Robert J. Spence

Effect of early body image dissatisfaction on subsequent psychological and physical adjustment after disfiguring injury.

Objective The impact of body image dissatisfaction on quality of life after severe burn injury was investigated after controlling for other determinants of outcome (ie, injury, distress, and preburn quality of life). Methods The postburn quality of life (2-months postdischarge) of groups with and without body image dissatisfaction was studied after controlling for preburn quality of life (measured 2–3 days postadmission). The patient population (N = 86) was 77.9% men, had an average total body surface area burned of 17.02%, and average full-thickness burn of 6.09%. Forty percent had facial injuries, 68.6% required surgery, most were injured by flame (39.5%), and 76.8% were employed. Results Multivariate analysis of covariance (covarying preburn level of Mental quality of life, facial injury, and size of burn) contrasting body image dissatisfaction groups found significantly lower psychosocial adjustment at 2-month follow-up in those with greater body image dissatisfaction (multivariate F = 3.61;p < .01). A second MANCOVA (covarying the preburn level of Physical quality of life and both facial injury and size of burn) found significantly lower physical functioning at 2-month follow-up in those with greater body image dissatisfaction (multivariate F = 2.78;p < .03). Adding two more covariates (depression and posttrauma distress) eliminated the effect of body image dissatisfaction on postburn Physical but not Mental adjustment. Conclusions Body image dissatisfaction affects quality of life after severe burn injury. Distress moderates this impact on aspects of physical but not psychosocial health.

Use of dermal regeneration template in contracture release procedures: a multicenter evaluation.

Integra dermal regeneration template (Integra Life Sciences, Plainsboro, N.J.) is an effective treatment for full-thickness burns. It can also be useful in contracture release procedures; however, the clinical utility of a dermal regeneration template in contracture release procedures has not been adequately characterized. In this multicenter investigation, the outcomes of release procedures incorporating a dermal regeneration template for 89 consecutive patients, who underwent a total of 127 contracture releases, were retrospectively evaluated. The procedures involved the application of Integra, which includes a temporary silicone epidermal substitute and an artificial dermal layer. After formation of a neodermis, the silicone layer is removed and replaced with an epidermal autograft. Data on patient and contracture site history, treatment methods, physician assessments of range of motion or function, patient satisfaction, recurrence, and adverse events were collected with a standardized questionnaire. Release procedures for the study patients involved the neck, axilla, trunk, elbow, knee, hand, and other anatomical sites. The mean postoperative follow-up period was 11.4 months. At 76 percent of the release sites, range of motion or function was rated as good (significant improvement in range of motion or function) or excellent (maximal range of motion or function possible) by physicians. Responding patients expressed satisfaction with the overall results of treatment at 82 percent of the sites. No recurrence of contracture at 75 percent of the sites was observed during follow-up monitoring. Patient age and prior surgical treatment at the site did not significantly affect the results of treatment. However, outcomes were superior at mature sites, i.e., those for which more than 12 months had elapsed since the original injury. Postoperative complications rarely necessitated regrafting. These results indicate that a dermal regeneration template provides a useful alternative technique for contracture release procedures. The study data indicate that this approach leads to favorable functional outcomes and a high rate of patient satisfaction. This modality also seems to be versatile, because a range of anatomical sites are amenable to treatment with a dermal regeneration template, regardless of prior surgical treatment, and both pediatric and adult patients respond well to this form of therapy. Furthermore, Integra confers functional and cosmetic benefits similar to those of full-thickness grafts but without comparable potential for donor-site morbidity.

Effects of oxandrolone on outcome measures in the severely burned: a multicenter prospective randomized double-blind trial.

Severe burns induce pathophysiologic problems, among them catabolism of lean mass, leading to protracted hospitalization and prolonged recovery. Oxandrolone is an anabolic agent shown to decrease lean mass catabolism and improve wound healing in the severely burned patients. We enrolled 81 adult subjects with burns 20% to 60% TBSA in a multicenter trial testing the effects of oxandrolone on length of hospital stay. Subjects were randomized between oxandrolone 10 mg every 12 hours or placebo. The study was stopped halfway through projected enrollment because of a significant difference between groups found on planned interim analysis. We found that length of stay was shorter in the oxandrolone group (31.6 ± 3.1 days) than placebo (43.3 ± 5.3 days; P < .05). This difference strengthened when deaths were excluded and hospital stay was indexed to burn size (1.24 ± 0.15 days/% TBSA burned vs 0.87 ± 0.05 days/% TBSA burned, P < .05). We conclude that treatment using oxandrolone should be considered for use in the severely burned while hepatic transaminases are monitored.

Development and Validation of the Satisfaction with Appearance Scale: Assessing Body Image among Burn-Injured Patients.

The Satisfaction With Appearance Scale (SWAP) is a 14-item questionnaire, assessing both the subjective appraisal and social-behavioral components of body image among burn survivors. Burn survivors requiring hospitalization (n = 165) completed a packet of psychometric instruments, including the SWAP at 1-week postdischarge. The SWAP demonstrated a high level of intemal consistency (Cronbachs alpha, r a = .87; the mean interitem correlation, r ii = .32, the mean item-total correlation, r ii = .53). Eighty-four participants were retested approximately 2 months after the initial assessment to evaluate test-retest reliability (r ii , = .59). A principal-components analysis with a varimax rotation yielded 4 easily interpretable factors accounting for 66% of the total variance. The correlations of the SWAP total score with other selected psychometric measures provided evidence for both convergent and discriminant validity. This initial evaluation of the SWAP suggests that it is both a reliable and valid measure of body image for a burn-injured population.

Cultured epidermis for the coverage of massive burn wounds. A single center experience.

Seven patients with a mean burn size of 69.6% total body-surface area underwent skin grafting with autologous cultured epidermis. They were compared with a historical group of 18 controls, with a mean burn size of 60%, who underwent grafting with conventional meshed split-thickness autograft. There were no statistically significant differences between the two groups in length of hospital stay, total number of surgical operations, or cost. There were no deaths and two major complications in the cultured epidermis group; there were six deaths and 11 major complications in the historical control group. Because of this encouraging early experience, a prospective, randomized study is now in order to evaluate this technology.

Coping with body image changes following a disfiguring burn injury

The influence of emotion-focused coping on distress following disfiguring injury was examined. Two types of emotion-focused coping (i.e., venting emotions vs. mental disengagement) were assessed in 78 patients with burn injury at baseline during acute hospitalization. Body image dissatisfaction (BID) was assessed 1 week and 2 months following discharge. Use at baseline of both venting emotions and mental disengagement, compared with use of only one or neither of these coping methods, was associated at the 2-month postdischarge follow-up with significantly higher BID related to nonfacial aspects of appearance and with a greater negative social impact of disfigurement. D. M. Wegners (1994) theoretical model of mental control and a proposed motivational analysis are used to interpret these findings.

Burns of the hand and upper limb—a review

This review article addresses the principles and controversies associated with thermal injury to the hand and upper limb. Accepted principles are outlined and areas of controversy are discussed in a balanced manner. The importance of hand burns is described functionally and epidemiologically. Burns appropriate to outpatient care are defined and treatment discussed, including debridement, topical therapy, rehabilitation and follow-up. The general principles of inpatient management are given, including the controversial issue to timing of surgery and treatment of the exposed tendon or joint. The extent of surgery, methods of wound closure and difficult problem of palm burns are also discussed. Reconstructive principles are outlined and a problem oriented approach to the most common reconstructive problems given.

Methods and results of rhinophyma treatment.

Rhinophyma is a disfiguring soft‐tissue hypertrophy of the nose. It is an uncommon disease that primarily affects Caucasian men in the fifth to seventh decades of life. Nine cases from the authors’ series and a comparison of results following various treatment modalities are presented. Eight of the patients were Caucasian and one was African American. Excision of the diseased tissue with a scalpel or Goulian dermatome using loupe magnification provided the safest means of preserving the underlying sebaceous gland fundi that permit spontaneous re‐epithelialization with the least scarring. (Plast. Reconstr. Surg. 107: 1115, 2001.)

Expanding the Limits of Composite Grafting: A Case Report of Successful Nose Replantation Assisted by Hyperbaric Oxygen Therapy

A successful nose replantation assisted by hyperbaric oxygen therapy is presented, with a brief discussion of the possible mechanisms and a brief literature review of the use of hyperbaric oxygen in tissue preservation and replantation. Although it is not certain that the hyperbaric oxygenation ensured the survival of the replanted nose in this 2-year-old girl, there was documented change in graft appearance during the initial hyperbaric oxygen treatment. A 1-month, 1-year, and 2-year follow-up is included.

Association of Increasing Burn Severity in Mice With Delayed Mobilization of Circulating Angiogenic Cells

OBJECTIVE To perform a systematic exploration of the phenomenon of mobilization of circulating angiogenic cells (CACs) in an animal model. This phenomenon has been observed in patients with cutaneous burn wounds and may be an important mechanism for vasculogenesis in burn wound healing. DESIGN We used a murine model, in which burn depth can be varied precisely, and a validated culture method for quantifying circulating CACs. SETTING Michael D. Hendrix Burn Research Center, Baltimore, Maryland. PARTICIPANTS Male 129S1/SvImJ mice, aged 8 weeks, and 31 patients aged 19-59 years with burn injury on 1% to 64% of the body surface area and evidence of hemodynamic stability. MAIN OUTCOME MEASURES Burn wound histological features, including immunohistochemistry for blood vessels with CD31 and alpha-smooth muscle actin antibodies, blood flow measured with laser Doppler perfusion imaging, and mobilization of CACs into circulating blood measured with a validated culture technique. RESULTS Increasing burn depth resulted in a progressive delay in the time to mobilization of circulating CACs and reduced mobilization of CACs. This delay and reduction in CAC mobilization was associated with reduced perfusion and vascularization of the burn wound tissue. Analysis of CACs in the peripheral blood of the human patients, using a similar culture assay, confirmed results previously obtained by flow cytometry, that CAC levels peak early after the burn wound. CONCLUSION If CAC mobilization and wound perfusion are important determinants of clinical outcome, then strategies designed to augment angiogenic responses may improve outcome in patients with severe burn wounds.