Scar Contracture Research Articles

Serial Casting as an Effective Method for Burn Scar Contracture Rehabilitation: A Case Series.

Guidelines and protocols for orthoses in burn scar contracture rehabilitation are limited. The current study aims to determine the optimal frequency of casting, potentially facilitating the development of a serial casting protocol. Previous literature supporting casting has low generalizability due to methodology limitations. Seven patients with burn scar contracted joints, who did not respond to traditional therapy, were recruited in this study. Patients were serially casted once, three times, or five times a week. Joint range of motion was maximized with stretching and exercise techniques before every new cast application. Across all patients, active range of motion increased from 65.8 ± 27.8° to 108.1 ± 23.3° with casting; or from 57.8 ± 16.2% to 96.7 ± 2.9% of normal. Similarly, scars improved from 9.5 ± 1.5 to 4.9 ± 1.4 on the Modified Vancouver Scar Scale score. This therapeutic effect was achieved within an average of 8.5 ± 3.7 d and 4.0 ± 2.2 new cast applications. Given the study findings, the procedures outlined could be used to develop a standardized serial casting protocol for burn scar contracture rehabilitation.

Short-term effectiveness of transverse antecubital incision for failed closed reduction of Gartland type Ⅲ supracondylar humerus fractures in children

To investigate the short-term effectiveness of transverse antecubital incision in the treatment of failed closed reduction of Gartland type Ⅲ supracondylar humeral fractures (SHFs) in children. Between July 2020 and April 2022, 20 children with Gartland type Ⅲ SHFs who failed in closed reduction were treated with internal and external condylar crossing Kirschner wire fixation through transverse antecubital incision. There were 9 boys and 11 girls with an average age of 3.1 years (range, 1.1-6.0 years). The causes of injuries were fall in 12 cases and fall from height in 8 cases. The time from admission to operation ranged from 7 to 18 hours, with an average of 12.4 hours. The healing of the incision and the occurrence of complications such as nerve injury and cubitus varus were observed after operation; the elbow flexion and extension range of motion after removing the gypsum, after removing the Kirschner wire, and at last follow-up were recorded and compared, as well as the elbow flexion and extension and forearm rotation range of motion at last follow-up between healthy and affected sides; the Baumann angle was measured on the X-ray film, and the fracture healing was observed. At last follow-up, the effectiveness was evaluated according to the Flynn elbow function evaluation criteria. All incisions healed by first intention, and there was no skin necrosis, scar contracture, ulnar nerve injury, and cubitus varus. Postoperative pain occurred in the radial-dorsal thumb in 2 cases. The gypsum was removed and elbow flexion and extension exercises were started at 2-4 weeks (mean, 2.7 weeks) after operation, and the Kirschner wire was removed at 4-5 weeks (mean, 4.3 weeks). All the 20 patients were followed up 6-16 months, with an average of 12.4 months. The fracture healing time was 4-5 weeks, with an average of 4.5 weeks, and there was no complication such as delayed healing and myositis ossificans. The flexion and extension range of motion of the elbow joint gradually improved after operation, and there were significant differences between the time after removing the gypsum, after removing the Kirschner wire, and at last follow-up ( P<0.017). There was no significant difference in the flexion and extension of the elbow joint and the forearm rotation range of motion between the healthy and affected sides at last follow-up ( P>0.05). There was no significant difference in Baumann angle between the time of immediate after operation, after removing the Kirschner wire, and at last follow-up ( P>0.05). According to Flynn elbow function evaluation standard, 16 cases were excellent and 4 cases were good, the excellent and good rate was 100%. The treatment of Gartland type Ⅲ SHFs in children with failed closed reduction by internal and external condylar crossing Kirschner wire fixation through transverse antecubital incision has the advantages of complete soft tissue hinge behind the fracture for easy reduction and wire fixation, small incision, less complications, fast fracture healing, early functional recovery, reliable reduction and fixation, and can obtain satisfactory results.

563 The Why Behind the Release- A 2 Year Review of Pediatric Burn Scar Contracture Releases

Abstract Introduction A burn therapy quality improvement project was identified to determine what factors led to burn scar contracture releases for improved range of motion from June 2020 to June 2022. The goals of the project were to determine: 1) What factors led to the burn scar contracture formation? 2) What factors led to the need for surgery to correct the contractures after the initial injury/surgery? and 3) What therapy interventions could be implemented to identify the patients' contracture risk, improve their outcomes, and prevent additional surgical interventions? Methods A review of the burn OR schedule in the EMR was conducted to identify reconstructive surgical cases from June 2020 to June 2022. The following information was obtained on the patients: type of surgery, the location of the release(s), percent TBSA burn, therapy interventions prior to the release, therapy location, and time from initial injury until surgical release. Results Out of 52 patients who had surgical interventions for scar contracture: 27 were in the category of patient growth (25 had no limitations in functional AROM at discharge from therapy), 19 in the category of compliance/complex social situations, and 6 in the category of aggressive scarring /difficult scar management. One outlying case was uncategorized. In the patient growth category, the average time from the initial injury to the release was 8.42 years. In the category of aggressive scarring/difficult scar management, all the patients were under 4 years old and had difficulty with scar management/positioning from the start. The one factor that was noted in both categories was a mVSS score of &amp;gt;/=4 with pliability and vascularity &amp;gt;/=1 and height score of &amp;lt; /=1 at d/c from therapy. In the compliance/complex social situations category, the factors affecting scar outcome were poor appointment attendance, shared custody, foster system placement, and limited follow-through with home program.4 Conclusions As a result of this analysis, strategies were implemented to lower the mVSS upon discharge: 1) therapists will set goals for the mVSS score to be &amp;lt; 2 upon discharge to assure that the score is at or below a 1 for pliability and vascularity, and 0 for height; 2) if the mVSS is not &amp;lt; 2 when patient is being considered for d/c from clinic, therapists will discuss this with medical team as patient may be at higher risk for contracture with continued growth; 3) a “maintenance education program” will be provided to all patients at d/c; 4) Social work/psychology will be consulted earlier to work with families on compliance with attendance/interventions; 5) UE casting with new materials utilized by therapists to improve positioning of burned hands/wrists in children &amp;lt; 4 years old. Applicability of Research to Practice Therapy practice changes to prevent contractures

564 Simplified Dynamic Splints for Common Scar Contractures of the Hand

Abstract Introduction Common problems associated with immature burn scarring of the hands include proximal interphalangeal (PIP)/distal interphalangeal (DIP) flexion contracture, first webspace contracture, and metacarpal phalangeal (MCP) hyperextension that require diligent splinting intervention in therapy and at home to improve patient outcomes. Dynamic splinting can be used to provide low-load long-duration stretch; however, they can be difficult for patients to don independently at home and are often time consuming for therapists to fabricate. Alternative methods of using neoprene strapping were utilized to provide the dynamic pull to simplify the supplies required and improve ease of use for the patient. Methods Using the “I splint” for elbow flexion contractures as a model, we fabricated a smaller version for use in finger PIP and DIP flexion contractures using thermoplastic material and neoprene strapping (Figure 1a). A novel splint for thumb abduction/extension in treatment of first web space scar contracture (Figure 1b). Based on a traditional MCP flexion splint, we utilized neoprene strapping instead of springs or rubber bands and a plastic D ring instead of metal outrigger (Figure 2). Splint wear started at 1x/ day for 5 minutes and progressed to 3-5x/day for 5-15 minutes as tolerated. Results Digit PIP or DIP extender (figure 1a.) after 1 week of daily wear improved PIP extension from 45 degrees (of flexion) to 25 degrees and DIP extension from 50 degrees to 30 degrees. Thumb Post Splint (figure 1b.) after 2 weeks of daily wear improved radial abduction from 45 degrees to 58 degrees. Dynamic MCP flexion splint (figure 2) after 1 month of daily wear improved left ring finger active MCP flexion from 0-20 degrees to 0-40 degrees. Left small finger active MCP flexion improved from (-50) - 0 degrees to (-40) - 5 degrees (negative parenthetical value denotes hyperextension). Conclusions Dynamic splints utilizing neoprene strapping contributed to improved range of motion for all patients included in this case series. Therapists noted that splint adjustments were infrequent and minimal throughout time of use. Patients reported ease of use and compliance with splint wear schedule outside of therapy sessions. The amount of time spent fabricating compared to traditional methods was not tracked and would be an interesting point to consider in the future. Applicability of Research to Practice We hope that this presentation may give other practitioners new tools to address common burn scar contractures of the hand and simplify both the fabrication process and materials required for dynamic splinting.

302 A Classification System and Surgical Algorithm for Pediatric Postburn Ear Deformities

Abstract Introduction The outward projection of the external ear makes this anatomically complex appendage susceptible to trauma. Notably, up to 40-60% of facial burns involve the ear, frequently impacting function and aesthetics. Significant postburn sensory deficits and changes to the ear’s intricate architecture can markedly impair physical health, psychosocial functioning, and quality of life. Scar tissue and contracture, traumatized cartilage, and compromised blood supply and surrounding soft tissues all influence the reconstructive plan. The authors describe a new classification system and surgical algorithm for pediatric postburn ear deformities informed by both their extensive operative experience on the traumatized ear and a retrospective study of different reconstructive techniques for more severe burn injuries to the pediatric ear. Methods To develop the classification system and surgical algorithm, three senior surgeons with over 85 years of combined experience reconstructing ears carried out an iterative joint review of their relevant clinical cases and insights, including their personal approach to assessing postburn ear trauma and developing an operative plan. Particular attention was focused on how the type and extent of soft tissue injury affects available reconstructive options. To inform classification of the most complex ear burn cases, a retrospective review was conducted on patients aged 0 to 21 years who underwent cartilage framework reconstruction between January 2004 to January 2021 at a specialized pediatric burn center. Medical records were screened and 54 patients (61 ears) who met study criteria were identified and patient demographics, procedural characteristics, and outcomes were analyzed. Results For postburn ear deformities (Table 1) involving total or near-total preservation of the ear’s anatomical structural elements (Type I and Type II deformities, respectively), scar release, local tissue rearrangement, and/or skin grafting are typically sufficient for optimal reconstruction. For cartilage defects involving less than or more than two-thirds of the helix (Type III and Type IV deformities, respectively), a partial to complete ear scaffold can be successfully reconstructed using a composite graft, conchal transposition flap, costal cartilage graft, or porous polyethylene implant. Conclusions The proposed classification system and surgical algorithm (not shown) for postburn ear deformities facilitate a tailored approach that addresses reconstructive course duration, anticipated aesthetic results, complication potential, and patient goals and expectations. Applicability of Research to Practice The authors provide a new classification system to pediatric postburn ear deformities that, along with a proposed surgical algorithm, can help guide planning for reconstruction.

123 Flexion Glove Modification to Isolate Proximal and Distal Interphalangeal Joint Range of Motion

Abstract Introduction Flexion gloves are a quick and easy way to provide a dynamic stretch to the digits for patients with limited composite flexion range of motion (ROM) or who are at risk for digit extension burn scar contractures. However, the flexion glove has been observed clinically to bias metacarpal phalangeal (MCP) joint flexion ROM when compared to the proximal and distal phalangeal (PIP and DIP) joints. The purpose of this case study is to demonstrate the use of a custom thermoplastic hand-based splint to block MCP joint motion in order to better isolate PIP and DIP joint ROM for a patient with primary PIP and DIP flexion ROM limitations. Methods A custom, thermoplastic, palmer hand-based splint was fabricated with an opening for the thumb and the splint extending to the proximal phalanxes stopping below the PIP joints in order to block MCP joint flexion ROM as seen in Figure 1b. Composite flexion passive ROM (PROM) measurements were taken for all MCP, PIP, and DIP joints of digits 2-4 with only the flexion glove donned and with the hand-based splint applied over the flexion glove as seen in Figure 1a and 1c. Results An increase in combined PIP and DIP joint PROM was found for all digits when the hand-based splint was donned over the flexion glove compared to the flexion glove only (see Table 1). These increases in combined PIP and DIP PROM included 35° for the index finger, 10° for the middle finger, 20° for the ring finger and 30° for the small finger, with an overall mean increase of 23.75° Conclusions This easy splinting technique combined with a flexion glove was effectively used to bias stretch of the PIP and DIP joints into flexion for a patient with adequate MCP flexion ROM and impaired PIP and DIP flexion ROM caused by burn scar contracture. Applicability of Research to Practice Using an off the shelf flexion glove and a basic hand-based splint, therapists can use this technique to easily adjust the angle of pull to maximize the benefit from a flexion glove to address specific joint limitations of the finger caused by burn scar contracture.

556 Minimally Invasive Contracture Release Improves Function in Patients with Burn Contractures

Abstract Introduction Scar contracture bands after burns are a persistent problem that cause discomfort and physical and aesthetic limitation. Standard treatment for contracture bands in burn scars involves physical therapy, stretching, splinting and laser treatment, as well as surgical releases with local/distant flaps and grafting. A minimally invasive transcutaneous approach for the release of scar bands was initiated in our institution 6 years ago. The method was derived from techniques pioneered by Jose Daher and Raul Gonzalez to interrupt platysma bands in neck rejuvenation. With IRB approval we evaluated this new approach regarding long term outcomes. Methods A retrospective review of 45 patient charts was conducted for those with burn scars who received subcutaneous contracture release from May 1, 2016, through March 31, 2022. The procedure involves introducing a braided suture to loop the contracture band and moving it in a sawing motion until it cuts through the band in multiple sites along the contracture. Demographic data, total burn surface area (TBSA), location, amount of contracture release increments, scar size, and duration of treatment was recorded. Concurrent scar treatments and whether performed under anesthesia was also noted. In follow up visits 3-12 months post release patients were surveyed on satisfaction with the treatment and whether they noticed increased mobility after the procedure. The Vancouver Scar Scale was administered pre- and post-treatment. Patient range of motion was measured pre-and post treatment to assess for change in mobility at treated sites. Results Male to female ratio was 51%:49%, average age was 38.8(6 to 68), 58% were white . TBSA ranged from 0.5% to 85%, with an average of 36.1 ± 22.3. The release was applied to 11 different sites spanning the entire body, 39% on the neck . The procedure involved an average of 19.0 ± 8.8 incremental releases, and the average scar size for treatment was 174.4 ± 140.0 cm2. 93% of the procedures involved laser treatment, 76% were done under anesthesia because of the laser, and 84% involved a site that was skin grafted. Only one of the 45 patients reported bleeding post-discharge, and none had an infection at a puncture site. Out of 20 responses, 13 patients reported being “satisfied” and 3 “very satisfied”; none reported being “dissatisfied”. 19 noted an increase in mobility at the contracture site and one did not. On average, patient range of motion increased by 13.6 degrees. Conclusions The minimally invasive contracture release described is a versatile, safe, and well-tolerated procedure that can help patients regain form and function after a burn injury. It was successfully applied to a large range of age groups, burn sizes, and scar contracture sites. Encouraging data regarding patient recovery and gain in mobility supports the use of this contracture release technique. Further studies should include prospective multicenter trials. Applicability of Research to Practice Immediate

117 Allocation of Therapist Time: Mobilization of CFU’s in Hand w/Burn Injury

Abstract Introduction Movement of the hands and digits are used to perform communication and activities for IADL’s and competitive employment. Following a second or third degree to the hand(s), there is a potential for the development of burn scar contracture(s) (BSC), which decreases hand skills creating the potential for decreased quality of life. The ABA data base identifies that 70% of burns are sustained to the upper torso, UE, hands. One ABA verified burn center created a study to identify the time required for the burn therapist to elongate hand CFU’s to pre-burn movement. Methods The one-year retrospective study included unilateral and bilateral hand burns with LOS of 2 days or greater or had an outpatient OT session within one week of the burn. Co-author created the Passive Motion Scoring Grid (PMSG), using a number score with higher number indicating greater passive movement. Education was provided to the OT’s to complete the PMSG at the beginning and end of each hand CFU elongation session. Otherwise, there was no change in the OT burn hand therapy treatment. The study included (5) OT’s with mean of 6 years of experience (3-46). Results There were 50 patients, average age was 48.91 years with majority male and African American. All burns were secondary to thermal with burns of 2nd and 3rd degree. There were 33 unilateral hand burns with an average TBSA of 7.02% and 17 patients sustained bilateral hand burns with an average TBSA of 21.3%. Unilateral hand burns had an average number of CFU’s of 39.4 (11-68) and hand CFU’s accounted for 87.1% of the CFU’s. Average number of CFU’s in bilateral hand burns was 90.3 (8-196) with hand CFU’s accounting of 83.4% of the CFU’s. A total of 539 OT sessions were provided to those with unilateral hand burns with an average of 18 OT sessions (3-36). Bilateral hand burns received a total of 487 OT sessions with average of 24.4 OT sessions (4-67) Therapist time for hand CFU elongation to pre-burn status: unilateral hand burns, 43.5 minutes (SD=24.7) and bilateral hand burns was 53.5 minutes (SD=32.2). The minutes only reflect CFU elongation not the entire therapy time. Conclusions Hand burns result in a small number for TBSA, however it results in a greater number of CFU’s than other body locati8ons. The greater number of CFU’s involved, indicates greater potential for development of BSC. At the completion of the burn OT therapy, no patient exhibited BSC. Providing education and information to funding sources regarding CFU’s in hand burns, equating that to potential BSC development and time required for therapist direct hands-on techniques to obtain pre-burn movement can positively influence authorization for therapy. Applicability of Research to Practice Can assist with allocating therapist time with hand burns. Can positively influence funding authorization for therapy.

560 Utilization of Alternate Hinge for Static Progressive Shoulder Orthosis: A Case Study

Abstract Introduction Management of shoulder burn injuries creates unique challenges as the shoulder girdle is comprised of four joints and has the largest degree of motion in the body. The complexity of arthrokinematics and cutaneokinematics requires creative positioning devices to achieve the desired effect. Shoulder positioning devices for pediatric patients are limited, and devices that allow positioning at end range can be bulky, heavy, and costly. Available hinges for upper extremity devices offer limited utility and do not withstand the tensile forces of burn scar contracture in conjuncture with and prolonged use. This is a report of a single patient for which a locking knee hinge was used to fabricate a custom static progressive shoulder flexion device. Methods This case study analyzes the impact of bilateral custom static shoulder flexion orthoses and static progressive orthoses on range of motion in a pediatric patient. Static shoulder flexion orthotics were implemented, and then transitioned to static progressive orthotics. Goniometric measurements were obtained through out hospitalization. Average variance in of range of motion at the glenohumeral joint (GH), and standard deviation of goniometric measurements comparing static and static progressive orthoses were collected. Results There was a total of 33 bilateral sets of goniometric measurements. Sixteen sets were collected utilizing static shoulder flexion orthoses. Mean flexion was 149.6⁰ and 154.6⁰ abduction of the left shoulder. Right shoulder flexion and abduction means were 149.3⁰ and 152.8⁰ degrees. There was a standard deviation (STD) of 22⁰ for the left shoulder mean goniometric measurements and STD of 23.2⁰ for the right shoulder. Seventeen sets were collected utilizing static progressive shoulder flexion orthoses. Results revealed a mean of 166.1⁰ and 166.7⁰ for flexion and abduction of the left shoulder. Right shoulder flexion and abduction averages were 169.3⁰ and 170.6⁰ respectively. There was an STD of 8.9⁰ for mean goniometric measurements of the left shoulder and STD of 4⁰ of the right shoulder. Introduction of a locking hinged shoulder flexion orthosis resulted in an increase of 80⁰ left and 90⁰ right shoulder flexion in 24 hours. The patient was able to achieve and maintain an average of 165⁰ of shoulder flexion throughout hospitalization (47 days). Conclusions Use of a locking hinged shoulder orthosis allowed for progressive increase in shoulder flexion without neurological symptoms and decreased pain and anxiety related to therapy and orthotic application. Compliance with wearing schedule was increased due to ease of application. Applicability of Research to Practice Utilization of locking hinges to create custom static progressive shoulder flexion orthoses may allow therapists to increase and maintain shoulder range of motion in pediatric patients following burn injury.

562 Therapy Resources for Management of Large TBSA Burns: A Case Study

Abstract Introduction Therapy studies involving large percent TBSA burns ( &amp;gt;50% TBSA) are not well described. Studies show the highest predictor of preventing burn scar contracture is the amount of burn rehabilitation time received per cutaneous functional units involved, but what does “more therapy time” mean for larger burns in terms of therapy resources for burn centers? Methods A case study was completed on a 20-year-old male admitted after sustaining 85% TBSA full thickness flame burns to his face, neck, arms, legs, and trunk, along with an inhalation injury. He was admitted to the inpatient burn ICU for 113 days, undergoing 16 surgeries to achieve skin coverage prior to discharge to acute rehab. Therapy was initiated &amp;lt; 24 hours after admission to the Burn ICU. Direct therapy contact minutes were tracked during all session and divided into therapy treatment domains. (resource). If co-treating occurred, a single unit of time was used for the time of the session to avoid doubling the units provided. Results Therapy occurred on 106/113 days of admission, receiving 238 therapy sessions (113 PT, 125 OT). He received 21,027 minutes of direct therapy, averaging 196.5 min/rehab days. The highest number of therapy minutes were spent on ROM (9,032 min). Other domains of care included Mobilization (3,171 min), Positioning (2,298 min), Orthotic management (1,326 min), etc. (Table 1). Despite focus on ROM and positioning, he discharged with 7 moderate (left wrist extension, bilateral hip abduction, bilateral ankle dorsiflexion, left neck rotation, and left forearm supination) and 4 severe contractures (right wrist extension, bilateral hip extension, neck extension). He was able to transfer with moderate assistance and walk 150 ft with a platform walker at discharge. Conclusions Therapy interventions in the literature are often described in isolated “domains” of practice, however guidelines on a global approach to management of those with catastrophic injuries does not exist. Prioritization between domains with limited therapy resources when facing patients with extensive deficits is challenging. A dedicated burn therapy staff with availability to secure additional resources was required to ensure optimal outcomes in the management of this patient Applicability of Research to Practice This case study demonstrates the comprehensive burden of care and need for additional therapy resources in the management large TBSA burns.

Outcomes of Linear Circumferential Skin Closure for Congenital Constriction Ring Syndrome.

Background: Congenital constriction ring syndrome (CCRS) is a rare condition diagnosed at birth characterised by deformation due to a constriction ring. The usual treatment for CCRS involves excision of the constriction ring and suture of the skin incorporating a Z-plasty to prevent scar contracture. A Z-plasty often results in an unsightly scar. In order to avoid this, we performed linear circumferential skin closure (LCSC). The aim of this paper is to report the outcomes of LCSC for CCRS. Methods: We retrospectively investigated all patients with CCRS who underwent LCSC between 2002 and 2020. Two linear incisions were placed proximal and distal to the constriction ring in parallel, and the constriction ring was excised carefully so as not to damage nerves or vessels. The deep subcutaneous and dermis layers were sutured. The skin was closed using adhesive tape. Two-stage surgery was performed in two patients with severe CCRS of the lower leg to avoid problems with distal circulation. Patients were followed up for at least 1 year and assessed for complications and quality of scar. Results: We performed LCSC for 31 sites in 19 patients, including one forearm, 14 fingers, 10 lower legs and six toes. The median age at the operation was 16 months (range: 4-175). The median follow-up period after surgery was 5.8 years (range: 1.9-16.0). The linear surgical scar had healed well in all patients and there were no complications. There was no recurrence of the constriction ring and no scar hypertrophy, though we did not perform fat mobilisation in all cases. None of the patients required additional surgery and the aesthetic outcome of the linear circumferential surgical scar was maintained at the final observation. Conclusions: Treatment for CCRS using LCSC resulted in no complications, no recurrence of constriction and an excellent aesthetic outcome. Level of Evidence: Level IV (Therapeutic).

Oblique Axis Hypothenar Free Flaps: Tips for Harvesting Larger Flaps with Minimal Donor Site Morbidity

Background Hypothenar free flaps (HTFFs) have been widely used for reconstructing palmar defects. Although previous anatomical and clinical studies of HTFF have been conducted, this technique still has some limitations. In this study, we describe some tips for large flap design that allows for easy harvesting of HTFFs with minimal donor site morbidity. Methods A total of 14 HTFF for hand defect reconstruction were recorded. The oblique flap was designed in the proximal HT area following relaxed skin tension line along the axis between fourth web space and 10 mm ulnar side of pisiform. A flap pedicle includes one or two perforators with ulnar digital artery and HT branch of basilic vein. In addition, innervated HTFF can be harvested with a branch of ulnar digital nerve. Electronic medical records were reviewed to obtain data on patients' information, operative details, and follow-up period. In addition, surgical outcome score was obtained from the patient, up to 10 points, at the last follow-up. Results Mean harvest time was 46 minutes, and two perforators were included in 10 cases. The mean flap area was 10.84 cm 2 . There were no problems such as donor site depression, scar contracture, keloids, wound dehiscence, numbness or neuroma pain at donor sites, and hypersensitivity or cold intolerance at flap site, either functionally or aesthetically. Conclusion Palmar defect reconstruction is challenging for hand surgeons. However, large HTFF can be harvested without complications using the oblique axis HTFF technique. We believe our surgical tips increase utility of HTFF for palmar defect reconstruction.

Self-reported health measures in burn survivors undergoing burn surgery following acute hospitalization: A burn model system national database investigation

Health Related Quality of Life (HRQoL) surveys such as PROMIS-29 may facilitate shared decision-making regarding surgery after burn injury. We aimed to examine whether scar revision and contracture release surgery after index hospitalization was associated with differences in HRQoL. Patient and PROMIS-29 Profile v2.0 data were extracted from the Burn Model System (BMS) at 6-, 12-, and 24-months after burn. PROMIS-29 measures 7 health-related domains. Linear regression was performed to identify associations between independent burn patient variables (e.g. scar-related surgery) and PROMIS-29 scores. Socio-demographic and injury variables were analyzed using logistic regression to determine the likelihood of undergoing burn-related surgery. Of 727 participants, 201 (27.6%) underwent ≥1 scar/contracture operation within 24 months of injury. Number of operations at index hospital admission and range of motion (ROM) deficit at discharge were correlated with an increased likelihood of undergoing subsequent scar/contracture surgery (p<0.05). Participants undergoing scar/contracture surgery and those that were Medicaid insured reported significantly worse HRQoL for PROMIS domains: anxiety, depression, and fatigue (p<0.05). After adjusting for burn severity and available confounders, participants who underwent scar-related burn reconstructive surgery after index hospitalization reported overall worse Health-Related Quality of Life (HRQoL) in multiple domains.

The importance of biomechanics and the kinetic chains of human movement in the development and treatment of burn scars - A narrative review with illustrative cases.

Burn scars are a major clinical sequelae of severe burn wound healing. To effectively establish a successful treatment plan and achieve durable results, understanding the pathophysiology of scar development is of utmost importance. A narrative review of the principles of the kinematic chain of movement and the hypothesised effect on burn scar development based on properties of burn scars was performed. An examination of the literature supporting these concepts is presented in conjunction with illustrative cases, with a particular focus on the effect of combination treatments that include ablative fractional resurfacing with surgical contracture releases. Ablative fractional resurfacing combined with the surgical release of contractures are an effective treatment modality for burn scar reconstruction. This treatment approach seems particularly effective because it is one of the only approaches where the principles of functional kinematics can be addressed when tailoring a reconstructive approach to an individual burn patient. The presented cases illustrate the importance of recognising and including the principles of functional kinematic chains in any reconstructive treatment approach for burn scars. Further, epifascial contracture bands are cord like structures which can be found underneath the subcutaneous fat of scar contractures which follow the principles of functional kinematics. Contractures can be more efficiently released if these structures are divided as well. Ablative fractional resurfacing combined with local tissue re-arrangements is a promising approach to address the underlying forces leading to hypertrophic burn scarring. To achieve an optimal outcome, it is essential to recognise and address the origin of the pathology when treating burn scars. Ablative fractional laser resurfacing allows a different scar approach as it is not limited to one surgical site and thus enables for effective treatment at the cause of the pathology.

Importance of correcting alar base ptosis during primary cleft lip repair.

Until 1999 at our hospital, primary cleft lip repair was performed by the straight-line method and external rhinoplasty was performed by the inverted trapezoidal suture method with bilateral reverse-U incisions for children with cleft lip and palate. Subsequently, repeated surgical corrections of the external nasal morphology became necessary during the growth period, often with unsatisfactory results because repeated external rhinoplasty results in a stronger scar contracture. From 2000 to 2004, we performed external rhinoplasty after patients had stopped growing; however, delaying surgery created a psychological burden for patients. Therefore, since 2005, we have focused on improving alar base ptosis and forming the nostril sill during the primary surgery. This study was performed to subjectively and objectively evaluate whether the current surgical method or the earlier technique produces a better treatment outcome. We subjectively and objectively evaluated alar base asymmetry after primary cleft lip repair but before bone grafting for alveolar cleft repair. For the objective evaluation, we measured the angle of alar base ptosis in frontal view photographs taken at the age of 6 or 7 years in patients who underwent repair before 1999 (Group A) and after 2005 (Group B). The median angle was 2.75° in Group A and 1.50° in Group B, demonstrating a significant difference (P=0.04). The current surgical method, which reflects our focus on improving alar base ptosis and forming the nostril sill, subjectively and objectively improved the external nasal morphology.

D65. Optimizing the Design of Biodegradable 3D-printed Scaffolds for Tissue Engineering Nipples with Lasting Projection and Biosimilar Stiffness

PURPOSE: Creating the nipple is the last surgical step of breast reconstruction. However, autologous tissue techniques are limited due to scar contracture and significant loss of neo-nipple projection. Poly-4-Hydroxybutyrate (P4HB) is a biodegradable polymer with a long track record of clinical use as a surgical mesh and we have previously shown long-term maintenance of nipple projection using 3D-printed P4HB nipple scaffolds filled with processed cartilage in nude rats. Here we aim to modify the interior reticular structure of the 3D-printed P4HB cylindrical scaffold to better mimic the biomechanical properties of the native nipple while maintaining the nipple projection in an immunocompetent rodent model. METHODS: Nipple scaffolds were 3D-P4HB printed (diameter: 1.0cm, height: 1.0cm) with different internal 3D latticework of P4HB filaments (infill density: 20, 25 and 30%; filament diameter: 0.15 and 0.2mm). All the scaffolds were subcutaneously implanted in rats using a CV flap technique. P4HB scaffolds without the internal latticework and Cook Biodesign® Nipple Cylinder were implanted as controls. RESULTS: The projection of 3D-P4HB nipples were well maintained over 3 months (>90%, p>0.05) and nipple stiffness slowly declined as the polymer was gradually replaced by tissue. In contrast, the Cook Biodesign® nipple lost 25% and 50% projection at 1- and 3-month respectively (p<0.05). CONCLUSION: We have successfully engineered neo-nipples that maintain projection over time, while simultaneously allowing for tissue ingrowth that is biomechanically similar to that of native nipples. Long-term observation will be warranted to verify the translatability of this novel 3D-P4HB nipple scaffold.

Clinical Evaluation of MINISCAR Cream

Background: Scars are areas of fibrous tissue that replace normal skin tissue after injury. In Ayurveda several medicines claimed to be beneficial for removing, rather reducing the scar is available. Objective: This clinical study is aimed to evaluate the effects of MINISCAR cream manufactured by Charak Pharma Pvt. Ltd. on skin scars. Method: 60 patients both male female between 18-50 years suffering from scar markings were included in trial. All patients were advised to apply MINISCAR cream once in a day for 30 days. Analysis was done on the basis of pre and post study photograph of the affected area taken along with the date and patient name. Results: There were 44 females and 16 male patients. In 24 patients of acne scar, 54% patients showed significant improvement. In 20 patients of stretch marks, almost 50% patients showed significant improvement. In 6 patients of hypertrophic scars, 66% patients showed significant improvement. While no significant improvement was observed in 2 patients of contracture scar and 8 patients of Keloid scar. Conclusion: Overall with MINISCAR cream almost 45% patient improved exceptionally well, which is certainly a very good outcome. A detailed clinical trial needs to be conducted further to verify the outcomes of the trial.

Prophylactic use of steroids for a mucosal defect with a circumference of less than three-fourths prevents both symptomatic and asymptomatic stricture after esophageal endoscopic submucosal dissection.

Subclinical stricture after esophageal endoscopic submucosal dissection (ESD) makes the detection and re-ESD of metachronous lesions difficult. This study aimed to investigate the effectiveness of prophylactic steroid use after esophageal ESD for mucosal defects with a circumference less than 75% for the prevention of symptomatic and asymptomatic stricture. In 80 retrospectively enrolled patients, we collected paired endoscopic images of a mucosal defects immediately after resection and a scar thereafter. After calculating circumference by image analysis software, all patients were classified into three groups in reference to mucosal defect circumference (MDC; ≤ 50%, 50-75%, ≥ 75%). Frequency of steroid use and symptomatic stricture were compared, and in < 75% MDC patients, a degree of asymptomatic stricture with or without steroid was compared by calculating a scar contraction rate (SCR). In the ≤ 50% (43 patients), 50-75% (27 patients) and ≥ 75% (10 patients) MDC groups, steroids were used in 12%, 59% and 100%, respectively, and symptomatic stricture occurred in 0%, 7% and 40%, respectively. In < 75% MDC patients, SCR in the steroid cohort was significantly lower than that in the nonsteroid cohort (42% vs. 65%, p = 0.002). No steroid-related adverse events occurred. Steroid use even for mucosal defects with < 75% circumference appears effective for the reduction of the risk on both symptomatic and asymptomatic stricture after esophageal ESD.

Congress Report on the Second World Congress of Global Scar Society with Scar Academy and Japan Scar Workshop

Pathological scars (including keloids, hypertrophic scars, and scar contractures) are present with high severity among certain populations, particularly in Asians and Africans who are highly prone to develop scars. Understanding the patho-mechanism that underlies scarring, such as mechanosignaling, systemic, and genetic factors, as well as optimal surgical techniques and integrated noninvasive therapeutic methods can guide clinicians to develop treatment protocols that can overcome these issues. This report summarizes a congress at Pacifico Yokohama (Conference Center) on December 19, 2021 involving researchers and clinicians from diverse disciplines who convened to discuss current clinical, preclinical, and most recent research advances in understanding pathological scarring, keloid and hypertrophic scar management, and research progress in wound healing. Presenters described the advances in scar therapies, understanding scarring mechanisms, and scar prevention and assessments tools. Moreover, presenters addressed the challenges during the COVID-19 pandemic and using telemedicine in management of scar patients.

Hybrid Palatoplasty: A Simplified DOZ (Double Opposing Z Plasty) with Palatal Myoplasty for Primary Palate Repair.

Introduction Surgical techniques for soft palate repair aiming for zero velopharyngeal insufficiency (VPI) are still not achieved. Straight line closure of the soft palate by various techniques of intravelar veloplasty (IVVP) leads to higher incidence of VPI due to scar contracture. Furlow's Z plasty has long, narrow, thin mucosal flaps and mucomuscular flaps with malaligned muscle closure. We present a technique of "hybrid palatoplasty" which borrows from and adds to the existing methods, is robust, is easy to replicate, and results in normal speech consistently. Aim (1) To design a technique of "hybrid palatoplasty"-combining double opposing Z (DOZ) plasty and IVVP, which is applicable to all types of cleft palate. (2) To evaluate the results of cleft palate children operated using the technique of "hybrid palatoplasty" from 2014 to 2015 in terms of surgical complications (fistulae and dehiscence) and incidence of VPI. Methods Our procedure combines aspects of both DOZ and IVVP. It is simplified with design of smaller Z plasties. On one side, from the oral Z plasty muscle is dissected off and sutured to the nasal mucomuscular flap of the opposite side to complete the palatal sling. Oral Z plasty is purely mucosal and reverse of the nasal side. A total of 123 cases, operated below 5 years of age were followed up. Speech was assessed by direct evaluation and tele-evaluation. Results A total of 123 cases, below 5 years of age, were operated between 2014 and 2016 with at least 5 years of follow-up. Note that 120 had normal speech, and 3 had VPI of which 2 were subsequently corrected and went on to develop normal speech. Conclusion This novel "hybrid palatoplasty" is a simple technique with good speech outcome as it combines the principles of Z plasty and direct muscle repair with palatal sling formation.