Safety and Cost-Effectiveness of Outpatient Surgery in Acute Burn Care.

Outpatient burn surgery is increasingly used in acute burn care. Reports of its safety and efficacy are limited. This study aims to evaluate the safety and cost reduction associated with outpatient burn surgery and to describe our center's experience. This was a single-center, retrospective cohort study of consecutive patients who underwent outpatient burn surgery requiring split-thickness skin graft or dermal regenerative template from January 2010 to December 2018. Patient demographics, comorbidities, burn etiologies, operative data, and postoperative care were reviewed. The primary outcome is complications involving major graft loss requiring reoperation. One hundred and sixty-five patients and 173 procedures met the inclusion criteria. The average age was 44 years and 60.6% (100/165) were male. Annual outpatient procedure volume increased 48% from 23 to 34 cases over the 9-year period. The median (interquartile range) grafted percentage total body surface area was 1.0 (1.0)%. Rate of major graft loss requiring reoperation was 5.2% (9/172) and the most common site was the lower extremity (8/9, 88.9%). Age, sex, comorbidities, total body surface area, and procedure types were not significantly associated with postoperative complication rates. The outpatient burn surgery model was estimated to save CA$8170 per patient from inpatient costs. Demonstration of the safety and cost savings associated with outpatient acute burn surgery is compelling for further utilization. Our experience found the adoption of improved dressing care, appropriate patient selection, increased patient education, adequate pain control, and regimented outpatient multidisciplinary care to be fundamental for effective outpatient surgical burn care.

Single-Stage Adipofascial Turnover Flap as an Alternate Option for Large Nasal Defects Usually Requiring Two-Stage Forehead Flap.

BACKGROUND: Large nasal defects involving the tip, ala, and/or columella with denuded cartilage have traditionally required a two-stage forehead flap. As many Mohs patients are presenting older with increased medical comorbidities, a single-stage adipofascial turnover flap with a full-thickness skin graft was developed by the senior author as an alternative method. The authors hypothesize that the adipofascial turnover flap would have similar success rates and cost less than the forehead flap. METHODS: A retrospective review of all patients in the senior author's practice who underwent either a forehead flap or adipofascial turnover flap between January of 2016 and February of 2019 was conducted. The two groups were compared regarding success, complications, and cost. RESULTS: There were seven forehead flap patients and 11 patients with adipofascial turnover flaps. Overall complications were three of seven (43 percent) for the forehead flap group and one of 11 (9 percent) for the adipofascial turnover flap group. There was one mortality, one revision for asymmetry, and one with airflow obstruction in the forehead group. The adipofascial turnover flap group had one partial skin graft loss that healed with local wound care only. There were no flap failures in either group, and the cost savings averaged over $22,000 in the adipofascial turnover flap group. CONCLUSIONS: The single-stage adipofascial turnover flap with full-thickness skin grafting is a safe, reliable, and less expensive alternate to the forehead flap. The forehead flap will remain a workhorse in nasal reconstruction, but multiple operations increase cost and may contribute to higher complication rates. The adipofascial turnover flap appears to be an efficacious and reasonable option compared with the forehead flap.

Comparative Effectiveness Analysis of Complex Lower Extremity Reconstruction: Outcomes and Costs for Biologically Based, Local Tissue Rearrangement, and Free Flap Reconstruction.

BACKGROUND: Various surgical techniques exist for lower extremity reconstruction, but limited high-quality data exist to inform treatment strategies. Using multi-institutional data and rigorous matching, the authors evaluated the effectiveness and cost of three common surgical reconstructive modalities. METHODS: All adult subjects with lower extremity wounds who received bilayer wound matrix, local tissue rearrangement, or free flap reconstruction were retrospectively reviewed (from 2010 to 2017). Cohorts' comorbidities and wound characteristics were balanced. Graft success at 180 days was the primary outcome; readmissions, reoperations, and costs were secondary outcomes. RESULTS: Five hundred one subjects (166 matrix, 190 rearrangement, and 145 free flap patients) were evaluated. Matched subjects (n = 312; 104/group) were analyzed. Reconstruction success at 180 days for matrix, local tissue rearrangement, and free flaps was 69.2 percent, 91.3 percent, and 93.3 percent (p < 0.001), and total costs per subject were $34,877, $35,220, and $53,492 (p < 0.001), respectively. Median length of stay was at least 2 days longer for free flaps (p < 0.0001). Readmissions and reoperations were greater for free flaps. Local tissue rearrangement, if achievable, provided success at low cost. Free flaps were effective with large, traumatic wounds but at higher costs and longer length of stay. Matrices successfully treated older, obese patients without exposed bone. CONCLUSIONS: Lower extremity reconstruction can be performed effectively using multiple modalities with varying degrees of success and costs. Local tissue rearrangement and free flaps demonstrate success rates greater than 90 percent. Bilayer wound matrix-based reconstruction effectively treats a distinct patient population. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

The Optimal Treatment for Partial Thickness Burns: A Cost-Utility Analysis of Skin Allograft vs. Topical Silver Dressings.

INTRODUCTION: Partial thickness burns not undergoing surgical excision are treated with topical silver products including silver sulfadiazine (SSD) and Mepilex Ag. Skin allograft is a more costly alternative that acts as definitive wound coverage until autogenous epithelialization. Economic constraints and the movement toward value-based care demand cost and outcome justification prior to adopting more costly products. METHODS: A cost-utility analysis was performed comparing skin allograft to SSD and Mepilex Ag using decision tree analysis. The base case modeled a superficial partial thickness 20% total body surface area burn. Utilities were derived from expert opinion on the basis of personal experience. Costs were derived from 2019 Medicare payments. Quality adjusted life years were calculated using rollback method assuming standard life expectancies in the United States. Probabilistic sensitivity analysis was performed to asses model robustness. RESULTS: The incremental costs of skin allograft to Mepilex Ag and SSD were $907.71 and $1257.86, respectively. The incremental quality adjusted life year (QALY) gains from allograft over Mepilex Ag and SSD were 0.011 and 0.016. This yielded an incremental cost-utility ratio for allograft vs. Mepilex Ag of $84,189.29/QALY compared with an incremental cost-utility ratio of $79,684.63/QALY for allograft vs. SSD. Assuming willingness-to-pay thresholds of $100,000/QALY, probabilistic sensitivity analysis demonstrated that allograft was cost effective to Mepilex Ag in 62.1% of scenarios, and cost effective to SSD in 64.9% of simulations. CONCLUSION: Skin allograft showed greater QALYs compared with topical silver dressings at a higher cost. Depending on willingness-to-pay thresholds, skin allograft may be a considered a cost-effective treatment of partial-thickness burns.

Characteristics of Patients Hospitalized for Cutaneous Squamous Cell Carcinoma.

BACKGROUND: Knowledge regarding the inpatient burden of cutaneous squamous cell carcinoma (cSCC) is limited. OBJECTIVE: To provide nationally representative estimates for hospitalization characteristics due to cSCC and determine predictors for increased length of stay (LOS) and cost of care. METHODS/MATERIALS: A retrospective cohort study of the 2009 to 2015 National Inpatient Sample. Weighted multivariate logistic/linear regression models were created to evaluate sociodemographic factors associated with cSCC hospitalization and to assess characteristics associated with cost of care and LOS. RESULTS: This study included 15,784 cSCC and 255,244,626 non-SCC inpatients (prevalence = 6.2/100,000 inpatients). On average, cSCC hospitalizations lasted 5.8 days and cost $66,841.00. Cutaneous squamous cell carcinoma most often occurred on the scalp (30.57%), face (21.08%), and lower limb (11.93%). Controlling for all other factors, cSCC inpatients presented to larger/urban/teaching hospitals and were most often older non-Hispanic white women. More chronic conditions/diagnoses/procedures and nonwhite race were associated with greater cost of care and LOS. Cost of care and LOS significantly differed between cSCCs of different anatomical sites. The most common procedures performed were skin grafts (27.96%), excisions (25.83%), and lymph node biopsies (11.39%). CONCLUSION: This study highlights the substantial burden of inpatient cSCC in the United States. Further research is necessary to prevent cSCC hospitalizations and improve inpatient dermatologic care for cSCC.

The Health Economic Impact of Living Cell Tissue Products in the Treatment of Chronic Wounds: A Retrospective Analysis of Medicare Claims Data.

OBJECTIVE: To investigate differences in wound-related costs; product waste; lower-extremity amputations; and number of applications, hospitalizations, and emergency room visits among patients treated with three cellular and/or tissue-based products. METHODS: This retrospective intent-to-treat matched-cohort study analyzed the full Medicare claims dataset from 2011 to 2014. Patients who received either a bilayer cellular construct (BLCC), dermal skin substitute (DSS), or cryopreserved human skin allograft (CHSA) were concurrently matched for Charlson Comorbidity Index, age, sex, and region, resulting in 14,546 study patients. Key variables were reported at 60, 90, and 180 days after the first product application. RESULTS: There were no statistically significant differences in the distribution of Charlson Comorbidity Index, age, sex, and region among cohorts. Wound-related costs and product wastage were lower for CHSA patients relative to both BLCC and DSS patients at all time intervals (P < .05). Patients treated with CHSA received fewer product applications than DSS at 90 and 180 days (P < .05). Amputations were significantly higher among patients treated with DSS than either CHSA or BLCC (P < .0001). CONCLUSIONS: The data demonstrate that wound-related costs, product waste, amputations, and frequency of applications are lower for CHSA than DSS. Wound-related costs and product waste are lower for CHSA compared with BLCC. Further claims analysis and prospective clinical trials could help develop appropriate quality measures and reimbursement models to ensure smarter spending for the growing population of patients with chronic wounds.

Healthcare resource utilization, treatment patterns, and cost of care among patients with thermal burns and inpatient autografting in two large privately insured populations in the United States.

The current standard of care for severe burns includes autografting; however, there is scarce knowledge regarding the long-term economic burden associated with thermal burns and inpatient autografting. The objective of this study was to characterize healthcare resource utilization, treatment patterns, and cost of care for thermal burn patients in two large privately insured populations in the United States who underwent inpatient autografting between 01/01/2011 and 06/30/2016. Patient demographics, clinical characteristics, healthcare resource utilization, and total cost were examined during baseline (one year before the initial hospitalization with autografting) and two-year evaluation period. There was a substantial economic burden on thermal burn patients who received inpatient autografts (HIRD® database [HIRD]: N=371, mean age=39.6 years, male=67.1%; MarketScan® database [MarketScan]: N=698, mean age=38.2 years, male=63.3%) in the year 1 evaluation period (HIRD: mean=$184,805; MarketScan: mean=$155,272), which was mainly driven by the initial hospitalization with autografting (HIRD: mean=$157,384 and MarketScan: mean=$131,470). The percentage of patients with burn-related healthcare resource utilization and average burn-related costs were considerably reduced in the year 2 evaluation period (HIRD: mean=$3020; MarketScan: mean=$1990). Consistent with previous studies, mean length of hospital stay (days) and mean total medical costs generally increased as the percentage of total body surface area burned increased.

Cost-Effectiveness of the Use of Autologous Cell Harvesting Device Compared to Standard of Care for Treatment of Severe Burns in the United States.

INTRODUCTION: When introducing a new intervention into burn care, it is important to consider both clinical and economic impacts, as the financial burden of burns in the USA is significant. This study utilizes a health economic modeling approach to estimate cost-effectiveness and burn center budget-impact for the use of the RECELL® Autologous Cell Harvesting Device to prepare autologous skin cell suspension (ASCS) compared to standard of care (SOC) split-thickness skin graft (STSG) for the treatment of severe burn injuries requiring surgical intervention for definitive closure. METHODS: A hospital-perspective model using sequential decision trees depicts the acute burn care pathway (wound assessment, debridement/excision, temporary coverage, definitive closure) and predicts the relative differences between use of ASCS compared to SOC. Clinical inputs and ASCS impact on length of stay (LOS) were derived from clinical trials and real-world use data, American Burn Association National Burn Repository database analyses, and burn surgeon interviews. Hospital resource use and unit costs were derived from three US burn centers. A budget impact calculation leverages Monte Carlo simulation to estimate the overall impact to a burn center. RESULTS: ASCS treatment is cost-saving or cost-neutral (< 2% difference) and results in lower LOS compared to SOC across expected patient profiles and scenarios. In aggregate, ASCS treatment saves a burn center 14-17.3% annually. Results are sensitive to, but remain robust across, changing assumptions for relative impact of ASCS use on LOS, procedure time, and number of procedures. CONCLUSIONS: Use of ASCS compared to SOC reduces hospital costs and LOS of severe burns in the USA. FUNDING: AVITA Medical.

Fibrin tissue sealant and minor skin grafts in burn surgery: A systematic review and meta-analysis.

BACKGROUND: The indications for use of fibrin glue in skin grafting burn patients remains understudied. The purpose of this study is to review the efficacy of fibrin tissue sealant in skin graft adherence, establish guidelines for use of fibrin tissue sealant, and review the cost effectiveness of fibrin glue. METHODS: Publications with the following criteria were included: comparative human studies, autologous skin grafts, and autologous or commercial fibrin sealant. Outcomes assessed included evidence of engraftment, wound closure, rates of hematoma/seroma, graft loss and infection. Meta-analysis obtained pooled odds ratios for outcomes of interest. Cost analysis was performed using data available in the literature. RESULTS: 7 studies and 751 interventions (fibrin) and controls (staples) were included in the final analysis. 67.6% grafts with fibrin were 100% adherent by one week, vs. 55.5% (OR 1.45, p = 0.086). Complete wound closure by one month was 80.2% with fibrin, vs. 73.3% (OR 1.34, p = 0.187). Hematoma/seroma occurred 38.2% with fibrin, vs. 64.7% (OR 0.487, p = 0.122). Graft loss was higher in the control group, 21% vs. 12.6% (OR 0.891, p = 0.604). Average cost of fibrin glue was $50 per ml, and averaged costs of stapler and staple remover was $30 USD ($10-50). CONCLUSION: Fibrin glue is as effective as staples for adhering skin grafts, and trends towards lower rates of hematoma/seroma. In topographically complex regions, fibrin glue may be a better choice for adherence of skin grafts.

Validation of the burn intervention score in a National Burn Centre.

The Linköping burn score has been used for two decades to calculate the cost to the hospital of each burned patient. Our aim was to validate the Burn Score in a dedicated Burn Centre by analysing the associations with burn-specific factors: percentage of total body surface area burned (TBSA%), cause of injury, patients referred from other (non-specialist) centres, and survival, to find out which of these factors resulted in higher scores. Our second aim was to analyse the variation in scores of each category of care (surveillance, respiration, circulation, wound care, mobilisation, laboratory tests, infusions, and operation). We made a retrospective analysis of all burned patients admitted during the period 2000-15. Multivariable regression models were used to analyse predictive factors for an increased daily burn score, the cumulative burn score (the sum of the daily burn scores for each patient) and the total burn score (total sum of burn scores for the whole group throughout the study period) in addition to sub-analysis of the different categories of care that make up the burn score. We retrieved 22301 daily recordings for inpatients. Mobilisation and care of the wound accounted for more than half of the total burn score during the study. Increased TBSA% and age over 45 years were associated with increased cumulative (model R2 0.43, p<0.001) and daily (model R2 0.61, p<0.001) burn scores. Patients who died had higher daily burn scores, while the cumulative burn score decreased with shorter duration of hospital stay (p<0.001). To our knowledge this is the first long term analysis and validation of a system for scoring burn interventions in patients with burns that explores its association with the factors important for outcome. Calculations of costs are based on the score, and it provides an indicator of the nurses' workload. It also gives important information about the different dimensions of the care provided from thorough investigation of the scores for each category.

Dermal Regenerative Template as a Cost-Effective Alternative for Complex Scalp Reconstruction.

BACKGROUND: Use of dermal regeneration template (DRT) is well documented in the literature for complex wounds ranging from the scalp, trunk, and lower extremity. METHODS: A retrospective cohort study was performed of the use of dermal regeneration template and skin grafting. A literature review was performed of all studies where DRT was used for scalp reconstruction. RESULTS: Patients in the DRT cohort had an average age of 70, with wounds averaging 108 cm in size. These patients also had a relatively low rate of complications (0.4), a short hospital stay (average 2 days), and a relatively short operating room time (114 minutes). CONCLUSION: This study demonstrates dermal regeneration template to be an effective and reliable option for soft tissue reconstruction with minimal morbidity and complications in patients with extensive medical comorbidities. Emerging applications include radiation exposure and hypercoaguable states.

Change in reimbursement and costs in German oncological head and neck surgery over the last decade: ablative tongue cancer surgery and reconstruction with split-thickness skin graft vs. microvascular radial forearm flap.

OBJECTIVES: Defects after ablative tongue cancer surgery can be reconstructed by split-thickness skin grafts or free microvascular flaps. The different surgical options may influence costs, reimbursement, and therefore possible profits. Our goal was to analyze the development of these parameters for different procedures in head and neck reconstruction in Germany over the last decade. MATERIALS AND METHODS: After tumor resection and neck dissection of tongue cancer, three different scenarios were chosen to calculate costs, reimbursement, length of stay (LoS), and profits. Two options considered were reconstruction by split-thickness skin graft with (option Ia) and without (option Ib) tracheotomy. In addition, we analyzed microvascular reconstruction with radial forearm flap (option II). Furthermore, unsatisfactory results after options Ia and Ib may make secondary tongue plastic with split-thickness skin grafting necessary (option I+). The calculations were performed considering the German Diagnosis Related Group (DRG) system and compared to the specific DRG cost data of 250 German reference hospitals. RESULTS: The overall average length of stay (aLoS) declined from 16.7 to 12.8 days with a reduction in every option. Until 2011, all options showed similar accumulated DRG reimbursement. From 2012 onwards, earnings almost doubled for option II due to changes in the DRG allocation. As was expected, the highest costs were observed in option II. Profits (reimbursement minus costs) were also highest for option II (mean 2052 €, maximum 3630 Euros in 2015) followed by options Ia (765 €) and Ib/I+ (681 €). Average profits over time would be 17 to 19% higher if adjusted for inflation. CONCLUSIONS: We showed the development of the DRG allocation of two commonly used methods of reconstruction after ablative tongue cancer surgery and the associated LoS, reimbursement, costs, and profits. As expected, the highest values were found for microvascular reconstruction. Microvascular reconstruction may also be the primary choice of treatment from a medical point of view. However, prolonged operation times, intensive care, and hospital stay in connection with complex microvascular operations can easily turn profits into losses as opposed to the results of simple, reliable, and fast split-thickness skin grafting. The inflation rate influences profits in reimbursement systems where costs are based on a previous period of time. CLINICAL RELEVANCE: Surgeons find themselves daily in an area of conflict between economic interests and medical decision-making. Due to its multidimensional aspects, the choice of the reconstructive technique should be primarily based on the best medical care for the patient. But there should also be awareness of the economic risk of all three surgical procedures.

Cost analysis of postmastectomy reconstruction: A comparison of two staged implant reconstruction using tissue expander and acellular dermal matrix with abdominal-based perforator free flaps.

BACKGROUND AND OBJECTIVES: Two staged tissue expander-implant with acellular dermal matrix (TE/I + ADM) and deep inferior epigastric perforator (DIEP) flap are the most common implant and autologous methods of reconstruction in the U.S. Implant-based techniques are disproportionally more popular, partially due to its presumed cost effectiveness. We performed a comprehensive cost analysis to compare TE/I + ADM and DIEP flap. METHODS: A comparative cost analysis of TE/I + ADM and DIEP flap was performed. Medicare reimbursement costs for each procedure and their associated complications were calculated. Pooled probabilities of complications including cellulitis, seroma, skin necrosis, implant removal, flap loss, partial flap loss, and fat necrosis, were calculated using published studies from 2010 to 2016. RESULTS: Average actual cost for successful TE/I + ADM and DIEP flap were $13 304.55 and $10 237.13, respectively. Incorporating pooled complication data from published literature resulted in an increase in cost to $13 963.46 for TE/I + ADM and $12 624.29 for DIEP flap. The expected costs for successful TE/I + ADM and DIEP flap were $9700.35 and $8644.23, which are lower than the actual costs. CONCLUSIONS: DIEP flap breast reconstruction incurs lower costs compared to TE/I + ADM. These costs are lower at baseline and when additional costs from pooled complications are incorporated.

The CelluTome epidermal graft-harvesting system: a patient-reported outcome measure and cost evaluation study.

Conventional split skin grafts (SSG) require anaesthesia, specialist equipment and can have high donor site (DS) morbidity. The CelluTome epidermal graft-harvesting device is a novel alternative, providing pain-free epidermal skin grafts (ESG) in the outpatient setting, with projected minimal DS trauma and improved patient satisfaction. This study aimed to compare ESG with SSG by evaluating patient-related outcome measures (PROMs) and the cost implications of both. Twenty patients answered a graft satisfaction questionnaire that evaluated: donor/graft site noticeability, aesthetic concerns, adverse problems and patient satisfaction. Cost/patient was calculated based on total operative expenses and five clinic follow-ups. In 100% of the ESG cases, there were no DS noticeability or adverse problems compared to 25% in the SSG group. Complete satisfaction with DS appearance was observed in 100% of the ESG cases (50% SSG). Noticeability, adverse problems and overall satisfaction were significantly better in ESG cases (P < 0.05). Graft site parameters were comparable with similar healing outcomes. The cost per patient for ESG was £431 and £1489 for SSG, with an annual saving of £126 960 based on 10 grafts/month. For the right patient, CelluTome provides comparable wound healing, with reduced DS morbidity and higher patient satisfaction.

[Application of combination of xenoskin with delayed microskin graft in extensively burned patients].

OBJECTIVE: To observe clinical effects of combination of acellular porcine skin with delayed microskin graft on extensively burned patients.
 Methods: Forty extensively burned patients were assigned into a treatment group and a control group. In the treatment group, 20 patients were covered with acellular porcine skin after escharectomy, and the delayed microskin grafting was performed 5 days later. In the control group, 20 patients were covered with allograft skin combined with microskin graft after escharectomy. The cure rate, the graft survival rate, wound healing time and cost per 1% wound were observed.
 Results: The cure rate for the 2 groups was the same (90%), and wound healing time was similar between the two groups (P>0.05). The graft survival rate in the treatment group was higher than that in the control group (P<0.05), and cost per 1% wound in the treatment group was less than that in the control group (P<0.05).
 Conclusion: The combination of acellular porcine skin with delayed microskin graft is an effective method to treat extensively burned patients, and it provides an ideal substitute for allograft skin combined with microskin graft.

The Use of Integra Dermal Regeneration Template Versus Flaps for Reconstruction of Full-Thickness Scalp Defects Involving the Calvaria: A Cost-Benefit Analysis.

BACKGROUND: INTEGRA® Dermal Regeneration Template is a well-known and widely used acellular dermal matrix. Although it helps to solve many challenging problems in reconstructive surgery, the product cost may make it an expensive alternative compared to other reconstruction procedures. This retrospective study aims at comparing INTEGRA-based treatment to flap surgery in terms of cost and benefit. PATIENTS AND METHODS: We considered only patients treated for scalp defects with bone exposure in order to obtain two groups as homogeneous as possible. We identified two groups of patients: 17 patients treated with INTEGRA and 18 patients treated with flaps. All patients were admitted in our institution between 2004 and 2010, and presented a defect of the scalp following trauma or surgery for cancer, causing a loss of the soft tissues of the scalp with bone exposure without pericranium. To calculate the cost in constant euros of each treatment, three parameters were evaluated for each patient: cost of the surgical procedure (number of doctors and nurses involved, surgery duration, anesthesia, material used for surgery), hospitalization cost (hospitalization duration, dressings, drugs, topical agents), and outpatient cost (number of dressing changes, personnel cost, dressings type, anti-infective agents). The statistical test used in this study was the Wilcoxon Mann-Whitney (α = 0.05). RESULTS: No significant difference was characterized between the two groups for gender, age, presence of diabetes, mean defect size, and number of surgical procedures. All patients healed with good quality and durable closure. The median total cost per patient was €11,121 (interquartile range (IQR) 8327-15,571) for the INTEGRA group and €7259 (IQR 1852-24,443) for the flap group (p = 0.34). A subgroup of patients (six patients in the INTEGRA group and five patients in the flap group) showing defects larger than 100 cm2 were considered in a second analysis. Median total cost was €11,825 (IQR 10,695-15,751) for the INTEGRA group and €23,244 (IQR 17,348-26,942) for the flap group. CONCLUSION: Both treatments led to a good healing of the lesions with formation of soft and resistant tissue. No significant difference was characterized between the two groups for days of hospitalization and costs. In cases of patients with defects larger than 100 cm2 for whom major surgery is needed, the treatment with INTEGRA seemed to be less expensive than the treatment with free flaps or pedicle flaps. 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 A5 online Instructions to Authors. www.springer.com/00266 .

Epidermal grafting versus split-thickness skin grafting for wound healing (EPIGRAAFT): study protocol for a randomised controlled trial.

BACKGROUND: Split-thickness skin grafting (SSG) is an important modality for wound closure. However, the donor site becomes a second, often painful wound, which may take more time to heal than the graft site itself and holds the risk of infection and scarring. Epidermal grafting (EG) is an alternative method of autologous skin grafting that harvests only the epidermal layer of the skin by applying continuous negative pressure on the normal skin to raise blisters. This procedure has minimal donor site morbidity and is relatively pain-free, allowing autologous skin grafting in an outpatient setting. We plan to compare EG to SSG and to further investigate the cellular mechanism by which each technique achieves wound healing. METHODS/DESIGN: EPIGRAAFT is a multicentre, randomised, controlled trial that compares the efficacy and wound-healing mechanism of EG with SSG for wound healing. The primary outcome measures are the proportion of wounds healed in 6 weeks and the donor site healing time. The secondary outcome measures include the mean time for complete wound healing, pain score, patient satisfaction, health care utilisation, cost analysis, and incidence of adverse events. DISCUSSION: This study is expected to define the efficacy of EG and promote further understanding of the mechanism of wound healing by EG compared to SSG. The results of this study can be used to inform the current best practise for wound care. TRIAL REGISTRATION: Clinicaltrials.gov identifier, NCT02535481 . Registered on 11 August 2015.

Submental island flap reconstruction reduces cost in oral cancer reconstruction compared to radial forearm free flap reconstruction: a case series and cost analysis.

BACKGROUND: In Canada, 4,400 cases of oral cancer are diagnosed yearly. Surgical resection is a key component of treatment in many of these cancers. Reconstruction of defects, with the goal of preserving function, is of utmost importance. Several choices are possible for reconstruction of larger defects, including both free and pedicled flaps. Free flap reconstruction is reliable and effective, but requires additional personnel and peri-operative resources. Pedicled flaps remain an important alternative to free flaps, and are less resource intensive. This paper reviews our inaugural experience with the submental island flap (SIF) and compares costs incurred to a matched cohort of oral cancer patients reconstructed with forearm free flaps. METHODS: Charts of patients who underwent SIF and RFFF reconstruction from January 1st 2013 to April 1st 2015 were retrospectively examined. Associated costs were obtained via online database and previously reported costs at the study institution. RESULTS: Mean length of ICU stay in glossectomy RFFF reconstruction was 4.7 days. Only one patient required ICU stay for one night in the SIF group. Mean length of hospital stay was not significantly different in SIF patients vs RFFF patients (12.4 vs 15.4 days, p > 0.05). Mean operative time was significantly lower in the SIF group compared to the RFFF group (347 vs 552 min, p < 0.05). Total mean intraoperative costs were found to be $4780.59 for RFFF operations, versus $2307.94 for SIF. Total mean cost of post-operative stay was $18158.40 in the SIF group and $43617.60 in the RFFF group. Total cost savings were therefore $27931.85 per patient for the SIF group. CONCLUSIONS: We have demonstrated the use of the submental island flap as an alternative to radial forearm free flaps, showing both decreased hospital costs and comparable patient outcomes. Pedicled flaps are making a resurgence in head and neck reconstruction, and the submental island flap offers an excellent alternative to more labour intensive and costly free flap alternatives.