Skin-Fat Composite Grafts for Reconstructing Large Full-Thickness Skin Defects.

BACKGROUND: The uppermost layer of subcutaneous tissue has a rich vascular network, the subdermal plexus and multiple perforating vessels in the interlobular septa. When skin-fat composite grafts (SFCGs) include this uppermost layer, they can be readily vascularized to enhance survival. The authors describe their clinical experience with large SFCG transplantations. METHODS: This retrospective study included patients who underwent SFCG transplantation for large, full-thickness skin defects, formed after burn scar contracture or contraction deformity excision. The recipient tissue bed was prepared by retaining the deepest layer of scar tissue or reticular dermis to preserve the interlobular septa, subdermal plexus, and ascending arterioles above the subcutaneous tissue. The SFCG was prepared by trimming fat lobules and preserving the interlobular septa and vessels to form a 1- to 4-mm-thick base of subdermal fat tissue. The trimmed SFCG was placed onto the defective tissue and secured with a tie-over dressing. RESULTS: Among 86 grafts, 76 (88.4%) survived completely (sizes, 6 to 161 cm 2 ; mean surface area, 68.7cm 2 ). Focal skin sloughing or graft loss occurred in 10 cases. These events were followed by spontaneous healing in eight cases. Focal hypertrophic scars formed in six cases. In 15 cases, hyperpigmentation occurred, but improved gradually. Most transplantations achieved satisfactory pliability (93.0%), contour (90.7%), and color (88.4%). CONCLUSIONS: SFCGs survived better than expected with minimal complications, probably because of the preservation of rich vascular networks in both the recipient and SFCG tissues. Therefore, SFCG transplantation may be a good option for reconstructing full-thickness skin defects with a large surface area. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Immunohistochemical analysis of neuropeptides (protein gene product 9.5, substance P and calcitonin gene-related peptide) in hypertrophic burn scar with pain and itching.

BACKGROUND: Neuropeptides have been recently reported as having an important role in wound repair, and relief from pain and itching sensation. The aim of this study was to evaluate the effect of neuropeptides on the wound healing process in hypertrophic scar formation that accompanies severe pain and itching sensation. METHODS: We collected forty-three hypertrophic scar specimens from hypertrophic scar release and skin graft under general anesthesia. Immunohistochemical stains for protein gene product (PGP) 9.5, substance P (SP), and calcitonin gene-related peptide (CGRP) were performed. Pain and itching over the scar were recorded using verbal numerical rating scale (VNRS). RESULTS: In the epidermis, PGP 9.5, SP, and CGRP were significantly increased in hypertrophic scars compared with matched unburned skin. In the reticular dermis, SP and CGRP were significantly increased in hypertrophic scars compared with control. The pain and itching verbal numerical rating scale in scar group were significantly higher compared to control. In the papillary dermis, the PGP represented significant correlation with Itching P (correlation coefficient 0.698) and the SP represented significant correlation with pain N (correlation coefficient -0.671). In the reticular dermis, the SP represented significant correlation with pain N (correlation coefficient -0.614) and CGRP represented significant correlation with pain P/Itching P (correlation coefficient 0.801/0.611). CONCLUSIONS: Neuropeptides such as PGP 9.5, SP, and CGRP seem to affect scarring via sensory neurotransmission, it have a regulatory role for pain and itching sensation in hypertrophic scars.

Clinical features and treatment outcomes of skin cancer arising from burn scar: a single-institution experience.

AIMS AND BACKGROUND: This study was conducted to investigate the clinicopathological features and long-term outcomes of patients with skin cancer arising from burn scar (SCBS). PATIENTS AND METHODS: We retrospectively reviewed the medical records of patients diagnosed with SCBS between January 2000 and May 2012. A total of 44 patients were enrolled in this study. RESULTS: The median latent period between burn injury and development of SCBS was 32 years (range, 8-78 years). The most frequent sites of SCBS were the lower limbs (68.2%) followed by the upper limbs (15.9%) and trunk (11.4%). Most patients (95.4%) had squamous cell carcinoma. Of 34 patients with localized disease at the time of diagnosis, 33 patients are alive with no evidence of recurrence. Of 10 patients with regional lymph node metastasis (referred to as locally advanced disease), 4 died of disease progression and 5 are alive with metastatic disease in the lymph nodes, bone or lung. Patients with localized disease survived longer than patients with locally advanced disease ( P = 0.000). In patients with locally advanced disease, the median overall survival time was 16 months (95% CI, 2.88-29.4 months). CONCLUSIONS: While localized SCBS is a potentially curable disease, locally advanced SCBS has a poor prognosis in spite of aggressive treatment. These results suggest that early recognition and aggressive treatment are essential to improve the outcomes of SCBS.

Clinical and histological correlation in post-burn hypertrophic scar for pain and itching sensation.

BACKGROUND: Hypertrophic scar following a burn is caused by the excessive deposit of collagen resulting in an exaggerated wound healing response. The burn patient complains of pain and itching over the scar, which can give rise to cosmetic and functional problems. OBJECTIVE: The aim of this study was to investigate the clinical and histological correlation of a hypertrophic burn scar for itching and pain sensations. METHODS: Thirty-eight patients underwent a scar release and skin graft. the modified Vancouver scar scale and the verbal numerical rating scale were recorded. All biopsies were taken from scar tissue (scar) and normal tissue (normal). Histologically, tissues were observed in the epidermis, the monocytes around the vessels, the collagen fiber, elastic fiber, and the mast cells. RESULTS: The mean total score of MVSS was 8.4±2.7 (pliability 2.0±0.9; thickness 1.8±0.9; vascularity 2.0± 0.9; and pigmentation 2.1±0.9). Pain and itching were 2.4±2.0 and 2.9±3.0. Epidermis were 7.9±2.8 layers (scar) and 4.0±0.8 layers (normal). The collagen fibers were thin and dense (scar) and thicker and loose (normal). The elastic fibers were thin and nonexistent (scar) and thin and loose (normal). Mast cells were 11.2±5.8/high power field (scar) and 7.4±4.1 (normal). CONCLUSION: As the scar tissue thickens, the itching becomes more severe. The stiffness of the scar with the pain appeared to be associated with the condition of the tissue. The correlation between clinical and histological post-burn hypertrophic scars will help further studies on the scar. This helped with the development of the base material for therapeutic strategies.

Proposed treatment protocol for frostbite: a retrospective analysis of 17 cases based on a 3-year single-institution experience.

BACKGROUND: This paper discusses the treatment protocol for patients with frostbite. METHODS: We performed a retrospective analysis of a series of 17 patients with second- and higher-degree frostbite who had been treated at our medical institution between 2010 and 2012. RESULTS: Our clinical series of patients (n=17) included 13 men and four women, whose mean age was 42.4±11.6 years (range, 22-67 years). The sites of injury include the foot in six patients (35.3%), the hand in six patients (35.3%) and the facial region in five patients (29.4%). Seven patients with second-degree frostbite were completely cured with only conservative treatment during a mean period of 12.7±3.3 days (range, 8-16 days). Of the five patients with third-degree frostbite, two underwent skin grafting following debridement, and the remaining three achieved a complete cure with conservative treatment during a mean period of 35±4.3 days (range, 29-39 days). Five patients with fourth-degree frostbite were treated with surgical procedures including amputation. CONCLUSIONS: With the appropriate conservative management in the early stage of onset, surgeons should decide on surgery after waiting for a sufficient period of time until the demarcation of the wound. Continuous management of patients is also needed to achieve functional recovery after a complete cure has been achieved. This should also be accompanied by patient education for the avoidance of re-exposure to cold environments.

Correction of postburn equinus deformity.

BACKGROUND: Equinus deformity is characterized by an abnormal tiptoe gait and does not allow normal walking, hence needing correction. Congenital causes of equinus deformity include neurological diseases such as cerebral palsy and poliomyelitis. Acquired causes include injuries such as extensive trauma. We have corrected equinus deformity from extensive lower leg burns by a single operation through excisional release of the scar, Achilles lengthening, and radial forearm free flap. METHODS: Fifteen patients with postburn equinus deformity who were treated between January 2000 and March 2012 were retrospectively studied. We investigated their age, sex, cause and severity of burn injury, equinus degree, ankle range of motion and the changes in the activity, extent of Achilles lengthening, flap size, complication, and the recurrence in these patients. RESULTS: The average degree of equinus deformity before the operation was 45 degrees. With an average Achilles lengthening of 4.6 cm, all patients achieved neutral position. The patients who had poor activity due to tiptoe gait before the operation showed good to fair levels of walking ability postoperatively. During an average follow-up period of 3 years and 9 months, no patients had a recurrence. CONCLUSIONS: Equinus deformity causes significant restrictions to walking and the reconstruction is a challenging problem. Although prevention is more important during the initial stages of treatment, we have successfully corrected patients with existing equinus deformity by scar release, Z-tenoplasty of Achilles, and radial forearm free flap.

Elbow reconstruction using island flap for burn patients.

BACKGROUND: Deep burns of the elbow lead to soft tissue necrosis and infection, with exposure of deep structures. Adequate wound coverage of this area requires thin, pliable, and durable tissue, while optimal functional recovery requires early coverage and functional rehabilitation. We have found 3 types of island flaps that provide reliable coverage for the elbow. METHODS: A retrospective study was performed on all patients who underwent flap coverage of an elbow defect at our hospital. The patients' data including age, sex, cause of injury, wound dimensions, timing of flap coverage, postoperative elbow motion, and complications were investigated. RESULTS: Between 2001 and 2012, 16 patients were treated at our hospital. The mean age was 53.3 years. Three kinds of flaps were performed: 9 latissimus dorsi flaps, 4 lateral arm flaps, and 4 radial forearm flaps. The average defect size was 183.5 cm(2) (range, 28 to 670 cm(2)). Wound coverage was performed at mean duration of 45.9 days (range, 14 to 91 days). The mean postoperative active elbow flexion was 98° (range, 85° to 115°). Partial flap failure occurred in 1 latissimus dorsi flap. Minor complications included partial flap loss (11.8%), hematoma (23.5%), seroma (35.3%), and wound infection (5.9%). CONCLUSIONS: Flap selection for elbow reconstruction is determined by the defect size and the extent of the adjacent tissue injury. Elbow reconstruction using an island flap is a single-staged, reliable, and relatively simple procedure that permits initiation of early rehabilitation, thereby improving a patient's functional outcome.

Algorithm for Primary Full-thickness Skin Grafting in Pediatric Hand Burns.

BACKGROUND: Pediatric hand burns are a difficult problem because they lead to serious hand deformities with functional impairment due to rapid growth during childhood. Therefore, adequate management is required beginning in the acute stage. Our study aims to establish surgical guidelines for a primary full-thickness skin graft (FTSG) in pediatric hand burns, based on long-term observation periods and existing studies. METHODS: From January 2000 to May 2011, 210 patients underwent primary FTSG. We retrospectively studied the clinical course and treatment outcomes based on the patients' medical records. The patients' demographics, age, sex, injury site of the fingers, presence of web space involvement, the incidence of postoperative late deformities, and the duration of revision were critically analyzed. RESULTS: The mean age of the patients was 24.4 months (range, 8 to 94 months), consisting of 141 males and 69 females. The overall observation period was 6.9 years (range, 1 to 11 years) on average. At the time of the burn, 56 cases were to a single finger, 73 to two fingers, 45 to three fingers, and 22 to more than three. Among these cases, 70 were burns that included a web space (33.3%). During the observation, 25 cases underwent corrective operations with an average period of 40.6 months. CONCLUSIONS: In the volar area, primary full-thickness skin grafting can be a good indication for an isolated injured finger, excluding the web spaces, and injuries of less than three fingers including the web spaces. Also, in the dorsal area, full-thickness skin grafting can be a good indication. However, if the donor site is insufficient and the wound is large, split-thickness skin grafting can be considered.

One stage reconstruction of skull exposed by burn injury using a tissue expansion technique.

BACKGROUND: An area of the skull exposed by burn injury has been covered by various methods including local flap, skin graft, or free flap surgery. Each method has disadvantages, such as postoperative alopecia or donor site morbidities. Due to the risk of osteomyelitis in the injured skull during the expansion period, tissue expansion was excluded from primary reconstruction. However, successful primary reconstruction was possible in burned skull by tissue expansion. METHODS: From January 2000 to 2011, tissue expansion surgery was performed on 10 patients who had sustained electrical burn injuries. In the 3 initial cases, removal of the injured part of the skull and a bone graft was performed. In the latter 7 cases, the injured skull tissue was preserved and covered with a scalp flap directly to obtain natural bone healing and bone remodeling. RESULTS: The mean age of patients was 49.9±12.2 years, with 8 male and 2 female. The size of the burn wound was an average of 119.6±36.7 cm(2). The mean expansion duration was 65.5±5.6 days, and the inflation volume was an average of 615±197.6 mL. Mean defect size was 122.2±34.9 cm(2). The complications including infection, hematoma, and the exposure of the expander were observed in 4 cases. Nonetheless, only 1 case required revision. CONCLUSIONS: Successful coverage was performed by tissue expansion surgery in burned skull primarily and no secondary reconstruction was needed. Although the risks of osteomyelitis during the expansion period were present, constant coverage of the injured skull and active wound treatment helped successful primary reconstruction of burned skull by tissue expansion.

Expanded flap and hair follicle transplantation for reconstruction of postburn scalp alopecia.

The advent of tissue expansion started a new era of aesthetically reconstructed scalp alopecia by providing a large hair-bearing scalp area with acceptable hair density. However, residual scalp alopecia and wide visible scars still raised aesthetic problems. The hair follicle transplantation carries the possibility of producing a more natural scalp because both the desired hair density and the natural direction of the hair can be reproduced using this procedure. Our study group consisted of 62 patients (41 males and 21 females) with a mean age of 26.3 years. The median age of suffering a burn to the scalp was 3 years. The causes of burn resulting to scalp alopecia were flame (n = 28), scald (n = 18), contact (n = 7), and electrical (n = 9) injuries. The first reconstruction for all patients was the expanded flap coverage. Three patients used 2-stage expanded flaps. Five patients underwent hair follicle transplantation after they had undergone the expanded flap coverage. Expanders (n = 86) were placed in 62 patients with a total of 9 major (9.3%) and 3 minor (3.5%) complications. The overall results after expanded flap reconstruction and hair follicle transplantation were excellent (43 patients, 69.4%), good (18 patients, 29%), and bad (1 patient, 1.6%). Postburn scalp alopecia can be reconstructed by 1-stage or multiple-stage expanded flap procedures. The visible remaining alopecia and marginal scar after the procedure, especially on the anterior hairline of the forehead and the sideburns, can be refined by hair follicle transplantation. This report also suggests the possibility that cicatrical scalp alopecia with intact deep tissue can be restored by hair follicle transplantations using hair transplanter.

Roles of spheroid formation of hepatocytes in liver tissue engineering.

The liver plays an important role in a broad spectrum of physiological functions and detoxifies endogenous and exogenous substances. The liver failure is associated with a high risk of mortality because it is one of important organs in our body. Various bioartificial liver (BAL) systems have been used for clinical trials as a bridge for liver transplantations in patients with liver failure. Long term and stable liver-specific functions of hepatocytes in the development of BAL support systems should be considered. Spheroid formation of hepatocytes enhances liver-specific functions. In this review, hepatocyte spheroid formation methods such as galactose density, topology of extracellular matrix, micro-molding technique, hanging-drop culture, non-adhesive surface, positive charged surface, spinner culture, rocked technique, medium component, external forces, coculture system and polymeric nanospheres are explained for enhancing liver-specific functions.

The risk factors of psychosocial problems for burn patients.

Many burn patients experience psychosocial problems such as personality change, post-traumatic stress disorder, family trouble, and financial burden. The purpose of this study was to identify the risk factors of these psychosocial problems that prevented burn patients from developing appropriate adjustments after burn. Six hundred eighty-six adult burn inpatients were interviewed. Most of them suffered from burns less than 10% of total body surface area. They were asked to fill in a questionnaire for this study, which was a psychosocial problem checklist of 17 items. Descriptive analysis, factor analysis, Chi-square test, and multiple logistic regression analysis were used to analyze the results. Lack of family support and living expense burden were the two significant risk factors for psychosocial problems including, burn treatment problems, rehabilitation problems, and welfare information problems on both acute and chronic burn patients. Medical expense burden was the risk factor among chronic burn patients. These findings suggested that active interventions by the burn team including mental health professionals (psychologist, psychiatrist or social worker) might reduce psychosocial problems of burn patients and encourage social rehabilitation.

Burns in epilepsy: seven years of experience from the Hallym Burn Center in Korea.

The objective of this retrospective epidemiological study was to identify the characteristics of burn injuries of seizure disorder patients in Korea, with the goal of developing programs to prevent or reduce the frequency and morbidity of such injuries. We reviewed the medical records of 34 acutely burned, epileptic-seizure patients who were admitted to a single regional burn center unit during the 7 years between January 1997 and April 2003, all of whom had been burned during an epileptic seizure. The most commonly associated seizure type was generalized tonic-clonic, followed by absence and complex partial. Females predominated in all age groups. There were more seizures in the morning hours between 3 and 10 am. The mean age was 43 +/- 16 years. Seizures occurred at home, while the patient was conducting daily household chores. Scalding was the most common injury, leaving small-but-deep wounds that required a mean hospital stay of 37 +/- 27 days. Typically, upper limbs and trunk were affected. To implement a successful burns injury-prevention program, patients with epilepsy should be better recognized as a high-risk group. Specific passive as well as active recommendations are suggested based on the epidemiologic features of seizure disorder patients in Korea.

Face burns caused by flambé drinks.

This study was conducted to identify the epidemiology of face burns in Korean adults caused by flambé drinks in the hope of developing preventive programs. We reviewed the medical records of 25 patients with burns caused by flame drinks that were admitted to the Hallym Burn Centre, Hangang Sacred Heart Hospital, Seoul, Korea, during the 30-month period of July 2002 to December 2004. The injuries occurred while drinking and spilling the whisky on the flame (68%) during the hours of social gathering and festivity. There were more men than women (male:female ratio=21:4); the mean age was 27.5+/-5.7 years (mean 27, range 21-43 years). Alcohol flames inflicted superficial (56%) to mid-second-degree burns in a relatively small area of body (TBSA 3.2+/-3.0%). The head was most commonly involved, followed by the upper extremity and trunk. All patients except two were treated with observation and daily dressing changes only. The mean length of hospital stay was 12.1+/-6.5 (10, 5-25) days. Long-term cosmetic outcomes were excellent. Some victims suffered mild corneal (n=4) and ear (n=6) burns, without permanent sequelae. Post-traumatic stress disorder and depression also were reported. Burn injuries induced by flambé drinks may be prevented by increasing public awareness about its danger and the potential risk for corneal and facial burns and by implementing a safety policy. All the involved parties--public, distillers, and bar and restaurant management--need to coordinate their efforts achieve a reduction in injuries.

Esthetic and functional reconstruction for burn deformities of the lower lip and chin with free radial forearm flap.

Burn injury often has produced deformity both of contours and cover in face and neck. Hypertrophic burn scar contracture of the lower face and neck is one of the most difficult subjects to solve because it produces problems with function and appearance. In planning the correction, the restoration of normal form and function is the best way in reconstruction. From January 1998 to January 2002, we had 7 patients who had scar contractures of the lower face and neck. We reconstructed their deformities with free radial forearm flap and skin graft. We could get restoration of the facial form to normal shape, position, and quality of the facial skin cover homogeneity. No remarkable complications have been found in all 7 patients. For better outcomes, there are some considerations. The lowest margin of the flap should be limited to at least 1 finger breadth above the hyoid bone because low setting of the flap may deteriorate the cervicomental angle. The skin graft is undertaken in the cervical region. Adhesion between the flap dermis and wound bed may be necessary for reconstruction of the labiomental sulcus. Burn deformities of the lower face and neck area were resurfaced with free radial forearm flap and skin graft. Flaps did not look completely normal, but those were compatible with the adjacent skin. We could have an adequate functional resurfacing and optimal esthetic outcomes while minimizing recurrent contractures.

Use of the artificial dermis for free radial forearm flap donor site.

The radial forearm free flap has been popular in many area of reconstructive surgery. Despite the many attributes of this flap in surgical reconstruction, one of the clear disadvantages has been the morbidity of the donor site. To solve problems associated with closure of the radial forearm flap donor site, the artificial dermis was used for better outcome in the donor site. From July of 2001 to October 2003, 13 patients (12 male, 1 female) ranging in age from 27 to 67 years underwent free radial forearm transfers. Flap size measured 49 to 144 cm2. Donor-site defects secondary to the flap elevation was closed first with the artificial dermis (Terudermis), marketed by Terumo Inc, Japan, and secondary split-thickness skin graft to the artificial dermis was performed in 15 days (range, 13 to 17 days) on average. There was no flap failure in all cases. Partial loss of the artificial dermis graft was noticed in 2 cases, but it was negligible. Secondary skin graft take was noticed in about 7 days, and there was no remarkable skin graft loss. The artificial dermis was used successfully in 13 patients with the donor defects of free radial forearm flap. Despite the disadvantage to need the secondary split-thickness skin graft, use of the artificial dermis gave us not only soft-tissue augmentation and graft-skin quality similar to full-thickness skin graft but also fast graft healing and diminished morbidity of the skin-graft donor site.

A retrospective analysis of 19,157 burns patients: 18-year experience from Hallym Burn Center in Seoul, Korea.

This is a retrospective, epidemiological study of 19,157 acute burn patients admitted to the Hallym Burn Centre, Hangang Sacred Heart Hospital, Seoul, Korea, during the period 1986-2003. The study was conducted to identify characteristics of burn patients that could lead to development of preventive programs to reduce both the frequency and mortality of burn injury. The majority of patients admitted had relatively minor burns, which were treated conservatively. Males predominated in all age groups with a summer peak seasonal variation. Typical burn in the children <5 years of age was a scald injury, occurring at home, affecting upper limbs and resulting in a relatively short hospital stay. Electrical burns due to steel chopsticks and steam burns due to electric rice cookers were also found in this age group. Adult burns, affecting upper and lower limbs, were caused by flames, hot liquids or electricity. Burns were sustained at the workplace and outdoors. Flame accidents in males were the leading cause of death with overall mortality of 8.2%. 13.9% of admissions needed intensive care and average length of hospital stay was 32.6 days. The annual number of patients undergoing burn related surgery has continuously increased reflecting a more aggressive surgical management. Our ongoing efforts are to promote prevention program and look for changes in the incidence of burn injury based on these epidemiologic features. Further study for implications of changes in management protocols and policies on treatment outcomes would improve the provision of appropriate care for the patients.

Paediatric electrical burn: outlet injury caused by steel chopstick misuse.

Electrical burn in children in compared with adults is rare due to less chance of exposure to electricity. Although studies have been reported regarding pediatric electrical injury, there are no reports concerning outlet injury, especially those suffered by placing a steel chopstick as conducting material into the wall socket. Steel chopsticks are widely used for eating food in Korea. Children have sometimes injured themselves by inserting these into wall sockets (220 V). A retrospective study was conducted to obtain information about the characteristics of pediatric electrical injury resulting from steel chopstick misuse between January 1996 to June 2002. A total of 57 children with outlet injury were involved. Wounds were multiple and localized within the hand. The prevalent age was about 3 years old. The children studied with low voltage minor electrical injuries were deeply injured, had a high operation rate and remarkable sequelae, although wounds were small and localized.

Diminished neuropeptide levels contribute to the impaired cutaneous healing response associated with diabetes mellitus.

Background. Patients with diabetic sensory neuropathy have significant risk of chronic ulcers. Insufficient nerve-derived mediators such as substance P (SP) may contribute to the impaired response to injury. Mutant diabetic mice (db/db), which develop neuropathy and have delayed healing, may provide a model to study the role of nerves in cutaneous injury.Methods. Skin from human chronic nonhealing ulcers and age-matched control skin was immunohistochemically evaluated for nerves. Nerve counts were also compared in murine diabetic (C57BL/KsJ-m+/+ Lepr(db); db/db) and nondiabetic (db/-) skin. Excisional wounds on the backs of db/db and db/- mice were grouped as: (a) untreated db/- mice; (b) untreated db/db mice; (c) db/db mice with polyethylene glycol (PEG); (d) db/db mice with PEG and SP 10(-9) M; or (e) db/db mice with PEG and SP 10(-6) M.Results. We demonstrated fewer nerves in the epidermis and papillary dermis of skin from human subjects with diabetes. Likewise, db/db murine skin had significantly fewer epidermal nerves than nondiabetic littermates. We confirmed increased healing times in db/db mice (51.7 days) compared to db/- littermates (19.8 days; P