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Aesthetic Satisfaction with Split-Thickness Skin Grafts in the Burn Population Is Related to Compliance with Ultraviolet Radiation Reduction Measures

Koltz, Peter F. M.D.; Childs, Sean M. B.S.; Bell, Derek E. M.D.

Plastic and Reconstructive Surgery: September 2014 - Volume 134 - Issue 3 - p 499e
doi: 10.1097/PRS.0000000000000426

Division of Plastic and Reconstructive Surgery, University of Rochester Medical Center, Rochester, N.Y.

Correspondence to Dr. Bell, Division of Plastic and Reconstructive Surgery, 601 Elmwood Avenue, Box 661, Rochester, N.Y. 14642,

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The number of individuals sustaining burn injuries requiring inpatient hospitalization is continuing to rise.1,2 Treatment for many severe burns requires wound coverage, commonly through the use of split-thickness skin grafts. Although specialized centers work vigorously to minimize complication rates of skin grafts during hospitalization, they also use various techniques to educate patients on the importance of posthospitalization care, with protection from ultraviolet light being a large component. Although case reports citing carcinoma arising from split-thickness skin grafts are beginning to appear in recent literature,3,4 there is a paucity of research investigating relationships between postsurgical skin care compliance and overall aesthetic appearance of grafts. No studies to date have examined burn patient compliance with ultraviolet light–reducing measures or aesthetic satisfaction in light of said compliance. This study hypothesizes that adherence to postoperative graft care and ultraviolet light protection will increase overall aesthetic satisfaction by minimizing complications arising primarily from ultraviolet light and its associated effects.

All emergency and outpatient consultations for full-thickness burns ultimately requiring split-thickness skin grafting between January of 2006 and May of 2012 were reviewed retrospectively. All patients received informal teaching on the risks of excess ultraviolet light exposure and methods of mitigating exposure. A telephone survey was created that examined patient demographics, knowledge of ultraviolet risks and reduction measures, compliance with ultraviolet light–reducing measures, and aesthetic satisfaction.

Five hundred fifty-seven patients sustained full-thickness burns requiring skin grafting. The average age of respondents was 39.8 years, sustaining an average total body surface area burn of 4.8 percent. Ninety-two percent recalled being educated about general skin graft care, and 68 percent recalled split-thickness skin graft ultraviolet light protection education. Patients reported wearing ultraviolet light protection on their sun-exposed skin graft as follows: all of the time, 15 percent; some of the time, 63 percent; and never, 22 percent. Although 90 percent of patients reported being happy with their split-thickness skin graft overall, 20 percent reported pigmentation aberration and 12 percent reported hypertrophic components to their graft.

In examining the results of this study, it was found that patients who were more compliant with graft care, including careful ultraviolet light protection and reduction, were more satisfied with the overall aesthetic properties of the graft. Although mechanisms behind graft dyschromia are not clearly understood, many accepted hypotheses implicate ultraviolet light as an important causative factor.5 With this in mind, education on the importance and rationale for strict ultraviolet light protection over graft areas becomes increasingly important in maximizing aesthetic satisfaction.

At our institution, all burn patients who underwent split-thickness skin grafting received the same education, and the majority (95 percent) could thereafter remember basic wound care instructions. Despite this, many patients could not remember much regarding specific details of ultraviolet light protection. Specifically, only 68 percent of patients remembered information regarding dyschromia, whereas a mere 31 percent claimed they were educated about potential skin cancer risks associated with the grafted area. This lack of recall undoubtedly resulted in poor compliance with ultraviolet light–reducing measures. With this in mind, educational measures on the importance of ultraviolet light protection for skin grafts must be delivered in a manner to optimize patient understanding and compliance.

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The authors have no financial interest to declare in relation to the content of this article.

Peter F. Koltz, M.D.

Sean M. Childs, B.S.

Derek E. Bell, M.D.

Division of Plastic and Reconstructive Surgery

University of Rochester Medical Center

Rochester, N.Y.

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1. Singer AJ, Dagum AB.. Current management of acute cutaneous wounds. N Engl J Med. 2008;359:1037–1046
2. Pauldine R, Gibson BR, Gerold KB, Milner SM.. Considerations in burn critical care. Contemp Crit Care. 2008;6:1–11
3. Angelos TM, Larsen MT, Janz BA.. Nodular basal cell carcinoma arising in a split-thickness skin graft of the scalp. Ann Plast Surg. 2013;71:372–374
4. Berking C, Takemoto R, Binder RL, et al. Photocarcinogenesis in human adult skin grafts. Carcinogenesis. 2002;23:181–187
5. Flament F, Bazin R, Laquieze S, Rubert V, Simonpietri E, Piot B. Effect of the sun on visible clinical signs of aging in Caucasian skin. Clin Cosmet Investig Dermatol. 2013;6:221–232
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