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Background: Oftentimes, obese dialysis patients develop a viable dialysis access but the access is too deep for cannulation and needs a superficialization procedure. Methods: We present our 14-patient cohort in whom we performed liposuction to superficialize viable but deep vascular accesses. Out of 14 patients, 12 had arteriovenous fistulas and 2 arteriovenous grafts. The primary end points were the ability to superficialize a completely unusable access and to remove the hemodialysis catheter (3patients), or to significantly extend the useful length of a deep access in which only a very short segment was used and to continue to use the access post-surgery without the need to place a dialysis catheter (11 patients). Results: The study goal was met in 13 out of 14 patients. In two of three patients, the catheters were removed and their access usable length was 14 and 13 cm, respectively. The accesses could be used immediately after liposuction in all patients in which this applied—11 patients. The usable access length increased from a mean of 5 to 12.7 cm. The access mean depth decreased from 10.8 mm pre-surgery to 7 mm post-surgery and 5.3 mm 4 weeks after surgery. The mean volume of fat removed was 43.8 cc. We had only one surgical complication: bleeding that was readily controlled with manual pressure. All patients were discharged to home the same day. Postoperative pain was mild. Conclusion: Liposuction is effective, safe, and seems to be the least invasive technique of superficialization.

The demand for car seat heaters is on the rise due to the added comfort they offer passengers. However, such luxury is not without risk and prolonged exposure to high surface temperatures of the seat may result in severe burns. We present a unique case of an 18-year-old paraplegic patient who sustained severe full-thickness burns requiring operative intervention after prolonged exposure to a car seat heater. We then tested 10 car seat heaters manufactured after 2014 to establish maximum temperature settings and safety features. We also examine the importance of raising awareness to this issue and share the concerns of previous publications regarding the lack of manufacturer standards in car seat heaters.

Introduction Today it is estimated that approximately 30–40% of the cars in U.S have seat warmers, with the demand increasing. Unfortunately, these seat warmers do not have any established guideline of safety, leading some warmers to stay on for extended periods of time and reach temperatures that far exceed the human skin tolerance levels. Magunia et al. first described a patient with full-thickness burns in 2003, however in the time since this publishing, minimal factory standards have been instituted. We report a unique case of a neurologically impaired patient who suffered posterior thigh full-thickness burns secondary to a car seat heater. A delay in her treatment led to the need for surgical intervention. We also tested car models 2014 and newer to establish whether modern cars still present a danger to vulnerable populations. Methods Testing of 10 cars, models 2014 or newer, with a contact surface temperature thermometer independently calibrated. Testing in 21°C ambient air. Four tests, average and highest temperature both recorded. Results Maximum seat temperatures range from 35°C - 53°C. Average seat temperatures range from 34°C - 49°C. Conclusions This case illustrates the dangers and risks presented with car seat heaters. Cases such as this, still happening after the voluntary NHTSA mandate, emphasize the need for heightened physician awareness and mandatory factory standards. In agreement with the National Highway Traffic Safety Administration (NHTSA) statement, under no circumstances should a seat heater top 43°C. We tested 10 cars and found 7 of these cars exceeded the 43°C. In addition, all seat heaters should include self-timers. In our unique case, the patient had no awareness the seat heater was on, suggesting the need for a clearer alert on the dashboard. Health-care providers should also help educate patients about the potential dangers of seat warmers, especially in vulnerable populations. Applicability of Research to Practice This research highlights the potential dangers car seat heaters present to consumers. Mounting evidence, including lawsuit and case reports, show car seat heaters far exceed voluntary standards set by NHTSA. These temperatures put patrons at increased risk of life-altering burns. Furthermore, these are not “faulty” heaters, these heaters are functioning as the manufacturers fabricated them. We also report seat heaters have not followed suggestions outlined by Manguina et al in 2003, such as dash alerts, automatic turn off timer, and other safety features. The first step is raising awareness to healthcare workers so proper warnings can be made to patients, especially those who are neurologically impaired.

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Glass fronted gas fireplaces (GFGFs) have exterior surfaces that can reach extremely high temperatures. Burn injuries from contact with the glass front can be severe with long-term sequelae. The Consumer Product Safety Commission reported that these injuries are uncommon, whereas single-center studies indicate a much higher frequency. The purpose of this multi-institutional study was to determine the magnitude and severity of GFGF injuries in North America. Seventeen burn centers elected to participate in this retrospective chart review. Chart review identified 402 children ≤10 years of age who sustained contact burns from contact with GFGF, who were seen or admitted to the study hospitals from January 2006 to December 2010. Demographic, burn, treatment, and financial data were collected. The mean age of the study group was 16.8 ± 13.3 months. The majority suffered burns to their hands (396, 98.5%), with burns to the face being the second, much less common site (14, 3.5%). Two hundred and sixty-nine required rehabilitation therapy (66.9%). The number of GFGF injuries reported was 20 times greater than the approximately 30 injuries estimated by the Consumer Product Safety Commission's 10-year review. For the affected children, these injuries are painful, often costly and occasionally can lead to long-term sequelae. Given that less than a quarter of burn centers contributed data, the injury numbers reported herein support a need for broader safety guidelines for gas fireplaces in order to have a significant impact on future injuries.

Management of head and neck burns involves acute and intermediate phases. Acutely, the goals are establish a secure airway and treat life-threatening injuries. Then, optimize nutrition, assess extent of the burn, perform local wound care, and provide eye protection. Management depends on the degree of the head and neck burn. Postinjury splinting and rehabilitation are vital to healing. After the acute inflammation has resolved and the scars have matured, reconstruction begins with the goals of restoring both function and aesthetics. Reconstruction ranges from simple scar release, to skin grafting, and possibly free flap reconstruction.

Amniotic membrane is immunologically privileged and is a reservoir of growth factors and cytokines known to modulate inflammation and enhance the healing process, while also possessing antimicrobial, antifibrosis, and antiscarring properties. These properties establish a strong argument for using amniotic membrane derived products as a treatment for burns. The purpose of this article is to describe the use of commercially available dehydrated human amnion/chorion membrane allografts in patients with partial-thickness and full-thickness burns.

Development of metrics for burn care, including healing of skin wounds during the acute phase of treatment, is essential in an environment of decreasing resources and increasing interest in quality and accuracy of medical information. Advantages of consensus metrics include: tracking of trends in care; consistency of care; and correlation of treatment with medical outcomes. For cutaneous burn wounds, these advantages are confounded by factors that contribute to the heterogeneity of burn wounds, including but not limited to: TBSA of injury, depth of injury (partial or full thickness), cause, patient-dependent factors such as age, sex, and comorbidities, anatomic site, and time between injury and treatment. Similar factors contribute to complex injuries from trauma, depth, debridement or excision of devitalized tissue, dressing or grafting of the prepared wound bed, and assessment to determine wound closure. In the absence of confounding factors or comorbidities, wound closure is one of the key criteria for discharge from acute care whether in hospital, or ambulatory care. Not surprisingly, these metrics for wound healing have been used repeatedly in the assessment of developing therapies for wound care. In response, review by the FDA of novel therapies has led to Guidance for Industry: chronic cutaneous ulcer and burn wounds developing products for treatment. and allow for risk adjustment of individuals in the population, who otherwise may be outliers to the statistical mean of the entire population.

SUMMARY Chemical burns are interesting and challenging to treat. When the practitioner is comfortable with the pathophysiology of chemical injury and treatment based on these principles, most patients can be treated effectively with good outcome (Fig. 2). Early treatment with water irrigation, followed by diligent wound care, will allow our patients to benefit to the maximum from our medical skills.

Background: Epinephrine administration for hemostasis during burn wound excision may produce potential anesthetic risks. Two patient groups were studied to determine the absorption of either topical concentrated epinephrine or exogenously injected dilute epinephrine. Methods: For the topical group (10 patients, 10 procedures), excision of wounds under tourniquet was performed, followed by epinephrine ( 1 mg/10 mL) gauze with pressure wrapping. For the clysis group (9 patients, 12 procedures), donor sites were injected with 0.5 mg epinephrine/1,000 mL lactated Ringer's solution before harvest. Nine intraoperative serum samples were collected and frozen during each procedure for epinephrine and norepinephrine assay. Results: Concentrated epinephrine (67 mL) was topically applied to excise 1,362 cm 2 . Dilute epinephrine (1,350 mL) was clysed to obtain 1,950 cm 2 autograft. No significant increases in the serum catecholamines or changes in the cardiovascular profiles occurred. Conclusion: The administration of either topical or clysed epinephrine during acute burn excision does not cause any side effects for safe anesthetic management; there were no detectable increased plasma levels of epinephrine or norepinephrine. Epinephrine provides the burn surgeon with two safe methods for controlling intraoperative blood loss.

Burn scar contractures of the foot cause significant morbidity. We reviewed 68 children in regard to number and rates of burn scar contracture recurrence, surgical techniques, and functional and aesthetic results. Two surgical techniques of foot burn scar contracture release have been used. Originally, an incision over the metatarsal heads perpendicular to the line of the metatarsals, which releases the longitudinal arch of the foot was used. More recently, additional releasing incisions parallel to the plane of the metatarsals to release the transverse metatarsal arch have been used. The time between burn injury and primary burn scar contracture release was 4.18 +/- 0.76 years, and the time until the first recurrence was 3.44 +/- 0.46 years. With release of only the longitudinal arch, recurrence of burn scar contractures occurred in 3.5 +/- 0.41 years and in 4.29 +/- 1.27 years in six patients who also received release of the transverse arch. Wound closure at the time of acute burn with split-thickness skin graft expansion ratios of 1:2 and 1:4 had burn scar contractures that required release in 4.21 +/- 0.70 and 2.29 +/- 0.52 years, respectively.

Twenty-nine patients with necrotizing fasciitis who were treated with 5% mafenide acetate solution (MAS) as an adjunct after grafting were compared with 45 patients treated without MAS. Statistical analysis of differences was obtained through P values by chi2 testing. The MAS+ (M) and MAS- (C) groups were similar in percent skin deficit (M = 7.5%; C = 9.8%), with the extremity being the most common area of infection. Streptococcus was the most common single organism but polymicrobial infections were the most prevalent (M = 48%; C = 58%). Patients with necrotizing fasciitis treated with MAS had fewer debridements per patient (M = 3.7; C = 5.4), fewer closure procedures (average per patient: M = 1.2; C = 1.73) and a higher percent of first-time closures (83 vs 59%; chi2 = 4.26; P = 0.039). There is a trend toward a lower mortality rate (3.4 vs 13%; chi2 = 2.00; P = 0.158). We conclude that MAS is a useful adjunct in necrotizing fasciitis wound care protocols.

A 42-year-old black man presented with an extensive keloid on the anterior section of his chest wall. He had acne as a child and developed a number of significant keloids, the most symptomatic being the keloid on his chest wall. This keloid had been treated with excision approximately 10 years previously in another city, followed by placement of a number of mesh split-thickness skin grafts (STSGs) obtained from his thighs. According to the patient, the superior edge of the keloid had also been irradiated some time after surgery. The entire keloid located on his chest wall had regrown significantly, causing the patient problems with bending at the waist and with full range of motion in his shoulders. The recurrence had been treated with intralesional corticosteroids and cryotherapy (separately and combined), as well as silicone gel and flurandrenolide (Cordran tape, Lilly, Eli and Co, Indianapolis, Ind) without significant improvement. In addition, a smaller keloid had been excised on his back and the epidermis removed from the keloid and replaced over the wound, with significant regrowth of that keloid as well. On physical examination the patient had an extensive keloid encompassing the surface area extending from the clavicle to the inframammary crease (Figure 1). The inferior portion of the keloid, which was the thickest portion, had curled under itself and had completely encased the patient’s areolae, which were not visible. In addition, the patient had a number of keloids located on his back and upper extremities. He had hypertrophic, but not keloidal, scars on his thighs at the donor sites from his previous STSGs.