O2C Laser Doppler and Digital Photo Analysis for Treatment Evaluation of Beta-Glucan versus Provitamin Pantothenic Acid of Facial Burns.

Various creams are available for superficial second-degree burns (SSDB) of the face. We evaluated provitamin pantothenic acid versus ß-glucan for SSDB of the face using the O2C laser Doppler system and digital photo analysis. Out of 20 patients (January to December 2012) with facial burns, 7 with SSDB of both cheeks were included to our study. Burned cheek wounds were treated using pantothenic acid or ß-glucan. Digital photos of marked regions were taken daily from predefined distances. Microcirculation was measured at marked regions for 7 days at scheduled time points using the O2C laser Doppler. Data were evaluated using the SPSS program (SPSS Inc., Chicago, IL). Wounds treated with ß-glucan showed faster reepithelialization. O2C laser Doppler measurements showed faster increase in SO2, microvascular perfusion, hemoglobin content, and blood flow. This correlated good with clinical Vancouver Scar Scale results. Although not statistically significant, ß-glucan cream therapy of SSDB results in aesthetically superior outcome and faster reepithelialization.

Deep sternal osteomyelitis: an algorithm for reconstruction based on wound width.

Patients with sternum osteomyelitis are transferred to plastic surgery departments for wound coverage. Several options of flap coverage are known; however, various wound diameters need different flaps. In a retrospective study, 135 patients from 2006-2010 with deep sternal wound infections were evaluated. From 2006-2009 various flaps were used for wound coverage, as described in published reports. In 2010 a developed algorithm was used for defect coverage based on wound width using pectoralis muscle flaps or the latissimus dorsi muscle flap. Two groups of patients were analyzed, from 2006-2009 and 2010, and in a matched pair analysis patients with small wound width less than 6 cm, medium wounds widths between 6-12 cm, and large wound width larger than 12 cm. End-point was wound dehiscence larger than 1 cm. Statistical analysis was done by Mann Whitney U-test using the SPSS program. Forty-eight patients were included in the match from a total of 130 study patients. Statistical analysis did not show significant difference in patient population of the two groups. In the group with wound sizes less than 6 cm a significant difference was found when using the algorithm. In the other groups no statistically significant difference was seen; however lesser numbers in wound dehiscence were found. In addition, a significantly lesser length of stay was found in the ICU and length of the hospital stay for all groups treated according to the algorithm. A reduction of costs may be achieved when using the algorithm based on wound size.

Staphylococcus aureus bacteremia after thermal injury: the clinical impact of methicillin resistance.

OBJECTIVE: To evaluate the impact of methicillin resistance in Staphylococcus aureus bacteremia (SAB) on mortality and length of stay in burn patients. DESIGN: Retrospective cohort study. SETTING: A 750-bed tertiary care university hospital in Cologne, Germany. PATIENTS: Patients registered in the database of the burn intensive care unit (BICU) between 1989 and 2009 with complete data sets (n=1688). RESULTS: Over the 21-year study period, 74 patients with SAB were identified; 33 patients had methicillin-resistant S. aureus (MRSA) and 41 methicillin-susceptible S. aureus (MSSA). Comparing the MRSA with the MSSA population the following parameters were significantly different in the univariate analysis: BMI (27.2 kg/m(2) vs. 23.6 kg/m(2); P=0.05), extent of deep partial thickness burns (17.8% vs. 9.0% of total body surface area; P=0.007), antibiotic requirement on admission (45.5% vs. 22.0%; P=0.046), median length of hospitalization prior SAB (24 days vs. 7 days; P<0.001), packed red blood cells administration (47.6 units vs. 26.1 units; P=0.003), intubation requirement (100% vs. 80.5%; P=0.007), intubation period (43.5 days vs. 26.8 days; P=0.008), catecholamine requirement (90.9% vs. 61.0%; P=0.004), sepsis (60.6% vs. 34.1%; P=0.035) and organ failures (81.8% vs. 39.0%; P<0.001). Regarding outcome parameters, methicillin resistance was not significantly related with mortality (adjusted OR 1.55, 95% CI 0.56-4.28; P=0.40) and length of BICU stay after SAB (Kaplan-Meier analysis log-rank test P=0.32; Cox's proportional hazards regression HR 1.22, 95% CI 0.65-2.27, P=0.535) in the univariate and multivariate analyses. CONCLUSION: Our data suggest that methicillin resistance is not associated with significant increases in mortality and length of BICU stay among burn patients with SAB.

Incidence and treatment of burns: a twenty-year experience from a single center in Germany.

OBJECTIVE: To analyze trends in incidence and treatment of thermal injuries over the last two decades. METHODS: We retrospectively reviewed our local single center database of patients with thermal injuries admitted to the burn intensive care unit (BICU) of the Cologne-Merheim Medical Center (University Hospital of Witten/Herdecke). The cohort was divided into two groups according to the decade of admission and the epidemiology and clinical course of the patient sample admitted during the period 1991-2000 (n=911) was compared to that of 2001-2010 (n=695). RESULTS: The following variables were significantly different in the bivariate analysis: mean age (39.8 years vs. 44.0 years), burn size of total body surface area (23.2% vs. 18.0%) and size of 3rd degree burns (9.6% vs. 14.9%). The incidence of inhalation injury was significantly lower in the last decade (33.3% vs. 13.7%) and was associated with a shorter duration of mechanical ventilation (10.8 days vs. 8.5 days). The ABSI-score as an indicator of burn severity declined in the second period (6.3 vs. 6.0) contributing partially to the decline of BICU length of stay (19.1 days vs. 18.8 days) and to the mortality rate decrease (18.6% vs. 15.0%). CONCLUSION: The severity of burn injuries during the last two decades declined, probably reflecting the success of prevention campaigns. Concerning mortality, the chance of dying for a given severity of injury has decreased.

Failure of secondary wound closure after sternal wound infection following failed initial operative treatment: causes and treatment.

BACKGROUND: Patients transferred to Plastic Surgery Departments for sternum osteomyelitis have a high morbidity of about 3%. Despite several known options for sternal wound coverage and salvage operations, wound dehiscence or wound necrosis can occur, increasing patient morbidity. PATIENTS AND METHODS: One hundred thirty-five patients admitted between January 2007 and December 2010 were evaluated in a retrospective study for wound dehiscence after salvage wound coverage at our institution. Various flaps were applied, such as pectoralis major myocutaneous pedicled flaps, pectoralis major muscle pedicled flaps, latissimus dorsi pedicled flaps, greater omental flaps, and vertical rectus abdominis muscle and transverse rectus abdominis muscle flaps. Inclusion criteria were sternal wound infection, bacterial wound infection, previous wound debridement outside our institution, vacuum-assisted closure device wound treatment at our institution, and secondary flap closure of the sternal defect at our institution. A multivariate regression analysis was performed. RESULTS: One hundred thirty patients met the inclusion criteria. In all patients, bacterial wound colonization was shown. Forty patients showed wound dehiscence after closure at our institution. Reasons for wound dehiscence were attributed to wound size, >4 different species of bacteria colonizing the wound, gram-negative bacteria, Candida albicans, intensive care unit stay, and female gender. Interestingly, wound dehiscence was not significant correlated to obesity, smoking, atherosclerosis, renal insufficiency or type of closure influenced significantly, or necrosis. CONCLUSIONS: Female patients after CABG, with large sternal wounds infected with gram-negative bacteria and candida, have an 85% risk of wound dehiscence after flap coverage for sternal wound infection.

Technique and indication of distal arterial-to-proximal venous anastomosis at an amputated distal phalanx.

Digital finger amputation with soft tissue injury is a frequent accident in reconstructive surgery. Several techniques about reconstruction of digital finger amputation are described in literature. However replantation is difficult when large segments of the arteries are missing. This is especially true for distal finger phalanx amputations, where replantation is done in selected patients such as artists or musicians. In this article a microsurgical replantation techniques of a distal artery and proximal vein anastomosis is presented in a distal phalanx amputation, which successfully solved the problem of venous reflux without venous anastomosis.

Combined latissimus dorsi and serratus anterior flaps for pelvic reconstruction.

In recurrent pressure sores, adjacent tissue has already been consumed by multiple surgeries. Additional problems are several co-morbidities of patients. Especially, severe atherosclerosis would be a contraindication for using free flaps. However, microsurgical techniques allow circumventing these limitations and preparing even severely atherosclerotic vessels. We performed a total of eight sacral pressure sore coverage in our standardized fashion, using the free combined latissimus dorsi and serratus anterior free flaps. All patients had severe atherosclerosis and needed large soft tissue coverage of the sacral defects. Five patients presented after bowel resection, three with recurrent sacral pressure sores. The average follow-up was 12 months. Postoperatively, all patients were allowed to be prone on the operated area. One minor wound dehiscence was sutured in local anesthesia. CT imaging analysis of the pelvis showed complete void space coverage. The combined latissimus dorsi and serratus anterior flaps are a valuable tool for pelvic reconstruction in our hands. In addition, severe atherosclerosis should not be considered an obstacle to microsurgery and the use of free flaps.

Suicide by burning: epidemiological and clinical profiles.

Self-immolation constitutes a rare form of suicide in developed countries, though it accounts for unique injury characteristics in the burn intensive care unit. The aim of this study was to present the epidemiological and clinical features of patients burned during a suicidal attempt seen in a North Rhine-Westphalia burn intensive care unit (BICU). To address this aim, we undertook a 21-year retrospective study involving patients with thermal injuries admitted to the largest burn unit in Germany. A total of 125 suicide-related burn victims were identified in the study period (9.4%). Comparing the self-immolation group with the rest burn patient cohort, suicide victims were more likely to be single and to act under the influence of alcohol. The suicidal group had a larger extent of burns, higher incidence of inhalation injury, required more surgical procedures, catecholamines, blood transfusions, and a longer BICU stay. Their clinical course was complicated by prolonged intubation period, higher rate of multiple drug-resistant bacteria acquisition and sepsis, leading to a higher mortality rate. Although the proportion of self-immolation victims among all burned patients is not high, the markedly higher severity of their burns and their poorer quality of outcomes makes them an important clinical subgroup for further study.

Vertical reduction mammaplasty combined with a superomedial pedicle in gigantomastia.

Vertical reduction mammaplasty using a superomedial pedicle is a well-accepted technique giving good results in mild to moderate breast hypertrophy. We describe modifications of the vertical reduction technique to achieve safe reductions even for very large breasts and minimize unsightly scarring, skin necrosis and poor shape. Over the past 4 years, 162 patients have undergone bilateral breast reduction using the vertical mammaplasty technique with a superomedial dermoglandular pedicle. We present a retrospective study of 23 cases of gigantomastia (reductions over 1100g) who underwent bilateral reduction mammaplasty, using our technique. The mean age was 49 years, BMIs ranged from 28 to 52 kg/m. The mean suprasternal notch-to-nipple distance was 40.5 cm on the right and 41.4 cm on the left. The average resection weight per breast was 1303 g on the right, and 1245 g on the left side. The suprasternal notch-to-nipple distance was reduced by between 13.2 and 36.0 cm (mean, 16.1 cm). Mean follow-up was 14 months. We observed a superficial infection in 2 patients, a deep hematoma in one patient, partial necrosis of the nipple-areola complex in 1, and 2 patients needed correction surgery due to dog-ear formation. By using the described modifications, the nipple and areola were safely transposed on a superomedial dermoglandular pedicle producing good breast shapes, while scarring and complications in vertical reduction mammaplasty for oversized breasts were effectively minimized.

Histometric and histomorphologic comparison of combustion and ambustion using in vivo reflectance-confocal microscopy.

BACKGROUND: When combustion and ambustion induce a superficial injury, they are summarized as superficial burns, regardless of the underlying cause. Reflectance-confocal microscopy (RCM) allows noninvasive imaging of the human skin on morphological features. We hypothesized that combustion and ambustion have different histomorphological effects on the human skin. METHODS: Superficial burns caused by combustion (CO-group, five females, three males; aged 26.8 +/- 14.2 years) and caused by ambustion (AM-group, four females, four males; aged 28.1 +/- 13.8 years) were evaluated 24 h after injury. The following parameters were obtained using RCM on injured and noninjured (control) site: horny layer thickness, epidermal thickness, granular cell size, basal layer thickness. RESULTS: Compared with the controls (12.8 +/- 2.5 microm), horny layer thickness decreased significantly to 10.6 +/- 2.1 microm in the CO-group, whereas it increased significantly to 17.8 +/- 2.8 microm in the AM-group. The epidermal thickness did not differ significantly in CO-group (47.9 +/- 2.1 microm) and AM-group (49.0 +/- 3.1 microm), however, both increased significantly compared with the controls (42.7 +/- 1.6 microm). The basal layer thickness increased more in AM-group (17.0 +/- 1.2 microm) compared to CO-group (15.4 +/- 1.1 microm). Both differed significantly compared with their controls (13.9 +/- 0.9 microm). The granular cell size increased significantly in both groups compared to the controls (721 +/- 42 microm), however, a significantly higher increase was observed in CO-group compared to AM-group (871 +/- 55 microm vs. 831 +/- 51 microm). CONCLUSIONS: RCM evaluates significant histomorphological differences in superficial burns caused by combustion and ambustion. The term "superficial burn" should consider the underlying cause and thus supplemented by the term "combustion" or "ambustion."

Severe burn injuries: acute and long-term treatment.

BACKGROUND: The physician that initially sees a patient with an extensive and deep dermal burn injury must be able to provide initial acute treatment and to make a well-founded decision whether to have the patient transported to a burn care center (BCC). Physicians from a variety of specialities will be involved in the management of long-term sequelae. METHODS: This article provides an overview of the treatment of severe burns and their commonest complications. Special attention is paid to initial emergency treatment (first aid) and to late complications, because physicians from multiple specialties are often involved in these phases of treatment. The data and guidelines that are summarized here were obtained through a selective Medline search and supplemented by the authors' experience in their own burn care center. RESULTS: Analgesia, careful fluid balance, and early intubation are important elements of the initial emergency treatment. Long-term complications of burns, such as disfiguring scars on exposed areas of skin and functionally significant contractures, often require surgical treatment. Early measures for scar care may improve the outcome. CONCLUSIONS: The effective treatment of severe burns is interdisciplinary, involving general practitioners and emergency physicians as well as plastic surgeons and physicians of other specialties. Knowledge of the basic principles of treatment enables physicians to care for patients with burns appropriately both in the acute setting and in the long term.

To heal or not to heal: predictive value of in vivo reflectance-mode confocal microscopy in assessing healing course of human burn wounds.

The purpose of this study was to assess if the healing course of burn wounds of indeterminate depth can be predicted based on serial in vivo reflectance-mode confocal microscopy (RMCM) analysis. Twenty-four patients (mean age, 33.1+/-11.4 years; mean burn size: 6% TBSA) were investigated at 12, 36, and 72 hours after burn of indeterminate depth and retrospectively grouped into healing group (HG: 16 patients) and nonhealing group (NHG: eight patients). Noninjured skin served as controls. The following parameters were assessed: quantitative blood cell flow (BCF), basal layer thickness (BLT), and inflammatory cells. At 12 hours postburn, BCF increased to 101.67+/-7.64 cells/min in HG vs 85+/-50 cells/min in NHG compared with controls (56.5+/-2.3 cells/min). At 36 and 72 hours, BCF increased to 115+/-10 cells/min and 125+/-50 cells/min in HG vs decreased to 80+/-5 cell/min and 75+/-5 cells/min in NHG (P<.05). At 12 hours postburn, BLT increased to 19.43+/-0.93 microm in HG vs 29+/-1 microm in NHG compared with controls (15.40+/-0.60 microm, P<.05). In HG, further gradual increase of BLT to 20+/-1 microm (36 hours) and 21+/-1 microm (72 hours) was observed, whereas BLT was destroyed after 36 hours in NHG. Qualitative assessment found insignificant amount of IC in controls and low amount in HG until 72 hours postburn, whereas progressive increase in IC from low amount (12 hours) to numerous (36 hours) and massive (72 hours) was observed in NHG. RMCM enables simultaneous evaluation of microcirculation, histomorphology, and inflammatory cell trafficking in burn wounds. RMCM may help to predict whether burns of indeterminate depth have the potential to heal and can be a valuable tool to clinicians to guide early therapeutic decision-making process in burn patients.

Assessment of microcirculatory influence on cellular morphology in human burn wound healing using reflectance-mode-confocal microscopy.

Previous studies have assessed the effects of changes in microcirculation on wound healing; however, the influence of microcirculation on tissue histomorphology remains widely unknown. Reflectance-mode-confocal microscopy (RMCM) enables in vivo tissue observation on a cellular level. We present RMCM data evaluating the local microcirculation and assess the influence on histomorphology during burn healing. RMCM was performed in 12 patients (aged; 36.2+/-14.2 years, maximum-burn-extent: 4% total body surface area) at times 12, 36, and 72 hours after a superficial burn. The following parameters were assessed: quantitative blood-cell-flow (cbf), epidermal thickness (Emin), basal-layer thickness (tbl), and granular cell-size (Agran). Cbf was found to be 54+/-3.6 cells/minutes (control), increased to 91+/-3.6 cells/minutes (p<0.05) 12 hours postburn; decreased to 71+/-6.1 cells/minutes (p<0.05) (36 hours), and to 63+/-2.3 cells/minutes (p>0.05) 72 hours postburn. Emin was 43.74+/-3.87 mum (control), increased to 51.67+/-4.04 mum (p<0.05) 12 hours, decreased to 48.67+/-3.51 mum (p<0.05) 36 hours, and to 45.33+/-3.21 mum (p>0.05) at 72 hours postburn. Tbl was 14.17+/-0.6 mum (control), increased to 16.93+/-1.15 mum (p<0.05) 12 hours, decreased to 15.93+/-1.20 mum (p<0.05) 32 hours, and to 15.00+/-0.85 mum (p>0.05) 72 hours postburn. Agran was 718+/-56.20 mum(2) (control), increased to 901+/-66.02 mum(2) (p<0.05) 12 hours, decreased to 826+/-56.86 mum(2) 36 hours, and 766+/-65.06 mum(2) at 72 hours postburn. RMCM enables in vivo observation of wound microcirculation and allows direct assessment of vascular effects on cutaneous histomorphology during the healing course of superficial burns.

New multifactorial burn resuscitation formula offers superior predictive reliability in comparison to established algorithms.

UNLABELLED: The Parkland-Baxter formula is a widely utilized resuscitation guideline for the initial management of fluid deficits in burn victims. Implementation of resuscitation formulas has helped to reduce the incidence of shock and hypovolemic organ failure such as acute renal failure in the setting of burn trauma. However, it has been shown that indiscriminate implementation of these formulas may inappropriately suit individual patient's requirements. In our experience resuscitation by the Parkland formula often forced corrections in order to reach predefined resuscitation goals. OBJECTIVE: Given these findings we felt the need to refine formula based resuscitation strategies. PATIENTS AND MEASUREMENTS: Reviewing a subset of 81 burn admissions we screened for predictive parameters in addition to total body surface area burned (TBSA burned) and body weight influencing resuscitation volume requirements. DESIGN: Using multivariate linear regression analysis (MRA) various parameters were integrated in a stepwise forward mathematical selection procedure resulting in a modified resuscitation formula. MAIN RESULTS: A new formula including body weight, TBSA burned, inhalation injury (IHI), high blood alcohol level (BAL) and a compensating factor for advanced age was set up. The new formula was compared to the original Parkland formula. Both were assessed for predictive reliability (PR(+/-20%)). Using this strategy we were able to improve PR(+/-20%) from 28.4% to 51.9%. CONCLUSIONS: Optimal fluid resuscitation of severe burn victims is a complex clinical challenge. Rigid-formula based resuscitation schemes often fail to match all subtleties of current clinical practice but need to provide a reliable starting point for fluid resuscitation. We demonstrate a new multifactorial formula resulting in a better guide to initial fluid resuscitation.

Severe brain damage by current flow after electrical burn injury.

Patients sustaining high-voltage electrical injury may experience neurological sequelae. The exact mechanism of nervous cell destruction is an ongoing subject of research, frequently a combination of both thermal and nonthermal causes. In this report, brain damage of the entire right hemisphere according to the current flow with isolated affection of pre- and postcentral gyrus of left hemisphere is described. Clinical findings, including neurological symptoms, radiographic images, and autopsy results, are presented. Possible mechanisms of brain destruction solely caused by current flow are discussed.

Treatment of second degree facial burns with allografts--preliminary results.

Facial burns are very common and have significant clinical impact. However, the treatment regimen for superficial to deep facial burns is not well defined. The purpose of this study was to investigate the effects of cadaver skin grafting in deep partial thickness facial burns in comparison to standard care. In a prospective open study design severely injured patients with superficial and deep partial thickness burns were randomized into the group receiving open treatment with silversulfadiazine (standard n=5) or into the group receiving early superficial debridement followed by coverage with glycerolized cadaver skin (n=5). The outcome measures were time and quality of wound healing, and incidence of hypertrophic scarring at 3 and 6 months post burn. There were no significant differences in demographics between groups. In the group treated with the allogenic material time to reepithelialization was 10.5 days, while it was 12.4 days in the silversulfadiazine group (p<0.05). Scar quality was found to be significantly improved in the allogenic treatment group. Three and 6 months postburn there were no patients with significant hypertrophic scarring in the allogenic group while there were two patients who developed hypertrophic scars in the silversulfadiazine group (p<0.05). In this study, we demonstrated that glyzerolized cadaver allograft skin represents a superior biological dressing for shallow and deep partial thickness facial burns. This is in concordance with other reports on scalds. It would be worthwhile to perform more clinical studies with a larger number of patients to further evaluate the effect and function of allogenic skin for facial burns.

Erbium:YAG laser treatment of post-burn scars: potentials and limitations.

Erbium:YAG lasers are successfully used to treat a variety of epidermal and dermal lesions, including rhytides, dyschromias, and certain types of scars. To date, however, no report has focused on the experiences with this laser in reconstructive burn surgery. Since 2001, the Erbium:YAG laser has become an integral part of the treatment of postburn scars at the Berlin Burn Center. This paper presents the techniques applied and clinical experiences obtained. In addition, a new stripe technique is introduced, which avoids healing disturbances in scars following deep burns. In conclusion, the Erbium:YAG laser has proven to be a valuable supplementary tool for the improvement of cosmetically disturbing mild postburn scars. It is particularly handy in areas difficult to treat, such as the eyes, nose, lips, and fingers. The individual advantages of the Erbium:YAG laser, other laser systems, and dermabrasion for the treatment of burn scars are compared in a brief survey.

Correlation between serum creatinine kinase levels and extent of muscle damage in electrical burns.

The relationship between clinical course and changes of laboratory findings in patients with high-voltage electrical burns with regard to creatinine kinase activity was analyzed in order to determine the value of this prognostic parameter with regard to patients survival and risk of limb amputation. In a retrospective study 42 patients with electrical burns were reviewed. CK serum levels were determined every day during the first 10 days following submission. Analysis of data revealed a relation between strongly elevated CK levels and patients risk of limb amputation and mortality. Although further research is necessary, there is strong evidence that the amount of burned body surface area does not directly correlate with the true extent of tissue damage caused by high tension injuries. Our data suggest that the degree of muscle tissue violation corresponds with the initial excess of creatinine kinase levels in blood serum. This may be an additional factor to support the decision for early surgical decompression of electrically burned extremities and aggressive surgical management of the high-voltage burn victim. Furthermore, it may provide a prognostic parameter for the clinical outcome of these patients.