Jonathan S. Friedstat

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.

Hypertrophic burn scar management: what does the evidence show? A systematic review of randomized controlled trials.

IntroductionHypertrophic scars (HTS) are a source of morbidity for burn survivors and can present with a range of lifestyle-limiting problems. These include pruritus, pain, burning, stiffness, and contractures. Many solutions have been developed, but few have been studied in the form of a prospective, randomized control trial (RCT). Given the importance these RCTs carry in shaping the treatment of burn patients, we sought to systematically and critically review this portion of the burn literature. MethodsPubMed was used to perform 2 separate searches with limits that included Humans, English, and Randomized Controlled Trial. A keyword search using “hypertrophic,” “Scar,” “burn,” and “treatment” was cross-referenced with a MeSH subject-heading search using “Cicatrix, Hypertrophic” AND “Burn.” Studies were then reviewed and excluded if they did not address management of burn HTS in the non-acute setting. ResultsTwo literature searches resulted in a total of 32 articles. Twelve articles were excluded because they were not relevant to the topic (n = 10) or could not be obtained (n = 2). The remaining 20 articles contained 882 patients treated for hypertrophic scars. Breakdown based on topics included laser therapy (58 patients, 2 articles), silicone gel (204 patients, 7 articles), compression garment (236 patients, 4 articles), silicone + pressure (226 patients, 3 articles), topical emollients (58 patients, 2 articles), systemic therapy (62 patients, 1 article), intralesional therapy (18 patients, 1 article), and surgical treatment (20 patients, 1 article). While some articles had favorable conclusions (laser, emollients, surgical, and intralesional therapy) or unfavorable conclusions (systemic therapy), there were conflicting results on silicone and/or compression. ConclusionsDespite hypertrophic scars being a common occurrence in burn survivors, both the number of studies and consensus for treatment are limited. Efforts to perform larger, adequately powered RCTs are needed, specifically in the areas of silicone, compression garments, and combination therapy.

Discrepancy in Initial Pediatric Burn Estimates and Its Impact on Fluid Resuscitation

One of the fundamental aspects of initial burn care is the ability to accurately measure the TBSA of injured tissue. Discrepancies between initial estimates of burn size and actual TBSA (determined at the burn unit) have long been reported. These inconsistencies have the potential for unnecessary patient transfer and inappropriate fluid administration which may result in morbidity. In an effort to study these inconsistencies and their impact on initial care, we evaluated the differences between initial TBSA estimates and its impact on fluid resuscitation at an American Burn Association–verified pediatric burn center. A prospective observational study of 50 consecutive burn patients admitted to Shriner’s Hospital for Children in Boston, Massachusetts, between October 2011 and April 2012 was performed. Data collected included age, mechanism of burn injury, type of referral center, referring hospital TBSA, and volume of fluid administration as well as admission TBSA and volume of fluid administration. Determination of over or under resuscitation was based on comparing the amount of fluids received at the referral center to that received at the pediatric burn center. A total of 50 patients were admitted during the 7-month study period. The average age was 4.1 years old (25 days–16 years) and the average TBSA was 2.5% (0.25–55%). There were significant differences in the TBSA calculations between referring centers and the pediatric burn center. Overestimation of scald and contact burn size (P < .05) was noted with no difference in flame burn size estimation. Community referrals were more likely than tertiary centers to overestimate TBSA (P < .05 vs P = .29). Overall, 59% of study patients were administered more fluid at the referring hospital than would have been expected by the burn size calculated at our facility. Inconsistencies with the estimation of TBSA burn between referring hospitals and tertiary referral centers remains a problem in pediatric patients and may lead to inappropriate resuscitation. This study highlights the continued need for educational outreach programs and for the provision of novel resources to initial burn providers. Additional support through online resources (eg, Lund–Browder diagram) and remotely assisting providers during their TBSA measurements are potential options which may help to improve the initial care of burn patients.

Acute Management of Facial Burns

Facial burns present significant acute and reconstructive challenges. It has long been our practice to excise facial burns unlikely to heal in a timely manner in order to reduce the risk of aesthetic and functionally debilitating scar contractures. We present our approach to the acute surgical management of facial burns.

Efficacy of intense pulsed light for the treatment of burn scar dyschromias: A pilot study to assess patient satisfaction, safety, and willingness to pay

IntroductionNo treatment algorithms exist to reliably treat burn scar dyschromias. Intense pulsed light (IPL) has been used successfully to treat hyperpigmentation disorders, but has not been studied extensively in the treatment of burn scars. The purpose of this investigation was to assess clinical efficacy and patient satisfaction with IPL for the treatment of burn scar dyschromia. MethodsPatients with burn scar dyschromias were treated using the Lume 1 platform (Lumenis) to target pigmented lesions, using fluences between 10 and 22 joules/cm2 and filters ranging from 560 to 650 nm. At the conclusion of the study, providers assessed changes in burn scar dyschromia, whereas patients were queried regarding satisfaction and perceived efficacy, using a 1 to 5 Likert scale. The patients, who were not charged for the IPL treatment, were queried regarding willingness to pay. ResultsTwenty patients (mean age, 35.4 years; mean total body surface area, 27.6%; mean composite Fitzpatrick score, 3.9) underwent IPL treatment of burn scar dyschromias, an average of 3.2 years after injury. Mean fluence was 15.4 J/cm2 (range, 10–22 J/cm2), and the most common filter used was 590 nm (range, 560–650 nm). Mean area treated was 90.7 cm2, with a range of 4 to 448 cm2. Complications included pain (4), hyperpigmentation (1), and blistering (2). Sixteen patients noted mild to moderate improvement, reporting a 4.5 for efficacy and a 4.4 for satisfaction. Regarding willingness to pay, patients would spend a mean of U.S.

The ACAPS and SESPRS surveys to identify the most influential innovators and innovations in plastic surgery: no line on the horizon.

7429 to completely remove their scars, but only a median of U.S.

Selection of appropriate empiric gram-negative coverage in a multinational pediatric burn hospital.

350 to get the actual results that they received. Mean length of follow-up was 3.8 months, with a standard deviation of 2.2 months. ConclusionsPatients perceived IPL as an efficacious modality in the treatment of burn scar dyschromia, with a high level of satisfaction, despite the potential for morbidity. However, we are reluctant to recommend IPL for routine treatment of burn scar dyschromias, given only minimal improvement observed, potential for complications, and a willingness to pay that is lower than the cost of providing care.

An unusual burn during routine magnetic resonance imaging

IntroductionWho and what have been the most influential innovators and innovations in plastic surgery? This historical paper attempts to determine our most important contributors and contributions. MethodsWe conducted an anonymous, 7-question, web-based survey of all members of the American Council of Academic Plastic Surgeons (ACAPS) and the Southeastern Society of Plastic and Reconstructive Surgeons (SESPRS). We asked respondents to list their top 5 most influential surgeons, the most important publications or bodies of work, and the most important innovations in plastic surgery, past and present. ResultsOf the 86 nominees from ACAPS, the 15 most influential surgeons of the past century were Tessier, Buncke, Murray, Millard, Gillies, Mathes, Jurkiewicz, Taylor, Converse, Blair, Kleinert, Edgerton, McCraw, Peacock, and Brown, in that order. The most 10 influential surgeons of the current era are Rohrich, McCarthy, Wei, Lee, Siemionow, Allen, Coleman, Guyuron, Serletti, and Nahai. Of the 112 nominees from SESPRS, the 15 most influential surgeons of the past century were Gillies, Millard, Tessier, Buncke, Murray, Jurkiewicz, Hartrampf, Mathes, Taylor, Bostwick, McCraw, Furlow, Converse, Peacock, and Blair, in that order. The 10 most influential surgeons of the current era are Rohrich, Nahai, Wei, McCarthy, Coleman, MacKinnon, McGrath, Rubin, Guyuron, and Hammond. Pooled from both lists, the 10 most influential publications or bodies of work were Hartrampf’s TRAM flap, Millard’s cleft lip repair, McCraw/Mathes/Nahai’s myocutaneous flaps, Furlow’s cleft palate repair, Tessier’s cleft classification and craniofacial repairs, Ramirez’s components separation, Buncke’s replantation/toe-to-thumb transfer, McCarthy’s mandibular distraction osteogenesis, Taylor’s free flap and angiosome concepts, and Murray’s kidney transplant. The top 10 innovations of the 20th century were myocutaneous flaps, microsurgery, craniofacial surgery, skin grafts, transplantation, liposuction, bioimplants, distraction osteogenesis, angiosome anatomy, and rigid fixation. The 10 most important, current innovations are hand/face transplantation, fat grafting, stem cells, neurotoxins and soft-tissue fillers, biologic scaffolds, information technology, tissue engineering and regenerative medicine, negative pressure wound therapy, perforator flaps, and noninvasive imaging. ConclusionPlastic surgery includes a rich history of both incremental and disruptive innovation, which has endowed our discipline with a competitive advantage over other medical and surgical subspecialties. Based upon our past success in managing change, there may be no limit, or no line on the horizon, as to what is possible, provided that we pursue innovation in a systematic way that combines creativity and discipline.

LIBERTI: A SMART study in plastic surgery

The choice of appropriate empiric antimicrobial therapy for burn patients with suspected multidrug-resistant organisms remains a challenge. Burn patients transferred from outside the United States seem to be at particularly high risk. Given this perceived risk of multidrug resistance among our international patient population, we set out to determine which empiric antimicrobial therapy should be used at admission. A retrospective analysis was conducted of all burn patients admitted to a pediatric burn specialty hospital between 2006 and 2010. Patients with burns >10% TBSA were included. Demographics, burn data, and routine/nonroutine culture data were collected. Of the 385 total patients, 133 (34.5%) were international. International patients had significantly larger burns (39.73 vs 22.80% TBSA; P < .001) and more inhalational injuries (27.1 vs 16.3%; P < .03) than their U.S. counterparts. International patients presented with a higher incidence of infection in general (66.9 vs 2%; P < .001) as well as a higher prevalence of infection caused by multidrug-resistant bacteria (51.2 vs 1%; P < .001) and pan–multidrug-resistant bacteria (13.5 vs 1.1%; P < .001). Bacterial resistance was not related to the length of time after burn injury or to a delay in transfer. In conclusion, multidrug-resistant and pan-resistant organisms seem to be more prevalent among the international pediatric burn population when compared with the U.S. pediatric burn population. Given the relatively high incidence of pan-resistant gram-negative organisms among international transfers, colistin seems to be a reasonable choice for empiric antimicrobial coverage for presumed infections.

Thermal injuries from exploding electronic cigarettes

Burn injuries are known to occur from magnetic resonance imaging. Prevention efforts focus on avoiding internal and external metallic objects from contacting the patients tissue during image acquisition. Despite rigorous screening, however, there is a subset of thermal injuries that can occur through the formation of closed loops of current within the patient. This case report describes an example of this uncommon type of injury as well as a successful, nonoperative management approach. Given the frequent use of magnetic resonance imaging, we report this rare case to raise awareness of this mechanism of injury and its treatment.