- [Show abstract] [Hide abstract] ABSTRACT: Septal cartilage is deficient in Asians seeking augmentation rhinoplasty. Economized utilization of resources is necessary for durable tip enhancement that complements a dorsal implant. We introduce a modified tongue-in-groove method designed to transmit forces across the dorsum, eliminating the need for robust caudal support and prioritizing nasal lengthening and tip projection. We aim to promote the roundness index parameter and demonstrate the feasibility of a novel method in the context of Asian rhinoplasty. Between 2012 and 2014, a total of 104 Taiwanese patients underwent rhinoplasty with dorsal augmentation and lengthening with a modified tongue-in-groove technique. The concept borrows from methods established by Byrd, Guyuron, and Toriumi but distinguished by exaggerated forward positioning of a septal extension graft. Paired extended spreader grafts obviate the need for a columellar strut. Soft-tissue changes were analyzed with photogrammetry. A new parameter, the roundness index, was measured. Tip projection, dorsal length, nasal height, alar and columellar length increased significantly after 5.5 months of follow-up. Nasal tip angle, roundness, columella-labial angle, and nostril axis inclination decreased. There were no statistically significant differences in the magnitude of change in patients followed for less than and greater than 6 months. The most common complication was new or persistent tip deviation in five cases (5%). This technique was designed for a nasal anatomy typified by deficient septal cartilage. Significant photogrammetric changes were maintained after 6 months. Economized tissue allocation, dorsal septal load sharing, and relative independence from caudal support are key features of this feasible method. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.
- [Show abstract] [Hide abstract] ABSTRACT: Unlabelled: Occupational and chemical assault injuries were the two most common factors associated with chemical burns. These two types of injuries were identified and analyzed covering a 20-year period. Methods: Patients with second- to third-degree chemical burns admitted to the Linkou Burn Center, Chang Gung Memorial Hospital from May 1986 to May 2005 were included in the analysis. Injuries other than occupational and chemical assaults were excluded from this study. Results: A total of 46,283 burns were admitted during the study period while 327 patients were included in the study with 250 (77.5%) cases classified to occupational injury (OI) and 77 (23.5%) in the chemical assault (CA) group. The mean age in the OI group was 33.2 years and 36.2 years for the CA group. The mean burn size was 10.9% for the OI group and 14.1% in the CA group. The mean length of hospitalization was 15.8 days in the OI group and 32.3 days in the CA group. The main causative agents were acids, which accounted for 57.2% of injuries in the OI group and 98.7% in the CA group. Sulfuric acid was the primary acidic agent and the main alkali was sodium hydroxide. The face was the most frequently injured area (59.6%) followed by the extremities (upper limb [52.2%], lower limb [44.2%]). The hand injury rate was significantly higher in the OI group (P = 0.009). The injury rates to the face, neck, and chest (P < 0.05) were significantly higher in the CA group. Conclusion: Chemical assault burns might cause more damage and suffering than occupational burn injuries. The promotion of occupational injury protection, public empowerment, and public security in recent years has markedly decreased the occurrence and severity of occupational and chemical-related burns. Modern advances in burn care and surgical procedures contribute greatly to decreasing the length of hospital stays for patients who have sustained an occupational or chemical assault injury. .
- [Show abstract] [Hide abstract] ABSTRACT: Toxic epidermal necrolysis (TEN) is a life-threatening skin reaction associated with a high mortality rate. Most TEN is induced by drugs, but some cases are caused by other insults. Mycoplasma pneumoniae and herpes simplex virus are the most common infectious pathogens associated with TEN. In identifying the etiology of TEN, it is crucial to include not only a detailed drug history but also potential infection sources. Any suspicious infections should be treated in a timely and efficient manner to improve survival rates. In this article, we report on five patients who developed TEN related to M. pneumoniae and herpes simplex virus infections. We also reviewed the relevant literature. We performed a retrospective medical chart review of five patients with TEN, which was considered secondary to M. pneumoniae and herpes simplex virus infections. We compared patients with infection-induced and drug-induced TEN. We found that patients with infection-induced TEN were younger in age and had lower SCORTEN scores, less renal dysfunction, shorter hospitalization periods, and higher survival rates compared with patients with drug-induced TEN. Identifying the etiology of TEN requires the inclusion of not only a detailed drug history but also infection sources, such as M. pneumoniae and herpes simplex virus. Our findings corroborate previously reported clinical and etiologic association with TEN. TEN induced by M. pneumoniae and herpes simplex virus manifested less severe clinical courses than its drug-induced counterpart.
- [Show abstract] [Hide abstract] ABSTRACT: Hypertrophic scar (HSc) treatment continues to be a clinical challenge. To evaluate the efficacy of a combined regimen of calcium channel blocker (verapamil), steroid, and interferon in treating HSc. Ten excised human HSc fragments obtained from surgically treated burn patients were divided into 3 groups: A (no drug), B (steroid, 0.05 mL), and C (verapamil, steroid, and interferon, 0.016 mL each). These specimens were implanted on the backs of nude mice after treatment with intralesional injections of drugs and observed for 4 weeks. Fibroblast proliferation, scar weights, hematoxylin-eosin (HE) staining, fibroblast activity using the fibroblast-populated collagen lattice (FPCL) method, and the quantity of collagen were determined to evaluate the efficacy of the treatments. Data were analyzed using analysis of variance. All the implants were removed from animal body 4 weeks later for study. For the fibroblasts activity study, another 10 days of cell culture was done. The viability and proliferation of HSc fibroblasts in group C mice were significantly decreased at 10 days after explantation. The fibroblast numbers in the 3 groups were as follows: (A) 16.6 × 10; (B) 1.5 × 10; and (C) 0.4 × 10 (P < 0.05). At 4 weeks after implantation, group C showed the significantly least amount of type I collagen (A, 0.12 μg/mL; B, 0.07 μg/mL; C, 0.055 μg/mL; P < 0.05). In the nonimplanted scars, the collagen in group C was 0.4 μg/mL, less than that in groups B (0.6 μg/mL) and A (1.7 μg/mL; P < 0.05). Significant differences were observed in reduction of scar weight among the 3 groups (A, 85%; B, 82.3%; C, 78.6%; P < 0.05). The combination therapy group, that is, group C, significant inhibition of FPCL contraction and delayed contraction of burn scar fibroblasts compared with the other groups. The FPCL contraction rate at 4 weeks in groups A, B, and C was 15.4%, 65%, and 73.4% of the original size, respectively (P < 0.05). Combined intralesional injection of steroid, verapamil, and interferon exhibits significant therapeutic efficacy than does a single high dose of steroid in the treatment of hypertrophic burn scars.This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 License, where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially.
Article: Postburn Contractures of the Hand[Show abstract] [Hide abstract] ABSTRACT: Several functionally limiting sequelae can follow deep thermal injury to the hand. Despite appropriate initial management, contractures are common. Whereas acute burn care is often managed by multidisciplinary, specialized burn units, postburn contractures may be referred to hand surgeons, who should be familiar with the patterns of burn contracture and nonsurgical and operative options to improve function and expected outcomes. The most common and functionally limiting sequelae are contractures of the webspace, hand, and digits. Webspace contractures and postburn syndactyly are managed with scar excision and local soft tissue rearrangement or skin grafting. The burn claw hand presents as extension contracture of the metacarpophalangeal joints and flexion contractures of the proximal interphalangeal joints. The mainstays of management of these contractures include complete surgical excision of scar tissue and resurfacing of the resultant soft tissue defect, most commonly with full-thickness skin grafts. If scar contracture release results in major exposure of the tendons or joints, distant tissue transfer may be required. Early motion and rehabilitative modalities are essential to prevent initial contracture formation and recontracture after surgical release.
- [Show abstract] [Hide abstract] ABSTRACT: Background: Carved autologous costal cartilage is widely used in different rhinoplasty procedures because of its availability and proven advantages. However, the usefulness of rib grafts is limited by warping postoperatively. The chimeric autologous costal cartilage graft is proposed. "Chimeric" means the combining of two different tissues (bone and cartilage in this case) to make a single dorsal onlay graft. Methods: From October of 2010 to August of 2013, 31 patients underwent rhinoplasty or nasal reconstruction with costal cartilage graft using the chimeric autologous costal graft method. There were 14 men and 17 women, with ages ranging from 20 to 66 years (average, 33 years). Of the 31 patients, there were 12 with congenital nasal deformities, six with previous nasal trauma, eight with aesthetic rhinoplasty (four with primary rhinoplasty and four with secondary rhinoplasty), and five with nasal deformities after tumor extirpation. Patients' profiles were documented and photographed. The outcomes were assessed by three plastic surgeons. Results: Follow-up for all patients was 4 to 30 months (average, 14 months). No cartilage warping was noted during the follow-up period. Two patients suffered from minor infection 2 weeks postoperatively. The average operative time for carving cartilage was 10 minutes. The overall average time of making a chimeric autologous costal onlay graft added approximately 20 minutes to the original method. Conclusion: From the clinical observation of all patients during the follow-up period, the chimeric autologous costal cartilage graft was shown to be effective for preventing cartilage warping.
- [Show abstract] [Hide abstract] ABSTRACT: In addition to burn surgeons, skilled nurses, and therapists, hand surgeons are a key part of the multidisciplinary team caring for patients following thermal injury to the hand. Despite appropriate initial treatment and compressive therapy, contractures are common after deep burn. The most common and functionally limiting are web space and hand contractures. Web space contractures can be managed with excision followed by local soft tissue rearrangement or skin grafting. The classic burn claw hand deformity includes extension contracture of the metacarpophalangeal joints and flexion contractures of the proximal interphalangeal joints. The mainstay of management of these postburn contractures includes complete surgical release of scar tissue and replacement by full-thickness skin graft. In cases in which scar contracture release results in major exposure of the tendons or joints, distant tissue transfer is required. This review focuses on prevention and management of late sequelae of thermal injury to the hand focusing on contractures of the webspaces and hand.
- [Show abstract] [Hide abstract] ABSTRACT: Many surgeons have to face the challenge of the sophisticated management of catastrophic high-voltage injuries to upper extremities. These patients present with both vast soft tissue defects and varied segmental main artery defects with compromised circulation of the distal limb. This study is a first attempt to analyze the outcome of the flow-through anterolateral thigh flap for reconstruction in acute electrical burns of the severely traumatized upper extremity.Method and patientFrom March 2001 to February 2012, five men were enrolled in the study. All in this series suffered from high voltage current (higher than 1000 V) electrical burn and had the presence of wide segmental soft tissue defects, exposure of underlying vital structures and segmental artery injury with compromised circulation. Flow-through anterolateral thigh flaps were used for limb salvage.ResultFollow up for all patients was present from 6 months to 7 years. The mean age was 37.8 years old. The mean timing of free flap transfer was 5.8 days after injury. The mean flap sizes were 31.6 cm × 16.5 cm. The mean artery defect was 14.2 cm in length. Venous thrombosis occurred 1 day post-operatively in one patient. No donor site morbidity was noted. In the postoperative period, no infection, no hematoma, nor deaths were noted. Successful limb salvage rate was 80% in this series.Conclusion In electrical injuries of the severely damaged upper extremity, flow through anterolateral thigh flaps provide for reconstruction of both the vessels and soft tissue simultaneously. Although the risk of flap failure is higher than with other etiologies of burn, the data shows that the above reconstruction technique is useful for upper extremity salvage.
- [Show abstract] [Hide abstract] ABSTRACT: Intrascar excision with debulking procedure is a good choice for scar revision in unique 3-dimensional facial aesthetic units, especially in the auricular area. It can remove or reduce scars in a shorter course without distortion of the surrounding anatomic structures and visible operative scars. This retrospective study was done to present intrascar excision procedures in persistent auricular hypertrophic scars or keloids. Between 1997 and 2010, 18 ears in 13 patient cases with persistent hypertrophic scars and/or keloids in their external ear due to burns or trauma were collected for evaluation. There were 10 males and 3 females. The age distributions ranged from 5 to 49 years with an average of 20.1 years. All received intrascar excision with debulking procedure for their ear deformity. One case combined with YV-plasty procedure to obtain better aesthetic result. The follow-up period ranged from 0.3 to 14 years with an average of 3.6 years. There was no recurrence in a series of average 3.6 years follow-up. Of the 13 patients, 11 (84.6%) objectively presented good and satisfactory surgical outcomes and the other 2 patients were acceptable. The intrascar excision in auricular persistent scars or keloids has the following advantages: it (1) achieves primary closure, (2) does not distort the anatomic landmarks, (3) does not sacrifice the important structures, (4) has a debulking effect, (5) can be done anytime, even if scars are not mature, (6) has good cosmetic results, (7) may combine with Z- or VY-plasty for functional improvement, and (8) has minimal complications.
- [Show abstract] [Hide abstract] ABSTRACT: Background: Loss of cervicomental angle is characteristic of severe facial and cervical burned patients due to scar contracture. This micrognathia-like deformity is also seen in patients following chin and neck reconstruction using skin expanded flaps. The aim of modern plastic surgery is to restore a harmonious and symmetrical facial appearance for burn survivors. Methods: Six facial and cervical burned patients with micrognathia-like deformity after neck reconstructions were reported. Chin augmentation with Medpor implant through submental approach was performed in 4 patients and intraoral access in 2 cases to restore their favorable chin projections. Five of them received cervicomental contour reconstruction simultaneously. Results: Patient follow-up ranged from 12 to 18 months. No implants became exposed nor infected. All patients had satisfactory results. We reviewed our experience with the use of the Medpor implant in burn chin reconstruction including preoperative and postoperative radiograph analysis. Conclusions: With proper patient selection, pre-operative planning, and taking care of details during operation, augmentation genioplasty with Medpor implant offers a reliable, simple and satisfactory solution for improving micrognathia-like facial configurations in patients with scar contracture following severe burns.
- [Show abstract] [Hide abstract] ABSTRACT: Nail fold deformities from burn injury frequently result in eponychial retraction, proximal nail exposure, pain, and distal phalangeal function impairment. Secondary nail abnormalities including longitudinal ridges, surface cracks, and fragility are common sequelae to nail fold deformities. Surgical management of postburn nail fold deformity is challenging because of scar contractures involving the dorsum of digits and lack of surrounding healthy tissues that can be used as source of soft tissue for reconstruction. Previous reports have discussed several methods for reconstruction of these deformities. However, all of these methods are associated with significant donor site morbidities. From August 2008 to January 2010, "onion" flap reconstruction was performed for postburn nail fold contractures and deformities on 32 fingers of eight patients (five men and three women; average age, 44.4 years; age range, 23-54 years). This novel technique was used to release scar contractures in the eponychial area and allow soft tissue restoration by redraping the eponychium in a single-step procedure. All 32 fingers received single-stage "onion" flap reconstruction for their nail fold deformities at least 6 months after the initial injury. The follow-up period, with an average of 7.8 months, revealed that all nails had good esthetic and functional results. All experienced amelioration of nail abnormalities. The "onion" advancement flap had effectively released the scar contracture around the nail fold and simultaneously restored the eponychial fold. The "onion" flap technique provides superior results compared with those from conventional techniques. We recommend it as the mainstay of treatment for reconstruction of the postburn eponychial deformities. V, therapeutic study.
- [Show abstract] [Hide abstract] ABSTRACT: Inhalation injuries contribute significantly to morbidity and mortality in both children and adults with burns. Pneumonia is a major compromising factor in these patients. The purpose of this article was to evaluate the characteristics, impact factors, incidence, morbidity, and mortality of pneumonia in inhalation injuries. Furthermore, a severity score has been formulated to help predict the probability of developing pneumonia following inhalation injuries. A retrospective study was performed of 214 patients, treated for inhalation injuries from 1999 to 2009 at the Burn Center in Chang Gung Memorial Hospital, Linkou, Taiwan. Patients' characteristics, length of hospitalization, total burn surface area, initial PaO2:FiO2 ratio, number of intubated days, bronchoscope grade, initial carboxyhemoglobin level (COHb) and mortality rate were recorded. A Student's t-test was used for comparison of inhalation injury patients with and without pneumonia and was also used for comparing a TBSA of >20% to those with a TBSA of ≤20% in patients with inhalation injury and pneumonia. Logistic regression analyses were utilized to create a severity score related to pneumonia. 129 patients with inhalation injury were included in the analysis. Overall, 38% (49/129) patients developed pneumonia. Pneumonia associated with inhalation injury occurred more often in patients with a TBSA>20% (P<0.05). The intubation days, bronchoscope grade and COHb level of pneumonia patients were significantly longer (P<0.05). Initial PaO2:FiO2 ratio (PaO2/FiO2) was significantly lower in patients with pneumonia (P<0.05). Mortality following pneumonia was increased sevenfold (P<0.05). Hospitalization days and intubation days were significantly longer in TBSA>20%. Logistic regression analysis was performed to find out the impact factors of pneumonia in inhalation injury patients and to set a severity score. Patients age >60 years, TBSA >20%, bronchoscope grade is 3 or 4, initial PaO2/FiO2≦300 and initial COHb level>10% showed a significant difference (P<0.05). The total severity scale was set at 5 points. Each impact factor was given one point and when the score ≥2 it means patients have high risk of development of pneumonia. This study had identified the significant risk factors for potential development of pneumonia in a group of inhalation injury patients. The impact of these risk factors should be validated in further prospective trials to improve outcome or at least reduce the incidence of the surrogate diagnosis of pneumonia.
- [Show abstract] [Hide abstract] ABSTRACT: Hypertrophic scars (HScs) are inelastic scars that can cause functional loss and disfigurement. Decorin regulates collagen fibrillogenesis, and its expression is lower in HScs than in normal skin and during wound healing. To evaluate the efficacy of combined verapamil and triamcinolone in treating HScs. Excised human HSc fragments from surgically treated burned patients were divided into three groups: A (normal saline), B (verapamil), and C (verapamil and triamcinolone). The specimens were bilaterally implanted in the back of nude mice, treated using intralesional injections, and observed for 4 weeks. We compared the fibroblast viability and proliferation, decorin staining, and scar weights to evaluate treatment efficacy. Viability and proliferation of HSc fibroblasts from groups B and C were significantly lower at all time intervals after transplantation (p<.001). Treatment (Groups B and C) stimulated strong decorin staining by 4 weeks. Nonsignificant differences in changes in scar weight were observed between groups. We present the first evidence of verapamil-augmented decorin expression spatially correlated with collagen bundles in HScs. Combination therapy can reduce the dosage of each drug but achieve equal or better efficacy than monotherapy, reducing the side effects of a single drug. The authors have indicated no significant interest with commercial supporters.
Article: Burn scar carcinoma[Show abstract] [Hide abstract] ABSTRACT: Since Jean-Nicolas Marjolin reported carcinoma arising in post-traumatic scars in 1828, the term 'Marjolin ulcer' has been applied to malignant changes in burn scars. Although many papers have been published already in this field, there are few reports from Oriental people. From 1989 to 2008, there were 11 cases noted as burn scar carcinoma in Chang Gung Memorial Hospital. Ten were reported as squamous cell carcinoma (SCC) and the one was verrucous carcinoma. Most of the cases occurred in the extremities (10/11). Ten cases underwent an operation initially with wide excision and skin graft or local flap for coverage. Forefoot amputation was performed in one patient. One patient received above-knee amputation and adjuvant therapy because recurrent verrucous carcinoma occurred 2 years later. One patient suffered from a new lesion 8 years later and another case had inguinal lymph node metastasis 8 months later. Five patients were lost to follow-up and six cases were tumor-free during the follow-up period. Most scar malignancies are SCC while other cell types are rarer. The casual association between burn injuries and a later risk of basal cell carcinoma is questionable. Owing to poor prognosis in advanced scar cancer, the best treatment for scar carcinoma is to prevent the scar from developing repeated ulceration by performing aggressive initial burn wound care: early grafting by surgeons and daily scar care with regular follow-up for patients. This may be why a lower incidence has been noted in recent years.
Article: Reconstruction in Pediatric Burns[Show abstract] [Hide abstract] ABSTRACT: The incidence of pediatric burn (<18 years old) in Taiwan according to data from Childhood Burn Foundation Taiwan ROC was about 33.4%. The incidence of reconstruction needed for this age group was also about the same. From the data presented at Singapore in the year 2006, there was an average of 36.3% (patient number: 2,833/7,795) of pediatric burn (<18 years old) in Linkou burn center (LBC), Chang Gung memorial Hospital (CGMH) from 1986 to 2004 . Among these, one-third of the patients needed reconstruction. This is a large reconstruction group and is of concern.
- [Show abstract] [Hide abstract] ABSTRACT: Dynamic and static complex scar contractures after burn commonly cause tendon adhesion, deep adipose tissue stiffness and further limitation of major joints motion. Skin autografting or locoregional flaps are not adequate reconstructive options, because of the easy recurrence and limitation of donor sites. Therefore, free perforator flaps are playing increasing role in reconstruction of complex scar contractures. The free medial thigh perforator (MTP) flap is an addition to the reconstructive armamentarium and is particularly useful since the medial thigh is commonly spared in burn injury. Between December 2001 and October 2005, eight patients with severe post-burn scar contractures received free MTP flaps treatment in the Linkou Burn Center. The free MTP flap harvest was modified to enhance its reliability and versatility. Flap sizes ranged from 5 x 15 cm to 8 x 24 cm. The follow-up period was from 12 to 26 months. Flap harvest is rapid, averaging 37.8 min. The significantly improved range of motion of the contracture joints approximated to normal activity at 6-22-month follow-up (p<0.05). No free major MTP flap complication was noted, except for mild marginal necrosis in one case. The free MTP flap with new modified harvest is a good choice for dynamic an static complex scar contractures of major joints, due to short harvesting time and few variations of the pedicle. However, thick skin paddle was considered in secondary hand reconstruction.
- [Show abstract] [Hide abstract] ABSTRACT: Heterotopic ossification (HO) is an uncommon, but high profile complication of burns. In this paper, a retrospective study was undertaken to evaluate our treatment and results of HO. Relevant literature was also reviewed to search for new advances in prevention and management for patients with HO after burns. A retrospective study was undertaken in Chang Gung Memorial Hospital, Linkou. We collected 12 patients who suffered from HO after burn and received operation in our hospital between June 2000 and September 2007. The data was expressed as mean. Patients' gender distribution was 10 males and 2 females. The mean age was 43 years old (range, 30-59). Causes of burn were flame burn (75%), scald burn (8%), contact burn (8%), and high-voltage electrical burn (8%). Mean TBSA was 39% (range, 8-90%). Nine of 12 patients (75%) were admitted to intensive care unit (ICU) and 6 (50%) received mechanical ventilator support. The mean ICU stay was 82 days (range, 26-240 days). The elbow was the most commonly affected joint (92%). The outcome of surgery was acceptable in all elbows at the time of surgery. The mean ROMs before surgery were 31 degrees (range, 0-75 degrees). The mean ROMs after surgery were 99 degrees (range, 70-115 degrees); mean gain was 68 degrees (range, 35-115 degrees). One (8%) patients had recurrent HO after operation. The mean outpatient department follow-up time was 14.6 months (range, 1-40 months). The incidence of HO in our burn center is 0.15%. Although HO after burn is uncommon, physicians should keep the complication in mind. When burn patients complain decreased ROM or "locking sign" in their joints, X-ray examination is indicated to rule out HO. Surgery is the treatment of choice when the diagnosis of HO is confirmed.