A Ten-Year Experience With Pediatric Face Grafts:

Integra's legacy unveiled: expert panel recommendations summarizing 25 years of experience in head and neck reconstruction

Background

Integra® Dermal Regeneration Template (IDRT) is used for its ability to facilitate wound closure and mimic various skin functions, marking a breakthrough in medical technology.

Methods

Through a synthesis of expert opinions, clinical experiences, and published evidence, this review sheds light on current applications of IDRT in head and neck wound care.

Results

This review covers the application of IDRT for post-oncological surgery reconstructions, trauma-induced injuries, and scar corrections. It focuses on the use of IDRT in specific anatomical regions (scalp, temporal, orbital, nasal areas, neck, and ears) and in pediatric and older patients. The economic aspects, including cost-effectiveness and value in the healthcare system, are also examined.

Conclusions

The insights presented aim to inform clinicians and encourage the broader integration of IDRT into clinical practice, enhancing patient outcomes in wound management.

A Collagen-Elastin Regenerative Dermal Matrix May Generate Unfavorable Results in Head and Neck Postburn Scar Reconstruction: A Case Series

Background and Objectives: Dermal matrices have brought solutions for many problems, mainly in the treatment of burns and burn scar revisions. The objective of this study was to draw attention to the limits of a collagen-elastin dermal matrix (MatriDerm®) in its 1 mm variant for the treatment of burn scars on the face and neck. Materials and Methods: A case series of four patients (three women and one man) with burn scars of the face (one case) and of the neck (three cases) treated with collagen-elastin matrices is presented. In all cases, the excision or release of the scars was performed, and the defects were covered with MatriDerm® and thin split-thickness skin grafts in the same operative time. Results: In all cases, the graft take was very good but was followed by the important contraction of the graft to such an extent that the results were found to be poor by both the surgeons and the patients. The surface of the new scar was irregular, and the elasticity was low. The article points out some probable causes and draws attention to the need for more objective studies regarding the use of this dermal matrix in burn scars of the head and neck. Conclusions: This collagen-elastin 1 mm dermal matrix should be used with caution for the surgical treatment of burn scars of the head and neck area, and its indication should be carefully weighted.

Availability, effectiveness and safety of cadaveric and fresh allogeneic skin grafts in pediatric burn care-a review

Burn injuries in children are a critical public health issue with significant mortality and morbidity. Allogeneic skin grafts, both cadaveric and freshly donated, have been utilized in pediatric burn care since many years, yet their efficacy and safety remain to be systematically assessed. This systematic review (PROSPERO number: CRD42024560654) analyzed studies from 01/2000 to 07/2024 sourced from PubMed. Inclusion criteria targeted RCTs and retrospective studies focused on the use of allogeneic skin grafts in pediatric burn patients. Extracted data were presented in a narrative synthesis and a comprehensive table. Established tools were used for risk of bias assessment. 13 studies were deemed suitable for analysis, with only two qualifying as RCTs. Allogeneic skin grafts have shown promise in managing pediatric burns, especially in resource-limited settings where autografts or skin substitutes are not available. Studies varied in their treatment approaches, with allogeneic grafts often used for more severe burns, suggesting that observed adverse effects may be due to injury severity rather than treatment type. The retrospective nature of the majority suggests a limited level of evidence. Moreover, the heterogeneity among study designs and patient populations makes it difficult to draw definitive conclusions. Allogeneic skin grafts represent a valuable treatment option in pediatric burn care. However, further well-designed RCTs are essential to establish a stronger evidence base for their use and to guide clinical decision-making. The current literature underscores the potential of allogeneic grafts but also the necessity for more nuanced research tailored to pediatric needs.

Wound Management of Pediatric Burns

The goal for treating pediatric burns is to allow the patient to heal with as little scarring as possible. Compared to older children and adults, very small children have anatomic differences that alter their treatment. They have thinner skin that leads to a higher risk for full-thickness burns. Children also tend to freeze when touching a hot item, so that the prolonged contact also leads to deeper burns. Two healing strategies are needed to treat these wounds. One must optimize reepithelialization in superficial burns to reduce scarring. Deeper burns require skin grafting, but there are techniques, such as the use of "sheet" autograft skin that lead to excellent outcomes. Strategies to treat the massive pediatric burn will also be covered. Finally, there are instances where different strategies are needed to cover exposed bone or tendon. The ultimate goal is to return the skin to as normal a state as possible.

Operative Management of Burns: Traditional Care

Surgical treatment of burn wounds has had a tremendous impact on burn patients. The survival of patients with massive burns is now very common. Expeditious coverage of the wound has been a major contributor to improved survival, but survival is not enough. There is a need to improve the ultimate functional and cosmetic outcomes of the wound in order to facilitate a patient's return to society. This paper reviews strategies, using fairly basic techniques, to optimize the outcomes of burn patients. While there are many new skin products available, the strategies presented here can apply to any surgeon treating burns throughout the entire world.

Face Burns: A 4-Year Experience

Burns on the face pose unique management challenges because they are in a place that is constantly visible, so scars are hard to hide. The goal of this study was to review our experience of adult patients who had face burns. We performed a retrospective review of adult patients (≥18 years old) who were admitted to a regional burn center from July 2015 to June 2019 with face burns. Sex, age, ethnicity, burn etiology, burn size, and discharge status were collected from electronic medical records of the patients who met study criteria. Descriptive statistics, Student's t-tests, and chi-square tests were performed in Stata/SE 16.1. Significance was defined as a P-value < .05. In 4 years, 595/1705 patients (~35% of admissions) were admitted with face burns. The mean age was 44.9 ± 17.0 (mean ± SD) years, with the majority being men (475, 80%). The mean burn size was 19.8 ± 20.9% TBSA with 10.1 ± 19.8% TBSA being third degree. The mean head burn size for any face burn was 2.8 ± 1.8% TBSA. The majority of burns were due to flames (478, 80%) and of those 122 (21%) were from accelerant use and 43 (7%) resulted from propane or butane use. Scalds caused 53 (9%), electric 25 (4%), hot tar 5 (1%), and chemical 5 (1%). Overall, 208 (35%) patients had grafting of some portion of their body, but only 31 patients (5.2%) had face grafting. The mean age of those with face grafting compared with patients who did not need grafting was 45.9 ± 13.8 and 44.9 ± 17.2 years, respectively. Patients who needed grafting had a mean third-degree burn size of 31.7 ± 25.4% TBSA and a mean head (including face) burn size of 4.7 ± 2.0% TBSA, whereas patients who did not need grafting had a mean third-degree burn size of 8.9 ± 18.7% TBSA and a mean head burn size of 2.7 ± 1.8% head TBSA. Patients requiring face grafts had longer lengths of stay, intensive unit stays, ventilator days, and mortality than those whose face burns healed spontaneously. Overall, head burns in adults were common within the 4-year time span we studied, but only a small fraction (5%) had face grafts. The patients who needed grafting for their head burns had significantly larger total body and face burns and had a 2.4-fold higher mortality rate compared to patients who did not need grafting. Most face burns were caused by flame, especially the use of accelerants or flammable gases. Prevention efforts should focus on avoiding the use of accelerants and being careful with flammable gases.

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.

A systematic review of intervention studies demonstrates the need to develop a minimum set of indicators to report the presence of burn wound infection

INTRODUCTION

Burn wound infections result in delayed healing and increased pain, scarring, sepsis risk and healthcare costs. Clinical decision making about burn wound infection should be supported by evidence syntheses. Validity of evidence from systematic reviews may be reduced if definitions of burn wound infectionvary between trials. This review aimed to determine whether burn wound infectionis defined, and whether there is variation in the indicators used to define burn wound infectionacross studies testing interventions for patients with burns.

METHOD

Searches were carried out in four databases (Ovid Medline, Ovid Embase, Cinahl, Cochrane Register of Trials) to identify studies evaluating interventions for patients with burns and reporting a burn wound infection outcome. Pre-defined inclusion and exclusion criteria were systematically applied to select relevant studies. Data were systematically extracted and reported narratively.

RESULTS

2056 studies were identified, of which 72 met the inclusion criteria, comprising 71 unique datasets. 52.1% of studies were randomised controlled trials. Twenty-eight (38.0%) studies reporting a burn wound infection outcome did not report how they had defined it. In the methods of included studies, 59 studies (83.1%) reported that they planned to measure burn wound infection as an outcome. Of these, 44 studies (74.6%) described how they had defined burn wound infection; 6 studies (13.6%) reported use of a previously developed consensus-informed definition of burn wound infection, and 41 studies (69.5%) described the specific indicators used to define it. Studies used between one (11 studies; 26.8%) and nine indicators (2 studies; 4.9%) to define burn wound infection (median = 3, inter-quartile range = 2). The most commonly used indicator was presence of bacteria in the wound (61.0% of studies). Only 13 studies (31.7%) defined burn wound infection using the same indicators as at least one other study.

DISCUSSION AND CONCLUSIONS

Within intervention studies reporting burn wound infection outcomes, a definition of this outcome is commonly not provided, or it varies between studies. This will prevent evidence synthesis to identify effective treatments for patients with burn injuries. Since there is no objective method for assessing burn wound infection, expert consensus is needed to agree a minimum set of indicators (Core Indicator Set) reported in all trials reporting burn wound infection as an outcome.

Injuries associated with electronic nicotine delivery systems: A systematic review

BACKGROUND

Since its introduction on the market in 2007, the number of reports on injuries caused by the overheating, ignition, or explosion of electronic nicotine delivery systems (ENDSs) has increased significantly. These injuries appear to have different causes, the most important one being lithium-ion battery overheating to the point of ignition or explosion.

METHODS

A literature search for all relevant studies concerning ENDS-related traumatic injuries of all kinds was conducted, according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses protocol. The search started with the first introduction of ENDSs in 2007 and ended February 2020. Articles included were reports on patients who sustained flame, chemical, or traumatic injuries of the skin, soft tissue, and/or bone, related to the use of ENDSs.

RESULTS

This systematic review includes 180 patients from 41 case series and reports, published between 2016 and 2020. The mean age was 30.8 years (range, 17-59 years) with an overall male predominance (168 of 180 patients, 93%). In most injuries, multiple anatomical sites were affected, with the thigh/lower limb being the most commonly injured area (77%) followed by the upper limb/hand (43%). Eighty-two patients (51%) required a surgical treatment, 70 patients (43%) were managed conservatively with dressings or ointments, and 9 patients (6%) underwent enzymatic debridement. Thirty-five percent of all patients underwent skin grafting.

CONCLUSION

Injuries from overheating, ignition, or explosion of ENDSs are an emerging, underreported, and underresearched issue. There is a need for increased regulation of ENDSs and improved surveillance of related injuries. Both health care providers and consumers should be made aware of the risks and be advised about how to safely handle these devices. In contrast to other articles, this systematic review includes all types of injuries related to ENDS overheating, ignition, and explosion. To our knowledge, this is the most extensive systematic review performed to date.

LEVEL OF EVIDENCE

Review article, level III.

Infectious Complications Associated with the Use of Integra: A Systematic Review of the Literature

Dermal regeneration templates such as Integra are effective reconstructive biomaterials used in a variety of soft-tissue defects. Fully understanding the complications associated with their use is paramount to improve outcomes and maximize patient safety. In this study, our purpose is to perform a comprehensive literature review to assess the previously reported infectious complications linked to Integra-based wound closure.

Management of facial burns

Burns to the face affect a part of the body that cannot be hidden and thus exposes potentially major changes in appearance to society. Therefore, it is incumbent upon the caregiver to optimize healing and minimize scarring. The goal for partial-thickness burns is to have them heal within 2-3 weeks to minimize healing time. For full-thickness burns there needs to be strategies to optimize the outcomes for skin grafting and minimize scarring. The goal of this review is to discuss the best way to improve the outcomes of these devastating injuries.

A New Method for Securing Dermal Substitutes and Skin Grafts to Difficult Portions of the Face Using a Custom 3D-Printed Facemask

Management of third-degree facial burns remains one of the most difficult challenges in burn care. Patients with deep facial burns usually require gradual escharectomy, tangential excision of the wound, and resurfacing with full-thickness skin grafts or dermal substitutes associated with split-thickness skin grafts to provide better and superior cosmetic results. Immobilization of skin grafts and dermal substitutes by reducing shearing forces and hematoma formation underneath is paramount to improve success rates. Due to the irregular shape of the face, the proper immobilization of grafts with traditional methods is often difficult, especially over concave portions of the face. Herein, we report the original use of a custom three-dimensional printing facemask for securing dermal substitutes and skin grafts to difficult sites on the face.

Dermal regenerative matrix use in burn patients: A systematic review

BACKGROUND

Dermal regenerative matrices (DRMs) have been used for several decades in the treatment of acute and reconstructive burn injury. The objective of this study was to perform a systematic review of the literature to assess clinical outcomes and safety profile of DRMs in full-thickness burn injury.

METHODS

Comprehensive searches of MEDLINE, EMBASE, CINAHL, and Cochrane Library were performed from 1988 to 2017. Two independent reviewers completed preliminary and full-text screening of all articles. English-language articles reporting on DRM use in patients with full-thickness burn injury were included.

RESULTS

Literature search generated 914 unique articles. Following screening, 203 articles were assessed for eligibility, and 72 met inclusion criteria for analysis. DRM was applied to1084 patients (74% acute burns, 26% burn reconstruction). Of the twelve studies that described changes in ROM, significant improvement was observed in 95% of reconstructive patients. The most frequently treated reconstructive sites were the neck, hand/wrist, lower extremity, and axilla. Vancouver scar scale was used in eight studies and indicated a significant improvement in the scar quality with DRM. The overall complication rate was 13%, most commonly infection, graft loss, hematoma formation, and contracture.

CONCLUSIONS

Although variability in functional and cosmetic outcomes was observed, DRM demonstrates improvements in ROM and scar appearance without objective regression. Essential demographic data were lacking in many studies, highlighting the need for future standardization of reporting outcomes in burns following application of dermal substitutes.

Multidisciplinary oral rehabilitation of an adolescent suffering from juvenile Gorlin-Goltz syndrome - a case report

Background

The Gorlin-Goltz syndrome is an autosomal dominant disorder characterized by keratocystic odontogenic tumors in the jaws, multiple basal cell carcinomas and skeletal abnormities. Frequently, the manifestation of the syndrome occurs in the adolescent years.

Case presentation

An 11-year-old boy was referred to our clinic due to the persistence of the lower deciduous molars. The further diagnosis revealed bilateral keratocystic odontogenic tumors in the region of teeth 33 and 45 representing a symptom of a Gorlin-Goltz syndrome. This case of the oral rehabilitation of an adolescent with bilateral keratocystic odontogenic tumors shows the approach of a multidisciplinary treatment concept including the following elements: Enucleation and bone defect augmentation using a prefabricated bone graft; distraction osteogenesis to extend the graft-block vertically after cessation of growth; accompanying orthodontic treatment, guided implant placement and prosthetic rehabilitation. Six months after implant insertion, a new keratocystic odontogenic tumor in the basal part of the left sinus maxillaris had to be removed combined with the closure of the oroantral fistula. During the follow-up period of 18 months in semi-annual intervals, the patient showed no sign of pathology.

Conclusion

In the presented case could be shown that distraction osteogenesis of prefabricated bone blocks is possible. With a multidisciplinary approach in a long-term treatment a sufficient oral rehabilitation of the patient suffering from extended keratocystic odontogenic tumors was possible.

A Novel Classification System for Injuries After Electronic Cigarette Explosions

Electronic cigarettes (e-cigarettes) contain lithium batteries that have been known to explode and/or cause fires that have resulted in burn injury. The purpose of this article is to present a case study, review injuries caused by e-cigarettes, and present a novel classification system from the newly emerging patterns of burns. A case study was presented and online media reports for e-cigarette burns were queried with search terms "e-cigarette burns" and "electronic cigarette burns." The reports and injury patterns were tabulated. Analysis was then performed to create a novel classification system based on the distinct injury patterns seen in the study. Two patients were seen at our regional burn center after e-cigarette burns. One had an injury to his thigh and penis that required operative intervention after ignition of this device in his pocket. The second had a facial burn and corneal abrasions when the device exploded while he was inhaling vapor. The Internet search and case studies resulted in 26 cases for evaluation. The burn patterns were divided in direct injury from the device igniting and indirect injury when the device caused a house or car fire. A numerical classification was created: direct injury: type 1 (hand injury) 7 cases, type 2 (face injury) 8 cases, type 3 (waist/groin injury) 11 cases, and type 5a (inhalation injury from using device) 2 cases; indirect injury: type 4 (house fire injury) 7 cases and type 5b (inhalation injury from fire started by the device) 4 cases. Multiple e-cigarette injuries are occurring in the United States and distinct patterns of burns are emerging. The classification system developed in this article will aid in further study and future regulation of these dangerous devices.

Tissue engineering in burn scar reconstruction

Nowadays, most patients with severe burns will survive their injury. This evolution is accompanied by the challenge to cover a large percentage of total body surface area burned. Consequently, more and more patients have to deal with the sequelae of burn scars and require (multiple) reconstructions. This review provides a gross overview of developments in the field of tissue engineering for permanent burn wound coverage and reconstructive burn surgery, focusing on usage and clinical effectiveness. Not only skin substitutes will be discussed but also the replacement of subcutaneous fat tissue and cartilage.

Preliminary results in single-step wound closure procedure of full-thickness facial burns in children by using the collagen-elastin matrix and review of pediatric facial burns

BACKGROUND

Management of full-thickness facial burns remains one of the greatest challenges. Controversy exists among surgeons regarding the use of early excision for facial burns. Unfortunately, delayed excision of deeper burns often results in more scarring and subsequent reconstruction becomes more difficult. A collagen-elastin matrix is used to improve the quality of the reconstructed skin, to reduce scarring and to prevent wound contraction. It serves as a foundation for split thickness skin graft and enhances short and long-term results.

AIM

We report the usage of a collagen-elastin matrix during single-step wound closure technique of severe full-thickness facial burns in 15 children with large burned body surface area, and also we review the literature about pediatric facial burns.

RESULTS

There were 15 pediatric patients with severe facial burns, 8 girls and 7 boys ranging in age from 10 months to 12 years, mean age 7 years and 6 months old. The facial burn surface area (FBSA) among the patients includes seven patients with 100%, five with 75%, and three with 50%. The average total body surface area (TBSA) for the patients was 72%, ranging between 50 and 90%. 5 of the patients' admissions were late, more than four days after burns while the rest of the patients were admitted within the first four days (acute admission time). The burns were caused by flame in eight of the patients, bomb blast in four, and scalding in three. All patients were treated by the simultaneous application of the collagen-elastin matrix and an unmeshed split thickness skin graft at Turgut Özal Medical Center, Pediatric Burn Center, Malatya, Turkey. After the treatment only two patients needed a second operation for revision of the grafts. All grafts transplanted to the face survived. The average Vancouver scar scales (VSS) were 2.55±1.42, ranging between one and six, in the first 10 of 15 patients at the end of 6 months postoperatively. VSS measurements of the last 5 patients were not taken since the 6 months postoperative period was not over.

CONCLUSION

In regard to early results, graft quality was close to normal skin in terms of vascularity, elasticity, pliability, texture and color. Esthetic and functional results have been encouraging. This study shows us that the collagen-elastin matrix as a dermal substitute is a useful adjunct, which may result in quick healing with satisfying esthetic and functional results. It also may enhance short and long-term results in after burn facial wound closure in children.