TY - JOUR
AU - FACS, Steven E. Wolf, MD,
AB - Abstract The goal of burn surgical therapy is to minimize mortality and to return survivors to their preinjury state. Prompt removal of the burn eschar, early durable coverage, and late corrections of functional deformities are the basic surgical principles. The operative burden, while presumed to be substantial and significant, is neither well described nor quantified. The burn registry at the U.S. Institute of Surgical Research Burn Center was queried from March 2003 to August 2011 for all active duty burn admissions; active duty subjects were chosen to eliminate subject follow-up as a significant variable. Subject demographics including age, sex, branch of service, injury type, injury severity score, transfusion, allograft use, length of stay, mechanism of injury, and survival were tabulated as were their percentage TBSA, specific body region involvement, and nature and dates of operations performed. Univariate analysis and multiple logistic regressions were performed to determine independent factors which predict early and late operative burden. In the 8-year study period, 864 active duty patients were admitted to the burn center. Among them, 569 (66%) were operative in nature. The operations that were performed during acute hospitalization were 62%, while the remaining 38% were performed following discharge. A linear relationship exists between TBSA and the number of acute operations with an average of one acute operation required per 5% TBSA. No direct relationships however were found between TBSA and the number of reconstructive operations. Based on multiple logistic regression, battle vs nonbattle (odds ratio [OR], 0.559; 95% confidence interval [CI], 0.298–1.050; P = .0706), injury severity score (OR, 1.021; 95% CI, 1.003–1.039; P = .0222), intensive care unit length of stay (OR, 1.076; 95% CI, 1.053–1.099; P ≤ .0001), allograft use (OR, 2.610; 95% CI, 1.472–4.628; P = .0010), and TBSA of the trunk (OR, 0.982; 95% CI, 0.965–1.000; P = .0439) (but not overall TBSA) were associated with a high acute operative burden. Battle vs nonbattle (OR, 0.546; 95% CI, 0.360–0.829; P = .0045), and TBSA of the upper extremities (OR, 1.008; 95% CI, 1.002–1.013; P = .0042) were noted to be significant variables in predicting late reconstruction operations. The operative burden of burn, not previously well characterized, consists of operations performed during as well as after the initial hospitalization. While injury severity and truncal involvement are significant determinants of acute surgical therapy, the presence of upper extremity burns is a significant determinant of reconstruction following discharge. Burns are a significant medical problem which is a burden to the individual and to the society. Patients typically undergo care at specialized burn centers with multi-disciplinary expertise in surgery, critical care, wound care, rehabilitation, and social work.1,2 While the specifics in caring for these patients among each of these disciplines are subjects of numerous investigations, few studies have quantified the operative needs in the treatment of a population of burn patients. This information serves multiple purposes. Aside from academic interests, this information can be useful for the practicing clinician in counseling patients and family members on the number and timing of anticipated operations as well as their lengths of stay. Furthermore, there are strategic implications in the military or in a mass-casualty scenario, where the knowledge of the immediate and late surgical utilization in the treatment of burn patients can be used to facilitate proper resource allocation. Surgery for burns can be divided into those performed early during the acute hospitalization or late following discharge. Early surgery involves prompt excision of the burn eschar followed by coverage. This concept of early excision and grafting, popularized by Janekovic, has clear advantages with respect to morbidity, mortality, and scarring and is near universally adopted.3 The duration of persistent open wound is inversely associated with the survival.4 Coverage in the form of autologous, partial thickness skin is the most common treatment but the use of skin substitutes is gaining popularity.5 Depending on the depth and location of burn, more complex coverage operations using local, distant, and free tissue transfers are needed, sometimes using previously burned tissue as flaps.6 Late surgery is usually reserved for the correction of persistent functional contractures and aesthetic deformities.7 Burn scar, an entity distinct from keloid scar, is postulated to be the product of an overly robust systemic inflammatory response and poor quality skin which leads to the characteristically thick, stiff, fibrotic, and unwieldy texture familiar to burn providers and patients alike.8 Fibrosis, the final common pathway of organ failure, renders skin, the largest organ of the body, incapable of delivering its basic function of stretch and recoil, qualities essential for joint movement and hence, most activities of daily living.9 Restoration of form and function, the goal of all reconstruction, attempts to restore normal anatomy and replaces bad skin with good or at least better skin.10 While the end of acute surgical needs is defined by the attainment of complete wound closure, reconstruction is driven by patients' complaints and can have no definite end. In this study, we have attempted to quantify early and late operative utilization after burn by reviewing the active duty admissions to our burn center. This is a unique population who received their care within a semi-enclosed health care environment which allows all information to be captured and studied. METHODS A retrospective review was performed using the Burn Registry maintained at the U.S. Army Institute of Surgical Research Burn Center in San Antonio, Texas. Correlative databases including the Joint Theater Trauma Registry and the surgical scheduling database were also used to extract demographics and operative data. The burn registry was queried from March 2003 to August 2011 for all active duty admissions for thermal injuries. Subject demographics including age, sex, injury type, injury class (defined as battle or nonbattle related injury), transfusion, allograft use, length of stay (LOS), mechanism of injury, and survival were tabulated as were their percentage TBSA, specific body region involvement, and nature and dates of operations performed. This study was conducted under a protocol reviewed and approved by the U.S. Army Medical Research and Materiel Command Institutional Review Board and in accordance with the approved protocol. The study population, operative burns, was distinguished from the total burn population based on whether an operation was found in the operative scheduling database. Univariate analysis was performed to determine factors which resulted in increased operative needs, both acute and late. Patients who underwent acute operations were divided into two groups for comparison; those who underwent a large number of acute operations (≥5) and those who underwent fewer. A similar univariate analysis was performed for reconstructive operations, as defined by operations performed after hospital discharge. Factors with P value less than .05 were deemed statistically significant. Multiple logistic regression was further performed to identify independent predictors for both early and late surgical intervention. Only significant factors were considered for the logistic regression model. Backwards elimination was used to remove the least significant factors one-by-one so that the final model contained only factors with P values less than .10. The mean number of operations required, as a function of TBSA, was determined for both early and late surgical operative interventions by dividing TBSA into five equal bins in modes of 20%. The frequency of the patient populations within each of these TBSA bins was superimposed for comparison. The operative needs by body region (head and neck, upper extremity, lower extremity, and trunk) were also determined for three separate time periods: for the entire duration of their care, during the intensive care unit (ICU) stay, and after the acute hospitalization as an outpatient. For each body region, the extent of burn is expressed as a percentage of the total possible range. For instance, full thickness burns to the entire bilateral upper extremities results in a maximum additional 18% TBSA. If one had a 9% upper extremity burn then this would be expressed as 9 ÷ 18 × 100 = 50% upper extremity TBSA. The timing of early surgical intervention by body region was determined by defining the time of first operative intervention from the time of admission in the form of a histogram. The timing of outpatient operations by body region was determined by illustrating the time of each operative intervention from the time of discharge. The median time intervals and interquartile ranges were tabulated. All data were analyzed using SAS v 9.2 (Cary, NC). For comparison of continuous data, a t-test was used. For comparisons of categorical data, two-tailed Pearson χ2 tests were used. Unless otherwise indicated, significance was defined as P value less than .05. RESULTS In the 8-year study period from March 2003 to August 2011, 864 active duty patients were admitted to the burn center. Among them, 569 (66%) had burns which underwent operative treatment. The demographics and characteristics of this subpopulation of operative burns were compared to its parent population (Table 1). A similar and nonclinically significant difference in age, sex, and injury class was observed. However, operative burns were noted to have higher TBSA, which involved head and neck and upper extremities, higher injury severity score (ISS), longer ICU LOS, and overall hospital LOS with more allograft utilization and blood transfusions. Table 1. Demographics of total burn admissions and operative burn admissions View Large Table 1. Demographics of total burn admissions and operative burn admissions View Large Operative treatments for burns were separated into operations performed during the acute hospitalization (ACUTE, 62%) and following discharge (LATE, 38%). Univariate analysis was performed to determine the factors associated with a high number of acute operations (n ≥ 5). Injury class, allograft usage, age, ISS, TBSA, ICU LOS, and overall LOS were all factors associated with high acute operative burden (Table 2). After multiple logistic regression, however, only the injury class (OR, 0.559; 95% confidence interval [CI], 0.298–1.050; P = .0706), ISS (OR, 1.021; 95% CI, 1.003–1.039; P = .0222), ICU LOS (OR, 1.076; 95% CI, 1.053–1.099; P ≤ .0001), allograft use (OR, 2.610; 95% CI, 1.472–4.628; P = .0010), and TBSA of the trunk (OR, 0.982; 95% CI, 0.965–1.000; P = .0439) but not overall TBSA were noted to be predictive (Table 4). Table 2. Factors associated with a greater number of total operations View Large Table 2. Factors associated with a greater number of total operations View Large Table 4. Odds ratio estimates of multiple logistic regression View Large Table 4. Odds ratio estimates of multiple logistic regression View Large Univariate analysis was also performed to determine the factors associated with late reconstruction (n ≥ 1). Branch of service, injury class, mortality, allograft use, ISS, LOS, and TBSA of the head and neck and upper extremities were all noted to be associated with outpatient surgery following discharge (Table 3). After multiple logistic regression, however, only the injury class (OR, 0.546; 95% CI, 0.360–0.829; P = .0045), and TBSA of the upper extremities (OR, 1.008; 95% CI, 1.002–1.013; P = .0042) were independently predictive variables (Table 4). Table 3. Factors associated with a greater number of total outpatient operations View Large Table 3. Factors associated with a greater number of total outpatient operations View Large A direct relationship was demonstrated between TBSA and the number of acute operations when the number of acute operations was plotted against TBSA (Figure 1A). According to the chart, approximately five operations were utilized for 20% TBSA and 20 operations for 100% TBSA, translating to approximate one operation per 5% TBSA. Figure 1. View largeDownload slide Frequency of TBSA and the relationship of mean number of operations and TBSA (A) frequency of operative burns divided into TBSA bins of 20 percentage points (red line). The number of operations performed expressed as a function of the TBSA bins (blue line). Frequency of TBSA and the relationship of mean number of outpatient operations and TBSA, (B) frequency of operative burns divided into TBSA bins of 20 percentage points (red line). The number of outpatient operations performed expressed as a function of the TBSA bins (blue line). Figure 1. View largeDownload slide Frequency of TBSA and the relationship of mean number of operations and TBSA (A) frequency of operative burns divided into TBSA bins of 20 percentage points (red line). The number of operations performed expressed as a function of the TBSA bins (blue line). Frequency of TBSA and the relationship of mean number of outpatient operations and TBSA, (B) frequency of operative burns divided into TBSA bins of 20 percentage points (red line). The number of outpatient operations performed expressed as a function of the TBSA bins (blue line). A direct relationship was, however, not demonstrated between TBSA and the number of reconstructive operations when the number of reconstructive operations was similarly plotted against TBSA (Figure 1B). The number of reconstructive operations peaked at 40% TBSA. Both lower and higher TBSA ranges demanded fewer reconstructive operations. When operative utilization was divided into the various body regions (head and neck, upper extremity, lower extremity, and trunk) and plotted against the regional burn percentage for the entire duration of care, a direct relationship was observed and there were no significant differences between the body regions (Figure 2A). However, when this was limited to when patients were in the ICU, truncal operations were significantly greater than other body regions (P< .05), followed by lower extremity, upper extremity, and then head and neck (Figure 2B). An opposite relationship was observed when only operations performed as an outpatient was studied, where the number of upper extremity and head and neck operations predominated over lower extremity and then truncal operations (Figure 2C). Figure 2. View largeDownload slide Number of operations performed per body region expressed as a function of the TBSA of the body region: (A) total number of operations, (B) total number of operations performed in the ICU , and (C) total number of outpatient operations. Head and neck (blue), Upper extremity (purple), lower extremity (red), and trunk (green). Figure 2. View largeDownload slide Number of operations performed per body region expressed as a function of the TBSA of the body region: (A) total number of operations, (B) total number of operations performed in the ICU , and (C) total number of outpatient operations. Head and neck (blue), Upper extremity (purple), lower extremity (red), and trunk (green). Finally, the timing of early and late surgical interventions was studied for each body region. When the interval (in days) between the date of admission and the date of first operative intervention was plotted in the form of a histogram, prompt discrete operative interventions centered on less than 2 days were noted in all the groups except for the head and neck where the interventions were more spread out (Figure 3A). In a similar manner, when the interval (in days) between the date of discharge and the postdischarge interventions was plotted by body region, a bimodal curve was observed in all the regions. The first peak for all body regions are all within 200 days of discharge. The second peak appears the soonest for the upper extremity at approximately 350 to 400 days, followed by the head and neck, lower extremity, and trunk (Figure 3B). The median and interquartile ranges for the interval to the first operative intervention, interval to the outpatient operations, and interval to the last outpatient operations are tabulated (Table 5). Table 5. Time interval of operative interventions View Large Table 5. Time interval of operative interventions View Large Figure 3. View largeDownload slide The timing of inpatient and outpatient operations: (A) the interval (in days) between the date of admission and the date of the first operative intervention was plotted in the form of a histogram (left column), and (B) the interval (in days) between the date of discharge and the date of the last operative intervention was plotted in the form of a histogram (right column), expressed in the form of total operations and region specific operations to the upper extremity, head and neck, trunk, and lower extremity. Figure 3. View largeDownload slide The timing of inpatient and outpatient operations: (A) the interval (in days) between the date of admission and the date of the first operative intervention was plotted in the form of a histogram (left column), and (B) the interval (in days) between the date of discharge and the date of the last operative intervention was plotted in the form of a histogram (right column), expressed in the form of total operations and region specific operations to the upper extremity, head and neck, trunk, and lower extremity. DISCUSSION Burns are both an acute and chronic surgical disease. The burn scar formed after the acute treatment remains with the patient for life and surgical needs vary according to the tempo of the disease and the demand of the patient. In this study, the acute and late operative burden of burns was studied in a population of active duty patients whose early and late treatments were rendered largely within the confines of a single burn center. In this study population, two-thirds of admissions were operative. A direct relationship exists between TBSA and the number of acute operations. A parabolic relationship was found between TBSA and the number of reconstructive operations. The most number of reconstructive operations were noted in mid-range TBSA burns. Injury class, ISS, ICU LOS, allograft use, and TBSA of the trunk were associated with a high acute operative burden while injury class and TBSA of the upper extremities were noted to be significant variables in predicting the need for late reconstructions. Among the factors significant in predicting greater number of acute operations, most correlate with the severity of injury. ISS is clearly a proven metric of injury severity. However, even overall LOS and ICU LOS are codependent variables expected to increase with worsening injury. Temporizing use of allograft, applied when the injury is deep, extensive or infected such that single stage auto-grafting is not possible, predicts more inpatient and outpatient procedures, not as a cause but again as a signal of injury severity. Battle injury, predominantly a result of high energy blasts, also results in more severe injuries than nonbattle mechanisms.11,–13 Truncal involvement, with the advent of body armor, implies a mechanism severe enough to overcome the protective barrier. Any burns to the trunk are likely to be associated with severe injury particularly in relatively nonprotected areas (head and neck, extremities). The causative variables for reconstruction were different from the variables found for acute operations. Overall injury severity such as ISS or TBSA was no longer as important. While battle injury was still an independent predictive variable, TBSA of the upper extremity became a dominant determinant. For burn care providers, this fact comes as no surprise. In the authors' experience, even numerically minor deficiencies in hand and digital range of motion are functionally limiting and can result in many patient complaints and operative interventions. This is also a unique patient population with a high level of preoperative function. The strong desire to return to duty may also have skewed the number of upper extremity operations. Furthermore, modern battle injury is known to result in a significant number of lower extremity amputations,14 which only made upper extremity function even more crucial. Interestingly, even though the head and neck was significant on univariate analysis of reconstructive needs, it fell off as a predictor with multiple logistic regression. The reason for this is less clear. The face, an apparatus with multiple organ functions (sensory, motor, digestive, respiratory, speech, and aesthetics) would be expected to be a significant reconstructive burden. This again, may be unique to a young male population where nonfunctionally scarring is better tolerated and perceived as a badge of honor.15 In studying TBSA as an independent variable, a linear relationship was noted to the number of acute operations. However, no direct relationship exists between TBSA and the number of reconstructive operations. In fact, after 40% TBSA, the number of reconstructive operations decreases with increasing TBSA. The reason for this may be multifactorial. Patients with large TBSA have limited donor sites which make reconstructive operations, which largely require transfer of local or distant tissue in the form of grafts or flaps difficult. Patients with large TBSA were also critically ill and might have sustained multiple cardiac and/or neurologic insults, rendering their demand for reconstruction less. Further, because the reconstructive options are limited in large surface area burns, the efficacy of each reconstruction is also less and patients may lose patience and become intolerant of multiple repeated operations with diminishing return. There are strategic implications to the findings of this report. For example, this data may be the basis of a predictive model based on a few variables (ie, TBSA, body region, allograft use) to predict the number of requisite operations in the future. While we cannot accurately predict the number of operations for a particular patient, we may for a large population of such patients. For instance, it might be expected that a hundred such patients would have a number of operations with particular contributors that would form a normal distribution around a mean. From that, predictions could be made, not for how many an individual patient would have, but instead operations per surgeon(s) serving that population and the need for reconstructive surgeons when upper extremity burns predominate. Perhaps not unexpectedly, operations associated with long ICU stays were largely truncal and lower extremity, opposite from operations performed as an outpatient, where the upper extremities and the head and neck predominate. This descriptive finding is consistent with the traditional priority of first removing large burn eschars (ie, posterior then anterior trunk and lower extremities) to rid the inflammatory and potentially infectious burden before embarking on the head and neck and upper extremities. Several differences between military patients and their civilian counterparts are worth explaining. First, all active duty burns are transferred to a single burn center and they all return for their outpatient operations; thus, few patients are lost to follow-up and the data is near complete for this time period. However, military patients are predominantly young men with different priorities and physical demand. The mechanism of injury is often a result of explosives which include a high energy blast and the cutaneous burn is often combined with a deeper skeletal injury. Further, the injuries may be pervasive and extremity amputations further limit donor skin options.1 Finally, because the geographic location of injury is far from their dedicated specialized burn center, there is a delay between the time of injury and the time of admission. While some critically ill service members can be transported through direct ICU equipped flights, most patients have multiple detours before arriving at the burn center. The interval from the time of injury to the time of admission to the burn center ranges from days to weeks with a median of 4 days in this study population (data not shown). While the date to the first operation from the date of admission is within 2 days for most body regions and within 6 days for the head and neck, this number has to be added onto the transport time, perhaps leading to a prolonged inflammatory response and late scarring. Finally, the results of this study may not be directly translatable to a general burn population. Explosives, the causative agent for the majority of subjects in this study resulted in more severe injuries than pure thermal injuries alone. The amount of kinetic energy that can be transmitted into a limited area also meant that concomitant non–burn-related injuries likely contribute to the significant LOS in patients with smaller surface area burns. The timing for late operations was noted to follow a bimodal temporal distribution in all regions of the body. In this study, we did not study in detail the nature of each operation performed, making it difficult to determine the constitutions of the two peaks. However, surgeons, anecdotally, prefer to allow the red, indurated tissue to settle before embarking on reconstruction.7 There is evidence that re-contraction may be greater with persistent inflammation which takes about a year to resolve to normal.7 Furthermore, indurated tissue is more fragile and difficult to manipulate, further urging surgeons to delay reconstruction until the suppleness returns.7 This may account for the reason second peak centers about the 1 year mark. Consequently, it follows that the early peak consists of operations for more pressing issues that cannot wait a full year. In the head and neck, for instance, where the first peak centers less than 100 days after discharge, there are multiple indications for early intervention including ectropion correction to prevent keratoconjunctivitis and blindness, microstomia correction to facilitate nutritional intake, as well as airway and dental manipulations. In our observations of the timing of the last operations performed, the persistent need for late upper extremity and head and neck operations supports our hypothesis that the upper extremities and head and neck are important functional body units. The number of reconstructive operations peak, on average, at 4. However, the range is broad, from 1 to 45. There is no finite end to reconstructive surgery and is driven by patients' desires. Most reconstructive surgeons try to address the most number of issues within a single anesthetic administration in order to limit the perioperative risks. In the postfacial burn patient population where a history of inhalational injury and restricted mouth opening and neck extension may be present, risks of airway compromise and respiratory failure is significant with each anesthetic administration. However, issues with blood supply and surgeon fatigue can preclude the correction of these deformities in the fewest settings. Several studies have demonstrated a relationship between surgeon fatigue and adverse outcomes.16,17 Ample literature also exists to suggest that exposing the patient to prolonged operative time increases the likelihood of hypothermia, anemia, thromboembolism, and wound healing complications.18,19 In other words, the number of operations performed in a single operative encounter depends on many factors and defining reconstructive needs purely based on the number of operations may be an over simplification yet is the closest surrogate for this retrospective analysis. Another reason why it is difficult to define the end of reconstruction is that every patient's tolerance for surgical treatment is different. Some patients may be tolerant of a gross correction of a functional contracture whereas another patient may desire a complete correction and submits to more operations. All patients in this study population are active duty patients receiving care in the burn center, but come from throughout the United States. They have a defined period before time away from family and home becomes no longer tolerated. In fact, many patients, because of this event, have established a new home in close proximity to the burn center. Current burn surgical therapy can be separated into acute and reconstructive operations. While acute surgery can be life-saving, late reconstruction can be life-giving. Few studies have addressed the issues of operative burden of burns to the individual patient and to the society. In this study, burns from battle explosions, truncal involvement are more likely to undergo many early operative interventions. Use of allograft predicts more inpatient and outpatient procedures, not as a cause but as a signal of injury severity. Burns to the head and neck and especially the upper extremities, particularly those with allograft utilization, have more reconstructive operations performed. Finally, reconstructive operations will occur usually within 3 years from injury, but can be much longer at the margin. Burns continue to be a significant problem which plaques young people. The burden of the disease is long lasting and requires longitudinal follow-up. Burn centers need to retain their capabilities for reconstructive surgery. REFERENCES 1. Renz EM, King BT, Chung KK, et al. The US Army burn center: professional service during 10 years of war. J Trauma Acute Care Surg. 2012;73(6 Suppl 5):S409–16. 2. Herdon DN Total Burn Care. 20073rd ed. New York WB Saunders. 3. Janzekovic Z. A new concept in the early excision and immediate grafting of burns. J Trauma. 1970;10:1103–8. 4. Nitzschke SL, Aden JK, Serio-Melvin ML, et al. Wound healing trajectories in burn patients and their impact on survival. J Burn Care Res. 2014;35:474–9. 5. Yannas I.V, Orgill DP, Burke JF. Template for skin regeneration. Plast Reconstr Surg. 2011;127(Suppl 1):60S–70S. 6. Pribaz JJ, Pelham FR. Use of previously burned skin in local fasciocutaneous flaps for upper extremity reconstruction. Ann Plast Surg. 1994;33:272–80. 7. Donelan MBThorne CH, Beasley RW, Aston SJ, et al. Principles of burn reconstruction. In: Grabb and Smith's plastic surgery 2007 Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. 8. van der Veer WM, Bloemen MC, Ulrich MM, et al. Potential cellular and molecular causes of hypertrophic scar formation. Burns. 2009;35:15–29. 9. Hazani R, Whitney R, Wilhelmi BJ. Optimizing aesthetic results in skin grafting. Am Surg. 2012;78:151–4. 10. Sood R. Achauer and Sood's burn surgery reconstruction and rehabilitation. 20061st ed. Philadelphia, PA Saunders. 11. Kittle CP, Verrett AJ, Wu J, Mellus DE, Hale RG, Chan RK. Characterization of midface fractures incurred in recent wars. J Craniofac Surg. 2012;23:1587–91. 12. Zachar MR, Labella C, Kittle CP, et al. Characterization of mandibular ractures incurred from battle injuries in Iraq and Afghanistan from 2001–2010. J Oral Maxillofac Surg. 2013:S0278–2391. 13. Chan RK, Siller-Jackson A, Verrett AJ, Wu J, Hale RG. Ten years of war: a characterization of craniomaxillofacial injuries incurred during operations Enduring Freedom and Iraqi Freedom. J Trauma Acute Care Surg. 2012;73(6 Suppl 5):S453–8. 14. Amputations of upper and lower extremities, active and reserve components, U.S. Armed Forces, 2000–2011, in Medical Surveillance Monthly Report. 2012 Armed Forces Health Surveillance Center:p. 2–6. 15. Evans CA Confederate military history: a library of confederate states history. 1899;Vol 11 Atlanta, GA: Confederate Publishing Company. 16. Gawande AA, Zinner MJ, Studdert DM, Brennan TA. Analysis of errors reported by surgeons at three teaching hospitals. Surgery. 2003;133:614–21. 17. Taffinder NJ, McManus IC, Gul Y, Russell RC, Darzi A. Effect of sleep deprivation on surgeons' dexterity on laparoscopy simulator. Lancet. 1998;352:1191. 18. Anonymous. Examination of the massive weight loss patient and staging considerations. Plast Reconstr Surg. 2006;117(1 Suppl):22S–30S; discussion 82S–83S. 19. Coon D, Michaels J 5th, Gusenoff JA, Chong T, Purnell C, Rubin JP. Hypothermia and complications in postbariatric body contouring. Plast Reconstr Surg. 2012;130:443–8. Copyright © 2014 by the American Burn Association
TI - Operative Utilization Following Severe Combat-Related Burns
JF - Journal of Burn Care & Research
DO - 10.1097/BCR.0000000000000132
DA - 2015-03-01
UR - https://www.deepdyve.com/lp/oxford-university-press/operative-utilization-following-severe-combat-related-burns-10sAIaLXg7
SP - 287
EP - 296
VL - 36
IS - 2
DP - DeepDyve
ER -