Split-thickness Autograft Research Articles

134 Early Split-Thickness Autografting over a Collagen-Elastin Dermal Matrix Aids in Vascularization and Decreased Contraction

134 Early Split-Thickness Autografting over a Collagen-Elastin Dermal Matrix Aids in Vascularization and Decreased Contraction

802 Increase in Surgical Burn Management During the COVID-19 Pandemic

Abstract Introduction The COVID-19 pandemic has had a profound impact on healthcare systems worldwide. This study explores the consequences of the pandemic on pediatric burn management, specifically focusing on whether the pandemic contributed to a surge in the volume of pediatric burns requiring surgical interventions. Methods All surgical cases that had a post-operative ICD-10 diagnosis of a burn was collected from the National Surgical Quality Improvement Program Pediatric database. Patient demographics, procedure codes, and postoperative complications was collected. Results From 2018 to 2021, there was a total of 872 pediatric burns that required surgical intervention. The median age of the patients was 5.4 years. There was an 8.7% increase in volume of these cases from 2019 to 2020. The overall rate of complications was 8.4%. The predominant surgical approach employed in the majority of cases was the utilization of split-thickness autograft. Conclusions There was an increase in pediatric surgical burn treatment volume during the COVID-19 pandemic. Further investigation into the underlying causes and implications of this surge is warranted. Applicability of Research to Practice This analysis provides more information on the incidence of pediatric burns managed by surgical treatment and how it was affected by the COVID-19 pandemic.

Cryoprecipitate and platelets-rich-plasma as a combined assisted therapy for burns: A promoted case series for future trials

IntroductionIn this paper, we present the first application of split-thickness skin autografts soaked in a combination of platelet-rich plasma (PRP) and cryoprecipitate for four cases of second and third-degree burns. Case presentationWe describe four cases of second and third-degree burns in males aged 35, 10, 24, and 5 years, respectively. The total body surface area (TBSA) affected in these cases ranged from 10 % to 35 %. The burn areas included the entire upper and lower back, the lower limbs, and the head, with involvement of the outer table of the calvarium according to Harrison's classification. To expedite wound healing, we applied split-thickness autografts soaked in a mixture of cryoprecipitate and PRP. Additionally, we covered the grafts with dressings soaked in the same mixture, resulting in successful graft acceptance and improved burn healing. DiscussionSkin wound healing involves increased angiogenesis, re-epithelialization, and modulation of inflammation. PRP has been shown to enhance re-epithelialization, a crucial process in skin wound healing. However, there is a lack of studies on the role of cryoprecipitate in re-epithelialization. Therefore, we propose the use of autologous skin grafts soaked in a combination of cryoprecipitate and PRP to expedite healing. ConclusionThis case series demonstrates that the use of split-thickness autografts soaked in a mixture of cryoprecipitate and PRP significantly improves and accelerates burn healing while contributing to acceptable graft outcomes.

Effectiveness of Autologous Platelet-Rich Plasma and Stromal Vascular Fraction in Autologous Skin Grafting

Introduction: Despite the medical advances, burns remain a serious challenge and require new and promising treatment options, such as biomedical technologies with a high potential for burn wound treatment. However, high cost and complexity of biotechnologies limit their routine use, but autologous tissues, such as stromal vascular fraction (SVF) and autologous platelet-rich plasma (PRP), overcome these shortcomings. Objective: To demonstrate a successful case of using a combination of adipose-derived SVF and autologous PRP during autologous skin grafting in a severely burned patient. Material and methods: We present a successful case of 84-year-old Patient B. treated at Saint Petersburg I. I. Dzhanelidze Research Institute of Emergency Medicine in September-October 2022. He was diagnosed with a 11% (6%) / II-III degree flame burn of the head, neck, trunk, and upper extremities and first-degree inhalation injury. At the first stage, the general condition of the patient was stabilized, and he was prepared for surgery. At the second stage, on day 25 of treatment we performed skin grafting using split-thickness autografts with rare perforations and application of SVF and autologous PRP on a burn wound. We evaluated the treatment effectiveness using planimetry, cytology, and histology. Results: We observed complete engraftment of the autograft with no lysis or rejection during the first dressing change on day 3 after surgery and complete skin restoration on day 11. Cytologic findings over time showed an active decrease in inflammatory cells and an increase in regenerative cells, indicating successful wound healing. Histology demonstrated formation of normal stratified squamous epithelium with areas of hyperkeratosis and young granulation tissue in the superficial layers of the dermis on day 6. Conclusions: Our case demonstrated that the combination of SVF and autologous PRP facilitates split-thickness skin autograft engraftment.

770 Outcome Results of the Prospective CEA Registry

Abstract Introduction Cultured epidermal autograft (CEA) is a permanent skin replacement indicated for use in adult and pediatric patients with deep dermal or full thickness burns comprising a total body surface area (TBSA) ≥ 30%. CEA may be used in conjunction with split-thickness autografts or alone, in patients for whom split-thickness autografts may not be an option due to the severity and extent of their burns. CEA was approved for use in adults in the United States in 2007 as a Humanitarian Use Device (HUD) under a Humanitarian Device Exemption (HDE) and was approved for pediatric use in 2016. Methods The objective of the CEA Registry is to allow prospective collection and analysis of demographic, treatment, and outcome data for the real-world use of CEA. Prior to initiation of the Registry, a central Institutional Review Board reviewed and approved written procedures and informed consent from each participating burn center. As of the date of this analysis, 5 centers were enrolling patients in the Registry. The data are collected and stored in a 21 Code of Federal Regulations (CFR) Part 11 and Health Insurance Portability and Accountability Act (HIPAA) compliant environment. First patient enrollment in the Registry was 13 June 2019 and data cutoff for this analysis was 28 July 2022. Results Sixtyeight patients (50 adults and 18 children) had completed data in the registry, up through hospital discharge, for this analysis. Except for age and revised Baux score, demographics and burn characteristics were similar between the adult and pediatric populations. The majority of patients were male in both the adult (76%) and pediatric (67%) groups, with burn caused by flame the most common etiology (86% and 78%, respectively). The total body surface area (TBSA) of burn was 58% in adults and 56% in pediatric patients (range 30% to 96%), and almost half had inhalation injury in each group. Approximately 74% of adults and 67% of pediatric patients had TBSA ≥50%. Median age in the adult group was 42 years, and in the pediatric group was 15 years. Since age is a component of the calculation of Baux score, pediatric patients had lower mean revised Baux scores (75) compared to adults (107.5). Overall, 59 of the 68 patients (87%) survived until hospital discharge. The mean % graft take (engraftment) in both adult (81%) and pediatric (84%) groups is notable when compared to mean final graft take in 453 Epiceltreated patients reported in the HDE database (67% in adults and 70% in pediatric). By age group, adults had 84% survival rate and pediatric patients had 94% survival. Conclusions Outcomes from this prospective collection of data in severely burned patients treated with CEA demonstrate favorable engraftment and survival rates and are in general agreement with recent literature. Applicability of Research to Practice Reported outcomes from the CEA Registry can be used as a benchmark by centers using CEA for treatment of burns.

Live Skin Allograft for Coverage of Deep and Extensive Burns: First Experience in Morocco

The gold standard for closure of excised full-thickness burns is split-thickness skin autograft. Patients with very large burns have limited donor sites for harvesting of autograft and may benefit from the use of skin Allografts. Taken from cadaveric or human skin as part of tissue donation. Allograft skin has been widely used for wound management in burn centers. Functional as biologic dressing, it can not only provide ideal temporary wound coverage in extensive burns when autograft is not immediately available but also prepare the wound bed for definitive autografting. In this study, we present the results of the use of allograft from living donors in three children, the use of this live skin allograft has permitted to keep the children’s alive in a balanced physiologic state until autologous skin graft or spontaneous healing closed all wounds. The procedure of live skin allograft is simple and replicable, and can be applied in settings where no skin bank is available in the management of deep burns.

601 Bromelain Based Enzymatic Debridement Followed by Application of Autologous Cell Suspension for Treatment of Burns

IntroductionBromelain based enzymatic debridement has been shown to have a unique selectivity for nonviable tissue and is being evaluated for its use in the treatment of select burn wounds. The treatment has potential to augment more traditional operative eschar excision. Herein, we retrospectively review our tertiary burn center’s early experiences in cases in which bromelain based enzymatic debridement (BBED) is paired with autologous cell suspension (ACS).MethodsPatients whose burn wounds were deemed eligible for BBED at our institution from July 2020 to June 2021 were queried for concurrent treatment with ACS. Inclusion criteria by study design consisted of 18 years of age or older, non-electrical and non-chemical burns, predominance of deep partial and/or full thickness burn, and less than 30% total body surface area. Success of escharotomy by BBED, grafting methods, infections, transfusions, inflammatory response, and response to grafting were analyzed.ResultsSeven patients met inclusions criteria from July 2020 to June 2021. The mean age was 44 (IQR: 39-53). The mean TBSA was 13.7% (IQR 8-20). The mean time from injury to BBED was 2.1 days (IQR 1.5-2.0). The mean time to ACS after BBED was 1.3 days (IQR 1.0-1.5). The mean area debrided with BBED was 2347 sq cm (IQR 1367-3534). All patients were determined to have complete eschar removal on the day of application by the multidisciplinary burn team. All seven cases had deep partial thickness areas treated with ACS alone, with a mean area of 1574sq cm (IQR 877-2327). The total area treated was 11,016 sq cm. Only two patients required delayed grafting, a combined total of 1573 sq cm, meaning that 86% of the total burn area treated with ACS alone was recovered. Five patients had ACS paired with split thickness autografts, with a mean area of 867 sq cm (IQR 519-1328). Graft imbibition was noted to be rapid with >95% wound closure by postoperative day eight. There were no graft infections, and no transfusions required. White blood cell (WBC) counts decreased after BBED, then increased marginally after grafting. Only two patients had WBC >20,000 and this aided in diagnosis of one donor site infection and one pneumonia.ConclusionsIn our series, BBED within three days of injury paired with ACS within two days of BBED resulted in excellent split thickness graft take and recovery of 86% of the burn wounds treated with ACS alone.

725 Case Series: New Porcine Placental ECM for Burn Injuries

IntroductionHuman amniotic membrane (HAM) has been used as a biologic dressing for burn wounds since 1955 but limited due to availability, size, and processing costs. In 2021 a new porcine placental product was FDA-approved overcoming challenges with human-sourced products. Our study is the first case series to report outcomes using porcine placental extracellular matrix (PPECM) in the use of adult burn patients.MethodsAdults with thermal burns resulting in partial-thickness burn wounds (PTBW) were consented and included in the study from 03/2021 to 09/2021. Patients with full-thickness injures, concomitant trauma, or adverse beliefs to porcine products were not included in the study. Serial still images and initial wound measurements were obtained intraoperatively and post-operatively. PPECM trial product processed with a proprietary decellularization method to produce single sheets up to 15x20cm was approved by the facility value assessment committee. Adverse events were defined a priori as infection, increased pain or itching relative to adjacent autografts, or failure to heal. Infection was defined as a PPECM treatment site requiring any change from standard of care or initiation of local or systemic antibiotics. Pain was assessed using a visual analogue scale. Itching was assessed at discharge and follow-up. Healing was assessed using the FDA guidance for wound closure with 2 consecutive visits 2 weeks apart demonstrating 100% epithelialization without drainage or dressing requirements.ResultsFour patients were treated during the study period with wounds involving the torso and major joints such as the hands/wrists and knees. None of the PPECM wounds demonstrated failure to heal or required revision excision, or autograft. None of the PPECM wounds had evidence of infection. PPECM wounds had decreased pain/itching relative to adjacent burn wounds which were treated with split-thickness autograft, autologous skin cell suspension, or allogeneic cultured skin substitute (VAS mean 1 vs 3.1). Healing was noted in all wounds at 1-week primary dressing removal with confirmation at 2-week interval follow-up.ConclusionsPPECM treatment of PTBW was not associated with adverse events and resulted in favorable outcomes clinically. The large size, ease of use, and lower costs relative to HAM is an intriguing alternative for PTBW. Comparative studies are needed in the field to determine best practices and overall value.

799 Autologous Skin Cell Suspension Versus Standard Split Thickness Autografting: a Comparison of Operative Efficiency

IntroductionThe surgical standard of care (SOC) for deep burns is autologous grafting, which is currently challenged by an innovative technology, autologous skin cell suspension (ASCS). Sprayed epidermal autografting provides comparable results to SOC while reducing donor graft size and morbidity, making it ideal for patients with large total body surface area (TBSA).1-3 The purpose of this study is to report and compare the size of burn wound coverage per operative minute for ASCS versus standard split thickness autografting (STSG). The authors hypothesize that ASCS covers large burn wounds more efficiently than STSG.MethodsThis study is a case-control analysis of all adult (age ≥18) surgical encounters for ASCS versus matched SOC STSG encounters at a single burn center. Patient demographics, burn characteristics, and surgical details were collected from the electronic medical record. Patients were matched with prioritization of treated size and anatomic area, followed by burn etiology, age, and sex.ResultsEleven ASCS surgeries were performed on 7 patients and matched to 11 STSG surgeries in 8 patients. The ASCS and STSG groups were not significantly different regarding age (46.6 vs 41.5), BMI (28.3 vs 26.4), and co-morbidities (57.1% vs 50.0%), respectively. Most burns resulted from flame injury (85.5% ASCS vs 87.5% STSG). Time to re-keratinization of the burn wound (20.4 vs 19.0 post-operative days; ASCS, STSG) and subjective analysis of graft adherence was comparable between matched groups.Treated burn wounds were located on the lower extremity (63.6% vs 62.5%), upper extremity (27.3% vs 50%), and trunk (18.2% vs 25.0%) in ASCS and STSG encounters, respectively. The average graft thickness harvested was thicker for ASCS surgeries than STSG (0.0061″ vs 0.0054″, p= 0.040). The average burn wound size and operative duration was 2612.2 cm2 in 108.4 minutes for ASCS and 1903.7 cm2 in 92.1 minutes for STSG. As a result, ASCS covered 24.1 cm2 in comparison to STSG coverage of 20.7 cm2 per operative minute.ConclusionsThe matched groups were not significantly different, and surgical encounters are acceptable for comparison. However, ASCS grafts were harvested thicker than STSG (0.0061″ vs 0.0054″, p= 0.040), which is unlikely to have any clinical implications as both are considered ultra-thin (< 0.008″).5ASCS treats a larger wound size per operative minute than matched STSG controls. Our results are likely restricted to large burn wounds and may not translate to smaller treatment areas. The increased operative productivity with ASCS assists in reduction of the technology unit cost. In conclusion, selective use of ASCS for large burn wounds can partially offset the unit cost through increased operative efficiency, lessen donor site morbidity, and produce similar results as standard split thickness autografting.

608 Utilization of Phase-Based Guidelines For Patient Care After Application of Cultured Epithelial Autograft

IntroductionCultured epithelial autografts (CEA) have been clinically utilized since 1981 & can be a lifesaving procedure in patients with extensive full thickness burns. CEA is more susceptible to bacterial contamination & complete graft loss than traditional split-thickness autografts, yet no standard of practice exists for the postoperative care of these grafts to minimize infection & maximize graft take.Prior to 2019, care of CEA patients at our institution was not standardized & instead varied upon the attending surgeon’s practice. With the input of interdisciplinary team members, CEA patient care was standardized via phase-based guidelines (PBGs), leading to improved team communication & improved patient outcomes.MethodsPBGs were created via interdisciplinary collaboration among surgeons, APCs, nursing staff, PT/OT, & psychosocial providers. Team members agreed upon 3 facets of patient care: Wound Care/Airing Out, Restrictions/Visitors, & Burn Therapy (Figure 1). As wounds progressed postoperatively, patient phases were advanced, liberalizing them from rigorous infection-prevention techniques to strict unit standards for non-CEA burn patients.In 2019, the utilization of patient-specific CEA care plans ceased in favor of standardized PBGs. A retrospective chart review was conducted on all patients from 2018-2021 who received CEA & survived their injuries. Some patients underwent a single CEA application while others underwent multiple operations. CEA graft take was assessed on all wounds from each surgery.ResultsCEA was rarely used at our institution. Beginning in 2018, seven patients received CEA & survived their injuries, ranging in age from 4-59 yrs (mean 24) & %TBSA from 38-80 (mean 53) (Table 1). Implementation of PBGs correlated with subjective improvement in team communication & increased mean percentages of CEA graft take from < 35% to >75%.ConclusionsPBGs have standardized care for our CEA patients, eliminated communication errors among team members, & increased CEA graft take. Further research is needed to determine efficacy in decreasing infection, antibiotic use, hospital stay length, & mortality in these patients.

Pavement Burns in New Mexico: Our Experiences, Treatments, and Outcomes.

This study focused on patients treated at the University of New Mexico Burn Center who sustained burn injuries from contact with environmentally heated pavement. We report on our patient demographics and outcomes as well as describe our institutional staged surgical approach to treatment. We provide a comparison of our results with other case reports as well as other findings. A retrospective review of patients admitted to the University of New Mexico Burn Center with injuries suffered from contact with hot pavement was performed. Patients were stratified on the presence or absence of altered mental status (AMS) and additional inciting factors. A total of six patients were reviewed from 2018 to 2019. We looked at patient demographics and comorbidities, time of contact with hot pavement, inciting factors, total body surface area (TBSA) burned, location of areas burned, depth of burn injury at the time of presentation and at the time of initial operative debridement, percentage of autograft take, complications, length of stay (LOS), and final disposition. The patients in our study had a mean TBSA of 9.82% corresponding to pressure points of the body. All patients had nearly 100% conversion to full-thickness burns at the time of initial operative debridement. With staged excision and split-thickness autografting, our patients had nearly 100% take of their skin grafts with minimal graft loss or related complications. At the time of presentation, 100% of patients had AMS and 66% (4/6) had a drug- or alcohol-related inciting event. Finally, the average LOS was 19.5 days in comparison to 7 to 9 days for uncomplicated burns of equivalent size at our burn center. Despite an initial appearance of a partial-thickness burn, pavement burns had a high propensity to convert to full-thickness burns. Patients with AMS contributed to our patient population being found with pavement burns. Patients with pavement burns had a distinct anatomic pattern corresponding to pressure points of the body which were often areas at high risk for skin and wound breakdown and complications. Staged excision and split-thickness autografting in the treatment of pavement burns yielded excellent results. Finally, our data showed that providers must be prepared for an extended LOS for patients with pavement burns.

Outcomes for Hand Burns Treated With Autologous Skin Cell Suspension in 20% TBSA and Smaller Injuries.

In order to address the confounder of TBSA on burn outcomes, we sought to analyze our experience with the use of autologous skin cell suspensions (ASCS) in a cohort of subjects with hand burns whose TBSA totaled 20% or less. We hypothesized that the use of ASCS in conjunction with 2:1 meshed autograft for the treatment of hand burn injuries would provide comparable outcomes to hand burns treated with sheet or minimally meshed autograft alone. A retrospective review was conducted for all deep partial and full-thickness hand burns treated with split-thickness autograft (STAG) at our urban verified burn center between April 2018 and September 2020. The exclusion criterion was a TBSA greater than 20%. The cohorts were those subjects treated with ASCS in combination with STAG (ASCS(+)) vs those treated with STAG alone (ASCS(-)). All ASCS(+) subjects were treated with 2:1 meshed STAG and ASCS overspray while all ASCS(-) subjects had 1:1, piecrust, or unmeshed sheet graft alone. Outcomes measured included demographics, time to wound closure, proportion returning to work (RTW), and length of time to RTW. Mann-Whitney U test was used for comparisons of continuous variables and Fisher's exact test for categorical variables. Values are reported as medians and 25th and 75th interquartile ranges. Fifty-one subjects fit the study criteria (ASCS(+) n = 31, ASCS(-) n = 20). The ASCS(+) group was significantly older than the ASCS(-) cohort (44 [32-54] vs 32 years [27.5-37], P = .009) with larger %TBSA burns (15% [9.5-17] vs 2% [1-4], P < .0001) and larger size hand burns (190 [120-349.5] vs 126 cm2 [73.5-182], P = .015). Comparable results were seen between ASCS(+) and ASCS(-), respectively, for time to wound closure (9 [7-13] vs 11.5 days [6.75-14], P = .63), proportion RTW (61% vs 70%, P = .56), and days for RTW among those returning (35 [28.5-57] vs 33 [20.25-59], P = .52). The ASCS(+) group had two graft infections with no reoperations, while ASCS(-) had one infection with one reoperation. No subjects in either group had a dermal substitute placed. Despite being significantly older, having larger hand wounds, and larger overall wounds within the parameters of the study criteria, patients with 20% TBSA burns or smaller whose hand burns were treated with 2:1 mesh and ASCS overspray had comparable time to wound closure, proportion of RTW, and time to return to work as subjects treated with 1:1 or piecrust meshed STAG. Our group plans to follow this work with scar assessments for a more granular picture of pliability and reconstructive needs.

35 Outcomes for Hand Burns Treated with Autologous Skin Cell Suspension in 20% TBSA and Smaller Injuries

Abstract Introduction Our group has previously reported our experience with autologous skin cell suspension (ASCS) in the treatment of all subjects with hand burns regardless of the total body surface area (TBSA) involved. In order to better address the confounder of TBSA on burn outcomes, we sought to analyze our experience in a cohort of subjects whose TBSA totaled 20% or less. We hypothesized that the use of ASCS in conjunction with a 2:1 meshed autograft would provide comparable outcomes to hand burns treated with smaller meshed autograft alone. Methods A retrospective review was conducted for deep 2nd and 3rd degree hand burns treated with split thickness autograft (STAG) at our urban verified burn center between April 2018 to September 2020. Exclusion criterion was a TBSA greater than 20%. The cohorts were those subjects treated with ASCS in combination with STAG (ASCS(+)) versus those treated with STAG alone (ASCS(-)). All ASCS(+) subjects were treated with 2:1 meshed STAG and ASCS overspray while all ASCS(-) subjects had 1:1 or piecrust mesh only. Outcomes included demographics, proportion returning to work (RTW), length of time for RTW, and time to wound closure. Mann-Whitney U test was used for comparisons of continuous variables, and Fishers Exact test for categorical variables. Values are reported as median and interquartile range. Results Fifty-one subjects fit the study criteria (ASCS(+) n=31, ASCS(-) n=20). The ASCS(+) group was significantly older than the ASCS(-) cohort (44 yrs. [32, 54] vs 32 [27.5, 37], p=0.009) with larger %TBSA burns (15% [9.5, 17] vs 2% [1, 4], p &amp;lt; 0.0001), and larger size hand burns (190 cm2 [120, 349.5] vs 126 cm2 [73.5, 182], p=0.015). Comparable results were seen between ASCS(+) and ASCS(-), respectively, for time to wound closure (9 days [7, 13] vs 11.5 [6.75, 14], p=0.63), proportion RTW (61% vs 70%, p=0.56), and days for RTW among those returning (35 [28.5, 57] vs 33 [20.25, 59], p=0.52). The ASCS(+) group had two graft infections with no reoperations, while ASCS(-) had one infection with one reoperation. No subjects in either group had a dermal substitute placed. Conclusions Despite being significantly older, having larger hand wounds, and larger overall wounds within the parameters of the study criteria, patients with 20% TBSA burns or smaller whose hand burns were treated with 2:1 mesh and ASCS overspray had comparable time to wound closure and return to work as subjects treated with 1:1 or pie-crust meshed STAG. Our group plans to follow this work with scar assessments for a more granular picture of pliability and reconstructive needs.

34 Rete Ridges are Decreased in Dyschromic Burn Hypertrophic Scar: A Histological Study

Abstract Introduction Dyschromic hypertrophic scar (HTS) with areas of hyper- and hypo-pigmentation is a common sequelae of burn injury. The mechanism behind the development of dyschromia has not been elucidated. In this study, we provide a histological analysis of these scars with a focus on rete ridge presence. Rete ridges occur in epithelial tissues such as oral mucosa and skin and can be described as undulating “pegs” that are interdigitated with dermal papillae. Rete ridges enhance adhesion of the epidermis to the dermis. We hypothesize that rete ridge presence is important for normal skin physiology, and their absence or presence may hold mechanistic significance in post-burn HTS dyschromia. Methods Subjects with post-burn dyschromic HTS were consented and enrolled (n=27). Punch biopsies of hyper-, hypo-, and normally pigmented scar and skin were collected and stored in formalin. Biopsies were paraffin embedded, sectioned, stained with H&amp;E, and imaged. The number of rete ridges were investigated by calculating a rete ridge ratio from the length of the basement membrane and the length of the epidermis. Results The patient population was predominantly female (55.5%), black (70.4%), and had Fitzpatrick skin Type V (51.9%). The injuries were primarily as a result of flame (37%) and scald (33.3%) and resulted in a median TBSA burn of 7%. The median age of the scar at the time of sample acquisition was 12.2 months. The rete ridge ratio of normally pigmented, un-injured skin was above 1 (1.31 ± 0.04), indicating that normal skin’s basement membrane is longer than its epidermal length due to the presence of rete ridges. HTSs resulting from burn wounds that healed without split thickness autografts were first investigated. The number of rete ridges was higher in normal skin compared to HTS that was either hypo- or hyperpigmented (1.31 ± 0.04 vs. 1.13 ± 0.05 and 1.14 ± 0.04 vs, p&amp;lt; 0.05). This difference was similar despite pigmentation phenotype. When hyper-pigmented scars resulting from wounds that were treated with split thickness autografts (Hyper(+)) were investigated, rete ridge number was significantly higher than in Hyper(-) (1.89 ± 0.23, p&amp;lt; 0.01). Patient age showed a weak correlation (R=-0.33) with rete ridge ratio where older patients had lower rete ridge ratios in normal, un-injured skin. Hyper(+) showed a weak correlation between rete ridge ratio and age of scar (R=-0.38). Conclusions Post-burn HTS that is dyschromic has fewer rete ridges than normal skin. This finding may explain the decreased epidermal barrier function that is associated with HTS.

657 Bilayer Dermal Substitute in Management of Deep Hand Burns

Abstract Introduction Bilayer dermal substitutes, composed of bovine collagen cross-linked with glycosaminoglycan and silicone, have become increasingly integrated into the algorithm for management of complex burns. In complex hand burns, dermal substitutes improve functional and aesthetic outcomes while also allowing early excision in high percentage TBSA burns. We detail the outcomes of 17 patients with 25 cases of complex hand burns managed at our center using a staged procedure of cadaveric allografting followed by dermal substitute placement and early definitive STSG. Methods Between Jan 2018 and Aug 2019, all patients who sustained deep partial/full thickness burns to their hands managed with dermal substitution were identified. Patients less than 18 yo, with additional non-burn trauma to the hands, and with initial operative management at another center prior to transfer were excluded. A retrospective chart review was used to collect data regarding time to operative excision, placement of allografts and substitutes, definitive STSG, and functional outcome. Results 17 patients from 18 and 89 yo presented with 25 deep partial/full thickness hand burns. TBSA varied from 0.75 to 78% (mean 17.7%). On average, patients underwent first excision 5.3 (2–16) days after initial burn or 4.2 days after presentation. Our protocol often uses allografting prior to placement of the dermal substitute, therefore, 22 of 25 burned hands received cadaver allografts at initial excision. Dermal substitute was placed an average of 9.2 days later. 3 of 25 burns had immediate application of dermal substitute at first excision. Following substitute, non-meshed, split-thickness autografts were placed on 18 hands. 5 of the burns did not require STSG and two hands were not further evaluated due to loss of patient follow-up. Of the 25 cases, all had near complete incorporation of the substitute without need for revision. In follow-up, patients who did not require STSG have shown no major limitations in ROM/scarring. Of those who underwent STSG, 6 hands underwent contracture release, with 2 of these progressing to amputation. One hand required repeat autografting due to graft loss. All remaining 18 hands healed well with near complete graft take and minimal scarring or functional limitation. Conclusions Dermal substitutes assist in the closure of complex deep hand burns. Cadaveric allografting prior to placement of the substitute ensures an appropriately excised wound base, allowing for near complete integration without need for reapplication. Autografting following dermal substitution placement may be initiated earlier than previously pursued and occasionally allows for healing without STSG.

560 Vacuum Assisted Dressing can be Used as an Effective Dressing Over Non-cultured, Autologous Skin Cell Suspension (ASCS) Combined with Wide Meshed Split Thickness Autografts (mSTSG)

Abstract Introduction There are accounts of various dressings being applied over epidermal spray cell suspension graft(s) (SCSG) with varying success and no one perfect dressing. We present 3 patients with ASCS grafts used in combination with mSTSG that were treated with vacuum assisted dressing with excellent outcomes. Methods All 3 of our patients received surgical debridement, down to healthy viable tissue with exposed tendon. BTM Dermal matrix was used in 2 of the 3 patients with exposed tendon. All three patients had mSTSG with ACSS autografts. All grafts were covered with telfa ™ clear, followed by tacky macroporous silver dressing, then a vacuum assisted closure device. These were left undisturbed until post operative day (POD) 5. Results All patients had their dressings taken down on POD #5 with excellent results. The interstices were closed quickly with no negative outcome noted from the vacuum dressings. All patients had excellent wound closure and good function postoperatively. Conclusions Vacuum assisted closure devices can be used to cover ASCS and wide meshed grafts with good outcomes. They provide patients with a stable dressing that does not need to be changed and leads to excellent graft take and wound closure.

618 Clinical and Humanistic Burdens of Pediatric Burns: A Systematic Literature Review

Abstract Introduction Children face long-term clinical and psychological sequelae from burn injuries. This review summarizes the scientific literature on the clinical and humanistic burdens of pediatric burns. Methods A systematic review of literature published between Jan 2015 and Jun 2020 was conducted based on PRISMA guidelines in Embase, Biosis, and MEDLINE to identify publications examining the clinical, humanistic, economic, and/or epidemiologic burdens of illness associated with pediatric burns in the US. Results Of 2,286 unique articles identified, 28 met eligibility criteria. This analysis focused on studies relating to the clinical (n=8) and humanistic (n=9) burdens of pediatric burns. Across all studies, flame and scald were the most common burn etiologies. Among the 8 clinical studies, several evaluated outcomes (n=2) or treatments (n=3) in predominantly graft recipients. One study found that 64% of pediatric split-thickness autograft recipients exhibited hypertrophic scarring (HTS) at the donor site. Other variables (time to re-epithelialization, donor-site harvest depth, harvest in an acute burn care setting, thigh donor-site location) were associated with increased risk of HTS. An increase in percentage total body surface area (%TBSA) burned corresponded to increased number of autograft procedures, risk for HTS, and viral infection risk. Other reported outcomes included infections (eg, healthcare-associated, wound, viral), pain, inhalation injury, and sepsis. One study found that while the frequency and intensity of pruritis decreased over time, 63% of children continued to report symptoms at 2 years after injury. Among the 9 humanistic studies, 4 reported larger %TBSA corresponded to worse health-related quality of life assessed by various instruments. In a study of patients under age 5 with burns, Burns Outcomes Questionnaire (0–4) scores improved over time in multiple domains. In youth with a history of burn injuries, patient-reported pain interference with daily living was significantly associated with decreased physical functioning, depression, and impaired peer relationships. Two studies assessed caregiver burden, with one study finding that 19% of caregivers self-reported clinical or at-risk levels of distress following the child’s burn injury. Conclusions Pediatric burns place a substantial clinical and humanistic burden on patients and their caregivers. While outcomes appeared to improve over time, clinical and humanistic consequences of pediatric burns endured. More research on novel treatment products and procedures is needed to reduce the burden of burns for this population.

541 72 Facial Burns Treated with Autologous Skin Cell Suspension- A Real World Data Analysis Across 5 U.S. Burn Centers

Abstract Introduction Optimal management of facial burn injuries remains a significant challenge in burn care. Acute surgical intervention is often coupled with delayed reconstructive procedures as an essential option for burn care. Experience with new surgical technologies could challenge historic reconstructive ladders. Our goal was to pragmatically assess the rate of successful intervention with autologous skin cell suspension (ASCS) for the treatment of facial burn injuries from real-world data. Methods A retrospective review from five burn centers over a three-year period was performed from deidentified registry data for facial burn injuries initially treated with ASCS. Cases of non-acute thermal burn and burns not involving the face were excluded. Data collection included: date of surgery, last follow-up date, need for grafting (split or full thickness skin graft, STSG or FTSG, respectively) or reapplication of ASCS within the same hospitalization, and reconstruction not including laser procedures due to scarring during the follow-up period. Descriptive statistics were calculated and data are reported as median with interquartile ranges where appropriate. Results A total of 72 burn injuries were treated with ASCS for facial burn injuries. Two burn centers treated 4 patients each, one treated 18, and the remaining two treated 22 and 24 patients. The median follow-up was 199 days (range 9 -1,150 days). Acute failure requiring a second treatment with ASCS or application of a full-thickness or split-thickness autograft occurred in 12 (16%) of the patients with 5 undergoing re-application of ASCS and 7 undergoing FTSG or STSG. reconstruction secondary to scarring during the follow-up period occurred in 10 (14%) of patients. Reconstruction was required in 1 of 5 patients that underwent a second treatment with ASCS as opposed to 4 of 5 patients treated with FTSG or STSG. Conclusions This study represents the largest experience with the use of ASCS for the management of facial burn injury in the reported literature. Use of ASCS from real-world data indicated that ASCS successfully resulted in definitive wound closure in 90% of the patients treated with facial burn injuries, with 10% requiring secondary intervention. This failure rate is below the previously published rate of 33%, indicating the disruptive potential of this technology for the management of facial burn injuries.

Negative pressure wound therapy with instillation and dwell time in the wound management of necrotizing fasciitis

ObjectiveRecent literature has shown that negative pressure wound therapy with instillation and dwell time (NPWTi-d) is a valid method of managing complex wounds and gained increasingly wider interest due in part to the increasing complexity of wounds. The purpose of this case study was to obtain information on the profile of NPWTi-d in necrotizing fasciitis patients, investigate the role it play in wound bed preparation, length of hospital stay and number of debridement operations. MethodsNPWTi-d has been used in patients with necrotizing fasciitis with either normal saline or Prontosan® solution and complete the treatment were involved in the present study. Following aggressive surgical debridement, NPWTi-d was initiated by instilling solution with a set dwell time of 5–10 min, followed by continuous NPWT of −125 mm Hg for 3–5 h. The system was changed on a 3–5 days schedule until sufficient granulation tissue was evident. Patients received systemic antibiotics and underwent wound debridement as indicated. Data of wound bed preparation, length of hospital stay, duration of NPWTi-d therapy, number of surgical interventions were collected retrospectively from patient medical records. ResultsA total of 32 patients with diagnosis of necrotizing fasciitis received NPWTi-d were included. Granulation tissue was found to be sufficient in 9–16 days. The mean duration of NPWTi-d therapy was 12.5 days prior to wound closure by split-thickness autograft (n = 21), suture (n = 9), or flap transplantation (n = 2).Patients received NPWTi-d treatment over a period of 8–16 days. The mean length of hospitalization was 22.8 days. All wounds were successfully closed and no recurrence of infection or adverse event was observed during NPWTi-d treatment. ConclusionIn these patients, NPWTi-d facilitates wound cleansing and wound bed preparation and offers the clinician an additional tool for the management of necrotizing fasciitis. Further well designed prospective investigations with low risk of bias are needed to confirm these findings in the future work.

Cultured Epithelial Autograft Combined with Micropatterned Dermal Template Forms Rete Ridges In Vivo.

For patients with large, full-thickness burn wounds, sufficient donor sites for autografting are not available, and thus, alternate strategies must be used to close these wounds. Cultured epithelial autografts (CEAs) can aid in closing these wounds but are often associated with slow deposition of basement membrane proteins, leading to blistering and graft loss. Rete ridges and dermal papillae present at the dermal-epidermal junction (DEJ) play a key role in epidermal adhesion and skin homeostasis. Promoting the development of an interdigitated DEJ may enhance basement membrane protein deposition and provide enhanced physical interlock of the epidermis and dermis. To develop a dermal template with stable dermal papillae, an electrospun collagen scaffold was seeded with human dermal fibroblasts. Ridged topographies were patterned into the cell-seeded dermal template using laser ablation, creating wide and shallow (ActiveFX) or narrow and deep (DeepFX) wells. Micropatterned or flat (control) dermal templates were combined with CEAs immediately before grafting to full-thickness excisional wounds on immunodeficient mice. CEAs grafted in conjunction with ridged templates showed rete ridge formation at 2 weeks after grafting and led to increased epidermal thickness, proliferation, and stemness compared to templates with a flat DEJ. As this technology is further developed, the dermal papilla-containing dermal templates may be utilized in combination with CEAs to improve adhesion and clinical function. Impact statement Cultured epithelial autografts (CEAs) serve as an adjunct to conventional split-thickness autograft in patients with very large burns, but they are susceptible to blistering that can reduce engraftment. Blistering results, in part, from relatively slow basement membrane deposition after grafting. This study demonstrates that basement membrane deposition and rete ridge formation are enhanced by combination of CEAs with a micropatterned, cell-seeded dermal template. These findings may lead to improved treatment and increased survival in patients with very large burns.