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Severe burn injury is a serious systemic insult that can lead to life-threatening secondary infections. Immunosuppression, inhalation injury, and prolonged length of hospital stay are factors that predispose patients to severe respiratory tract infections. Furthermore, evidence shows that burns can put one at risk of infection long after the original injury. Currently in the United Kingdom, the annual National Flu Immunisation programme outlines guidance for groups who are deemed high risk and, therefore, eligible for the influenza vaccine. At present, no guidance exists for the administration of the influenza vaccine in burn-injured patients, despite knowledge of immunosuppression. The aim of this literature review is to examine the evidence for associations between burn injury and influenza and, where available, evaluate efficacy of influenza vaccines in this cohort. In addition, literature was searched for the effectiveness of the influenza vaccine in patients 65 years and above and in patients admitted to the intensive care unit (ICU), two domains common to patients with severe burns. Three papers were found to suggest increased susceptibility to influenza following burn injury; however, no papers studying the effectiveness of the influenza vaccine in this group were found. Several studies demonstrated improved outcomes in patients over 65 years and patients admitted to ICU. Following the evaluation of the evidence, this review advocates for the consideration of hospitalized burn patients for the influenza vaccine. We suggest the avoidance of vaccine administration in the acute burn phase. Further prospective clinical trials would be required to validate these findings.

Introduction There has been considerable concern in the UK with what seems to have been an increase in so-called ‘Acid Attacks’. The key data sources (Police data, Hospital admissions and Burns unit data) have limitations in capturing the acid attacks comprehensively. Incidents not reported to the police are missed in the Police data. The more serious injuries are included in the hospital admissions data, with no information on people with less severe injuries, not accessing health care. Burns unit data reveals detailed information on the burns treatment but represents only a small percent of all the acid attacks. Our aim was to explore the role of media reports as an additional data source. Methods Data was obtained from the public domain using generic online search engines along with a formal medical literature review. Search parameters included any news articles on ‘Acid Attacks’ printed between 01/01/2016 and 31/12/2017 in England and Articles in National Press only. We compared the data from media reports to the only other data sources available on these crimes which were (a) Crime statistics from police (b) the proportion treated in hospital (c) the subgroup treated in the burns service in the highest incidence location in the UK. Results Two hundred and Thirty media articles in total were found in the preliminary search. Following the application of the exclusion criteria, sixty attacks were analysed. The demographic data, the geographic data were obtained from the articles and the results were analysed using Microsoft Excel. There were a total of 118 survivors with an average age of 29.5 years and a male to female ratio of 5.1:1. There were no reported deaths. In the assailants group, the average age was 21.6 years with a male to female ratio of 15.7:1. All the data sources revealed higher male survivor predominance. The average age of the survivors was similar in the media reports, police data and the Burns centre data and was higher in the hospital data. Information on assailants and motives, available only on media reports and police data, corroborated well with each other. Media reports gave further information on the circumstances of the incident, the location and the number of survivors per assault, which was not available on any other data source. Though there was a rise in chemical assaults reported in media reports and MPS data in 2017 compared to the previous year, there was no rise in chemical assault related hospital admissions. Conclusion The majority of the survivors were males, which is consistent between all UK data sources. Media reports revealed that the South east of England had the majority of chemical assaults in England. Data from this source provides a further piece in the jigsaw especially in relation to the circumstances, the geographic location of the chemical assault and number of survivors per incident. We acknowledge the limitations of media reporting. In the absence of a formal database for such injuries and incomplete data from various sources, we have to consider all possible data sources to provide new information. We have discussed the utility, pros & cons of media reports as one of the additional sources of information to better understand these injuries.

Hand burns are common and often complex injuries, requiring referral to specialist centers. The patient’s thumbprint is a rapid means of accurately assessing hand burn surface area. This study aimed to establish categories and evaluate sites of hand burn surface area in order to facilitate comparison of hand burns. Sixteen burns involving the hand and wrist among 14 patients referred to a burns center were retrospectively categorized by burn mechanism, burn thickness, and hand burn surface area. The burn surface area in the clinical record was compared with that calculated by the thumbprint method and the rule of thumb diagram. Burn surface area in the clinical record was either “1%” or “

Introduction Advances in the evidence base of acute thermal hand burns help to guide the management of these common injuries. The aim of this literature review was to evaluate recent evidence in the field over 10 years. Methods The Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols methodology was used as a guide for this literature review. PubMed, MEDLINE, EMBASE, CINAHL, and Google Scholar were searched for English language articles related to hand burns published between 2009 and 2018 inclusive, and the Cochrane Library was reviewed. Exclusion criteria were as follows: participants younger than 18 years, scar or contracture management, rehabilitation, outcomes assessment, late reconstruction, and electrical or chemical burns. Results An initial search retrieved 6493 articles, which was narrowed to 403 full-text articles that were reviewed independently by 3 of the authors and categorized. Of 202 included articles, there were 8 randomized controlled trials and 2 systematic reviews. Six evidence-based guidelines were reviewed. Referral of hand burns to specialist centers, use of telemedicine, early excision and grafting, and immediate static splintage have been recommended. Enzymatic debridement results in earlier intervention, more accurate burn assessment, preservation of vital tissue, and fewer skin grafts, and ideally requires regional anesthesia. Guidance on escharotomy emphasizes indication, technique and adequate intervention, and potential for enzymatic debridement. Inclusion of topical negative pressure, dermal regenerative templates, acellular dermal matrices, and noncellular skin substitutes in management has helped improve scar and functional outcomes. Discussion The results of this literature review demonstrate that multiple national and international societies have published burns guidelines during the decade studied, with aspects directly relevant to hand burns, including the International Society for Burn Injuries guidelines. There are opportunities for evidence-based quality improvement across the field of hand burns in many centers. Conclusions More than 200 articles globally in 10 years outline advances in the understanding of acute management of thermal hand burns. Incorporating the evidence base into practice may facilitate optimization of triage referral pathways and acute management for hand burns.

Introduction: Many healthcare workers have contracted SARS-CoV-2 during the pandemic, many cases of which have resulted in severe illness and death. No studies have assessed the potential for powered dermatomes to generate aerosol, an essential technique in burns and plastic surgery. The primary aim of the present study was to capture video footage to illustrate the potential for a powered dermatome to generate significant spray and hence aerosol. Methods: We utilised a simulated skin graft harvest experimental method. Fluorescein-stained saline was used with ultraviolet (UV) backlighting to demonstrate fluorescent spray from a popular brand of air-powered dermatome. Ultra-slow-motion (960 frames/s) video was used to demonstrate the oscillation of the dermatome blade and the origin within the machine of any spray generated, and the extent of spray generated. Results: The key finding from this study is the captured video footage linked with this paper. Droplets of various sizes are seen spraying out from the leading edge at the sides where the blade oscillates. UV backlighting provides a clear demonstration of the dermatome generating fine spray. Conclusion: Our study demonstrates that powered dermatome usage is likely to generate aerosol from blood or blood-contaminated fluid, but does not demonstrate or quantify to what extent this may be clinically relevant in terms of viral transmission potential. We suggest ways to reduce the risk of spray from dermatomes including limiting donor-site bleeding and avoiding a wet donor area. Lay Summary A dermatome is a device used by surgeons to harvest split skin grafts (SSGs). SSGs are an essential component of burns and reconstructive plastic surgery. Aerosol-generating procedures (AGPs) have implications for transmission of viruses including COVID-19. It has not previously been formally assessed whether use of a dermatome should be classified as an AGP. This study uses a fluorescent dye in the context of simulated surgery using a dermatome to see if any, and how much, fine spray is generated from the device and also utilises ultra-slow-motion videography to see how any spray may be generated. At the heart of this study is the included video footage that demonstrates considerable fine spray generation which suggests it is best to assume that dermatomes are likely to generate some degree of aerosol depending on the clinical scenario and how it is used. However, this information does not translate to providing any information about the risk of transmission of the virus from using a dermatome, especially in relation to COVID-19, and separate research would be required to answer this.

Summary Background Burns patients are at high risk of nosocomial infection, and Pseudomonas aeruginosa is one of the most common causes of wound and systemic infections resulting in significant morbidity and mortality in burns patients. Aim To describe an outbreak of multidrug-resistant P. aeruginosa (MDR-Pa) at a specialist burns service and highlight the challenges in identifying the reservoir of infection despite extensive epidemiological, microbiological, and environmental investigations. Methods Multi-disciplinary outbreak control investigation. Findings Following an inter-hospital transfer of a burns patient from another country, an admission screen revealed that the patient was colonized with MDR-Pa. Subsequently nine more patients contracted MDR-Pa in the period from November 2015 to September 2017. Given the relatively long gap between confirmation of the index and subsequent cases, it was not possible to identify with certainty the reservoirs and mechanisms of spread of infection, although contamination of the burns service environment and equipment are likely to be contributory factors. Conclusion Preventing infection transmission in specialist burns services is highly challenging, and it may not always be possible to identify and eradicate the reservoirs of infection for P. aeruginosa outbreaks. Our study supports the literature, providing additional evidence that inanimate, common contact surfaces play an important role in nosocomial transmission of P. aeruginosa. These surfaces should either be decontaminated efficiently between patient contacts or be single patient use. Enhanced vigilance is crucial, and, with strict adherence to infection prevention and control procedures, it is possible to reduce the risk of acquisition and spread of infection in patients.

Photodynamic therapy (PDT) involves the use of a photosensitiser, a light source and the presence of oxygen to create reactive oxygen species (ROS) intercellularly. The accumulation of free radicals directs cell apoptosis and modulates cellular protein expression and signalling. PDT has a range of applications including treatment of cancers, in particular of the skin. It is recommended by the British Association of Dermatologist for actinic keratoses, Bowen’s disease and superficial basal cell carcinoma [1]. Off label, it is used in inflammatory and infective conditions such as acne, psoriasis and viral warts [1, 2]. Recent research has found PDT to be effective in scar management including hypertrophic, keloid, striae and burns scars in animal, ex vivo and case studies.

This chapter investigates the use of Pulsed Dye Laser (PDL) as a therapeutic tool for hypertrophic burns scarring. The progression of hypertrophic scars from burn wounds is first described. The chapter then reviews the evidence for treatment of hypertrophic scars with PDL. The efficacy of PDL for both prevention and treatment is summarised for all hypertrophic scarring with particular emphasis on early intervention. The chapter concludes with recommendations for treatment methodology using 595 nm PDL and gives photos of a case example.

No treatment or intervention is without risk. The only way to completely avoid any complication is never to treat. In certain circumstances, not treating can be the best option for a range of reasons beyond the scope of this chapter.

Intense pulsed light (IPL) is a non-coherent filtered flash lamp, emitting a broadband spectrum (515–1200 nm) of visible polychromatic-pulsed light of a high intensity [1]. As such, it is not a laser technology per se using a filter to narrow the spectrum of light rather than emitting a single wavelength of light as lasers do. Its use was first conceived as therapeutic treatment of vascular lesions in 1992 [2].

This chapter focuses on the basic pathophysiological mechanisms associated with scarring. Anatomy and physiology of the skin, as well as our current understanding of how scar tissue forms, and how the process of scarring can be modulated are described.

Heterotopic hair growth is characterised by excessive hair growth in an abnormal anatomical location. The most common causes in the general population include an overproduction or increased sensitivity to circulating androgens, although most patterns of hair growth vary depending on sex and ethnicity [1]. In patients who have required reconstructive surgery, this can lead to hair-bearing donor tissue being present in non-hear-bearing areas, or an excess. Examples include: ear reconstruction with hair-bearing scalp skin leading to hairy ears; skin grafts such as full-thickness skin from the groin causing course or even pubic hair on the reconstructed areas including the face; and internal reconstructions such as tongue, floor of mouth, nose, lumen of the penis or neovagina after reconstruction growing hair.

The aim of this chapter is to provide an overview of consent as relevant to laser therapy. This is especially relevant because lasers and laser treatment can be complex and difficult to explain, may require multiple sessions and have a distinct risk of complications that can be mitigated through good communication, safe practice and appropriate documentation.

Laser scar management is a complex area that relies on the use of a number of different laser modalities to achieve a variety of modulatory effects on scar tissue. The challenges involved include the availability (and cost) of a range of lasers, clinical experience—especially with complex conditions such as burns, and hence patients tend to gravitate to regional and supra-regional referral centres where sufficient numbers of patients are treated. This chapter provides clinical examples of laser interventions for patients with a range of scars including complex burns scars, keloid scars, and how lasers can be used to improve scarring.

ObjectivesIdentifying the issues and concerns that matter most to burns survivors can be challenging. For a number of reasons, but mainly relating to patient empowerment, some of the most pressing concerns patients may have during a clinical encounter may not naturally be the focal point of that encounter. The Patient Concerns Inventory (PCI) is a tried and tested concept initially developed in the field of head and neck cancer that empowers patients during a clinical encounter through provision of a list of prompts that allows patients to self-report concerns prior to consultation. The aim of this study was to develop a PCI for adult burns patients.DesignContent for the PCI was generated from three sources: burns health-related quality of life tools, thematic analysis of one-to-one interviews with 12 adult burns patients and 17 multidisciplinary team (MDT) members. Content was refined using a Delphi consensus technique, with patients and staff members, using SurveyMonkey.SettingWithin outpatient secondary care.ParticipantsTwelve adult burns patients and MDT members from two regional burns centres.ResultsA total of 111 individual items were generated from the three sources. The Delphi process refined the total number of items to 58. The main emergent domains were physical and functional well-being (18 items), psychological, emotional and spiritual well-being (22 items), social care and social well-being (7 items) and treatment-related concerns (11 items).ConclusionsThe Adult Burns Patient Concerns Inventory is a 58-item, holistic prompt list, designed to be used in the outpatient clinic. It offers a new tool in burn care to improve communication between healthcare professionals and patients, empowering them to identify their most pressing concerns and hence deliver a more focused and targeted patient-centred clinical encounter.

The initial management of patients with an acute burn injury is often undertaken by individuals with relatively little experience in this area. To optimize outcomes and minimize the risk of long-term sequelae, clinicians should understand the key steps in initial management and safe transfer of these patients to a specialist burns unit. These include safely extricating patients and providing prompt first aid at scene; rapidly and accurately assessing them at the nearest emergency department or trauma centre; appropriately managing their airway and oxygenation; obtaining intravenous access and initiating fluid resuscitation; assessing burn extent and depth and considering the potential need for escharotomies; providing analgesia and appropriate tetanus prophylaxis; and covering and warming the patient while temporarily dressing their burns. Once these measures are taken, any patient with a burn injury may be discussed with a specialist burns unit for advice. If deemed necessary and accepted, they should be promptly transferred to a burns unit with an appropriate escort. Prior to transfer, a systematic re-assessment should be undertaken, and any required treatments should be continued during the transfer. Copies of all referral information and the results of initial assessments and investigations should be sent with the patient to ensure a robust handover process.

This chapter provides an overview of laser as applied to burns and scar management.

This chapter explores the topic of non-accidental injury burns in children. It is important to consider the possibility of non-accidental injury and recognize injury patterns. The chapter gives a concise overview of the patient and parent characteristics, assessment of such patients and differential diagnoses to consider in the process of managing children in these situations. Patterns of injury in non-accidental burns are described.

Creative Commons CC-BY-NC: This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 3.0 License (http://www.creativecommons.org/licenses/by-nc/3.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage). Follow the path of the unsafe, independent thinker. Expose your ideas to the danger of controversy. Speak your mind and fear less the label of ‘crackpot’ than the stigma of conformity.

Introduction Rapid estimation of acute hand burns is important for communication, standardisation of assessment, rehabilitation and research. Use of an individual’s own thumbprint area as a fraction of their total hand surface area was evaluated to assess potential utility in hand burn evaluation. Materials and methods Ten health professionals used an ink-covered dominant thumb pulp to cover the surfaces of their own non-dominant hand using the contralateral thumb. Thumbprints were assessed on the web spaces, sides of digits and dorsum and palm beyond the distal wrist crease. Hand surface area was estimated using the Banerjee and Sen method, and thumbprint ellipse area calculated to assess correlation. Results Mean estimated total hand surface area was 390.0 cm2 ± SD 51.5 (328.3–469.0), mean thumbprint ellipse area was 5.5 cm2 ± SD 1.3 (3.7–8.4), and mean estimated print number was 73.5 ± SD 11.0 (range 53.1–87.8, 95% CI 6.8). The mean observed number of thumbprints on one hand was 80.1 ± SD 5.9 (range 70.0–88.0, 95% CI 3.7), χ2 = 0.009. The combined mean of digital prints was 42, comprising a mean of two prints each on volar, dorsal, radial and ulnar digit surfaces, except volar middle and ring (3 prints each). Palmar prints were 15 (11–19), dorsal 15 (11–19), ulnar palm border 3, first web space 2, and second, third and fourth web spaces one each. Using the surface of the palm alone, excluding digits, as 0.5% of total body surface area, the area of one thumbprint was approximated as 1/30th of 1%. Conclusions We have demonstrated how thumbprint area serves as a simple method for evaluating hand burn surface area.

Introduction: Current guidelines suggest a multimodal approach to treating scars but there is no gold standard for treatment; however, there is exciting therapeutic potential for the use of autologous fat grafting (AFG). Functional and aesthetic improvements have been reported, including pain relief and scar quality improvement. Aims: To explore the current evidence regarding the use of AFG in hypertrophic and painful scars. Methods: A systematic review of the literature was conducted using 11 MeSH terms in PubMed, Medline and EMBASE. English studies that used AFG to treat scars in human participants were included. Results: A total of 746 studies were found and 23 studies (from 2008 to 2016) were included: five studies were evidence level V; nine studies were evidence level IV; eight were evidence level III; and one study was evidence level II. A total of 1158 patients were assessed for improvement in scar characteristics including colour, thickness, volume, pain and restoration of function at affected sites, following treatment. Positive outcomes were noted for all parameters and a significant improvement in AFG’s analgesic effect was recorded in 567 out of 966 patients, P < 0.05. Discussion: AFG is a minimally invasive and safe approach to treating scars, a promising alternative to surgical excision. The technique of blunt cannula insertion optimises the release of scar retraction, which contributes to the analgesic effect of this treatment method. The evidence supports current theories of mesenchymal stem cell’s regenerative and anti-inflammatory properties responsible for scar healing. There are limited high quality studies to support its use and future randomised controlled trials should be conducted., Lay Summary Currently there is no gold standard treatment for scars, however there is exciting potential for the use of autologous fat grafting (AFG). This technique uses liposuction to extract fat from areas of the body where it is readily available. It is then processed to remove all debris and injected under a scar. We carried out a study to review its use in clinical practice. Results of the literature suggest fat contains specialised stem cells that possess properties which improve the quality of scars. Fat injection has been shown to decrease tension which softens scar tissue and provides pain relief. Analgesic effects are caused by nerve repair and scar entrapment release. As well as functional benefits, the evidence also shows fat grafting improves the cosmetic appearance of a scar. In conclusion, AFG is a safe treatment method with few complications. This method poses promising benefits in future treatment of scar-related conditions.

Systemic anaplastic large cell lymphoma (ALCL) is a distinct disease classification provisionally sub-divided into ALCL, Anaplastic Lymphoma Kinase (ALK)+ and ALCL, ALK− entities. More recently, another category of ALCL has been increasingly reported in the literature and is associated with the presence of breast implants. A comprehensive review of the 71 reported cases of breast implant associated ALCL (iALCL) is presented indicating the apparent risk factors and main characteristics of this rare cancer. The average patient is 50 years of age and most cases present in the capsule surrounding the implant as part of the periprosthetic fluid or the capsule itself on average at 10 years post-surgery suggesting that iALCL is a late complication. The absolute risk is low ranging from 1:500,000 to 1:3,000,000 patients with breast implants per year. The majority of cases are ALK-negative, yet are associated with silicone-coated implants suggestive of the mechanism of tumorigenesis which is discussed in relation to chronic inflammation, immunogenicity of the implants and sub-clinical infection. In particular, capsulotomy alone seems to be sufficient for the treatment of many cases suggesting the implants provide the biological stimulus whereas others require further treatment including chemo- and radiotherapy although reported cases remain too low to recommend a therapeutic approach. However, CD30-based therapeutics might be a future option.

In recent times, there has been evolving interest in the fascial structure of the ear, especially in relation to otoplasty techniques. Although the fascial tissues used in these procedures are referred to as "postauricular/retroauricular fascia," the sparse anatomical studies that exist use this terminology to describe what is the adjacent thicker and more fibrous structure of the superficial temporal area continuous with the mastoid region, rather than the tissue actually used in these procedures which is adherent to the posterior surface of the ear. There are clear clinical differences in the properties of these two structures, and this study set out to identify the anatomical nature of these differences, looking in detail at the anatomy and vascularity of the fascia directly posterior and adherent to the ear itself, highlighting its unique properties, and how it interfaces with the rest of the fascia. We provide a nomenclature to differentiate the fascia adherent to the posterior of the ear (the intrinsic postauricular fascia) from the more fibrous tissues continuous with the scalp fascia (the extrinsic postauricular fascia). Clinical applications for the fascia are suggested based on the vascularity and anatomy described, and our clinical experience.

Many decellularized dermal matrices are available with various applications, all with slight differences. AlloDerm appears to have the greatest presence in the literature. The purpose of this systematic review is to provide an overview of the experience with AlloDerm, stratified by clinical indication.A literature search was performed across Medline, EMBASE, and the Cochrane Collaboration using the search terms "AlloDerm" and "acellular dermal matrix." Two independent authors applied a priori inclusion and exclusion criteria. Relevant articles were categorized by application, type of study, and evidence level.A total of 753 articles met the initial inclusion criteria, and 311 remained after discarding irrelevant articles: skin (25), head and neck (82), breast (34), trunk (66), pelvis (10), extremities (8), and basic science (86). Non-basic science study designs included 32 analytic articles (3 randomized controlled trials and 29 observational studies including 11 cohort studies, 1 cross-sectional study, and 17 case-controlled studies), 192 descriptive articles (106 case series, 51 case reports, 2 cross-sectional studies, and 33 qualitative studies), and 1 systematic review. More than 85% of articles had a level of evidence of 4 or 5. Articles showed outcomes that were 70% positive, 23% neutral, and 7% negative.AlloDerm has many clinical uses with promising results. Most evidence lies in descriptive and nonrandomized studies, but randomized trials are emerging. Cost and logistics of large trials with these products make large-scale trials challenging but necessary. Emphasis needs to shift to randomized controlled trials focusing on areas where most clinical benefit can be realized.