Burn Surgery Research Articles

Phenotypic and Genotypic Isolation of MRSA from Burn Wound Infected Patients at a Tertiary Care Hospital in Bangladesh

Background: Patients of burn wound are generally more susceptible to infection due to concurrent status of malnutrition and immunosuppression. Among many bacteria, MRSA has appeared as a challenging pathogen irrespective of effective antibiotic therapy.
 Objective: The purpose of the present study was to detect the prevalence and antibiogram of MRSA in burn wound infected patients.
 Methodology: The present cross sectional study was conducted at Department of Microbiology in Rajshahi Medical College, Rajshahi, Bangladesh. The samples were collected from Burn and Plastic Surgery Unit of Rajshahi Medical College Hospital, for a period of one year. Phenotypic detection of MRSA were done by cefoxitin disc diffusion method and genotype (mecA gene) was detected by PCR which was conducted at Dhaka Medical College, Dhaka among all the S. aureus isolates.
 Result: A total of 212 wound swabs were subjected to bacteriological culture media for isolation of MRSA and other organisms. As a whole 89.62% samples yielded growth in culture of which Pseudomonas aeruginosa was the predominant pathogen (34.18%). Out of 21 S.aureus isolates, 07(33.33%) were detected as MRSA by cefoxitin resistance and presence of mecA gene. Although over 85% MRSA were resistance to ciprofloxacin and ceftriaxone, but the present study could not detect any vancomycin resistant MRSA.
 Conclusion: The high prevalence and decreased sensitivity of MRSA to commonly used antibiotics has been observed in Burn Unit of RMCH. Therefore it is necessary to establish an antimicrobial surveillance system in hospital settings to prevent the spread of MRSA.
 Bangladesh Journal of Infectious Diseases 2020;7(1):12-17

Establishment and application of a clustered management plan for pulmonary care of massive burn casualties

Objective: To establish a clustered management plan for pulmonary care of massive burn casualties (hereinafter referred to as the clustered management plan for pulmonary care), and to explore its application effects. Methods: (1) A clustered care intervention group was established, including the medical and nursing staff from the Department of Burns and Plastic Surgery, Department of Respiratory Medicine, and Department of Infection Control at the Fourth Medical Center of PLA General Hospital (hereinafter referred to as our hospital). Four major links, including pulmonary care assessment, chest and lung physical therapy, artificial airway management, and specialized infection control were sorted out according to the key points and difficulties in pulmonary care for massive burn casualties. Evidence-based nursing methods were employed to retrieve articles related to the above-mentioned four links from PubMed, Chinese Journal Full-Text Database, VIP Database and Wanfang Data using terms of " mass burn, respiratory management and airway management" and terms of ",," , and the clustered management plan for pulmonary care was established based on reading and discussion in combination with clinical practice and experience. (2) In this non-randomized controlled study, the clustered management plan for pulmonary care was applied to 73 massive burn patients (48 males and 25 females, aged 32 (25, 38) years) who were admitted to our hospital from January 2016 to December 2019 and met the inclusion criteria, and they were included into the clustered care group; 43 massive burn patients (25 males and 18 females, aged 35 (17, 45) years) who were admitted to our hospital from January 2013 to December 2015, received routine care and met the inclusion criteria were retrospectively included into routine care group. The pulmonary infection rate and mortality of patients in the two groups were recorded during the hospital stay. Data were statistically analyzed with chi-square test, Mann-Whitney U test, and independent sample t test. Results: (1) The clustered management plan for pulmonary care included a total of 12 specific measures covering four aspects of pulmonary care. The contents in pulmonary care assessment clearly stated to include the previous medical history, history of injury, respiratory status, hoarseness, pulmonary auscultation, etc. Chest and lung physical therapy included how to guide patients to effectively cough and do pursed lip breathing and abdominal breathing exercise, etc. Artificial airway management specified the preparation for the establishment of artificial airway at clinical reception, the observation index and frequency after tracheotomy, the method of humidification, the method and frequency of sputum suction, and the management of mechanical ventilation, etc. Specialized infection control required to strengthen hand hygiene and ventilator management. (2) The pulmonary infection rate and mortality of patients in the clustered care group were 2.74% (2/73) and 4.11% (3/73), respectively, significantly lower than 25.58% (11/43) and 18.60% (8/43) in routine care group (χ(2)=11.986, 5.043, P<0.05 or P<0.01). Conclusions: The clustered management plan for pulmonary care developed for massive burn casualties focuses on the major links and key points. The measures are systemic and comprehensive, simple but precise, and highly operable, covering the entire process of massive burn care, hereby reducing the pulmonary infection rate significantly and improving the success rate of treatment.

Admission Neutrophil-Lymphocyte Ratio (NLR) Predicts Survival in Patients with Extensive Burns

BackgroundExtensive burns is one of the most common severe injuries, with a high annual death rate. Previous studies showed that the neutrophil to lymphocyte ratio (NLR) is a prognostic factor for some inflammatory diseases. However, until now, no study has evaluated the clinical prognostic value of NLR in extensively burned patients. The aim of this study was to investigate the prognostic value of NLR in this medical condition to provide clinical guidance. Methods271 patients diagnosed with extensive burns were analysed retrospectively between 2005 and 2018 in the Department of Burn Surgery of Changhai Hospital. NLR cut-off values at the first 3 days of hospitalization were calculated by the ROC analysis. ResultsOf the 271 patients in this study, the majority (82.3%) were injured by flame. The median total body surface area (TBSA) was 55% (IQR, 40% to 85%) and the median full thickness burn (FTB) was 20% (IQR, 3%–44%). The patients’ NLR declined within the first 3 days after admission, and we found that NLR was negatively correlated with the ventilator-free days at day 28 (r = -0.127, P = 0.048). In a multivariate logistic regression analysis, higher admission NLR was independently predictive of higher mortality. According to the ROC curve, the best cut-off values for day 1 (or admission day), day 2 and day 3 NLR were 14, 13 and 7.5, respectively. We then performed a survival analysis, finding that those NLR above the cut-off point had decreased overall survival compared to those with NLR below the cut-off point (p = 0.023, 0.045 and 0.019 for day 1, 2, and 3, respectively). ConclusionsNLR continuously decreased in the first 3 days of hospitalization. Admission NLR above 14 is associated with a decreased survival in patients with extensive burns. These findings demonstrate that NLR has prognostic value in these patients.

Outcome of honey dressing on pain relief and re-epithelization of donor site wound of split thickness skin graft.

Objectives: To determine the frequency of pain relief and re-epithelization of the donor site wound of split thickness skin graft with the use of honey dressing. Study Design: Descriptive Case Series. Setting: Plastic Surgery Department, Jinnah Burn and Reconstructive Surgery Centre Lahore. Period: From 1st January, 2019 to 30th November, 2019. Material &amp; Methods: A total of 100 patients with healthy granulating wound were included in the study. All patients undergone operations under general anaesthesia by the same surgeon. The dressing was done by a layer of honey on gauze piece, wrapped around the donor wound site of split thickness skin graft. Patients were followed at the 7th post-operative day and outcome measures were noted. Pain was scored by the use of Visual analogue score (VAS) and re-epithelization was complete healing of the wound. Results: A total of 100 patients were enrolled with mean age of 33.11±9.72 years and there were 45% (45) females and 55% (55) male patients. Mean wound size was 7.70±1.83 cm2. At the 7th post-operative day follow up; pain relief was seen in 74% patients and re-epithelization was seen in 78% of patients. Both the outcome measures i.e. pain relief and re-epithelialization was effectively controlled with the use of honey dressing. Conclusion: Honey dressing is useful and effective on split thickness skin graft donor site in terms of pain relief and re-epithelization.

The State of Burn Care Training During Plastic Surgery Residency.

There is an ongoing shortage of burn specialists, and workforce reports suggest possible hurdles attracting plastic surgeons into burn care. The purpose of this study was to (1) determine the state of burn care in plastic surgery residency and (2) identify what barriers might exist for plastic surgeons pursuing a practice that involves burn care. Surveys were distributed to North American plastic surgery program directors and residents, respectively, during the 2018-2019 academic year. Fifty-eight program directors (response, 54%) and 320 plastic surgery residents (response, 30%) participated. Burn care was felt to be an important component in training by most program directors (USA, 88%; Canada, 100%) and residents (USA, 87%; Canada, 99%). The majority of program directors included a burn unit rotation (USA, 88%; Canada, 90%). Rotations for integrated residents averaged 2.5 months and most commonly occurred during second year; independent residents spent 1.2 months on rotation, usually in first year. Three-quarters of American residents were interested in a career that involves burn care in some capacity, primarily burn reconstruction (40%). Factors that would discourage a trainee from practicing burn care in the future included the nature of burn care (60%) and burn operations (45%), the on-call commitment (39%), and a narrow scope of practice (38%). This study challenges the belief that plastic surgery trainees are disinterested in burn care. Burn surgery remains an important component of training programs, and we propose several steps to encourage greater interest and participation in the burn surgery workforce.

Prevalence of Dental Anomalies in the Patient with Cleft Lip and Palate Visiting a Tertiary Care Hospital.

Dental anomaly is one of the major problems in a child born with cleft lip and palate. These anomalies have deleterious effects on the dentition leading to aesthetic problems, impairment of mastication andimproper phonation. The aim of our study was to find out the prevalence of dental anomalies in patient with cleft lip and/or palate radiographically. A descriptive cross-sectional study was conducted from the 208 radiographs, collected by the convenience samplingtechnique with cleft lip and/or palate in Department of Burns, Plastic and Reconstructive Surgery, Nepal Cleft and Burn Centre, Kirtipur Hospital from January 2017 to July 2019.Ethical clearance for the study was obtained from Institutional Review Committee. Demographic data were collected and radiographs were evaluated for possible dental anomalies. Data obtained were entered and analysed in Statistical Package for Social Sciences version 23. Dental anomalies were highly prevalent among cleft lip and palate patients with at least one anomaly present in 188 (90.4%) of patients with male 120 (57.4%) presenting more anomalies than female 88 (42.6%) population. The most common anomaly was dental agenesis 161 (77.9%). The prevalence of positional anomaly, morphological anomaly and supernumerary teeth were found to be 54 (26%), 33 (15.9%) and 20 (10%) respectively. Lateral incisor showed the highest incidence of agenesis among all other missing teeth 223 (65.2%). The prevalence of dental anomalies among patients with cleft lip and/or palate was found to be high. Tooth agenesis was the most common anomaly observed in the study with lateral incisor having the highest incidence of agenesis.

Treatment of vascular soft tissue malformations: A retrospective study of 90 patients from Albania.

Vascular malformations (Vascular Malformation) of soft tissue are a consequence of abnormal development of vascular elements during embryogenesis. They are named after the vessel responsible. Their presence at birth raises the hypothesis of an intrauterine etiology of Vascular Malformation, but the influence of other factors may play an important role in their appearance, localization, and size. The literature suggests that treatment of Vascular Malformation is rarely surgical. Surgery is applied in cases of voluminous malformations and in cases of possible hemorrhagic complications. Meanwhile, patient outcomes have improved with new discoveries in laser technology for the treatment of Vascular Malformation, especially those of capillaries and the results are, in most of the cases, quite satisfactory and without significant complications. After institutional review board approval, we collected and analyzed the medical records of 90 patients diagnosed with Vascular Malformation, between January 2015 and December 2019 at the service of Burns and Plastic Surgery, "Mother Teresa" University Hospital Center of Tirana, Albania and from another private clinic in Tirana. Data were collected from the medical records on patient's charts. The aim of this study is to analyze different treatment modalities and the outcomes achieved for each group.

Effect of modified double negative-pressure wound therapy combined with debridement and tension-reduced suture in treatment of patients with stage 4 pressure sores and infection in sacrococcygeal region and its surrounding area

Objective: To investigate the effect of modified double negative-pressure wound therapy combined with debridement and tension-reduced suture in treatment of stage 4 pressure sores and infection in sacrococcygeal region and its surrounding area. Methods: From January 2015 to June 2019, 20 patients with stage 4 pressure sores and infection in sacrococcygeal region and its surrounding area were admitted to Department of Burns and Plastic Surgery and Cosmetology of Linyi People's Hospital. Among them, there were 11 males and 9 females, aged 48 to 88 years. The wounds of 13 patients were located in the sacrococcygeal region, and 8 of them had exposed sacrococcyx. The wounds of 4 patients were located in the greater trochanter area of femur, and the wounds of 3 patients were located in the ischial tuberosity area. All the patients had fever in different degree, bacterial infection, hypoproteinemia, and electrolyte imbalance, etc. at admission. After thorough debridement and dressing change, routine negative-pressure wound therapy with negative pressure value of -16.6 kPa was performed according to the scope of lesions in period Ⅰ. When granulation tissue was fresh with less exudate and without residual necrotic tissue, modified double negative-pressure wound therapy in combination with debridement and tension-reduced suture was performed immediately in period Ⅱ. Modified double negative-pressure wound therapy were persistently performed through negative pressure drainage tube inserted into deep part of wounds and negative pressure drainage tube on surface at the same time, with superficial negative pressure value of -19.9 kPa. Meanwhile, systemic anti-infection and nutritional supports were given. The wounds were monitored for the grade of wound healing and whether skin necrosis, split, or fluid accumulation develop at the suture site. The patients were followed up for 1 to 6 months after discharge to monitor wound healing. Length of hospital stay, infection condition before and after the debridement and tension-reduced suture, and complications during treatment were recorded. Results: All wounds achieved first grade healing, with the skin at the suture site healed without split, fluid accumulation, or necrosis. The patients were followed up for 1 to 6 months after discharge, with good shape of surgical incision, little pigmentation on the skin, no hypertrophic scar or contracture, and no recurrence of pressure sores. Length of hospital stay of patients was 24 to 33 d, with an average of 28.5 d. Before debridement and tension-reduced suture, 2 cases were infected with Pseudomonas aeruginosa, 1 case was infected with Escherichia coli and Staphylococcus aureus, and 1 case was infected with Proteus mirabilis. The results of bacterial culture were all negative after debridement and tension-reduced suture. During the treatment, all patients were not complicated with bone or joint infection, necrotizing fasciitis, septicemia, etc. Conclusions: Modified double negative-pressure wound therapy combined with debridement and tension-reduced suture for treatment of patients with stage 4 pressure sores and infection in sacrococcygeal region and its surrounding area is easy to operate with minimal injury, easy for patients to accept with a very high level of satisfaction, and is suitable to popularize and applicate for primary hospitals.

Italian recommendations on enzymatic debridement in burn surgery

IntroductionNexobrid®, a bromelain-based type of enzymatic debridement, has become more prevalent in recent years. We present the recommendations on enzymatic debridement (Nexobrid®)’s role based on the practice knowledge of expert Italian users. MethodsThe Italian recommendations, endorsed by SIUST (Italian Society of Burn Surgery), on using enzymatic debridement to remove eschars for burn treatment were defined. The definition followed a process to evaluate the level of agreement (a measure of consensus) among selected experts, representing Italian burn centers, concerning defined clinical aspects of enzymatic debridement. The consensus involved a multi-phase process based on the Delphi method. ResultsThe consensus panel included experts from Italy with a combined experience of 1068 burn patients treated with enzymatic debridement. At the end of round 3 of the Delphi method, the panel reached 100% consensus on 26 out of 27 statements. The panel achieved full, strong consensus (all respondents strongly agreed on the statement) on 24 out of 27 statements. DiscussionThe statements provided by the Italian consensus panel represent a “ready to use” set of recommendations for enzymatic debridement in burn surgery that both draw from and complete the existing scientific literature on the topic. These recommendations are specific to the Italian experience and are neither static nor definitive. As such, they will be updated periodically as further quality evidence becomes available.

Cell salvage in burn excisional surgery

BackgroundHemostasis during burn surgery is difficult to achieve, and high blood loss commonly occurs. Bleeding control measures are limited, and many patients require allogeneic blood transfusions. Cell salvage is a well-known method used to reduce transfusions. However, its evidence in burns is limited. Therefore, this study aimed to examine the feasibility of cell salvage during burn surgery. Study design and methodsA prospective, observational study was conducted with 16 patients (20 measurements) scheduled for major burn surgery. Blood was recovered by washing saturated gauze pads with heparinized saline, which was then processed using the Cell Saver. Erythrocyte concentrate quality was analyzed by measuring hemoglobin, hematocrit, potassium, and free hemoglobin concentration. Microbial contamination was assessed based on cultures at every step of the process. Differences in blood samples were tested using the Student’s t-test. ResultsThe red blood cell mass recovered was 29 ± 11% of the mass lost. Patients’ preoperative hemoglobin and hematocrit levels were 10.5 ± 1.8 g/dL and 0.33 ± 0.05 L/L, respectively. The erythrocyte concentrate showed hemoglobin and hematocrit levels of 13.2 ± 3.9 g/dL and 0.40 ± 0.11 L/L thus showing a concentration effect. The potassium level was lower in the erythrocyte concentrate (2.5 ± 1.5 vs. 4.1 ± 0.4 mmol/L, p < 0.05). The free hemoglobin level was low (0.16 ± 0.21 μmol/L). All cultures of the erythrocyte concentrate showed bacterial growth compared to 21% of wound cultures. ConclusionRecovering erythrocytes during burn excisional surgery using cell salvage is possible. Despite strict sterile handling, erythrocyte concentrates of all patients showed bacterial contamination. The consequence of this contamination remains unclear and should be investigated in future studies.

Versatility of Bipedicle Flap for Reconstruction of Large Scalp Defects

Background: Reconstruction of Scalp defects is a challenging problem. The unique hair bearing characteristics of scalp impose unique reconstructive challenges for coverage of scalp defects. Size, location and depth of the defect determine the complexity of the procedure. Patients with large scalp defects require reconstruction with broad based large scalp flaps. Objective: To determine the outcome of use of bipedicle scalp flap for coverage of large scalp defects. Study Design: Prospective & Observational study. Settings: Department of Plastic Surgery, Lahore General Hospital and Jinnah Burn & Reconstructive Surgery Centre Lahore-Pakistan. Duration: March 2010 to February 2019. Methodology: Eighteen patients of both genders with scalp defects secondary to trauma, tumor excision and burn injury were operated. Defect size more than 25cm2 were included in the study. Those patients in which residual scalp tissue was traumatized or inadequate for scalp reconstruction were excluded from the study. The variables and outcome measures included size, location of defect, flap survival and donor site complications. Bipedicle flaps designed in different axis depending on location and size of the defect. Results: Out of 18 patients included in this study, 12(66.67%) were male and 6 (33.3%) female. Age ranged from 32 to 78years (mean 48.66). Size of the defect ranged from 5.2x10.4cm to 18x14cm. Postoperatively 14(77%) flaps survived completely while marginal flap necrosis and dehiscence seen in 2(11%) patients. Hospital stay on average was 11 days. Recovery was quick in all patients and wound healing was satisfactory. The mean follow up period was 8 months. Minor complications like hematoma seen in 1(5%) patient. In 3 (16%) patients there was partial graft loss at flap donor site that healed with conservative management. Conclusion: Bipedicle flap provides healthy, durable and hair bearing tissue with good cosmetic outcome. Large defects can be reconstructed with a simple technique.

Clinical effect of X-N advancement flap in repairing pressure ulcer on the buttock or back

Objective: To explore the clinical effect of X-N advancement flap in repairing pressure ulcer on the buttock or back. Methods: From June 2018 to June 2019, 20 patients with grade Ⅳ pressure ulcers on the buttock or back were hospitalized and treated in the Department of Traumatology, Burns and Plastic Surgery of Fourth Affiliated Hospital of Guangxi Medical University, including 15 males and 5 females, aged 48-89 years. The area of the patient's wound was 8 cm×5 cm-15 cm×12 cm after debridement, and all were repaired with the X-N advancement flap designed by the author. The flap was designed according to the direction of skin relaxation on both sides of the wound, and the skin was incised in X-shape and sutured in N-shape. The width and advancement distance of the flap were recorded, and the ratio of the advancement distance to the width of the flap was calculated. The flap survival, complication, and follow-up were observed and recorded. Results: The width of the flap was (5.9±1.2) cm, the advancement distance of the flap was (10.3±2.5) cm, and the ratio of the advancement distance to the width of the flap was 1.8±0.4. All the flaps survived, and none of the flaps had blood flow disorder. Local dehiscence occurred in the flap of one patient 1 week after surgery, which was healed after laying on the floating bed, strengthened care, and wound dressing change. The flap of one patient developed infection 5 days after surgery, which was healed after partial suture removal, smooth drainage, and replacement with sensitive antibiotics. The wounds of the remaining 18 patients were all cured. After 3 months of follow-up, the flaps survived well with good elasticity and texture. Conclusions: The X-N advancement flap can make the skin and soft tissue move forward effectively. It is simple and effective to repair pressure ulcers on the back or buttock of patients with this flap, which is worthy of clinical promotion and application.

Expression of Pancreatic Stone Protein is Unaffected by Trauma and Subsequent Surgery in Burn Patients.

Altered levels of pro-inflammatory markers secondary to trauma or surgery present a major problem to physicians in being prone to interfere with the clinical identification of infectious events. Patients admitted to Zurich Burn Center between May 2015 and October 2018 with burns ≥10% total body surface area (TBSA) and without infection. Longitudinal analysis of the time course of PSP and routine inflammatory biomarkers [procalcitonin (PCT), C-reactive protein (CRP) and white blood cells (WBC)] over two days after (a) trauma with initial debridement and (b) subsequent burn surgeries was performed. The influence of TBSA, abbreviated burn severity index (ABSI), age and length of operation was investigated using a linear mixed effect regression model. Sixty-six patients (15 female) were included with a mean age of 45.5 ± 18.3years, median TBSA of 22% (IQR 17) and mean ABSI score 6.8 ± 2.7. PSP was the only biomarker that showed no association with any of the baseline characteristics. Additionally, PSP serum levels did not change over time neither after the burn trauma (p = 0.832) nor after secondary procedures (p = 0.113), while PCT levels increased significantly after the trauma (p < 0.001). Similarly, CRP serum levels were elevated significantly after both trauma and surgery (p < 0.001), whereas WBC values demonstrated a significant decline after the trauma (p < 0.001). Established biomarkers (WBC, CRP and PCT) demonstrate decisive alterations after tissue destruction caused by burn injuries and subsequent surgical interventions. The robustness of PSP serum levels toward these inflammatory insults is a quality criterion for an upcoming sepsis biomarker.

Epidemiological study of self-immolated patients referring to Velayat burn and reconstructive surgery center of Rasht

Introduction: Self-immolation is a deadly and painful issue that incurs high costs socially and individually. People who self-immolatearehardly cured and they will undergo serious mental and physical complications. This study aimed to determine the epidemiological distribution of self-immolated patients referring to Velayat Burn and Reconstructive Surgery Center in Rasht, Iran. Methods: This study was conducted based on a descriptive and cross-sectional design in Velayat Hospital in Rasht, Guilan province. The sample included all cases of self-immolation referring to Velayat Hospital from the beginning of April 2009 to the end of March 2017.The total number of self-immolated patients referred to hospital and registered was 96 individuals. Data were extracted from patients’ records using a researcher-made checklist. Descriptive statistics, such as mean, standard deviation, and analytical tests such as Poisson and multivariate logistic regression have been used for data analysis. Data were completely analyzed using STATA-SE software (version 13.1). Results: According to the results, 51% of the patients were female, and 67% of the cases were married; moreover, 43% of the females were housewives, and 42 % of the patients had a history of mental illness. It is worth mentioning that91% of the cases had no history of self-immolation. The most common reasons for self-immolation has been mental disorders (38.5%) and family problems (37.5%). The frequency of the rate of self-immolation has been almost equal in urban and rural areas, whereas the majority of the cases were observed in Rasht, Talesh, and Lahijan. In total, 60% of the patients died. The mean±SD age, total body surface area (TBSA), and hospitalization period were 37.5±1.5 years, 61.3±2.8, and 9.3±8 days, respectively. Analysis of regressions shows that the mortality rate has a direct and significant relationship with age and TBSA. Moreover, hospitalization time has a direct relationship with gender (i.e., male), TBSA, history of mental disease, previous records of suicide, and marital status (i.e., being married). However, it has a negative relationship with age and education. Conclusions: The level of burns is high in patients who are self-immolating, and mental disorders and familial problems have been the main reason for it. Therefore, although the frequency of self-immolation rate is lower, compared to other suicide methods, thesesmall groups of patients need special care due to the high rate of mortality.

Accuracy of Thermal Imaging Camera in Identification of Perforators.

To determine the diagnostic accuracy of thermal imaging camera in the identification of perforators using peroperative visual inspection as gold standard. Descriptive study. Place of Study: Jinnah Burn and Reconstructive Surgery Centre / Allama Iqbal Medical College, Lahore, from October 2017 to September 2018. Patients undergoing pedicled or free perforator flap for reconstructive surgery of upper and lower limb, abdomen, groin, and head and neck region, where soft tissue defect was caused by trauma (road traffic accidents and electric burns), were included in this study. All patients underwent the same treatment protocol of identification of perforator location with Flir One camera preoperatively. Later, it was confirmed peroperatively by visual inspection. Diagnostic accuracy was calculated in terms of sensitivity, specificity, positive predictive value, and negative predictive value. Diagnostic accuracy in identification of perforators in pedicled (n=154) and free flaps (n=30) by thermal imaging camera was calculated as sensitivity of 86.2%, specificity of 80.0% with the positive and negative predictive values of 98.7%, and 25.0%, respectively. Flir One, a smartphone-compatible miniature thermal imaging camera, is useful for the detection of perforators and is highly sensitive and specific. Key Words: Flir One, Perforators, Thermal imaging, Thermal imaging camera.

Effect of free medial plantar perforator flap in repairing deep burn wound on palm with the assistance of three dimensional computed tomography angiography

Objective: To explore the effect of free medial plantar perforator flap in repairing deep burn wound on palm with assistance of three dimensional computed tomography angiography (CTA). Methods: From March 2015 to January 2018, 11 patients with deep burn wounds of palm were admitted to the Department of Burns and Plastic Surgery of Yidu Central Hospital of Weifang City, including 6 males and 5 females, aged 19-53 years. The wound area after debridement was 3.0 cm×2.5 cm-8.0 cm×6.0 cm. Before the operation, CTA of the foot was performed, and the three dimensional digital model was reconstructed by computer software to observe the initial position, course, and distribution of the arteries and veins in the donor site. The medial plantar perforator flap was designed according to the area and shape of the wound, with area of 3.5 cm×3.0 cm-8.5 cm×6.5 cm. After the wound was covered by the flap, the perforating branch of the medial plantar artery was anastomosed end to end with the carpal epithelial branch of the ulnar artery, the accompanying vein or the branch of the great saphenous vein was anastomosed end to end with the accompanying vein of the carpal epithelial branch of the ulnar artery, and the terminal branch of the saphenous nerve or the medial dorsal cutaneous nerve was anastomosed end to end with the superficial palmar branch of the ulnar nerve. The wound of donor site was covered with full-thickness skin graft from the outer thigh of the same side. The perforators of the medial plantar artery observed during the operation were compared with the reconstructed three dimensional CTA images. The survival of flap was observed, and the appearance and function of the flap were followed up and evaluated with trial standard for the evaluation of the functions of the upper limbs of the Hand Surgery Society of the Chinese Medical Association. Results: The initial position, course, and distribution of the perforator of the medial plantar artery during the operation were basically the same as those of the reconstructed three dimensional CTA images before the operation. All the flaps of patients survived after the operation. During the 6 months to 1 year follow-up, the appearance of flap was good, with no obvious swelling or pigmentation, but with good elasticity. The discrimination distance between the two points was 5.0-8.0 mm, and the flaps were evaluated as excellent in 4 cases, good in 6 cases, and fair in 1 case. Conclusions: The free medial plantar perforator flap is an ideal choice for repair of the deep burn wound on palm. Three dimensional CTA before the operation can detect condition of vascular variation, with high accuracy of vascular anastomosis during operation.

Glycerol Preserved Amnion: A Viable Source of Biological Dressing for Superficial Partial Thickness Facial Burns.

To evaluate the role of amnion as a biological dressing in superficial partial thickness facial burns. Randomized controlled trial. Jinnah Burn and Reconstructive Surgery Centre, Lahore, from January 2017 to December 2018. Sixty two patients with superficial partial thickness facial burns were randomly divided into two groups (A and B). Ointment containing Polymyxin B and Bacitracin was applied in group A (n=28) while amnion was applied in group B (n=34). The patients were monitored for the pain related to burns needing analgesia, time of healing of burns, and cosmetic outcome of the facial scarring over a period of six months. The mean age of the patients was 26.5 ±12.2 years. 39 (62.9%) patients were male and 23 (37.1%) were females. The mean percent total facial surface area burned was 2.7% ±1. None of the patients developed facial wound infections. The average healing time was 6 ±2 days. The mean frequency of analgesia for 3 days of group B was less as compared to group A. infection rate was similar in both groups. No significant difference was observed in VAS score at 1, 3 and 6 month follow up between both groups. Amnion is a safe, cost effective and most readily available biological dressing for superficial partial thickness facial burn management. Key Words: Amnion, Facial burn, Biological dressing, Scarring, Partial thickness burn.

Comparison of Vacuum Assisted Closure Technique Versus Conventional Dressing for Management of Wounds in Term of Duration of Wound Healing

Background: Negative pressure wound therapy in the form of vacuum assisted closure is known to be a useful adjunct in wound healing. It can downstage surgical reconstruction options from large flaps to simpler skin grafts or secondary wound closure. Objective: To compare mean duration of wound healing between conventional dressings and negative pressure wound therapy for management of wounds. Study Design: Randomized Controlled Trial. Settings: Allied Burn and Reconstructive Surgery Centre, Faisalabad, Pakistan. Duration: June 1, 2018 to November 30, 2018. Methodology: All the patients were randomly divided into 2 groups. Group A underwent negative pressure wound therapy while group B underwent conventional dressings. Patients in both groups were observed for a period of maximum two weeks. Results: Comparison of mean duration of wound healing between conventional dressings and negative pressure wound therapy for management of wounds was done. It was 9.83+1.32 days in Group-A and 16.30+1.37 days in Group-B, p value was 0.0001. Conclusion: Mean duration of wound healing was significantly higher in cases with conventional dressings compared with negative pressure wound therapy for management of wounds.

The Use of Dermal Substitute in Deep Burns of Functional/Mobile Anatomic Areas at Acute Phase After Early Excision and Subsequent Skin Autografting: Dermal Substitute Prevents Functional Limitations.

We aimed to evaluate the results of dermal substitute implantation after early excision in the acute phase of major burn cases within the scope of efforts to reduce contractions and scar formation in functional anatomic areas (face, neck, axilla, elbow, popliteal). Twelve patients with major burn who were treated in the burn center between September 2017 and September 2018 were included in the study. In these patients, Nevelia® dermal substitute was implanted into 24 functional areas with deep partial or full-thickness burns after surgical debridement of the wound. Autologous split-thickness skin graft was applied to these areas after 14 to 21 days. The patients were followed for 4 to 14 months (mean 6 months). Postoperative scar formation was assessed by the Vancouver Scar Scale at the end of the follow-up period. A simple qualitative staging system was used for aesthetic and functional evaluation. The time from burn injury to dermal substitute implantation was 3 to 21 days. Skin graft take was complete in 22 of 24 regions and partial in one of them, while graft loss developed in one region. In the implantation sites, the Vancouver Scar Scale ranged from 1 to 7. The aesthetic and functional evaluation showed excellent/good results in 21 of 24 anatomic regions, moderate results in 2 regions, and poor results in 1 region. The use of dermal substitute in deep burns of functional/mobile anatomic areas at the acute phase after early excision and subsequent skin autografting has opened a new alternative area in the burn surgery arena to prevent contractures and functional limitations.

Burn service costing using a mixed model methodology.

The escalating cost of modern healthcare is threatening the fundamental "free at the point of delivery" principle of the UK National Health Services. A new remuneration system using a fixed tariff for pre-assigned diagnostic groups caters poorly for the heterogeneity of burn injuries. This study was to develop a system for Patient Level Costing (PLC), the first steps of which were to determine the true cost of burn care at service level. Detailed interrogation was conducted of the cost of care in our Burns & Plastic Surgery Department. Costs were determined through the amalgamation of two fundamental methodologies: (1) Top-Down Costing (from detailed budgetary analysis for the hospital) and (2) Bottom-Up Costing (detailed itemised costing of staff, equipment, drugs, consumables & maintenance). These costs were categorised & using various apportionment tools, traced to specific care areas. We demonstrated that the accuracy of costs derived by host organisations cannot be relied upon (our Burn Service was 62% more expensive than estimated by our host organisation), which therefore questions the accuracy of most published work on burn care costing based upon these assumptions. Using our costing model, an analysis was made of the cost of running the Department with zero activity but "open & ready for business". Costs such as drugs and consumables were thus removed. This demonstrated that despite no clinical activity, costs still remained at 90% of full occupancy cost and are thus fixed costs. We hope application of this new system of Patient Level Costing to burn care will avoid the threatened viability of burn services imposed by changes in remuneration, although it will inevitably be an iterative process. A fuller understanding of the true cost of healthcare, facilitates service development and planning, both at a local and national level.