Stuart Watson

ISBI PRACTICE GUIDELINES FOR BURN CARE

Practice guidelines (PGs) are recommendations for diagnosis and treatment of diseases and injuries, and are designed to define optimal evaluation and management. The first PGs for burn care addressed the issues encountered in developed countries, lacking consideration for circumstances in resource-limited settings (RLS). Thus, the mission of the 2014-2016 committee established by the International Society for Burn Injury (ISBI) was to create PGs for burn care to improve the care of burn patients in both RLS and resource-abundant settings. An important component of this effort is to communicate a consensus opinion on recommendations for burn care for different aspects of burn management. An additional goal is to reduce costs by outlining effective and efficient recommendations for management of medical problems specific to burn care. These recommendations are supported by the best research evidence, as well as by expert opinion. Although our vision was the creation of clinical guidelines that could be applicable in RLS, the ISBI PGs for Burn Care have been written to address the needs of burn specialists everywhere in the world.

Use of Integra to resurface a latissimus dorsi free flap

The successful use of Integra to cover a muscle flap as a secondary reconstructive procedure is presented.

Prelaminated free radial forearm flap for a total nasal reconstruction

A prelaminated osteocutaneous radial forearm flap has previously been described for total nasal reconstruction, but achieving good aesthetics at the dorsum and tip tends to be difficult with a flap that can be too bulky. We present a case of total nasal reconstruction in a burns patient where a tight adherent scar at the forehead precluded the use of a forehead flap, ideal for such reconstructions. We successfully used a prelaminated free radial forearm flap, with a non-vascularised bone graft. The existing scarred skin at the dorsum was turned down as pedicled flaps for the lining. We were able to achieve a successful total nasal reconstruction which was aesthetically pleasing and made a tremendous impact on the quality of life of the patient.

7 Surgical management of burns

The systemic sequelae of burn injury preclude isolated treatment of the burn wound. A multidisciplinary approach is essential for optimal burn patient care. Early surgical debridement and closure of the burn wound can reduce mortality and improve outcome. The patients age, co-morbid state, burn type and site make each injury unique, requiring a judicious application of all therapeutic options. The ultimate aim of surgical intervention is not only to reduce mortality but also morbidity by improving the functional and aesthetic outcome of burn wound healing. The aetiology and nature of the burn wound are described and the common treatment modalities discussed.

Nasal tip reconstruction of the nose with composite ear-helix free flap.

To the Editor: We applaud the authors of the recent publication, “The Impact of Breast Reconstruction on the Oncologic Efficacy of Radiation Therapy: A Retrospective Analysis,” (Nahabedian and Momen. Ann Plast Surg. 2008;60:244 – 250) for attempting to address the important issue of whether or not postmastectomy reconstruction has a detrimental effect on the surveillance and/or progression of breast cancer recurrence. Current evidence would suggest that the performance of postmastectomy implant and/or autogenous tissue reconstruction is oncologically safe. This paper, however, appears to be making a statement that contradicts current thinking. The authors suggest that “tumor recurrence and patient demise may be increased when radiation therapy is performed following breast reconstruction.” Such a significant statement could potentially affect current practices and the standard of care for breast cancer patients. It follows that such a statement must be based on only the highest level of evidence possible. After examination of the data presented in this paper, we would challenge the authors by suggesting that their conclusions are not justified for the following reasons. Firstly, the rate of locoregional breast cancer recurrence in ‘all-comers’ in this study is alarmingly high. Recurrence rates for the total cohort in this series—all of whom underwent mastectomy and postmastectomy radiotherapy (PMRT)—were reported as 19.8%, “of which 27% was when radiation followed reconstruction and 14.9% when radiation preceded reconstruction.” This is a concerning finding. By contrast, a 2005 Early Breast Cancer Trialists’ Collaborative Group (EBCTCG) subset analysis of postmastectomy patients with 4 or more positive lymph nodes demonstrated a 5-year locoregional recurrence rate (LRR) of 11.6% with the use of PMRT. Among patients with 1-3 positive lymph nodes, the 5-year LRR was 4.0% with PMRT. This discrepancy suggests that the current study patients many have had other clinicopathologic risk factors putting them at extremely high risk of recurrence, and/or the treatment of their primary disease was inadequate. Secondly, while the authors conclude that the incidence of tumor recurrence and death appears to be increased when radiation is performed following reconstruction, significant noncomparability exists between subgroups of patients. For example, the raw data presented suggests that the 2 groups (those who are radiated before reconstruction and those who were radiated after reconstruction) may differ with respect to stage of disease and the proportion of patients who received chemotherapy. In addition, the authors do not tell us how many patients in each group had other potential risk factors for recurrent disease such as number of positive lymph nodes, margin status, tumor ER/PR positivity, lymphovascular invasion, extracapsular extension, etc. Finally, while the authors acknowledged that the peak incidence of local recurrence is reported to occur during the second year after primary breast cancer treatment, the mean follow-up was reported as 26.4 months. This suggests that a large proportion of patients had less that 2 years of follow-up. In addition, length of follow-up was not recorded for each subgroup of patients (ie, those radiated before reconstruction or those radiated after reconstruction) so it is unclear whether follow-up was comparable between these patient cohorts. Perhaps more importantly, however, the statistical analysis performed here needs to be clarified. We would argue that in general, logistic regression analysis should not be used when evaluating ‘censored’ data (ie, individuals are followed for different lengths of time or their follow-up is incomplete) because such analysis does not take time or length of follow-up into account. Instead, when the data is censored, survival analysis should be performed. We would strongly advise the authors to re-analyze their data using the appropriate statistical techniques and to work in collaboration with an oncologic surgeon. We certainly agree that the oncologic safety of postmastectomy reconstruction should be evaluated and urge the authors to apply increased scientific rigor to their current evaluation. Colleen M. McCarthy, MD, MS Peter G. Cordeiro, MD Joseph J. Disa, MD Babak J. Mehrara, MD Andrea L. Pusic, MD, MHS Memorial Sloan Kettering Cancer Center New York, NY

Surgical management of neonatal limb ischaemia: A technique for open thrombectomy and the novel use of Integra

Neonatal limb ischaemia (NLI) is a rare but potentially catastrophic condition. Although medical therapy remains as first-line treatment, surgery has an important role when limb-threatening events are present. In this paper we outline the milking technique for open thrombectomy used by the senior author in the treatment of 5 NLI cases. We also present the use of Integra and its specific benefits in the management of wounds in these challenging situations. Skin grafts over the Integra can be avoided by staged excision of the silicone layer from the margins. We believe this is a novel approach to the use of Integra.

Keratoderma hereditarium mutilans (Vohwinkel syndrome).

Keratoderma hereditarium mutilans, or Vohwinkel syndrome, is a very rare genetic skin condition which causes palmoplantar hyperkeratosis and constricting rings of the fingers and toes. Approximately 50 cases have been reported in the literature with only three having been managed surgically. All three had a high rate of recurrence and unfavourable results in the long term. We report two more cases managed surgically with a follow up of 5 and 8 years respectively. Our experience suggests that the use of full thickness grafts to line the released contractures does not work in the long term as the grafts become raised and painful, requiring multiple revisions. Surgical correction was easy to achieve but difficult to maintain and achieved poor outcomes in general. We therefore feel that the indication for surgical treatment should be a neurovascular compromise.

Stem cell enriched dermal substitutes for the treatment of late burn contractures in patients with major burns

We read with interest the recent article in Burns by Foubert et al. [1], where the authors showed that Integra 1 dermal substitutes seeded with adipose derived regenerative cells (ADRCs) harvested with the Cytori system, promoted improved angiogenesis, blood vessel maturation and matrix remodelling, compared to Integra alone, in a swine animal model of full-thickness burns. We are writing to share our own clinical experience of using this technique in two patients with major burns to treat complex late contractures involving functionally and cosmetically significant areas. In both cases, very good surgical outcomes and patient satisfaction were achieved. We are aware of the scarcity of available clinical data on the subject and hope that our experience will benefit surgeons dealing with similar complex late burns sequelae.