Estimation of wound surface area: an evaluation of medical professionals' assessment in a plastic surgery unit.

The percentage of skin graft take following the resurfacing of burn injuries is routinely calculated in a subjective fashion, in order to make management decisions. Given the gravity of decisions made based on this clinical assessment of graft check, it is notable that limited research has been carried out on this subject. No standardised subjective assessment tools exist to measure surface area of graft take in a manner similar to that of Wallace's Rule of Nines or Lund and Browder. This study set out to examine the accuracy of visual assessments of graft take within the multidisciplinary team regularly making assessments of newly grafted burn wounds. A total of 15 digitally drawn images were used to assess 36 staff members' estimations of percentage of surface area. The results showed a wide variation in estimation in all staff types, including senior burns surgeons, who were found to underestimate surface area by as much as 30%. The British Burns Association has removed 'healing time' as an outcome measurement from its guidance, as it recognises how hard it is to make a standardised assessment of wound healing. This study demonstrates the difficulty in subjectively assessing surface area and makes some suggestions for further research and clinical applications of technology to aid assessment.

Nasal reconstruction in panfacial burns: useful techniques in challenging cases.

Nasal reconstruction after severe panfacial burns can be challenging to correct because of scarring, loss of suitable donor sites, and variably limited blood supply of local flaps. We describe 2 cases of subtotal nasal reconstruction in which we overcame these difficulties. Both cases had alar subunit loss, which had left significant functional and esthetic deformities. However, both cases were managed very differently because of availability of donor sites.The first patient had 70% total body surface area burns with bilateral alar subunit loss: nasal reconstruction required a meticulous multistaged forehead flap. The second patient required nasal reconstruction using a turn-down flap to maximize take of a composite graft from previously burned ear donor sites.A number of surgical techniques have been described to manage subtotal burns nasal reconstruction, foremost of which are the nasolabial and paramedian forehead flaps. Cartilage grafts from the septum and the conchal bowl can be integrated into these flaps. Composite grafts can be unpredictable and are often used with caution.Such cases demonstrate that large composite grafts can be an extremely robust method of reconstruction even in a subset of patients with extensively scarred recipient and donor sites. In our second case, composite grafting avoided multistaged procedures such as the forehead flap and can be considered as a first-line procedure in large alar subunit loss.

Treatment of rhinophyma with the Versajet Hydrosurgery System.

Rhinophyma is thought to represent the most severe expression of acne rosacea for which surgery is the mainstay of treatment. The use of Versajet Hydrosurgery System has not been previously described for the treatment of this condition. We present six patients with moderate to severe rhinophyma ranging from 41 to 77 years of age who were treated successfully with this technique.

Bullous pemphigoid mistaken for a burn.

Burns in the elderly are extremely common. Often, the history is obscure or nonexistent because of confusion or dementia. We describe the case of a 78-year-old woman who was admitted to a burns center with the history of a 21% scald burn. However, this burn had unusual characteristics, and further investigation confirmed the cause to be bullous pemphigoid. This case report highlights the extreme care that must be taken in the assessment of children and the elderly who may not be able to give a complete history. We also present a table to aid in the differential diagnosis of unusual burns, which may be useful in such circumstances.