Charles Scott Hultman

Laser resurfacing and remodeling of hypertrophic burn scars: The results of a large, prospective, before-After cohort study, with long-term follow-up

Objectives:Hypertrophic burn scars produce significant morbidity, including itching, pain, stiffness, and contracture, but best management practices remain unclear. We present the largest study to date that examines long-term impact of laser therapies, a potentially transformative technology, on scar remodeling. Methods:We conducted a prospective, before-after cohort study in burn patients with hypertrophic scars. Pulsed-dye laser was used for pruritus and erythema; fractional CO2 laser was used for stiffness and abnormal texture. Outcomes included (1) Vancouver Scar Scale (VSS), which documents pigmentation, erythema, pliability, and height, and (2) University of North Carolina “4P” Scar Scale (UNC4P), which rates pain, pruritus, paresthesias, and pliability. Results:A total of 147 burn patients (mean age, 26.9 years; total body surface area, 16.1%) received 415 laser sessions (2.8 sessions/patient), 16 months (median) after injury, including pulsed dye laser (n = 327) and CO2 (n = 139). Laser treatments produced rapid, significant, and lasting improvements in hypertrophic scar. Provider-rated VSS dropped from 10.43 [standard deviation (SD) 2.37] to 5.16 (SD 1.92), by the end of treatments, and subsequently decreased to 3.29 (SD 1.24), at a follow-up of 25 months. Patient-reported UNC4P fell from 5.40 (SD 2.54) to 2.05 (SD 1.67), after the first year, and further decreased to 1.74 (SD 1.72), by the end of the study period. Conclusions:For the first time, ever, in a large prospective study, laser therapies have been shown to dramatically improve both the signs and symptoms of hypertrophic burn scars, as measured by objective and subjective instruments. Laser treatment of burn scars represents a disruptive innovation that can yield results not previously possible and may displace traditional methods of operative intervention.

Prospective, before-after cohort study to assess the efficacy of laser therapy on hypertrophic burn scars.

IntroductionHypertrophic burn scars produce significant morbidity, including itching, pain, stiffness, and contracture. Best practices for management continue to evolve. Lasers have recently been added to treatment algorithms, but indications and efficacy have not been fully defined. We studied the impact of laser therapies on hypertrophic burn scars. MethodsWe conducted a prospective, before-after study in burn patients with hypertrophic scars. Procedures were performed more than 6 months after burn injury and were repeated monthly. The pulsed-dye laser was used for pruritus and erythema, whereas the fractional CO2 laser was used for stiffness and abnormal texture. All procedures were performed in the OR, with anesthesia. Outcomes are as follows: (1) Vancouver Scar Scale (objective changes in pigmentation, erythema, pliability, height; range, 0–15) and (2) UNC Scar Scale (subjective changes in pain, itching, tingling, stiffness; range, 0–12). Before-after scores were compared by Student t test, with significance assigned to P values of <0.05. ResultsDuring 2011, we treated 147 patients (mean age, 26.9 years; mean TBSA, 16.1%) over 415 sessions (2.8 sessions/patient), including pulsed dye laser (n = 327) and CO2 (n = 139), mean surface area of 83 cm2. Etiology included flame (75), scald (37), and other (35). Treatments occurred 16 months (median) and 48 months (mean) after burn injury. Vancouver Scar Scale decreased from 10.4 (SD, 2.4) to 5.2 (1.9) (P < 0.0001). UNC Scar Scale decreased from 5.4 (2.5) to 2.1 (1.7) (P < 0.0001). Mean length of follow-up was 4.7 months. ConclusionsLaser therapies significantly improve both the signs and symptoms of hypertrophic burn scars, as measured by objective and subjective instruments.

Management of recurrent hernia after components separation: 10-year experience with abdominal wall reconstruction at an academic medical center.

Purpose:Separation of the components has become the standard of care for abdominal wall reconstruction, especially in the setting of infected, previously infected, or contaminated wounds. Although the safety and efficacy of this technique have been established, less is known about long-term outcomes. This article focuses on the management of recurrent hernia after components separation for abdominal wall reconstruction. Methods:We performed a retrospective, institutional review board-approved study of components separation for abdominal wall reconstruction at an academic medical center, over a 10-year period. Results:Between 2000 and 2009, we performed components separation in 136 patients (mean follow-up, 4.4 years). Twenty-six patients (19.1%) developed recurrent hernia (mean age, 49.8 years; body mass index, 30.7; previous abdominal operations, 3.5; hernia size, 342 cm2; length of stay, 9.1 days). Mean time to recurrence was 319 days. Of the 16/26 patients who underwent repair of recurrence, 15 had successful repair, leaving 11/136 patients (8.1%) with persistent hernia. Of the 26 recurrences, 22 (85%) occurred within the first half of the study. Repair of recurrent hernias was accomplished by placement of additional mesh in 14/15 patients. Conclusions:Recurrent hernia after components separation may be related to procedural learning curves and can be successfully treated through repeat repair, yielding high rates of successful abdominal wall reconstruction.

Utility of the omentum in pelvic floor reconstruction following resection of anorectal malignancy: patient selection, technical caveats, and clinical outcomes.

This study assesses the usefulness of the omentum in the reconstruction of complex perineal defects, following abdominoperineal resection or pelvic exenteration, for anorectal malignancy.Between 2000 and 2008, 70 patients (mean age: 59 years) with anorectal malignancy underwent abdominoperineal resection (n = 57) or pelvic exenteration (n = 13) and were reconstructed by primary repair alone (n = 13), primary repair with omentum (n = 16), myocutaneous flap alone (n = 28), or myocutaneous flap with omentum (n = 13). Patients with and without omental flaps were compared by Student t test and &khgr;2 analysis. Omental flaps were based on a single pedicle, tunneled in the retrocolic plane lateral to the ligament of Treitz, and transposed across the sacrum to the pelvic floor.In total, 29 patients had pelvic floor and perineal reconstruction with the omentum, and 41 patients had reconstruction without the omentum. Incidence of major pelvic complications (abscess, urinoma, deep vein thrombosis, flap dehiscence, hernia, bowel obstruction, fistula) was greater in the “no omentum” group (25/41 patients, 61%), compared with the “omentum” group (6/29 patients, 21%) (P < 0.01). No differences were observed regarding age, stage, incidence of radiotherapy, blood loss, length of stay, or mortality.Use of the omentum as a primary flap, or in combination with a myocutaneous flap, in the reconstruction of complex perineal defects, is associated with a decreased incidence of postoperative complications, strongly supporting the use of the omentum in pelvic floor reconstruction.

Incidence and management of adverse events after the use of laser therapies for the treatment of hypertrophic burn scars.

IntroductionHypertrophic burn scars may generate significant morbidity, due to intense pruritus, persistent dysesthesias, and contracture. Although treatment with pulsed dye laser and fractional CO2 laser may improve symptoms, incidence of secondary wound complications is not well known. We examined the adverse event profile of laser therapies for the treatment of hypertrophic burn scars. MethodsWe performed a descriptive, retrospective, 6-month study of all patients who underwent laser therapies, at an accredited regional burn center, to improve the vascularity, texture, thickness, and stiffness of symptomatic burn scars. Data regarding skin type, mechanism, area treated, and laser parameters were collected. Main outcome measures included pigmentation changes, blistering, rash, infection. &khgr;2 analysis and Student t test were used to evaluate associations between variables. ResultsA total of 95 patients underwent 163 treatment sessions (mean, 2.7 sessions/patient) with pulsed dye laser (71%), CO2 laser (22%), and other lasers (7%). Forty-one adverse events were recorded: hyperpigmentation (2%), hypopigmentation (12%), mild blistering (27%), pain (37%), rash (7%), fever (10%), and infection (2%). Patients with scald burns were more likely to develop blistering, rash, and fever after treatment (all P < 0.05). Higher Fitzpatrick skin type was associated with hypopigmentation and blistering, whereas CO2 laser was associated with increased postoperative pain (all P < 0.05) ConclusionsDespite the frequent occurrence of pain and mild blistering after laser treatment of hypertrophic burn scars, major adverse effects were exceedingly rare, with improvement noted in all patients. Patients with higher Fitzpatrick skin types must be handled with care, to avoid complications of blistering and hypopigmentation.

Comparison of Outcome After Mesh-Only Repair, Laparoscopic Component Separation, and Open Component Separation

Component separation (CS) has been advocated as the technique of choice to reconstruct complex abdominal hernia defects, especially in the setting of gross contamination. However, open CS was reported to have relatively high incidences of wound complications. Minimally invasive approaches to CS were proposed by several surgeons to reduce wound morbidity. To date, there are limited comparative data between minimally invasive CS (MICS) versus open CS. In this article, we reviewed existing literature on open CS versus MICS with respect to their recurrence and complication rates. Our analysis appeared to show that MICS has comparable recurrence and complication rates relative to open CS although our analysis had several limitations. To demonstrate the management of complications after MICS, we reported our experience of using MICS to repair a recurrent incisional hernia in a 63-year-old man after a perforated ulcer.

Get on your boots: Preparing fourth-year medical students for a career in surgery, using a focused curriculum to teach the competency of professionalism

INTRODUCTION Few educational programs exist for medical students that address professionalism in surgery, even though this core competency is required for graduate medical education and maintenance of board certification. Lapses in professional behavior occur commonly in surgical disciplines, with a negative effect on the operative team and patient care. Therefore, education regarding professionalism should begin early in the surgeons formative process, to improve behavior. The goal of this project was to enhance the attitudes and knowledge of medical students regarding professionalism, to help them understand the role of professionalism in a surgical practice. METHODS We implemented a 4-h seminar, spread out as 1-h sessions over the course of their month-long rotation, for 4th-year medical students serving as acting interns (AIs) in General Surgery, a surgical subspecialty, Obstetrics/Gynecology, or Anesthesia. Teaching methods included lecture, small group discussion, case studies, and journal club. Topics included Cognitive/Ethical Basis of Professionalism, Behavioral/Social Components of Professionalism, Managing Yourself, and Leading While You Work. We assessed attitudes about professionalism with a pre-course survey and tracked effect on learning and behavior with a post-course questionnaire. We asked AIs to rate the egregiousness of 30 scenarios involving potential lapses in professionalism. RESULTS A total of 104 AIs (mean age, 26.5 y; male to female ratio, 1.6:1) participated in our course on professionalism in surgery. Up to 17.8% of the AIs had an alternate career before coming to medical school. Distribution of intended careers was: General Surgery, 27.4%; surgical subspecialties, 46.6%; Obstetrics/Gynecology, 13.7%; and Anesthesia, 12.3%. Acting interns ranked professionalism as the third most important of the six core competencies, after clinical skills and medical knowledge, but only slightly ahead of communication. Most AIs believed that professionalism could be taught and learned, and that the largest obstacle was not enough time in the curriculum. The most effective reported teaching methods were mentoring and modeling; lecture and journal club were the effective. Regarding attitudes toward professionalism, the most egregious examples of misconduct were substance abuse, illegal billing, boundary issues, sexual harassment, and lying about patient data, whereas the least egregious examples were receiving textbooks or honoraria from drug companies, advertising, self-prescribing for family members, and exceeding work-hour restrictions. The most important attributes of the professional were integrity and honesty, whereas the least valued were autonomy and altruism. The AIs reported that the course significantly improved their ability to define professionalism, identify attributes of the professional, understand the importance of professionalism, and integrate these concepts into practice (all P < 0.01). CONCLUSIONS Although medical students interested in surgery may already have well-formed attitudes and sophisticated knowledge about professionalism, this core competency can still be taught to and learned by trainees pursuing a surgical career.

Does voltage predict return to work and neuropsychiatric sequelae following electrical burn injury

Voltage has historically guided the acute management and long-term prognosis of physical morbidity in electrical injury patients; however, few large studies exist that include neuropsychiatric morbidity in final outcome analysis. This review compares high (>1000 V) to low (<1000 V) voltage injuries, focusing on return to work and neuropsychiatric sequelae following electrical burn injury.Patients with electrical injuries admitted to the University of North Carolina Jaycee Burn Center between 2000 and 2005 were prospectively entered into a trauma database, then retrospectively reviewed. Patients were divided into 4 cohorts: high voltage (>1000 V), low voltage (<1000 V), flash arc, and lightning. Demographics, hospital course, and follow-up were recorded to determine physical and neuropsychiatric morbidity. Differences among cohorts were tested for statistical significance.Over 5 years, 2548 patients were admitted to the burn center, including 115 patients with electrical injuries. There were 110 males and 5 females, with a mean age of 35 years (range, 0.75–65 years). The cause of the electrical injury was high voltage in 60 cases, low voltage in 25 cases, flash arc in 29 cases and lightning in 1 case. The mean total body surface area burn was 8% (range, 0%–52%). The etiology was work-related electrical injury in 85 patients. Mean follow-up period was 352 days with 13 (11%) patients lost to follow-up. Patients with high voltage injuries had significantly larger total body surface area burn, longer ICU stays, longer hospitalizations, and significantly higher rates of fasciotomy, amputation, nerve decompression and outpatient reconstruction, with 4 cases of renal failure and 2 deaths. In spite of these differences, high and low voltage groups experienced similar rates of neuropsychiatric sequelae, limited return to work and delays in return to work. Final impairment ratings for the high and low voltage groups were 17.5% and 5.3%, respectively.Electrical injuries often incur severe morbidity despite relatively small burn size and/or low voltage. When comparing high and low voltage injuries, similarities in endpoints such as neuropsychiatric sequelae, the need for late reconstruction, and failure to return to work challenge previous notions that voltage predicts outcome.

Changing characteristics of facial fractures treated at a regional, level 1 trauma center, from 2005 to 2010: an assessment of patient demographics, referral patterns, etiology of injury, anatomic location, and clinical outcomes

Introduction: Despite improvements in automotive safety, motor vehicle collision (MVC)-related facial fractures remain common and represent preventable injuries. This study examines the changing characteristics of facial fractures treated at a regional, level I trauma center, from 2005 to 2010. Methods: We identified all patients with facial fractures admitted to our hospital, from 2005 to 2010, by querying the North Carolina Trauma Registry, using International Classification of Diseases, Ninth Revision codes. Prospectively collected data, sorted by year, were descriptively analyzed for demographics, referral patterns, etiology, anatomic location, and clinical outcomes. Results: Number of patients with facial fractures increased from 201 per year to 263 per year (total n = 1508). Although transport distances remained constant at ∼85 miles, standard deviation increased from 37 to 68 miles. Transport time increased from 87 to 119 minutes. Referrals came from 28 surrounding counties in 2005 and 43 counties in 2010. Regarding etiology, MVCs decreased from 40% to 27%, all-terrain vehicle crashes decreased from 6% to 2%, falls increased from 8% to 19%, and bicycle accidents increased from 3% to 6%. Regarding anatomic location, frontal sinus fractures increased from 8% to 37%, zygomaticomaxillary fractures increased from 9% to 18%, nasoethmoid fractures decreased from 12% to 6%, orbital floor fractures decreased from 6% to 3%, and mandible fractures decreased from 28% to 18%. Single-site fractures increased from 75% to 90%. Length of intensive care unit and hospital stay remained stable at 3 and 7 days, respectively. Conclusions: Despite a decrease in MVC-related facial fractures, the overall increase in facial fractures referred to our trauma center is due to a growing number of patient transfers from rural hospitals, where a paucity of qualified surgeons may exist.

Fat Grafting for Neuropathic Pain After Severe Burns.

BackgroundChronic neuropathic pain after burn injury is a significant problem that affects up to 29% of burn patients. Neuropathic burn scar pain is a challenge for plastic and burn surgeons, who have limited solutions. Fat grafting, with its mechanical and regenerative qualities, can improve neuropathic pain from various traumatic and postsurgical etiologies, but its effectiveness in neuropathic burn scar pain has yet to be demonstrated. In this study, the possible role of lipotransfer in treating neuropathic burn scar pain is explored, focusing on safety, graft take, and short-term efficacy. MethodsWe performed an institutional review board–approved, retrospective case review of 7 patients with chronic, refractory neuropathic pain, who underwent fat grafting to burn scars. These patients had failed conventional therapy, which included pharmacologic, medical, and laser treatment of the burn scars. Each patient had 2 sessions of fat grafting, spaced 2 months apart. The Patient-Reported Outcomes Measurement Information System (PROMIS) was used to assess pain perception, with patients answering the questionnaire before and after fat grafting, to assess subjective outcomes. ResultsSix of 7 patients had improvement in neuropathic pain after fat grafting, permitting reduction in their neuropharmacologic regimen. Tinel sign, present in all patients preoperatively, was absent on examination in all patients at follow-up. Three of the 5 patients who completed PROMIS questionnaires had PROMIS scores indicating improvement in pain by 1-year follow-up. One patient had similar preoperative and postoperative PROMIS scores, and 1 patient had an increase in pain at follow-up; however, he had suffered an additional burn to the same extremity. Analysis of pooled mean PROMIS scores reflects a statistically significant improvement in subjective outcomes by 1-year follow-up. Donor-site seroma in 1 patient was the only complication, with no cases of infection, wound breakdown, or graft loss. ConclusionsAdipose tissue can be safely grafted into burn scars and may improve symptoms in patients with refractory neuropathic pain after burn injury. Further translational and clinical research is necessary to elucidate mechanisms of action, indications, optimal type of transfer, and long-term effectiveness.