Peri-Procedure Laser Scar Therapy Protocol: A Pilot Survey of Plastic Surgeons' Practices.

BACKGROUND: Scar management using laser phototherapy continues to evolve as it gains wide acceptance among patients and providers. Despite widespread use of laser therapy, there are no guidelines or consensus published regarding optimal pre- and post-procedure patient management. Our objective is to gain insight into the best laser practices; we decided to poll colleagues nationwide. METHODS: An online survey was distributed to members of the American Society of Plastic Surgeons. The survey consisted of 34 questions regarding pre- and post-procedure protocols related to laser scar therapy. RESULTS: Forty plastic surgeons responded to the survey. The survey demonstrated that ten types of lasers are currently used to treat scars. The most commonly used lasers are fractional Er:YAG (44.7%), pulsed dye (42.1%), and fractional CO2 (36.8%). On a Likert 3-point scale, providers favored the use of pre-procedural sunblock (2.12), topical analgesics (1.91), and oral antivirals (1.83). They also preferred the use of topical moisturizer (2.45), oral analgesics (2.29), and oral antivirals (1.97) as a part of the post-laser treatment regimen. CONCLUSION: The study verified there is no consensus regarding peri-procedure laser scar therapy regimens. As laser scar management continues to grow in popularity, this lack of consensus suggests the need for experts in the field to come together and propose agreeable protocols to be used as guidelines. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

A Descriptive Study of Hospital- and Community-acquired Pressure Ulcers/Injuries.

Hospital-acquired pressure ulcers/injuries (HAPU/I) have been a major focus of research, but information about community-acquired pressure ulcer/injuries (CAPU/I) is limited. PURPOSE: The aim of this study was to compare HAPU/I and CAPU/I in a 620-bed academic medical center in the western United States. METHODS: This descriptive study involved prospective/retrospective data collected from the National Data for Nursing Quality Indicators, including pressure ulcer stage (January 1, 2015, through December 31, 2017); the hospital's incident reporting system (January 1, 2017, through December 31, 2017); electronic medical records (EMR) as needed for verification; and the hospital's pressure ulcer registry (January 1, 2012, through December 31, 2017), developed by both EMR and manual extraction. Data regarding point prevalence, length of stay (LOS), source of admission, ulcer stage, and frequency of hospital encounters from patients at least 18 years of age with a pressure ulcer/injury documented in their records were abstracted. Data from pregnant or incarcerated persons and persons with missing or incomplete information on staging or origin of admission were excluded. Variables were analyzed using descriptive statistics. RESULTS: The number of patients with data reviewed for point prevalence was 1787 for 2015, 1989 for 2016, and 1917 for 2017. For 2015, the average CAPU/I and HAPU/I point prevalence was 6.6% and 0.8%, respectively; for 2016, 6.0% and 1.5%, respectively; and for 2017, 6.9% and 0.9%, respectively. The average LOS for patients analyzed for 2017 admitted with a CAPU/I or HAPU/I was 10.5 days and 38.9 days, respectively. Hospital encounters were more frequent in the CAPU/I than in the HAPU/I group, with 821 CAPU/encounters compared to 45 HAPU/I encounters. The majority of patients with a HAPU/I (80%) or CAPU/I (65.4%) were admitted from home. CONCLUSION: In this study, CAPU/I were more prevalent than HAPU/I and most patient encounters originated from home. More descriptive research that includes staging and source of admission is needed to document the rate of CAPU/I and characteristics of HAPU/I compared to CAPU/I in order to optimize pressure ulcer/injury practices across the continuum of care.

Antibiotic beads: tips and tricks learned at a busy county hospital.

This technique simplifies and improves the production of antibiotic beads in the operating room.

A New Injury Prevention Target: Summer Hair Braids.

Scald injuries caused by hair braiding have become increasingly common in our pediatric burn center's African-American population. This injury mechanism has received little attention in the medical literature. To guide prevention, the present study aims to characterize this novel mechanism of injury and identify patterns underlying its frequency. A retrospective cohort analysis was performed on all cases of scald injury due to hair braiding in African-American girls treated at our burn center from 2000 to 2016. Data were gathered from the patient's medical records to determine demographics, details of the injury, and treatment rendered. Patterns of injury frequency were identified and statistically analyzed. Thirty-four patients suffered scald injuries associated with hair braiding. The mean patient age was 8.4 years (SD ± 5 years). The majority of injuries (90%) occurred in the home. The frequency of injuries significantly increased starting in the year 2012, rising from less than 3% to more than 10% of evaluated injuries in African-American girls (P = .0015). Injuries were significantly more frequent in summer months. Injuries resulted in considerable usage of medical resources, including ambulance transport, hospital admission, clinic visits, prolonged wound care, and surgery. Complications developed in 41% of injured children; the most frequent complication was scarring. Pediatric scald injuries caused by braiding practices are morbid, have recently become increasingly frequent, tend to occur in the summer, and may be related to a new do-it-yourself style trend among African-American girls.

Invasive Conidiobolomycosis Can Be Successfully Treated on Burn Survivors.

Conidiobolus infection is difficult to diagnose and treat. We report successful treatment of invasive conidiobolomycosis, only one third such report is in the literature, and the first case reported was on a burn survivor. Our patient is also the first case reported on an adult surviving conidiobolomycosis. This case illustrates that serum ß-D-glucan (BDG) may be useful in the diagnosis and monitoring of invasive Conidiobolus infection, contrary to the misconception that Zygomycetes do not release detectable levels of BDG. Aggressive, surgical management and care in the burn unit can lead to successful treatment of this otherwise lethal infection.

Autologous fat grafting does not improve burn scar appearance: A prospective, randomized, double-blinded, placebo-controlled, pilot study.

OBJECTIVE: It has been proposed that fat grafts can improve the appearance of mature burn scars. The pluripotent progenitor cells contained within autologous adipose tissue grafts are believed to induce skin repair and improve scar appearance. We conducted a prospective, randomized, double-blinded, placebo-controlled study to evaluate the effects of fat grafts on the appearance of mature burn scars. METHODS: Pediatric burn survivors with mature scars were recruited for this study. A homogeneous scar measuring 10×5cm was randomized into two halves: one was injected with autologous fat graft and the other with normal saline. Scar injection was performed using standard Coleman technique. Appearance of the two scar halves was assessed, six to twelve months later by the operating surgeon, by blinded observers and by the blinded patients. RESULTS: Eight patients completed the study pilot with 6-12 month follow-up. Assessment by the patients did not clearly favor fat grafts or saline injections; the operating surgeon did not identify any differences on any of the patients; the blinded observers measured all scars using Vancouver Scar Scale and noticed no differences in pigmentation, vascularity and height; differences in pliability showed similar changes in both the fat grafted and control arms. After the pilot was completed, decision was made to stop enrolling patients for this study since no benefit to fat grafting was observed. CONCLUSIONS: Single treatment with autologous fat grafts did not improve mature pediatric burn scars when compared to normal saline injections.

Butane Hash Oil Burns: A 7-Year Perspective on a Growing Problem.

With the legalization of marijuana in four states, and decriminalization in many others, marijuana is becoming easier to obtain. The authors have experienced an increase in burn injuries related to the production of butane hash oil (BHO; a concentrated tetrahydrocannabinol product produced by the distillation of marijuana plant products with pressurized butane). This article updates our experience and highlights the increasing public health problem associated with these burns. Charts of patients who presented to the burn center with suspicion of BHO-related injuries between January 2007 and December 2014 were examined. Data collected included demographics, injury characteristics, treatment utilized, and outcomes. Charts of 101 patients were identified as having BHO-related burn injury. The mean age of these patients was 30.5 ± 10.6 years (mean ± standard deviation, range: 2-55 years) and 93.1% were male. Patients sustained a mean of 26.8 ± 24.1% TBSA burn with 14.3 ± 25.1% third degree burns. Three patients died as the result of their injuries. Patients required a mean of 12 ± 48.4 ventilator days, and 27.1 ± 59.4 days in the hospital. The number of patients presenting with these burns increased over the past 7 years. BHO burns occur most commonly in February (12 patients), on Wednesday (19 patients), and between 18:00 and 06:00 (58 patients). There has been a sharp increase in the number of patients presenting with burn-associated BHO production in the region over the past 7 years. The authors as burn care providers need to increase public awareness of this issue and aid in the development of legislation to help prevent these burns before it becomes a public health crisis.

The Unrecognized Epidemic of Electronic Cigarette Burns.

Electronic cigarettes (e-cigarettes) are novel battery-operated devices that deliver nicotine as an inhaled aerosol. They originated from China in 2007 and their use has rapidly increased worldwide in the past decade, yet they remain largely unregulated. Reports of injuries associated with their use have appeared as unusual events in the news media and as case reports in the medical literature. This study was undertaken to explore e-cigarettes as a mechanism of burn injury. Referral records to three burn centers from January 2007 to July 2016 were searched to identify patients with injuries caused by e-cigarettes. Data were gathered from the electronic medical records (EMRs) of patients referred within the most recent 18 months. Thirty patients with burns resulting from e-cigarettes were identified. Twenty-nine were referred within the most recent 18 months. Only one was referred in the preceding 8 years. An explosion was identified by the patient as the inciting event in 26 of the 30 injuries (87%). Explosion of an isolated battery while it was carried on personal attire was reported in 10 cases. Explosion of a fully assembled e-cigarette was described in 16 cases. In seven of these 16 cases, the explosion occurred while the device was idle and carried on personal attire. In the other nine cases, the explosion occurred while the device was being operated. No injury occurred while batteries were charging. The mean age of injured patients was 30 years. The mean size of burn was 4% TBSA. The thighs, hands, and genitalia were the most common sites of injury. Twenty-six patients required hospital admission and nine required surgery. Serious burn injuries from e-cigarettes have recently occurred with greatly increased frequency. The increase in injuries appears out of proportion to the increased popularity of e-cigarettes. The most common pattern of injury is explosion when either the idle device or its batteries are carried on personal attire.

Honey oil burns: a growing problem.

There is an emerging mechanism of burn injury as a result of the ignition of butane, during the manufacture of a tetrahydrocannabinol concentrate known as butane honey oil. The authors report of a series of patients who presented with this mechanism of injury and a description of the process that causes these burns. Patient data were gathered from the medical records of eight patients treated at the University of California Davis Medical Center and Shriners Hospital of Northern California. Information on the manufacturing process of butane honey oil was gathered from Internet searches and published literature on the topic. The burns witnessed at the abovementioned institutions ranged from 16 to 95% TBSA, with an average of 49.9%. The average length of stay for the patients was 118.3 hospital days and 114.4 intensive care unit days, with an average of 43.8 days spent on mechanical ventilation. The average age of patients was 22 years, with only one patient above the age of 30 years. Accidents during honey oil production have resulted in a surge of burn injuries in our community during the past year. The manufacture of this product, which involves the use of volatile butane gas, is gaining in popularity. Although considered to be safer than previous methods, multiple casualties with extensive burn injuries have resulted from this process. Associated injuries from blast trauma or chemical burns are not likely to occur in these types of explosions and have not been observed in the series reported in this article. In light of the increasing popularity of honey oil, it is important for burn care providers to gain awareness and understanding of this problem and its growing presence in the community.

Split thickness skin grafting for recreation of the scrotum following Fournier's gangrene.

Fournier's gangrene is an infection of the genitals and perineum that is treated with extensive soft tissue debridement, often leading to loss of scrotal skin. Multiple options for reconstruction of the scrotum are available. Four cases of recreation of the scrotum with meshed split thickness skin grafts (STSG) are presented. The discussion includes a comparison of STSG with other treatment options. We conclude that STSG are a safe, technically easy treatment option with satisfactory cosmetic and functional results.

Treadmills: a preventable source of pediatric friction burn injuries.

Treadmills are a burn risk for children. A child's hand can get trapped in the conveyor belt, causing friction burns to the underlying tissue. The purpose of this retrospective study was to review the characteristics and treatment of treadmill-related burns in children from 1998 to 2002. Ten patients, at a mean age of 3.4 years, sustained injuries associated with treadmill use. Trapping of the hand between the conveyor belt and the base was the most frequent injury mechanism. Burn location was predominantly on fingers and palms. Four patients required operative intervention. All patients required specialized wound care as well as scar management and occupational therapy. Treadmills pose a danger to children. Current safety devices are ineffective for preventing serious hand injuries in children. New design modifications and public awareness are needed to improve child safety.

Car seat heaters: a potential hazard for burns.

Car seat heaters have gained popularity in America and worldwide. They offer comfort by heating the sitting surface to a soothing temperature. Several cases of heating-element malfunction resulted in burn injuries and have triggered recalls of thousands of cars by the manufacturers. We present a case of a 48-year-old patient with long-standing paraplegia who sustained third-degree burns on his buttock during the initial drive of a new car with seat heaters. Car seat heaters can cause severe burns. Patients with decreased sensation or immobility are at increased risk and should not use car seat heaters. This case illustrates the need for design modifications and consumer education regarding the risks associated with car seat heaters.

The circle of safety: a campfire burn prevention campaign expanding nationwide.

Camping is a popular family activity, especially during the spring and summer months. Campfires are a common activity among campers. They offer a source of recreation but also pose a risk for severe burns. The rising number of children with campfire burns seen at our institution triggered a quest for a campaign for the prevention of these injuries. A chart review was performed to study the characteristics and the circumstances of burn injuries of all children treated for campfire-related injuries over a 4-year period between 1997 and 2001. Thirty-two children sustained campfire-related burn injuries, with 88% being under the age of 7. The children had either fallen into the campfire or walked into simmering coals. All accidents would have been prevented if the children had kept a safe distance from the campfire. Normal growth charts were used to determine the average height of 7-year-old children as being 48 inches. A campaign was started to encourage families to keep a safe distance of 4 feet from their campfires by drawing a "circle of safety" with a stick on the ground 4 feet away from the fire.

Hospital-acquired pressure ulcer prevention: a burn surgeon's team approach.

Hospital-acquired pressure ulcers (HAPUs) are a problem that has been under increased scrutiny in recent years. To help reduce the incidence of HAPUs and to improve their management, a burn unit-centered wound care team was established. The team decided to pursue two goals: to identify opportunities for improvement that may help prevent HAPUs and to evaluate all available support surfaces to identify those that might best help with pressure redistribution. To identify opportunities for improvement, the team studied each new case of HAPUs throughout our hospital with a forensic chart review for a 3-year period. To identify the best support surfaces to help reduce the incidence of pressure ulcers, we evaluated all support surfaces available at our institution by pressure mapping in healthy volunteers. From 3 years of collecting and reporting data for quality improvement, we identified 23 patients with HAPUs and obtained more than 800 data sets from pressure mapping in healthy volunteers. Most (23/24; 96%) patients with HAPUs identified in this series had undergone a surgical procedure. The results of the quality improvement studies are presented. We conclude that prevention planning of HAPUs needs to be improved in patients undergoing surgery, in particular. No single support surface can prevent pressure ulcers, but use of overlays may help reduce peak pressures over bony prominences.

Review of epinephrine solution use in 400 consecutive cases of burn reconstruction. Are infusion pumps safe?

Infiltration of diluted epinephrine solutions is often used in reconstructive surgery to produce local vasoconstriction and minimize bleeding. A total of 400 burn reconstruction procedures were performed with the aid of epinephrine solution between July 2008 and July 2011. We used to consider this practice very safe, but after encountering several complications, we decided to perform a retrospective review to look at all complications in detail and identify opportunities to improve safety. We encountered nine complications including one case of flash pulmonary edema and one patient with acute carpal tunnel syndrome. All severe complications were seen when the epinephrine solution was infiltrated with the aid of an electric infusion pump. Infusion pumps do not allow for reliable control of the amount of infiltration of epinephrine solutions. We conclude that infusion pumps may unnecessarily increase the risk for complications. This has resulted in a change in our practice. We now use infusion pumps only in selected cases.

Mini-abdominoplasty in burn reconstruction.

The excision of excessive fat and subcutaneous tissue in the infraumbilical region, also known as "mini-abdominoplasty, " can be used to harvest skin for burn reconstruction. The resultant full-thickness grafts are less prone to contracture than split-thickness grafts. They are particularly useful in areas where mobility is important, such as the neck and areas overlying major joints. It allows a single-stage reconstruction with little donor site morbidity and favorable long-term functional outcomes. Multiple other donor sites have been reported, most commonly the groin and small pinch grafts on the trunk, but they provide only small amounts of skin when compared with the abdomen. The authors report 12 cases of patients who were treated for sequelae of burns with full-thickness abdominal skin grafts that were procured by mini-abdominoplasties for the sole purpose of obtaining the skin. The mini-abdominoplasty in this series was found to be an effective, safe technique that provides large amounts of full-thickness skin for reconstruction. While the size of the grafts varied with age and size of the abdomen, up to 40 × 15 cm can be obtained in adults. The donor site complications are rare but most commonly include seromas and dehiscence of the wound.

The ABC daycare disaster of Hermosillo, Mexico.

On June 5, 2009, the ABC Daycare facility in Hermosillo, Mexico, caught on fire with an estimated 142 children and 6 adult caregivers inside. The purpose of this article is to describe the factors contributing to the disaster including care of the survivors, tertiary burn center triage, patient transport, and treatment for this international mass casualty event. Finally, the results of an investigation performed by the Mexican Government are reviewed. A summary of the Mexican Government's investigation of the circumstances of fire and an examination of prevention lapses in other Mexican daycare centers was obtained from their public Web site. The demographic and clinical characteristics of the children transported to the burn center were obtained from the patients' medical records and transport data sheets. The ABC Daycare had many fire safety breaches that contributed to the severity of the tragedy. Twenty-nine children died at the scene and more than 35 children were hospitalized throughout Mexico. A total of 12 children were transported to two Shriners Hospitals, 9 to Sacramento, and 3 to Cincinnati. The mean age of patients sent to the Shriners Hospitals was 2.9 ± 0.16 years (2-4 years), with 5 being male and 7 female. The mean duration between injury and arrival was 9.2 ± 2.1 days, the burn size was 43.0 ± 6.8% TBSA (6.5-80%), and there were 3.75 operations per patient. Four had fourth-degree burns requiring finger amputations (2), flaps to cover bone (1), or a through-knee amputation (1). Ten patients were admitted to the intensive care unit, and nine patients (seven with inhalation injury) required mechanical ventilation for a mean of 23.6 ± 10.3 days. All the surviving children were discharged after a mean length of stay of 45.9 ± 8.7 days. In the first year postinjury, seven children were readmitted a total of 11 times for reconstructive surgery, wound care, or rehabilitation. Ultimately, a total of 49 children died. A review of other daycare centers in Mexico revealed similar safety lapses that could lead to future major disasters. This burn disaster in Hermosillo was potentially preventable with adherence to standard prevention principals. The young age of the victims and the need for an international medical response posed special problems. Prevention efforts need to be improved to prevent future disasters in Mexico.

Local tissue flaps: definitive treatment for chronic blisters after chemical burns.

Chronic blistering in grafted burn wounds is an infrequently described but severely debilitating complication that can appear after alkali burns and seems to coincide with a delay in initial treatment. Histological studies have concluded that the pathogenesis of chronic subepidermal blister formation in previously grafted burn wounds is related to abnormalities in the basement membrane. Although several reports have described this problem, none have reported adequate treatment for the chronic blistering in previously grafted alkali burns. The authors describe the case of a 30-year-old man in whom caustic soda burns treated with excision and split-thickness skin grafting resulted in chronic subepidermal blistering that failed to improve over the next 2 years. The problem was resolved with full-thickness skin excision and reconstruction with bipedicled fasciocutaneous flaps.

Burn unit experience treating giant melanocytic nevi: 10-year review.

Giant congenital melanocytic nevi (GCMN) are rare lesions that are present in 1 in every 20,000 new births. A 10-year review of all patients treated at a pediatric burn center was performed with the goal of identifying the characteristics of patients with GCMN and the outcomes of the treatment provided in a burn center. Thirty-six patients met the definition of GCMN; 64% were female and 36% were male. The most common ethnicity was white (47%), followed by Latino (19%). Most patients were between the ages of 1 and 10 years at the time of their first procedure (64%), and the mean age of patients at the time of their first procedure was 7 years. Eighty-nine percent had only one lesion. The most common location of lesions was the face (64%), followed by the scalp (17%) and back (17%). Seventy-four percent of the samples sent to pathology were congenital compound melanocytic nevi, and 20% were congenital intradermal melanocytic nevi. None of the lesions contained malignant changes at the time of the pathological examination. The various treatment modalities provided in the burn unit are reviewed. The authors conclude that the burn unit is an ideal setting for the treatment of GCMN.