexter system. Time saving occurs primarily at three points: (1) electronic data entry directly from the measuring instruments, (2) compilation of data, and (3) rapid generation of reports.

Silipos neck wraps

Burns of the neck are a problem. Grafted anterior necks can result in disfiguring hypertrophic scar contractures and wrinkling of the graft. The development of contractures can be prevented by effective splinting as soon as possible after the burn and by following a continuous wearing schedule until scar maturation is complete. Traditional neck conformers do not allow free neck rotation and can lead to stiffness as a result of decreased mobility. We used Silipos neck wraps for 10 patients who had good range of motion in the neck and who required pressure only for flattening of grafts and wrinkle prevention. The neck wrap is user-friendly, low in cost, and easy to fabricate and custom-fit for individual patients.