Exploring Advancement in Operative Burn Care: A Multidimensional Approach

Advancements in burn care, particularly in high-income countries, have significantly improved survival after severe burns. As a result, optimizing quality of life has become increasingly important. This includes improving surgical techniques and adopting multidisciplinary, patient-centered research approaches supported by technological innovations. Despite these developments, many burn patients still require surgical interventions, posing challenges for wound healing and scar formation. This thesis explores opportunities to optimize operative burn care, focusing on wound outcomes and scar quality.

Part I – Wound and short-term scar management

Split-thickness skin grafts (STSG) are frequently used for deep burns and other wounds. This thesis compares two STSG expansion techniques: mesh grafting, the most used since 1964, and Meek micrografting, first introduced in 1958 and reintroduced in the 1990s. While mesh grafting allows expansion up to 1:9, ratios above 1:3 can be harder to manage and less effective in extensive burns. Meek micrografting may conserve donor site size and improve scar outcomes, but clinical evidence remains inconsistent.
Chapter 2 reviews clinical outcomes of Meek micrografting, analyzing graft take, healing time, donor site size, and scar quality. However, most studies were methodologically weak, limiting firm conclusions. The review emphasized the need for high-quality trials comparing both techniques across consistent parameters.

Chapter 3 describes a multicenter intra-patient randomized controlled trial (RCT) conducted in the Netherlands and Belgium. Seventy patients with burns <20% TBSA received both mesh and Meek grafts on comparable wounds, enabling direct comparison. The study evaluated outcomes such as graft take, wound healing, infection rates, and scar quality at 3 and 12 months, as well as patient-reported satisfaction and preference.

Short-term results in Chapter 4 showed mesh grafting led to faster healing, higher take rates, and better scar quality. Meek micrografting was associated with more delayed healing but was occasionally preferred by patients using a 1:3 expansion ratio. Despite its advantage in reducing donor site size, mesh grafting appeared superior for short-term outcomes. Long-term results are not yet available.

Part II – Long-term scar management

Part II focuses on long-term scar management after burn surgery. Chapter 5 explores patient satisfaction with donor site outcomes one year after STSG. Though essential for grafting, donor sites often cause pain, altered sensation, or disfigurement. An observational study assessed preoperative counseling using a checklist, revealing gaps in communication about donor site size and post-operative pain. A patient survey showed overall satisfaction but highlighted concerns about appearance and discomfort, particularly influenced by donor site color and gender. These findings underline the need for realistic counseling and expectation management.

Chapter 6 evaluates adherent scars, which can cause functional limitations and aesthetic issues. A prospective cohort study assessed the effect of autologous fat grafting (AFG) with adhesiolysis, using fat processed by filtration. Scar outcomes were measured through several outcome parameters at baseline, 3, and 12 months. While patients reported improvements in pliability, pain, and satisfaction, objective measures showed no significant changes. Compared to centrifuged fat grafts, filtration-based AFG showed less measurable improvement. This discrepancy highlights the value of patient-reported outcomes alongside objective assessments.

Chapter 7 addresses the importance of accurate scar measurement. While advanced devices exist, they are often expensive and impractical. A low-cost 3D depth sensor was tested and validated in clinical settings. Despite some difficulty capturing curved surfaces, the system proved reliable, supporting its use in daily practice.

In conclusion, this thesis identifies opportunities to improve operative burn care, particularly in grafting strategies, donor site outcomes, scar treatments, and measurement tools. By integrating clinical and patient-reported outcomes, it advocates for patient-centered approaches and calls for standardized measurements, technological innovation, and inclusive study designs to enhance burn care and quality of life