Patient-reported scar quality of donor-sites following split-skin grafting in burn patients: Long-term results of a prospective cohort study

Long-term patient satisfaction with their split-thickness skin graft donor site and the need for improved preoperative counselling

OBJECTIVE

There is a lack of studies on patient-reported outcomes of split-thickness skin graft (STSG) donor sites, especially on patient satisfaction. Donor site counselling could contribute to realistic patient expectations, which could improve postoperative patient satisfaction. Therefore, this study aimed to investigate donor site counselling and patient satisfaction with the final donor site outcome.

METHOD

Preoperative consultations were observed and given donor site information reviewed by means of a checklist. Next, a dual survey on donor site satisfaction and patient-reported donor site scar quality (measured using the patient scale of the Patient and Observer Scar Assessment Scale 3.0 adapted for this study to cover the donor site) was sent to patients who received STSG surgery 12±3 months prior to the study start. A backward linear regression analysis was used to identify potential satisfaction predictors.

RESULTS

A total of 35 preoperative consultations were observed (19 adult and 16 paediatric consultations) and 36 patients (mean age: 41 years) responded to the survey. For the adults, 'location options' was the most discussed item and 'size' was the least discussed. Of the patients, 83% were satisfied with the donor site in general and 50% were dissatisfied with postoperative complaints, such as pain or itching. Most (92%) patients experienced colour differences, which was also a negative predictor for satisfaction with donor sites in general and their appearance. Being male was a positive predictor for satisfaction with donor sites in general, size and colour differences.

CONCLUSION

The majority of patients in the study were satisfied with their donor sites. Dissatisfaction was observed with size, appearance and postoperative complaints. Unrealistic expectations could play a role in dissatisfaction; information tools as illustrations and animations may help in managing patient expectations. Future research should focus on improvement of patient satisfaction with donor site aspects such as size and colour.

Timing of surgery in acute deep partial-thickness burns: A study protocol

For deep partial-thickness burns no consensus on the optimal treatment has been reached due to conflicting study outcomes with low quality evidence. Treatment options in high- and middle-income countries include conservative treatment with delayed excision and grafting if needed; and early excision and grafting. The majority of timing of surgery studies focus on survival rather than on quality of life. This study protocol describes a study that aims to compare long-term scar quality, clinical outcomes, and patient-reported outcomes between the treatment options. A multicentre prospective study will be conducted in the three Dutch burn centres (Rotterdam, Beverwijk, and Groningen). All adult patients with acute deep-partial thickness burns, based on healing potential with Laser Doppler Imaging, are eligible for inclusion. During a nine-month baseline period, standard practice will be monitored. This includes conservative treatment with dressings and topical agents, and excision and grafting of residual defects if needed 14-21 days post-burn. The subsequent nine months, early surgery is advocated, involving excision and grafting in the first week to ten days post-burn. The primary outcome compared between the two groups is long-term scar quality assessed by the Patient and Observer Scar Assessment Scale 3.0 twelve months after discharge. Secondary outcomes include clinical outcomes and patient-reported outcomes like quality of life and return to work. The aim of the study is to assess long-term scar quality in deep partial-thickness burns after conservative treatment with delayed excision and grafting if needed, compared to early excision and grafting. Adding to the ongoing debate on the optimal treatment of these burns. The broad range of studied outcomes will be used for the development of a decision aid for deep partial-thickness burns, to fully inform patients at the point of consent to surgery and support optimal person-centred care.

A Comprehensive Review of Evaluating Donor Site Morbidity and Scar Outcomes in Skin Transfer Techniques

This comprehensive review delves into the intricacies of donor site morbidity and scar outcomes in skin transfer techniques central to the field of reconstructive surgery. The review synthesizes existing literature to illuminate the multifaceted factors influencing outcomes by surveying a broad spectrum of grafting methods, from traditional autografts to cutting-edge tissue engineering approaches. Key findings underscore the complex interplay of graft characteristics, surgical techniques, and patient-specific variables. The implications for clinical practice advocate for a nuanced, patient-centered approach, incorporating emerging minimally invasive procedures and adjuvant therapies. The review concludes with recommendations for future research, emphasizing the importance of longitudinal studies, comparative analyses, patient-reported outcomes, advanced imaging techniques, and exploration of tissue engineering innovations. This synthesis advances our understanding of donor site morbidity and scar outcomes. It provides a roadmap for refining clinical protocols, ultimately enhancing the delicate balance between therapeutic efficacy and patient well-being in reconstructive surgery.

First do no harm: A patient-reported survey of split skin graft donor site morbidities following thin and super-thin graft harvest

The split-thickness skin graft (STSG) donor site is the commonest used during burn surgery which has its own complications and as such the focus should be on minimizing it. Modifications to practice in our unit which we believe aid this include limiting the amount of STSG taken and the harvest of super-thin STSGs, with 0.003-0.005 in. (0.08-0.13 mm) being the commonest dermatome settings used. A patient-reported survey via a mobile phone link to a questionnaire was sent to 250 patients who had a STSG for an acute burn between 1st August 2020 and 31st July 2021. Patient demographics were collected from electronic records including the thickness of the FTSG taken when recorded. Patient responses were statistically analyzed and logistic regression with backwards elimination was performed to explore which contributing factors led to an improved experience of the donor site. Questionnaire responses were obtained from 107 patients (43%). These were between one and two and a half years after the injury. Concerning early donor site issues, itch was a problem for 52% of patients, pain was a problem for 48% of patients. Less common problems (fewer than 25% of patients) were leaking donor sites, wound breakdown, and over-granulation. Regarding long-term outcomes, increased, decreased or mixed pigmentation at the donor site was reported by 32% patients at the time of the survey. Hyper-vascular donor sites were reported by 24% patients. Raised or uneven feeling donor sites were reported by 19% patients, firm or stiff donor sites by 13% patients, and altered sensation by 10% patients. At the time of the survey, 70% responders reported their donor site looked "the same or about the same as my normal skin". Of these, 62 reported how long it took for this to happen, and it equates to a third looking normal at 6 months and half looking normal at a year. For the 32 patients who reported their donor site looking abnormal, 72% were "not bothered" by it. Patients with super-thin grafts (0.003-0.005 in.) were significantly more likely to have normal sensation, normal stiffness, and be less raised at their donor sites than those who had thin grafts (0.006-0.008 in.). This survey gives important information on patients' experiences of donor site morbidity that may form part of an informed consent process and allow tailored advice. Furthermore, it suggests that super-thin grafts may provide a superior donor site experience for patients.

Nanostructured fibrin-agarose hydrogels loaded with allogeneic fibroblasts as bio-dressings for acute treatment of massive burns

The prompt management of patients with massive burns is essential to maximize survival by preventing infection, hemorrhage, fluid and heat loss, and to optimally prepare the wound bed for the application of autografts or cultured tissue-engineered artificial autologous skin. Acute treatments are typically based on temporary bio-dressings, commonly cadaveric skin allografts, but supply challenges, high costs and increasingly stringent regulatory requirements preclude their widespread use. Nanostructured fibrin-agarose hydrogels (NFAH) have been proven to be safe and effective biomaterials in preclinical and clinical studies, and show good hemostatic and biomechanical properties. Here we generated and tested NFAH with embedded allogeneic dermal fibroblasts (NFAH-F) under Good Manufacturing Practice (GMP) conditions. Fibroblasts were first expanded and characterized to create a GMP bank and the NFAH-F was manufactured on demand. Three patients with major burns were treated with this product as a temporary bio-dressing under compassionate use. Our results suggest that NFAH-F product was a safe product and no adverse reactions were observed. In all cases, the patients survived until definitive treatment. Therefore, the application of NFAH-F might be a temporary bio-dressing for patients with massive burns when cadaveric skin allografts are not available.

Full-thickness skin columns: A method to reduce healing time and donor site morbidity in deep partial-thickness burns

The current standard of care for the coverage of large wounds often involves split thickness skin grafts (STSGs) which have numerous limitations. One promising technique that has gained traction is fractional autologous skin grafting using full-thickness skin columns (FTSC). Harvesting occurs orthogonally by taking numerous individual skin columns containing the epidermis down through the dermis and transferring them to the wound bed. The purpose of this porcine study was to investigate the efficacy of implanting FTSCs directly into deep partial-thickness burn wounds, as well as examining donor site healing at the maximal harvest density. It was hypothesised that by utilising FTSCs, the rate of healing in deep partial thickness burns can be improved without incurring the donor morbidity seen in other methods of skin grafting. Deep partial-thickness burns were created on the dorsum of female red duroc swine, debrided 3 days later and FTSCs were implanted at varying expansion ratios directly into the burn wounds. At day 14, 1:50 expansion ratio showed significantly faster re-epithelialisation compared to the debrided burn control and 1:200. Donor sites (at 7%-10% harvest density) were 100% re-epithelialised by day 7. Additionally, the maximal harvest density was determined to be 28% in an ex vivo model, which then five donor sites were harvested at 28% density on a red duroc swine and compared to five STSG donor sites. At maximal harvest density, FTSC donor sites were significantly less hypopigmented compared to STSGs, but no significant differences were observed in re-epithelialisation, contraction, blood flow or dermal thickness. In conclusion, implantation directly into deep partial-thickness burns is a viable option for the application of FTSCs, favouring lower expansion ratios like 1:50 or lower. Little difference in donor site morbidity was observed between FTSC at a maximal harvest density of 28% and STSGs, exceeding the optimal harvest density.

Translation and psychometric validation of the Finnish version of the Patient Scar Assessment Scale for use in patients with burn scars

BACKGROUND

The aim of this study was to create a Finnish scar assessment scale by translating and evaluating the psychometric properties of the Patient Scar Assessment Scale (PSAS), a part of the Patient and Observer Scar Assessment Scale (POSAS), with burn patients to enable its use in burn care.

METHODS

The translation process followed international guidelines with forward and backward translations and cognitive debriefing with patients. Psychometric validation was performed with adult patients with burns who had been treated at the Helsinki Burn Centre between 2006 and 2017 with skin grafting following the excision of deep second- or third-degree burns. To ensure reproducibility, the PSAS was sent to the study participants twice. The correlation between the PSAS and health-related quality of life (HRQL) was also tested.

RESULTS

In total, 192 patients, of whom 71 % were male, participated in this study. The mean (SD) age of the participants was 57 (17) years. The internal consistency of the PSAS was good, Cronbach's α 0.89 (95 % CI: 0.86-0.91). The reproducibility was also good concerning all items and the total score, ICC from 0.77 to 0.89. As expected, the total PSAS score correlated negatively with HRQL.

CONCLUSION

The PSAS was successfully translated and culturally adapted into Finnish and the newly translated version has good validity and reproducibility for assessing mature burn scars.

Historical Evolution of Skin Grafting-A Journey through Time

Autologous skin grafting was developed more than 3500 years ago. Several approaches and techniques have been discovered and established in burn care since then. Great achievements were made during the 19th and 20th century. Many of these techniques are still part of the surgical burn care. Today, autologous skin grafting is still considered to be the gold standard for burn wound coverage. The present paper gives an overview about the evolution of skin grafting and its usage in burn care nowadays.