everything you have ever desired the new generation of hair … · great versatility for all your...

http://sbh.sagepub.comISSN 2059-5131

This reprint was supported by an educational grant from LumenisUltraPulse®

The Most Powerful CO2 Laser in Aesthetic Dermatology

DeepFXTM | ActiveFXTM Fractional Modesgreat versatility for all your resurfacing needs

Deepest Impact with SCAAR FXTM Mode up to 4mm in a single pulse

Best Ablation/Coagulation ratio for optimal clinical outcomes

Shortest Pulse Duration for maximum patient safety and comfort

Stretching the limits of performance

AESTHETIC.LUMENIS.COM

The Starting Point to Your Success

Everything You Have Ever Desired The New Generation of Hair Removal Systems

Gold Standard 805nm diode laser

Fast and comfortable

Intuitive and upgradable

Portable and affordable

Highest return on investment

NEW



Lumenis (UK) LtdTelephone: 020 8736 4110e-mail: [email protected]

SBH_Cover.indd 1 04/12/2015 6:19:11 PM

Scars, Burns & Healing

Editor-in-Chief: Professor Kayvan ShokrollahiMersey Regional Centre for Burns and Plastic Surgery, Liverpool UK Edge Hill University, Ormskirk [email protected]

Managing Editor: RuthAnn FanstoneChelsea and Westminster Hospital, London, [email protected]

Scars, Burns & Healing is a new peer reviewed, open access journal bringing together the specialist focus of scar and burns research with the breadth of the science and medicine related to healing.

A truly multi-disciplinary journal, Scars, Burns & Healing seeks to publish suitable material relevant to all clinical specialties related to scar and burn care, ranging from basic science (including genetics, immunology, nanotechnology and tissue engineering) to clinical practice.

The journal breaks new ground in a number of areas:

It is the only international journal which includes a specialist focus on scar research

Its content is designed in such a way to have relevance to a lay audience as well as a clinical and scientific one

It is fully peer reviewed and published open access to ensure maximum dissemination; all published content is freely available to view, ensuring the greatest visibility and impact for research in the areas of scars, burns and healing

It is the only burns-related journal which guarantees full colour publication for all articles

A free language editing service can be provided for articles from non-English speaking regions

A considerable amount of targeted PR activity will help promote and disseminate the works of authors and institutions in both scientific and mainstream media

Affiliation with The Katie Piper Foundation ensures a wide and varied audience for research

Open for SubmissionsPlease visit https://mc.manuscriptcentral.com/sbh to upload your manuscript and view the guidelines

Commercial SalesFor information on advertising, reprints and supplements please contact Neil Chesher [email protected]

Further InformationFor further information about Scars, Burns & Healing, please contact the Publishing Editor, Jovie [email protected]

This is a print-on-demand copy of content from a SAGE online journal. Please visit www.sagepublications.com and follow the journal links for full details of this title including editors, editorial board, submissions procedures, subscription information and more.

© SAGE Publications Ltd (issue compilation); individual articles, © The Author(s) or as otherwise indicated


Editorial Board

Baljit Dheansa, Queen Victoria Hospital, East Grinstead, UKWilliam Dickson OBE, South West Burn Operational

Delivery Network, UKPeter Dziewulski, St. Andrew’s Centre for Plastic Surgery

and Burns, Broomfield Hospital, Essex, UK & Anglia Ruskin University

Dale Edgar, Health Department Western AustraliaNicolas Frasson, Cliniques Ster, Saint Clément de Rivière,

FranceGerd Gauglitz, Ludwig Maximilian University, Munich,

GermanyC. Scott Hultman, UNC School of Medicine, North Carolina,

USAFredrik Huss, Burn Center, Department of Plastic and

Maxillofacial Surgery, Uppsala University Hospital, SwedenJorge Leon-Villapalis, Chelsea and Westminster Hospital,

London, UKWei Liu, Department of Plastic and Reconstructive Surgery,

Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, P.R. China

Koen Maertens, Organisation for Burns, Scar After-Care & Research, Antwerp, Belgium

Peter Moorgat, Organisation for Burns, Scar After-Care & Research, Antwerp, Belgium

Ciaran P O’Boyle, Nottingham University Hospitals NHS Trust & The University of Nottingham, UK

Sarah Pape, Royal Victoria Infirmary, Newcastle upon Tyne, UK

Susan Peirce, Cedar, Cardiff University School of Engineering, Cardiff, UK

Alan Phipps, Pinderfields General Hospital, Aberford Road, Wakefield, West Yorkshire, UK

Warren Matthew Rozen, Department of Surgery Monash University, Victoria, Australia

Ascanio Tridente, Whiston Hospital, St Helens’ and Knowsley NHS Trust, Prescot, UK & Sheffield University, Sheffield, UK

Marcela Vizcaychipi, Chelsea and Westminster Hospital, London, UK

Stuart Watson, Canniesburn Plastic Surgery Unit, Glasgow Royal Infirmary, Glasgow, UK

Iain S. Whitaker, Swansea University Medical School & Welsh Centre for Burns and Plastic Surgery, Swansea, UK

Amber Young, The Healing Foundation Children’s Burns Research Centre and South West Children’s Burns Centre, Bristol, UK

SBH_Cover.indd 2 04/12/2015 6:19:12 PM

Scars, Burns & Healing Volume 1: 1 –4DOI: 10.1177/2059513115607756© The Author 2015 sbh.sagepub.com

Creative Commons CC-BY-NC: This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 3.0 License (http://www.creativecommons.org/licenses/by-nc/3.0/) which permits non-commercial use, reproduction and

distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage).

Follow the path of the unsafe, independent thinker. Expose your ideas to the danger of controversy. Speak your mind and fear less the label of ‘crackpot’ than the stigma of conformity.

Thomas J. Watson, American Entrepreneur and Founder of IBM, 1874–1956

The treatment of patients with scars is always a challenge because of exactly that: we are treating patients with scars and we are not simply treating scars. A holistic approach is essential to ensure patients’ needs are understood, improvements are made and no harm is done – although there is little published work on patient expectations in scar revision. Clinicians have increasingly under-stood and considered the psychological aspects of scarring that need to be addressed alongside the physical aspects of scar management. Similarly, there are social aspects of scarring which have been investigated and have increased our understanding of the impact of scars on the individual and their wider interactions. One social aspect of scarring that has been explored (but not extensively) is the stigma associated with scars.1,2 Indeed there is evidence that healthcare professionals themselves may contribute to this

stigma,3,4 and interesting blogs and web-snippets gives us stark insights into some of the issues from patients’ perspectives.5,6

While we have increased our understanding of the general stigmatising effects of scars on patients, more work is needed, and one thing that we know less about is stigma arising from specific types of scarring where the stigma extends beyond the scar itself, and is related to the mechanism of that scarring.

In my clinical practice I have increasingly come to appreciate the importance of the stigma-tising effect of specific types of scarring in certain patient groups, which appears to completely change the rules of the game for scar manage-ment in these patients. For certain groups, this aspect of their scarring is so important that it has implications with regards to both their assessment and management. The most relevant of these are:

• scars from deliberate self-harm• scars from knife or glass injuries to the face• scars from any mechanism that can look

like either of the above – including sur-gery that might leave scars looking like either of the above

Making scars worse to make patients better? The role of surgery in changing the appearance of archetypal stigmatising injuries and the concept of mechanistic stigma in scar management

Kayvan ShokrollahiPostgraduate Medical Institute, Edge Hill University, Ormskirk, Lancashire, UK Mersey Regional Burns and Plastic Surgery Unit, Whiston Hospital, Liverpool, UK

KeywordsSelf harm, scars, deliberate self harm, DSH, stigma, mechanistic stigma, skin graft

607756 SBH0010.1177/2059513115607756Scars, Burns & HealingEditorialeditorial2015

Editorial

2 Scars, Burns & Healing

The underlying concern for many patients with deliberate self-harm scars can be the stigma asso-ciated with the implication of underlying past or current mental health issues, which are known to be associated with considerable social stigma.7

This has considerable implications for both assessment and treatment because neither our cur-rent assessments nor outcome measures formally consider the stigma related to mechanism of injury and which may influence the various domains of patient-reported outcome measures (PROMs) and quality of life (QoL) outcome measures, e.g. gen-eral mental health, social functioning and satisfac-tion with treatment. Indeed, the entire basis for decision-making and treatment-planning is likely to change considerably.

The consequences may be that mainstream treatments that objectively improve scars may yet result in dissatisfied patients. Similarly, treat-ments that make scars cosmetically worse could potentially be a complete success if the stigma from the mechanism of injury is modified to the satisfaction of the patient. Hence the following scenarios become possible:

• Excellent objective outcomes after scar treatments, very dissatisfied patient: the stigma from mechanism of injury is not disguised or removed after treatment, however objectively ‘successful’.

• Poor or worsened objective outcomes after scar treatments, very satisfied patient: the stigma from mechanism of injury is modified or concealed despite ostensibly worse scarring.

This reversal, or potential reversal, of traditional logic when treating such scars is clearly impor-tant not only for the treatment of the patient but also for the consent process for any treatments. If in some cases ‘success’ resulted from scars that are ‘worse’ when assessed using every conceiva-ble objective, clinical and PROM we clearly need to consider new tools to measure outcome in this patient group, or modification of existing tools.

Deliberate self-harm: the archetypal stigmatising scarTransverse scars on the upper limb from self-harm are the scars that I think are most relevant in this context. This is, first, because their pat-tern, distribution and mechanism is relatively easily recognised by most people, and second because most scar treatments cannot readily remove the features of those scars that make

them recognisable as self-harm marks (i.e. distri-bution, pattern and anatomical location).

One patient highlights some of these issues:

‘The problem is that I still feel like I am unable to truly embrace myself, because my body is covered in scars. I still carry a lot of shame. I feel a lot of anxiety about how other people will react to my scars, as I know that to the majority of people, self-injury is unfathomable. It is incredibly distressful because I feel like self-injury is not a part of who I am anymore, and I want to be able to embrace myself completely.’5

I am increasingly convinced that for many patients, only interventions that change the appearance of the scar in a way that alters or dis-guises the mechanism of injury will result in satis-fied patients. For this reason, psychological support must underpin the decision-making pro-cess for both surgeon and patient. Nevertheless, the reverse is likely to be true for others, and fur-ther perusal of the personal experiences of patients online demonstrates a wide variability of patient opinions, including from those who are proud to bear their scars as signs of having over-come adversity, and do not appear to feel stigmatised:

‘Someone told me recently that I could get plastic surgery on my arm to get rid of the scars. “I’m sure that would just make it worse,” I replied. “No, they can do amazing things these days,” they said. I thought about it for about 5 seconds, but really, I have no interest in hiding or getting rid of my scars. To me, it is not worth the money or the hassle. I don’t feel that they affect my life at all. When I look at them, there is no emotional register. My scars may not be beautiful, but they mark the passage of time; they are a very physical record of how much my life has changed, and how much I have evolved.’5

The implications for scar management for this patient group are significant. First, we need a reliable mechanism to pick up whether the stigma of an injury or scar is a major component of the presenting complaint. We then need to decide whether we are treating specific and phys-ical aspects of scarring, or whether we are actu-ally focusing on the treatment of the stigma itself and the features that allude to the mechanism of that scarring. The successful treatment of certain patient groups may therefore rely on our evolv-ing exploration and understanding of these con-cepts and the underlying issues.

Editorial 3

Case exampleThis illustrative case has been selected from a group of 20 patients with a variety of complex scars referred over the last 18 months from out-side the catchment area of our regional burns and plastic surgery service.

A female patient in her mid-30s presented as an out-of-region referral with extensive bilateral classical transverse self-harm scars on her upper arm and forearm, in addition to other areas of her body including abdomen and both thighs (Figure 1). She had an extensive psychiatric history with ongo-ing support, but had recovered from most of her past mental health issues, found a stable partner and was planning to get married. A variety of scar management modalities were offered, each addressing some component of her scars includ-ing erythema and contour. Some laser test patches were undertaken with a variety of ablative and non-ablative lasers to demonstrate what potential improvements could and could not be achieved.

It became clear during the course of early treatment that regardless of the degree of improvement of her scars, they would always look like self-harm scars, and it was simply release from this stigma that the patient was seeking. When the prospect of more radical treatment was raised, such as excision and skin grafting, the patient saw this treatment modality as dramati-cally altering the appearance of her scars in such a way as they could be ‘explained away’ – as a burn injury for example – and an intervention that drew a line under her past. After extensive counselling and discussion, it was agreed that the arm would be excised and skin grafted and if she was satisfied with the outcome, consideration would be given to treat the forearm.

Figure 2 demonstrates the process of her exci-sion and grafting and early final result, with which she was delighted and I less so, purely from a cos-metic perspective at least. In my view, the scarring was ostensibly (but expectedly) worse simply by nature of the chosen intervention. The patient was nevertheless very happy with the outcome, and felt that the scarred area no longer looked like, or attracted the stigma of, self-harm scars and is now pursuing similar surgery to her forearm.

DiscussionNot only does the potential exist for what I term mechanistic stigma to be an important factor in relation to self-harm scars, it could also be a fac-tor in other scars. Personal correspondence with colleagues in addition to my own experience has

provided further anecdotal examples of patients with scars not related to self-harm where stigma from the mechanism was the primary concern:

• A woman from Africa with facial scarifica-tion relocating to the UK

• A man with a facial wound from a knife assault who felt the injury stigmatised him as having a criminal past

• Patients with elective surgery that leave scars on the forearm or face (e.g. excision of a volar wrist ganglion, removal of facial or forearm skin lesions)

• Similar scars in these anatomical locations from trauma or assault

DiscussionIt appears that the concept of making scars potentially ‘worse’ to make patients ‘better’

Figure 1. Preoperative multiple upper arm self-harm scars. Similar scars are replicated across both arms, both thighs and the entire lower abdomen.

Figure 2. Intraoperative, immediate postoperative and 3-month postoperative photographs of excision and sheet skin grafts to upper arm transverse self-harm scars.


might be the solution in specific patient groups where stigma relating to the mechanism of injury is their primary concern, rather than specific or measurable aspects of the physical scar itself. A simple one-liner could provide an effective screening tool for mechanistic stigma:

‘Is it the scars you are most concerned about or the fact they look like self-harm scars?’

However, there are many potential hazards with this strategy and there is much more we need to understand to minimise the potential for harm. Any such surgery in this vulnerable patient group should always be conducted with involvement of psychological and psychiatric services and sup-port. It is also important to consider functional aspects of treatment as ‘worsening’ scars may include the potential for reducing function, not only cosmesis, including from scar-related compli-cations initially absent from the presenting scars.

I urge my esteemed colleagues in their diverse fields of endeavour to further and more exten-sively (and certainly more scientifically) explore these concepts. I invite and welcome develop-ment of these ideas, hypotheses and opinions further with well-conducted studies and robust evidence and which we would be delighted to consider for publication in Scars, Burns & Healing.

‘Life is about choices. You can choose to be embarrassed or ashamed of your past, or you can choose to accept it and move forward. I have chosen to see my scars as part of my journey towards something beautiful.’5

SummaryThis article explores the hypothesis that some patients with scars seek treatment not necessarily to improve physical aspects of their scarring (such as redness or thickness) but to disguise the mech-anism of the scarring. It is suggested that this is most relevant where the pattern of scarring car-ries with it some stigma – such as from self-harm scars. The idea that in some cases the only treat-ments that can disguise stigmatising scars actually look worse than the original scars, but may be the only satisfactory solution for some patients is explored, and a case example provided. The wider context of stigma arising from the mecha-nism of scarring, rather than the scars themselves are explored. The readership is invited to explore this concept with evidence-based research.

References 1. Lawrence JW, Rosenberg L, Mason S, et al. Comparing parent

and child perceptions of stigmatizing behaviour experienced by children with burn scars. Body Image 2011; 8(1):70–73.

2. Knudson-Cooper MS. Adjustment to visible stigma: the case of the severely burned. Soc Sci Med Med Anthropol 1981; 15B(1): 31–44.

3. Emerson AL. A brief insight into how nurses perceive patients who self-harm. Br J Nurs 2010; 19(13): 840–843.

4. Law GU, Rostill-Brookes H and Goodman D. Public stigma in health and non-healthcare students: attributions, emotions and willingness to help with adolescent self-harm. Int J Nurs Stud 2009; 46(1): 107–118.

5. Cutting and Self Harm: The Stigma & the Aftermath. http://galadarling.com/article/cutting-self-harm-the-stigma-the-aftermath/.

6. The Stigma around Self Harm. http://www.time-to-change.org.uk/blog/the-stigma-around-self-harm.

7. Corrigan P. How stigma interferes with mental health care. Am Psychol 2004; 59(7): 614–625.

http://galadarling.com/article/cutting-self-harm-the-stigma-the-aftermath/



http://www.time-to-change.org.uk/blog/the-stigma-around-self-harm

http://www.time-to-change.org.uk/blog/the-stigma-around-self-harm




Assaults from corrosive substances and medico legal considerations in a large regional burn centre in the United Kingdom: calls for increased vigilance and enforced legislation

Alethea Tan1,2, Amrit Kaur Bharj3, Metin Nizamoglu1, David Barnes1 and Peter Dziewulski1,2

Abstract

Burn injuries from corrosive substances have been recognised as a common method of assault in low and middle income countries (LMICs) motivated by various factors. Such injuries often leave survivors with severely debilitating physical and psychological injuries and scars. The number of reported cases of acid assaults within the United Kingdom (UK) appears to be on the rise. As one of the largest regional burn centres in the UK, we have reviewed our experience of chemical burns from assault. This study aims to: (1) review the demographics, incidence and patient outcomes; (2) evaluate the long-term psychosocial support provided; and (3) review current criminal litigation proceedings and preventative legislations in the UK specific to assault by corrosive substances. A 15-year retrospective review of 21 burn injuries from assault with corrosive substances presenting to a regional burn unit was conducted. Victims were mostly young men; male perpetrators were more common. The most common motive cited was assault. The most common anatomical region affected was the face and neck. The number of victims who pursue litigation is disproportionately lower than the number of total cases at presentation. In an effort to better understand the legal considerations surrounding such assaults, we also collaborated with lawyers experienced in this particular field. We hope that our work will help educate healthcare professionals regarding the legal assistance and existing laws available to protect these patients.

Keywords

Assault burns, corrosive substances, legal, legislation, prevention, acid attack, scar

1St. Andrew’s Centre for Plastic Surgery and Burns, Broomfield Hospital, Chelmsford, UK2St. Andrews Anglia Ruskin Plastic Surgery and Burns Research Unit, Postgraduate Medical Institute, Chelmsford, UK3Blavo & Co. Solicitors Ltd., Uxbridge, UK

Corresponding author:Alethea Tan, St. Andrew’s Plastics and Burns Unit, Broomfield Hospital, Room 1, 9 Hazel House, Woodlands Way, Swan Housing, Chelmsford, CM1 7TH, UK. Email: [email protected]

612945 SBH0010.1177/2059513115612945Scars, Burns & HealingTan et al.research-article2015

Original Article

e e e

es s s e e

e

e

s

mailto:[email protected]


Lay summary

Burn injuries from corrosive substances can have fatal complications and leave survivors with severely debilitating physical injuries and psychological scars. The incidence of acid assaults appears to have increased in the UK and gained much publicity through widespread news coverage. This prompted us to look at our experience in managing patients who were victims of assault using corrosive substances. Over a 15-year period, we treated 21 people who sustained burn injuries as a result of an assault involving corrosive substances. Five people required hospital admission for the extent of their injuries and required significant burn reconstructive procedures. Interestingly, only nine out of 21 cases initiated a criminal investigation. Only two of the nine cases that initiated criminal investigations proceeded to indictment. In an effort to better understand legal considerations surrounding such assaults, we collaborated with lawyers experienced in this particular field and lay out for the first time the UK landscape of litigation in this complex area. We hope that our work will help educate healthcare professionals of the legal assistance and existing laws present to protect these vulnerable patients.

Introduction

Acid burns have been well recognised as a vicious act of assault among low and middle income countries (LMIC) including India, Iran, Jamaica, Bangladesh and Uganda.1–4 The profile of vic-tims varies accordingly to their cultural back-ground. For instance, victims in South Asia are commonly young women who have rejected a suitor or young wives who have been punished by their husbands or in-laws as a result of

dissatisfaction over the marriage dowry.5 In Iran,4 political motivation has driven assaults with hom-icidal intent towards government officials. Male victims are more common in Jamaica, with mari-tal dispute and jealousy cited to be a driving fac-tor for these crimes of passion. The use of corrosive substances to inflict injury can also be entirely motivated by random criminal acts such as robberies.1

Excerpt 1 – Acid attack in Europe: A walk through history

In ancient times, vitriol (containing sulphuric acid) was used to purify gold and fabricate imitation precious metals. It was introduced to Europe in the 16th century and not long after that, one of the first recorded acid assaults occurred in France. Its incidence continued to rise, what was described as ‘a wave of vitriolage’ occurred particularly in France. The term ‘La Vitrioleuse’ was coined gaining popular press coverage as ‘crimes of passion’, perpetrated mostly by women against other women, and fuelled by ‘jealousy, vengeance… and provoked by betrayal or disappointment’. Les Vitrioleuses intended to disfigure their disloyal mate or female rival. During the late 19th century, the image of Vitrioleuses was popularised by Art Nouveau artists. ‘La Vitrioleuse’ by Fernand Pelez is still considered an Art Nouveau masterpiece today.

The first reported case of acid attack in Europe was thought to occur as early as the 16th century (see excerpt 1).6,7 On the whole, burn injuries sus-tained from assault with corrosive substances are relatively uncommon in western societies. Literature describing the incidences of chemical burns from assaults in the western world is lim-ited.8 Acid was not the only agent used. In the United States, household lye (sodium hydroxide) was noted to be a common agent preferred by per-petrators.9–11 Patient demographics also differ with male victims predominating, and assailants were more often women. Domestic disputes are often the motivating factor behind these assaults.

In 1990, Beare et al. reported ophthalmic injuries in 64 patients admitted to The Western Ophthalmic Hospital in London12 as a result of chemical assaults inflicted by gangs of male youths from lower socioeconomic backgrounds.

Regardless of the variation in patient demo-graphics globally, the physical and psychological morbidity of such assaults can be devastating (Figure 1). Patients can be left visibly disfigured, some requiring multiple reconstructive proce-dures to recreate key facial features. Although there is legislation against such assaults, the pro-portion of victims who fully pursue criminal charges against their perpetrator is low. We noted

Tan et al. 3

this recurrent theme during our literature search14 which led us to review our numbers of assault victims suffering chemical burns treated in a regional burn centre, with the intention of understanding: (1) current epidemiology; (2) some indictors of patient outcomes; and (3) leg-islation and processes within the UK law available to assist such victims. We collaborated with an independent law firm that has had experience in dealing with acid assaults within the UK. No arti-cles specific to the UK have previously focused on an understanding of legal proceedings for vic-tims wishing to pursue criminal prosecution of the assailant in this patient group.

Methodology

From our available database spanning 1 January 2000 up to and including 31 December 2014 (15 years), approximately 680 total chemical burn injuries have been recorded during that period which included both accidental injuries and inten-tional burns. A retrospective review of all patients coded as sustaining assault related to burn injuries from chemical or corrosive substances on our data-base was carried out from that 15 year database. A list of 26 patients was generated. The inclusion cri-teria was all patients who were assaulted with chem-ical or corrosive substances during that period. The study was registered with our clinical govern-ance department (CA14-135) as an audit and a ser-vice evaluation. We obtained medical case-notes, from which information was collected on patient epidemiology, burn details, substances used,

gender and relationship of assailant, location of the assault, involvement of psychological support, involvement of police, documentation of likely criminal proceedings and number of successful prosecution. We collaborated with a London-based law firm who has had experience dealing with vic-tims of acid assaults for their perspective on legal proceedings and the UK legislation.

Results

Our initial search revealed 26 patients coded as assault-related burns. Five patients were excluded from this search following detailed review of the presenting history showing that these were actu-ally accidental injuries. We included the remain-ing 21 patients for analysis of the following areas:

•• Patient demographics•• Burn demographics•• Extent of injury, management strategies

and length of inpatient stay•• Psychological support provided•• Circumstances of assault

Patient demographics

The male:female ratio was 15:6. The age range was 16–56 years (mean age, 28.5 years). The propor-tion of victims aged 25 years or younger was almost twice that in the above 25-year age group. Victims came from various cultural backgrounds such as Caucasian (n = 16), African (n = 3), Oriental (n = 1) and South Asian subcontinent (n = 1). Ten patients (48%) were unemployed, nine (43%) were in employment at the time of the event and two (9%) were students. Four patients had prior history of trauma sustained from another assault. One patient had a history of previous domestic dispute resulting in trauma during the altercation. Only one patient was known to social services prior to the assault. Current trends of assault involve more female victims than male victims compared to a decade ago (Figure 2).

Circumstances of assault

A total of 76% (n = 16) cases occurred on the streets, although assaults were also noted to occur at home (14%, n = 3), hostel (5%, n = 1) and pub (5%, n = 1). Concurrent substance abuse such as combination of alcohol and/or recrea-tional drugs by the victims at time of assault was reported in six cases. Seven (33%) of the assail-ants who carried out the attacks were known to

Fatal outcomes•• Homicide•• Suicide•• Maternal mortality

Non-fatal outcomes•• •Physical health (functional impairment, permanent

disability, poor subjective health)•• •Mental health (Post-traumatic stress, depression,

anxiety, low self-esteem, sexual dysfunction, eating disorders, substance abuse)

•• •Negative health behaviours (under-eating, physical inactivity)

•• •Chronic conditions ( chronic pain syndromes, somatic complaints)

•• •Reproductive health (pregnancy complications, unwanted pregnancy)

Figure 1. Health Outcomes of acid attack violence.13


their victims prior to the incident. Eight assail-ants were documented to be men, one woman and four unknown as they had their faces cov-ered, and in eight cases there was no documenta-tion at all. In 16 cases, there was clear documentation of the patient account indicating a motive for the assault and five cases were ran-dom or unprovoked.

Police involvement at presentation was docu-mented in 15 cases (17%). Five cases (24%) self-presented and there was no initial or subsequent police involvement. In one case, it was unclear whether police were involved. Criminal investiga-tion was only initiated in nine cases (43%). Of these, only two cases have successful criminal prosecution thus far. With regard to the Criminal Injuries Compensation Act, only two victims pro-ceeded to make claims.

Burn demographics

The total burn surface area affected was in the range of 0.3–16% with a median of 1% TBSA. The burn depth was either full thickness or mixed depth type. Acid was the most commonly documented substance used (n = 10), followed by alkali (n = 4), bleach (n = 3), unknown (n = 2) and other (n = 2). In all 21 cases, first aid was given although there was a delay in four patients. Sixteen patients presented immediately to their nearest accident and emergency department while in the other five cases, there was a delay (median, 1 day). Burn injuries sustained during the assault often affected more than a single region of the body, with the face being the com-monest area to be affected (18/21), followed by the upper limbs (11/21), neck (8/21), trunk (7/21) and lower limbs (5/21). Many patients had involvement of multiple anatomical sites (Figure 3). Nine patients had eye involvement,

all of whom received ophthalmology review acutely (Figure 4).

Extent of injury, management strategies and length of inpatient stay

Five patients were admitted to hospital as a result of their injuries at initial presentation. Their length of stay in hospital was in the range of 0–41 days with an average of 6.3 days (median, 1 day). One patient also sustained upper limb fractures during the assault. Sixteen patients (76%) were solely managed non-operatively with dressings

Face37%

Neck16%

Upper Limb23%

Trunk14%

Lower Limb10%

Anatomical Involvement

Figure 3. Chart demonstrating anatomical involvement.

Y43%

N57%

Eye Involvement

Figure 4. Chart showing ophthalmic involvement.

57

3

1

2

3

6 9 6

2000-2004 2005-2009 2010-2014

Male and Female proportions

M F

Figure 2. Trends of total cases noted every 5 years, with the number of male and female victims described.

Tan et al. 5

and outpatient visits. Five patients (24%) required surgical debridement at presentation and wound coverage with autografts and skin substitutes such as Matriderm®.

One patient developed burn wound infec-tion and graft loss, necessitating further surgery. Two patients suffered cartilage loss of an ear as a result of the burn injury. These patients required late repeated burn reconstructive procedures as a result. Of the nine patients who had eye involve-ment, only one subsequently developed partial loss of sight as a result.

Psychological treatment

Eight of the 21 patients received clinical psychol-ogist review and follow-up. All patients admitted to our burns unit are offered psychosocial sup-port. Patients whose burn injuries were managed at outpatient clinic visits are always referred on to clinical psychology when required or upon patient request. All inpatients were seen by the clinical psychologist. Four of the 16 outpatients received clinical psychologist input. One possible explanation for the discrepancy between the total number of cases and the numbers actually receiving psychosocial support is patients refus-ing to be referred on, but the reasons were not clear. In cases where victims self-presented unac-companied by the police, they declined review by a clinical psychologist.

Discussion

Approximately 1500 acid assaults are reported worldwide annually.15 Burn injuries from acid attacks have been well described in LMICs. Bangladesh has the highest worldwide incidence of acid violence and acid burns, constituting 9% of its total burn injuries.16 In Pakistan, around 400 acid attacks on women occur annually although this figure may represent an overesti-mation from non-formal data collection tech-nique.17 Sri Lanka, India, Cambodia and Uganda have also reported cases of acid assaults although its true incidence is difficult to ascertain. This is largely due to problematic reporting mecha-nisms and under-reporting by victims.

The epidemiology of acid violence varies geo-graphically. Examples from the published litera-ture show that in Bangladesh, victims are often young women who have rejected a potential suitor or new brides punished by their husbands and in-laws over dowry disputes.2 In Cambodia,18 the majority of victims are young mistresses attacked by their lovers’ wives. Acid burns have

also been used as forms of violence during rob-beries, political protestations and, in rare cases, of assassination plots.4 Our series showed a higher proportion of young male victims and male perpetrators, contrary to that seen in LMICs. In Taiwan, victims were mainly women, with a higher proportion of male perpetrators. Marital and financial problems were cited as the most common motive.19 In the United States, vic-tims were generally men and perpetrators were women although motive(s) were unclear.8,14 These findings suggest the demographics of burns from assault using corrosive substances vary geographically and points to complex under-lying social and cultural factors relating to both perpetrators and victims.

Any corrosive substance can be used as a weapon in an assault. Acid is commonly used, with sulphuric acid quoted to be a common agent. In LMICs, sulphuric acid is easily obtaina-ble from most car garages at an affordable price to the public.1 Lye, caustic soda and caustic pot-ash have also been described in the literature as potential substances used in assault.10 An accu-rate description of the substance used is often difficult to ascertain unless there are characteris-tic features to the burn injury indicative of the acid type such as nitric acid (which forms yellow stains and produces a garlic odour).20 Our review showed that identification of the exact substance used by perpetrators was difficult and the descrip-tion ‘colourless liquid’ was used. It is therefore important that initial evaluation of the burn wound includes pH measurement, which itself can be challenging particularly in cases where presentation is delayed. In our study, we also found that bleach was frequently used, and household bleach is both cheap and easily accessible.

Despite the vast variation in motives and epi-demiology of acid assaults, there are recurrent themes of concern outlined in the existing litera-ture. Acid attacks are malicious attacks with the intent to cause devastating bodily mutilation and functional impairment. The resulting disfigure-ment can be a constant taunt to the survivors mentally, physically and emotionally. Often, the long-term psychosocial effects are so severe that they can impede the progress of social reintegra-tion following the burn injury. As a result, many victims lead a life as a recluse.19 Although loca-tion is not a key factor in social reintegration, we found that these injuries most commonly involved visible and public facing parts of the body such as the face, neck and hands. Our find-ings mirrored that reported by Faga et al.21


Psychological morbidity of burns survivors have been extensively studied.22,23 Mannan et al. showed that burn injury and the event itself (the assault), are both important contributors to psy-chosocial outcomes.5 The study also noted lower self-esteem in women who have suffered acid attacks. Anatomical location of the assault, rela-tionship to the assailant and consequent func-tional limitations have been shown to be predictors of distress.5 Psychosocial support is important as part of burn rehabilitation. Worldwide, charitable foundations exist to offer a vital source of support to these victims beyond their initial injury. In the UK, The Katie Piper Foundation24 (London), Acid Survivor Trust International15 (ASTI) and Domestic Violence UK25 are among charities available to provide support beyond initial injury. Beyond the UK, government organisations (GOs) and non-gov-ernment organisations (NGOs) exists worldwide to support victims of acid violence (Table 1).

In 2001, the National Burn Care Review Committee (NBCRC) had acknowledged that psychosocial rehabilitation, which is an integral part in burn care, had been seriously neglected in the UK.36 Following their report, recommenda-tions have been put forward including the need for a named coordinator for psychosocial reha-bilitation who is responsible for managing these aspects of care for the burn patient. Since then, improvements have been built upon this princi-ple, including the set-up of psychological care ser-vices in various burn units across the nation.36

In our review, nine cases out of a total of 21 resulted in the initiation of a criminal investiga-tion. The number of cases that actually proceed to court cases was difficult to ascertain accurately. We have identified two successful prosecutions that have gained publicity through news coverage.37 One possible explanation for this disparity is the unwillingness of patients to pursue the case or press charges. Several studies have previously reported similar findings.3,38,39 Victims who are experiencing the emotional and mental trauma following an assault may feel unsafe and vulnera-ble, fearing that pressing charges may provoke fur-ther attacks. Lack of knowledge on how to instigate legal proceedings may also account for the low proportion of victims pursuing court action. This is especially important for victims where perpetra-tors are still ‘out there’.

Acid attacks and the law

Within the UK, the police or hospital are usually the first point of contact and would be able to

assist as much as they can. The above-mentioned charities can provide advice and direction for individuals seeking legal support beyond the ini-tial phase of hospital care.

Classification of assaults and expected sequence of litigation events

There is no single law firm dedicated solely to acid assaults prosecutions. We collaborated with a legal firm that has previously dealt with acid assaults.40 These assaults fall into two categories: domestic vio-lence or criminal assault. The ability to deal with domestic violence law or criminal law by any law firm dictates its ability to manage acid assault cases.

The most common setting for chemical attacks to take place is within domestically violent relation-ships.15 If the crime is committed within a domestic relationship, the survivor could be introduced to domestic violence organisations and thereafter potentially to family law solicitors. Threats of vio-lence originate from the perpetrators who, in order to affirm their control, threaten to throw acid on their partners. A Non-Molestation Order and Occupation Orders from the family courts could potentially be sought in such circumstances.

If the act is carried out and acid is thrown at a victim, then this attack is dealt with as a crimi-nal offence, which is most likely to be considered under one of the following two offences:

(1) Grievous Bodily Harm (GBH): This offence is committed when a person unlawfully and maliciously, with intent to do some grievous bodily harm, or with intent to resist or prevent the lawful apprehension or detainer of any other person, either: wounds another person; or causes griev-ous bodily harm to another person.41

(2) Attempted Murder:42 This offence is com-mitted when a person does an act that is more than merely preparatory to the commission of an offence of murder, and at the time the person has the inten-tion to kill.43

If the offence committed is GBH, then this will be dealt with in a Crown Court and can result in a maximum sentence of life imprisonment. Criminal sentences of more than 10 years for this offence are rare. However, if acid is used in a fur-ther manner, for example, poured down the vic-tim’s throat, this is deemed to be an attempted murder. The sentencing for this varies depend-ing on the nature of the offence and the extent of damage caused. There is arguably no need for

Tan et al. 7

any legislative change in the UK unlike other countries as the sentencing powers reflect the severity of the crime.

In 2004 Greenbaum et al.39 suggested that the incidence of acid violence has remained steady. However, from 2006 onwards, the number of reported admission from acid assaults has gradually risen according to NHS data (Table 2).44 The discrepancy could be attributed to better reporting systems for acid assault cases and increased reporting in the media.

Applying for Legal Aid and instigating court proceedings

Entitlement to Legal Aid has recently changed due to the Legal Aid, Sentencing and Punishment of Offenders Act (2012).45 Up-to-date information is given on the following website: http://www.jus-tice.gov.uk/private-family-matters-legal-aid/vic-tims-domestic-violence.46 If victims wish to apply for Legal Aid to cover the costs of seeking protec-tion from domestic abuse (e.g. a Non-Molestation

Table 1. International organisations supporting victims of acid violence.

Organisation Role

Cambodian League for the Promotion and Defense of Human Rights (LICADHO); Cambodia26

• PAT programme provides financial, counseling, medical, and legal and advocacy assistance

• Reporting of incidences

Children’s Surgical Centre (CSC); USA-based NGO27

• Burn treatment assistance and rehabilitation

Cambodian Acid Survivors Charity (CSAC); Cambodia28

• Surgical, medical and psychological treatment• Vocational training and social reintegration• Legal assistance and advocacy for legal reform• Awareness through research, education and advocacy

Campaign and Struggle Against Acid Attacks on Women (CSAAAW); India29

• Assists survivors with access to legal, medical and social services• Works to prevent further attacks

Acid Survivors Foundation; Bangladesh30 • Assistance with treatment, rehabilitation, legal and advocacy for legal reform, increase awareness through research advocacy and prevention measures

Naripokkho, Bangladesh31 • Works to advance situation of women, to struggle against violence and inequity, lobby for women’s rights

• Brought media attention and initiated campaign against acid violence in mid 1990s

Acid Survivors Foundation Pakistan ASFP; Pakistan32

• Stop acid and burn violence and prevent the proliferation of attacks• Ensure survivors receive the best available medical treatment in the

long run• Ensure survivors get justice, exercise their fundamental rights

in accordance with the Pakistani constitution and international conventions

• Enable survivors to end up as proactive, democratic, empowered and autonomous citizens

Human Rights Commission of Pakistan (HRCP); Pakistan17

• Collects statistics from newspaper reports pertaining to acid attacks

Human Rights Watch (HRW); International33 • Investigate and report on human rights violations on global scale

Ansar Burney Trust; Pakistan34 • Medical treatment aid and legal support

Acid Survivors Foundation; Uganda[35] • Funds medical care• Trains and educates community• Police and other agencies• Provides counselling and advocacy

http://www.justice.gov.uk/private-family-matters-legal-aid/victims-domestic-violence




Order, Occupation Order or Forced Marriage Protection Order) then victims will qualify for Legal Aid subject to a means test.46

Individuals who are threatened with or become victims of acid violence can try and obtain protection from their abuser by applying for a civil injunction or protection order. An injunction is a court order that requires someone to do or not do something. In order to apply for an order, the applicant must be an ‘associated person’ otherwise the matter would not fall under family law.

If the applicant does not fall within the defi-nition of an associated person under the Family Law Act but is being continually harassed, threat-ened, pestered or stalked after a relationship has ended, they may have grounds to apply for a civil injunction under the Protection from Harassment Act 1997. In this way they will still be able to receive protection from the courts.

A Non-Molestation Order is aimed at pre-venting the abuser from threatening violence against, intimidating, harassing or pestering the victim in order to ensure their safety and wellbe-ing. An Occupation Order regulates who can live in the family home and can restrict the abuser from entering the surrounding area (e.g. 100 m). A breach of a Non-Molestation Order is a criminal offence and is punishable with up to 5 years’ imprisonment. Breach of an order can result in contempt of court and can be dealt with in the family courts. The perpetrator or respond-ent who continually harasses the victim can be imprisoned for a period of 2 years following com-mittal in the family courts.

The application is made on Form FL401: Application Form for Non Molestation Order and Occupation Order, supported by a sworn statement. This statement will set out the facts and the reasons for making the application and why the victim protection of the court. The most recent and most traumatic incidents of domestic

violence should always be included. This is a short hearing without compulsory notice to the Respondent. In almost all cases it is necessary to get a return hearing date as soon as possible (usu-ally within 1–2 weeks). Sometimes this is neces-sary because there is a fear that as soon as the Respondent learns about the application, they may cause more harm. The judge then makes a decision (after hearing from the Respondent at this hearing) as to whether the order will con-tinue and the duration of the order. The court rarely makes an Occupation Order at this stage, as this issue is more complex and a further sub-stantive hearing will be needed, with notice to the Respondent.

Even with an order in place, one should not assume that the victim is completely protected. Threats of acid violence are very serious. While a court order can be a deterrent, it may not always stop the respondent/perpetrator from carrying out the acts.

Collaborative efforts and working framework

An integrated public health response with strong formalised partnership between survivors, GOs and NGOs, health authorities and law enforce-ment can lead to better collaboration and coor-dination of efforts to end acid violence. Governments should also maintain a zero-toler-ance policy in order to eliminate acid violence. Close collaboration with forensic criminologist, psychologist and perpetrators may help develop a better understanding of motivations and ana-lyse root causes of such assaults. Beyond local organisations, such collaborations should ven-ture out to include international and regional working groups that offer a platform for infor-mation sharing and raising awareness in prevent-ing acid attack violence.

Education and prevention

Prevention remains key to reducing the inci-dence of burn injuries. Publicised education campaigns have increased awareness and appear to have reduced the number of attacks in LMICs.47 Some have feared that publicity can lead to an increase in such attacks, but there is no evidence to support this view at this time. Healthcare professionals would benefit from education and information on the available psy-chosocial and legal support for such assault vic-tims. As the first point of contact in a protected

Table 2. Assaults by a corrosive substance as reported by the NHS Information Centre.44

Year Admissions

2006–2007 44

2007–2008 67

2008–2009 69

2009–2010 98

2010–2011 110

Tan et al. 9

environment such as in hospital, this may be the only opportunity to provide these patients with a setting in which they may feel ‘safe’ enough to accept help. There are dedicated charitable foundations to acid assault survivors within the UK such the KPF and ASTI. Together, these char-ities offer information on burn scar rehabilita-tion, support access to quality medical care, assist with survivors’ psychological and social rehabili-tation, and advocacy work to prevent further attacks.15,24

Regarding prevention laws, more stringent legislation on the purchase of corrosive sub-stances is needed. Currently in the UK, corrosive substances such as heavy-duty drain cleaners are easily obtainable by the general public from large DIY superstores. While it is impossible to stop the public purchasing such agents freely over the counter, a legal requirement for sellers to record details of every purchase should be implemented. Such a step may assist criminal investigations. We appreciate this may not completely restrict other means of obtaining corrosive substances by other means, such as that from car batteries. Nonetheless, this will reduce the number of avail-able sources for the potential assailant.

Conclusion

Burn injury by assault with corrosive substances is a malicious criminal act intended to cause griev-ous bodily harm with potentially devastating long-term morbidity to the victim. As healthcare professionals, we have a professional and ethical obligation to provide the best standard of care to our patients. For victims of assaults, this includes offering prompt access to existing legal, psycho-social and external agency support. To prevent these injuries, we recommend stricter legislation on purchase of corrosive substances, which is likely to have a significant impact on reducing future rates of these attacks.

Declaration of conflicting interestsThe authors declare that there is no conflict of interest.

FundingThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

References 1. Branday J, Arscott GD, Smoot EC, et al. Chemical burns as

assault injuries in Jamaica. Burns 1996; 22(2): 154–155. 2. Das KK, Khondokar MS, Quamruzzaman M, et al. Assault by

burning in Dhaka, Bangladesh. Burns 2013; 39(1): 177–183.

3. Asaria J, Kobusingye OC, Khingi BA, et al. Acid burns from personal assault in Uganda. Burns 2004; 30(1): 78–81.

4. Maghsoudi H and Gabraely N. Epidemiology and outcome of 121 cases of chemical burn in East Azarbaijan province, Iran. Injury 2008; 39(9): 1042–1046.

5. Mannan A, Ghani S, Clarke A, et al. Psychosocial outcomes derived from an acid burned population in Bangladesh, and comparison with Western norms. Burns 2006; 32(2): 235–241.

6. Shapiro A-L. Breaking the Codes: Female Criminality in Fin-De-Siecle Paris. Stanford, CA: Stanford University Press, 1996.

7. Harris R. Murders and Madness: Medicine, Law and Society in the Fin-De-Siecle. Oxford: Oxford University Press, 1989.

8. Purdue GF and Hunt JL. Adult assault as a mechanism of burn injury. Arch Surg 1990; 125(2): 268–269.

9. Brodzka W, Thornhill HL and Howard S. Burns: causes and risk factors. Arch Phys Med Rehabil 1985; 66(11): 746–752.

10. Milton R, Mathieu L, Hall AH, et al. Chemical assault and skin/eye burns: two representative cases, report from the Acid Survivors Foundation, and literature review. Burns 2010; 36(6): 924–932.

11. Wolfort FG, DeMeester T, Knorr N, et al. Surgical management of cutaneous lye burns. Surg Gynecol Obstet 1970; 131(5): 873–876.

12. Beare JD. Eye injuries from assault with chemicals. Br J Ophthalmol 1990; 74(9): 514–518.

13. Heise L, Ellsberg M and Goetemoeller M. Ending violence against women. Population Reports. Baltimore, MD: Johns Hopkins University School of Public Health, Population Information Program, 1999.

14. Krob MJ, Johnson A and Jordan MH. Burned-and-battered adults. J Burn Care Rehabil 1986; 7(6): 529–531.

15. Acid Survivor Trust International. http://www.acidviolence.org/index.php/how-we-help/specialist-teams.

16. Acid Survivors Foundation. 6th Annual Report. Dhaka: ASF, 2004. 17. Human Rights Commission of Pakistan (HRCP). http://hrcp-

web.org/hrcpweb/campaigns/. 18. Ly H, Sarom N, Gollogly, et al. 88 Burns operated at the ROSE

rehabilitation Centre, Phnom Penh. Paper read at the 7th annual Cambodian Surgical Congress, November 2001.

19. Yeong E, Chen MT, Mann R, et al. Facial mutilation after an assault with chemicals: 15 cases and literature review. J Burn Care Rehabil 1997; 18(3): 234–237.

20. Harchelroad F and Rottinghaus D. Chemical Burns in Emergency Medicine: A Comprehensive Study Guide. 6th ed. New York, NY: McGraw-Hill, 2004.

21. Faga A, Scevola D, Mezzetti MG, et al. Sulphuric acid burned women in Bangladesh: a social and medical problem. Burns 2000; 26(8): 701–709.

22. Blalock SJ, Bunker BJ and DeVellis RF. Psychological distress among survivors of burn injury: the role of outcome expecta-tions and perceptions of importance. J Burn Care Rehabil 1994; 15(5): 421–427.

23. Williams EE and Griffiths TA. Psychological consequences of burn injury. Burns 1991; 17(6): 478–480.

24. Katie Piper Foundation. http://www.katiepiperfoundation.org.uk. 25. Domestic Violence UK. http://domesticviolenceuk.org. 26. Lim J-A. Violence Against Women in Cambodia. Phnom Penh:

LICADHO, 2006. 27. Children’s Surgical Centre (CSC). http://www.csc.org. 28. Cambodian Acid Survivors Charity. Helping survivors heal and

working to prevent future acid attacks. http://cambodianacid-survivorscharity.org.

29. Campaign and Struggle Against Acid Attacks on Women (CSAAAW) Vs. Department of Women and Child Welfare.

30. Acid Survivors Foundation. http://www.acidsurvivors.org. 31. Naripokkho. http://www.copasah.net/naripokkho.html. 32. Acid Survivors Foundation Pakistan. http://acidsurvivorspaki-

stan.org/about. 33. Human Rights Watch (HRW). http://www.hrw.org.

http://www.acidviolence.org/index.php/how-we-help/specialist-teams

http://www.acidviolence.org/index.php/how-we-help/specialist-teams

http://hrcp-web.org/hrcpweb/campaigns/

http://hrcp-web.org/hrcpweb/campaigns/

http://www.katiepiperfoundation.org.uk

http://domesticviolenceuk.org

http://www.csc.org

http://cambodianacidsurvivorscharity.org

http://cambodianacidsurvivorscharity.org

http://www.acidsurvivors.org

http://www.copasah.net/naripokkho.html

http://acidsurvivorspakistan.org/about

http://acidsurvivorspakistan.org/about

http://www.hrw.org


34. Ansar Burney Trust. http://ansarburney.org. 35. Acid Survivor Foundation Uganda. asfuganda.org. 36. National Burn Care Review 2001: Standards and Strategy for

Burn Care. http://www.britishburnassociation.org/down-loads/NBCR2001.pdf (2001, accessed 6 April 2015).

37. Mary Konye guilty of acid attack on friend Naomi Oni. http://www.bbc.co.uk/news/uk-25867695 (2014).

38. Mannan A, Ghani S, Clarke A, et al. Cases of chemical assault worldwide: a literature review. Burns 2007; 33(2): 149–154.

39. Greenbaum AR, Donne J, Wilson D, et al. Intentional burn injury: an evidence-based, clinical and forensic review. Burns 2004; 30(7): 628–642.

40. Blava & Co. Solicitors. http://www.legalblavo.co.uk.

41. Section 18 of the Offences Against Person Act 1861. 42. Section 4(1) of the Criminal Attempts Act 1981 43. Legal Aid. http://legislation.gov.uk/ukpga/Vict/24–25/100. 44. Assaults by a corrosive substance as reported by the NHS

Information Centre. http://www.dawsoncornwell.com/en/documents/Acid_Violence.pdf page 8 (2015)

45. Legal Aid, Sentencing and Punishment of Offenders Act 2012.

46. GOV.UK. Legal Aid. http://www.justice.gov.uk/private-family-matters-legal-aid/victims-domestic-violence.

47. Acid Survivors Foundation. Research Advocacy and Prevention. http://www.acidsurvivors.org/Research-Advocacy-and-Prevention (2015).

http://ansarburney.org

http://www.britishburnassociation.org/downloads/NBCR2001.pdf

http://www.britishburnassociation.org/downloads/NBCR2001.pdf

http://www.bbc.co.uk/news/uk-25867695

http://www.bbc.co.uk/news/uk-25867695

http://www.legalblavo.co.uk

http://legislation.gov.uk/ukpga/Vict/24

http://www.dawsoncornwell.com/en/documents/Acid_Violence.pdf

http://www.dawsoncornwell.com/en/documents/Acid_Violence.pdf



http://www.acidsurvivors.org/Research-Advocacy-and-Prevention

http://www.acidsurvivors.org/Research-Advocacy-and-Prevention




Hair transplantation in burn scar alopecia

Bessam Farjo, Nilofer Farjo and Greg Williams

Farjo Hair Institute, Manchester and London, UK

Corresponding author:Greg Williams, Farjo Hair Institute, 70 Quay Street, Manchester M3 3EJ, UK. Email: [email protected]: @Drgregwilliams

607764 SBH0010.1177/2059513115607764Scars, Burns & HealingWilliams et al.research-article2015

Original Article

AbstractTreating patients with burn alopecia or hair loss can often be a challenge to both the surgeon and the patient. As with other reconstructive procedures that are required in the post-burn phase, this is usually a multiple stage process often requiring surgery over several years. This is because graft take is not as reliable as in healthy non-scarred skin and may need repeating to achieve adequate density. Also, different areas of hair loss may need to be addressed in separate procedures. There are several limiting factors that will determine whether or not a patient is a candidate for hair restoration which includes but is not limited to the amount of hair loss and the availability of suitable donor hair. Here we discuss how the current surgical technique of hair transplant surgery by follicular unit extraction (FUE) or strip follicular unit transplant (FUT) has become the treatment of choice for alopecic areas that require a more refined aesthetic result. Eyebrow, eyelash, beard and scalp hair loss can all have a negative impact on a burn survivor’s self-esteem and even if surgery is not a possibility, there are non-surgical options available for hair restoration and these are also discussed.

KeywordsBurns, hair transplantation, burn scar, alopecia, strip follicular unit transplant, follicular unit extraction, hairloss, hair restoration, scalp, beard, eyebrows, eyelashes

Lay SummaryThis article explores the procedure of hair transplantation in the context of general options for hair restoration for individuals that have suffered hair loss due to burn injuries.Treating hair loss due to burns can often be a difficult process for both the surgeon and the patient. As with other surgical procedures that are required in the post-burn phase, hair restoration is usually a multiple stage process often requiring surgery over several years. This is because transplanted hairs are not as reliably successful as in healthy non-scarred skin and many repeat treatments may be needed to achieve adequate density, which is important for a natural look. In addition, different areas of hair loss may need to be addressed in separate procedures. There are several factors that will determine whether or not a patient is a good candidate for hair restoration which includes such things as the amount of hair loss and how much suitable donor hair (the donor is the area from which hair is taken, or donated) is available if the scalp has been affected by scarring. Eyebrow, eyelash, beard and scalp hair loss can all have a negative impact on a burn survivor’s self-esteem and confidence. Even if surgery is not a possibility there are non-surgical options, outlined in this article, which may be available for hair restoration. In this article we explain why the current surgical technique of hair transplant surgery has become the surgical treatment of choice for restoring areas of hair loss, especially in areas that require a more refined and natural result such as eyebrows.

e e e

es s s e e

e

e

s

s

e e

mailto:[email protected]


IntroductionBurn injuries, whether caused by chemical (acid/alkali), flame, scalds (including steam, hot water and cooking oils) and rarely electrical injury, may be isolated to the head and neck region or be part of injuries affecting a larger total body sur-face area. Functional problems are common and include intrinsic and extrinsic contractures resulting in microstomia, upper and lower eyelid ectropion, lip eversion and nostril constriction. After the acute management of life-threatening problems has been concluded, wound healing has been completed, and functional deficits have been addressed attention can be turned to the improvement of the aesthetic concerns of the patient such as partial or complete loss of the nose and external ear. Complete destruction of the hair follicle is usually associated with deep burns, the nature of which also results in severe scarring and which makes hair transplantation more challenging. Although hair loss from previ-ously hair-bearing areas of the head and neck is hard to hide with clothing – specifically the scalp, eyebrows, eyelashes and beard region – it is often seen by clinicians as less important than scar management per se. However, hair loss can have an equal or greater impact on the self-esteem and quality of life of patients than the scars them-selves and act as a constant reminder of the caus-ative traumatic incident.

Many patients will choose non-surgical options to address their visible difference, but for many patients there are a variety of surgical hair restoration options available that can produce superior results in certain cases.1 Follicular unit (FU) hair transplantation is an important option for consideration by burns multi-disciplinary teams (MDTs), especially for those areas requir-ing a more refined outcome rather than simply the presence of hair. The challenge with these techniques is to understand both the characteris-tics of naturally growing hair and also predicting a realistic outcome for the patient.

Non-surgical options for managementNot all burns patients will be suitable candidates for hair restoration surgery and some will opt not to choose this option. Therefore, the burn MDT should be aware of the non-surgical choices avail-able to the patient. These include:

•• Cosmetic camouflage – scalp dyes, col-oured hairsprays, keratin microfibres, eye-brow make-up

•• Semi-permanent micro-pigmentation tat-tooing – particularly effective for eyebrows but can be used to simulate hair stubble or strands of hair

•• Scalp hair replacement systems – partial hair pieces or complete wigs

•• Hair-bearing adhesive prostheses – eye-brows, false eyelashes

•• Scalp hair bearing prostheses combined with Branemark ear prostheses – useful when the hair loss is limited to the post-auricular area

Patients who are not suitable for hair transplanta-tion include those who do not have enough donor hair to cover the non-hair bearing defects, male patients who have advanced male pattern baldness themselves or a significant family his-tory of advanced male pattern hair loss (which limits the size of the safe occipital scalp donor area) and inflammatory dermatological condi-tions that are contraindications to hair transplan-tation (for example, lichen plano-pilaris). Patients may also be unsuitable for hair trans-plantation because there are multiple other reconstructive surgical priorities for functional rehabilitation that are higher on the priority list. The non-surgical options listed above can be used as temporary solutions, and for many patients who are tired of having surgical proce-dures, they can provide an adequate long-term camouflage. It is worth noting that hair trans-plantation is not an option for many patients due to cost.

Surgical options for managementThe surgical options for treating burn alopecia will depend on the location of the hair-bearing area affected and the size of the defect. These include one or a combination of the following techniques:

•• Serial excision with or without tissue expansion

•• Hair-bearing flaps with or without tissue expansion

•• Hair-bearing full thickness grafts•• Hair transplant surgery

As there is a limit to the hair density achievable per hair transplant procedure, and at least three procedures will be required to simulate the appearance of normal density, large areas of scalp and beard burn scar alopecia (greater than 80–100 cm2) are often best managed initially by

Williams et al. 3

reducing the size of the defect. This is best achieved with serial excision, tissue expansion and hair-bearing flaps leaving hair transplanta-tion as the last stage to refine hairlines, fill in smaller areas of residual burn scar alopecia and cover surgical scars.

Hair-bearing full-thickness grafts are rarely completely successful and hair growth is often not in a natural direction so hair transplantation should be the first treatment of choice for the reconstruction of hair in or around the face. This is especially crucial in producing naturalness in eyebrow and eyelash alopecia.

However, most burns reconstructive surgeons and burns services do not have the skill, training, infrastructure, resources or possibly case load to provide a quality hair transplantation service. Hence, these treatments are commonly unavail-able in publicly-funded health systems and patients who can afford the care or can gain pub-lic funds through, for example, an Individual Funding Request (IFR) are seen in the private sector. As a consequence, there is little published literature on hair transplantation for burn scar alopecia since private hair transplant providers will rarely see (or be experienced in the treat-ment of) significant numbers of burns patients. In addition, private providers are generally less likely to be involved in scientific research.

Hair transplant surgery

Historical contextIt is universally acknowledged that the era of hair restoration surgery commenced in Japan with techniques developed to treat burn survivors. In the 1930s, Okuda published his technique of transplanting hairs derived from punch grafts into areas of burn scar alopecia in the Japanese Journal of Dermatology.2 Shortly after, Tamura also published his work using hairs derived from spin-dle shaped strips of scalp skin.3 These two publi-cations described the fundamentals of the Strip Follicular Unit Transplant (Strip FUT) and Follicular Unit Extraction (FUE) methods used today. There was a delay in these techniques reaching the Western world due to the interven-tion of World War II. It was not until 1959 that Orentreich from the USA published his tech-nique transplanting 4 mm punch grafts in the Annals of the New York Academy of Science and he also described the concept of ‘donor domi-nance’, noting that transplanted follicles retained the anatomical and physiological properties of their donor site in the parieto-occipital scalp

which does not go bald. The popularisation of hair transplantation for treating male pattern baldness (MPB) soon followed and the method of obtaining donor hair follicles changed over the following years from extraction with smaller punches to strip excision from the donor area. In 1988, Limmer, working under stereoscopic micro-scopes in the USA with Strip FUT cases, applied the concept of the follicular unit natural group-ings to hair transplantation and suggested better aesthetics and hair survival this way (Figure 1). Headington had previously described that scalp hairs do not grow individually but in small groups and designated these groups as FUs.4 Coincidentally in 1988, Inaba from Japan had also published a refined technique of FUE using a 1 mm needle. However, it was Woods from Australia who first demonstrated this technique in the West and it was then first formally described in the Western medical literature in 2002 by Bernstein and Rassman.5

General considerationsHair loss from burn injury falls under the cate-gory of a secondary scarring alopecia. While there is a long and extensive global anecdotal experience with successful treatment with hair transplantation, there is little research or publi-cation in this area with regards to the percentage survival of follicles transplanted into burn scars. The authors’ anecdotal experience in over 100 cases is that hair follicle graft survival in scar tissue can be in the range of 0–90%.

Prior to embarking on transplantation, the scars should be fully mature, i.e. as pale, soft, flat and as supple as they are likely to become.

Figure 1. FUs with three, two and one hairs.


Patients are often anxious to proceed with hair restoration as soon as possible but a cautious approach should be advocated in order to ensure the best outcome. If scars remain pink, they are likely to bleed when incisions are made causing inserted grafts to be ejected by the blood flow. The altered architecture of the cutaneous layers means that the natural ‘grab’ of the skin to hold the graft in place is diminished. This decrease in scalp elasticity is also important when consider-ing the method of donor harvesting as there is not always enough scalp laxity to remove a strip of donor hair bearing skin and achieve adequate wound closure. This may restrict the potential of strip FUT and make FUE a better donor follicle harvesting method (see below).

Another consideration is that the vascularity in mature scars is variable and a diminished blood supply will have an impact on grafted fol-licle survival and over-enthusiastic attempts to pack incisions densely may compromise the blood supply to the scar further, resulting in necrosis. If skin grafts have been previously used in an area there may be a limited amount of sub-cutaneous tissue and when the skin graft is stuck to the cranium transplantation will not be possi-ble. The authors are aware of anecdotal cases of autologous fat grafting to create enough underly-ing tissue into which grafts can be inserted through thin scars. Results have been variable but this is an interesting area of development for future treatment. An added benefit to the intro-duction of multiple fragments of dermis with the transplanted FU may be an overall improvement in the scar quality.

Most follicular unit hair transplants for burn scar alopecia will be performed in private hair transplant clinics and therefore will not have their own MDTs. Ideally, contact should be made with the patient’s burn team not only to

coordinate prioritisation of the hair transplant procedure with other reconstructive surgical needs but also to confirm suitability to have a procedure under local anaesthetic. As these pro-cedures will take a minimum of 2–3 h and a maxi-mum of up to 12 h, local anaesthesia is much safer than general anaesthesia, and remains our preference in most cases.

The consent and patient education process for hair transplantation in burn scars is important and should take into account the variability in follicular unit graft take, the limitation in hair density that can be achieved per procedure, and the likelihood that multiple procedures might be required to achieve a satisfactory density. It is important to understand the patient’s motivation for the proce-dure and to uncover what their expectations are for short- and long-term outcomes.

Hair transplantation methodsModern hair transplantation is focused around follicular units being taken from the ‘safe’ donor zone in the non-balding scalp as these provide longlasting, natural results. The donor:recipient ratio concept refers to the number of hairs avail-able in the donor area compared to the number of hairs required to cover a scarred area.

There are two main ways to harvest donor hair – the Strip Follicular Unit Transplant (Strip FUT) method and the Follicular Unit Extraction (FUE) method (Figure 2). Both have advantages and disadvantages for the surgeon and prospec-tive patient to consider.3

In Strip FUT surgery, an ellipse of skin is removed from the donor area leaving a perma-nent linear surgical scar, the width of which var-ies depending on the skill of the surgeon and the patient’s scalp healing properties. It is designed to be completely hidden within the patient’s own

Figure 2. Strip FUT (left) vs. FUE (right) donor site harvesting methods.

Williams et al. 5

donor hair. In general, this is a quicker way to harvest grafts compared to FUE but a major dis-advantage is that it requires a large team of trained assistants to dissect the grafts into indi-vidual follicular units when transferring a large number of grafts (Figure 3).

In FUE surgery, there is no linear scar but instead each extraction site leaves a small round dot scar that can be hidden even with shorter hairstyles compared to a strip scar. The punches vary in size but generally are in the range of 0.75–1.2 mm in diameter attached to either a hand-held manual device, a hand-held mecha-nised drill device or an automated robotic device. Disadvantages of this technique are that large harvesting sessions require the entire donor area to be shaved and the grafts tend to have less tis-sue around them and therefore more care is needed in handling them. Only with multiple or ill-planned procedures will there be thinning out of the donor area. One distinct advantage of using this technique in burn alopecia is that the scalp is often very tight in these cases so strip FUT is not advised as only a narrow ellipse can be removed limiting the amount of hair that can be transferred and closure under tension will lead to a widened, or potentially hypertrophic, scar.

The FUE technique can also be applied to the harvesting of beard donor hair for use in beard to beard transplants, or beard to scalp transplants, although the physical characteristics of beard hair are different to scalp hair (beard hairs tend to be of thicker calibre, more ‘bristly’ and may be a different colour) so patients need to be willing to accept the aesthetic difference. Body hair can also be harvested by FUE but the growth characteristics are very different to scalp and beard hair with body hair having a shorter growth phase and a longer resting phase. This means that body hair transplants to the scalp might result in fluctuations in hair density as the body hairs enter their longer hair growth cycle resting phase.

Regardless of the method used to harvest hairs, the implantation is the same and it is the angle and direction of the transplanted hairs along with the hairline design6,7 and recipient site density that are responsible for a pleasing hair transplant result, not the method of harvest-ing. Follicular unit grafts can be implanted into pre-made incisions using forceps or implanters (Figure 4), or the implanters can be used to cre-ate incisions at the same time the graft is implanted. The advantage of the former is that the overall design of the transplant is made prior to the onset of graft implantation whereas the

advantage of the latter is that no incision sites are missed.

Complications in hair transplant surgery are mainly related to the aesthetic outcome with density or design as the main area of contention. Infections in the form of folliculitis or cellulitis are rare as is donor or recipient site skin necrosis. Unlike patients with genetic hair loss where the transplanted area can be designed to simulate a naturally occurring thinning pattern, patients with burn scar alopecia often have dense hair adjacent to the areas of alopecia. They therefore require repeated procedures to achieve adequate density and this should be made clear at the time of the original consultation. It can take up to 18 months for transplanted hairs to reach matura-tion, therefore the ability to assess the results of the transplant. Multiple procedures can take 5 years or more to complete. Camouflage products can be a useful adjunct to hair transplantation to give the illusion of greater density during this period. Likewise micropigmentation tattooing which can give the scars a colour similar to the

Figure 3. Strip FUT sliver and dissected follicular units.

Figure 4. Follicular units being placed in incisions dyed with methylene blue for ease of identification.


hair can reduce the colour contrast of pale scar and darker hair and give the illusion of greater hair density.

Specific areas – scalpThere are several classifications of scalp burns scar alopecia but that by McCauley8 is widely accepted (Table 1). Type I and Type II are often best treated with tissue expansion initially, reserving hair trans-plantation for the refinement of hairlines and sideburns as well as filling in surgical scars created in the tissue expansion process. Historically, the hairline in patients with facial burns has been reconstructed with a temporo-parieto-occipital (Juri) flap but this tends to lead to a harsh straight hairline with the hair exiting at an unnatural angle. Modern follicular unit transplants can pro-vide a much more natural appearance even under close inspection (Figures 5 and 6).

Furthermore, in male patients where hair-bearing advancement or rotation flaps are being considered, either in isolation or as part of tissue expansion, it is important to understand the potential for MPB in the future and warn the patient that flaps taken from areas that are genet-ically predetermined to lose hair will do so in their transferred location which may lead to

unnatural patterns of balding.9,10 In some cases such loss can be prevented by using approved medications for androgenetic alopecia such as oral finasteride11 or topical minoxidil12 and these should be started as soon as there is evidence of androgenetic alopecia. A classification for male pattern hair loss has been provided by Norwood and is commonly used to classify the degree of baldness.13

Where there are localised areas of hair loss adjacent to the loss of the external ear, a Branemark-based prosthetic ear combined with a

Figure 5. Left hairline burn scar alopecia (a) pre and (b) post hair transplant.

Figure 6. Scalp burns scar alopecia (a) pre and (b) post hair transplant.

Table 1. McCauley’s classification of scalp burns scar alopecia.

Type I Single alopecia segmentA Less than 25% of the hair-bearing scalpB 20–50% of the hair-bearing scalpC 50–75% of the hair-bearing scalpD 75% of the hair-bearing scalp

Type II Multiple alopecia segments amenable to tissue expansion

Type III Patchy burn alopecia not amenable to tissue expansion

Type IV Total alopecia

Williams et al. 7

hair bearing prosthesis can produce a result that is often superior to attempts at autologous recon-struction especially where the severity of the burn scarring precludes the use of localised skin or fas-cial flaps for ear reconstruction (Figure 7).

Specific areas – beardIn men, if the roots of the beard or moustache hair have been damaged, scarring alopecia will occur. In hirsute men, especially those with dark hair, this loss of beard or moustache hair can accentuate the post-burn scarring appearance, even with the best quality burns scars that approach normal skin colour and texture. Small areas of beard scar alopecia can be excised, although the resulting surgical scars will still leave residual non-hair bearing scars. Although micropigmentation tattooing can very effectively mimic stubble, beard hair grows quickly and the discrepancy between the tattooed stubble and even short surrounding hairs makes the appear-ance unnatural. Hence hair transplantation remains the best option for beard and moustache scarring alopecia (Figures 8 and 9). Although scalp hair can be used as the donor, the best match will be from FUE-derived beard hair.

Specific areas – eyebrowsEyebrows are essential for what we recognise as a ‘human’ face and when they are lost, there is a ‘de-humanisation’ of the appearance. Over-plucking of eyebrows with the resulting perma-nent hair loss has led many women either to use temporary makeup or more permanent micro-pigmentation tattooing. This tattooing tech-nique, although commonly applied to eyebrow burn scar alopecia, often produces a harsh appearance (Figure 10).

Modern eyebrow micropigmentation aims to produce a ‘three-dimensional’ appearance, but

this is only effective when viewed straight on and in order for ‘texture’ to be appreciated, hair transplantation is required (Figures 11 and 12).

In the interim period when scars are matur-ing prior to being suitable for a hair transplant, self-adhesive eyebrow prostheses (Figure 13) can be used and this is particularly the case for men where eyebrow makeup and tattoos tend to be less socially acceptable.

Specific areas – eyelashesUpper eyelash replacement is possible using either retrograde or anterograde techniques. The retrograde technique is similar to that of a stand-ard hair transplant procedure where follicles are inserted, bulb first, into an incision at the lid mar-gin.14 The anterograde technique was popular-ised by Marcelo Gandelman15 and has the advantage of greater control of the direction of growth of the eyelash, reducing the incidence of inward growth of the eyelash causing corneal abrasions. In this technique a curved French eye needle is inserted 5–10 mm from the lid margin and a long hair is threaded subcutaneously to the lid margin where is then pulled through until the

Figure 7. (a) Loss of external ear and burn scar alopecia. (b) With Branemark. (c) Ear and hair-bearing prosthesis attached.

Figure 8. Partial beard scarring alopecia (a) pre and (b) post hair transplant.


bulb is buried under the needle insertion point on the lid (Figure 14). Lower lash replacement is usually not recommended as they are less promi-nent aesthetically, achieving a natural curl is

difficult, and there is a much higher complication rate. For women, false eyelashes are a good alter-native to transplantation.

Other hair-bearing areasAlthough rarely requested, it is possible to restore hair to other hair-bearing parts of the body. In men, this may involve the chest, axillae, arms and legs. In both sexes, restoration of pubic hair may

Figure 10. Eyebrow burn scar alopecia (a) pre and (b) post micropigmentation tattooing. Photos courtesy of Marcia Trotter.

Figure 11. Partial right eyebrow scarring alopecia (a) pre and (b) post hair transplant.

Figure 9. Beard and moustache scarring alopecia (a) pre and (b) post full beard hair transplant.

Figure 12. Complete right eyebrow scarring alopecia (a) pre and (b) post hair transplant.

Figure 13. Eyebrow scarring alopecia (a) pre and (b) post eyebrow prostheses application.

Figure 14. Anterograde technique for eyelash transplantation. Note strand of hair in eye of curved needle – bulb will be positioned under insertion point of needle and distal end of hair will be pulled out through exit point of needle at lid margin.

Williams et al. 9

be important in regaining a feeling of masculin-ity or femininity and can contribute to improved rehabilitation of sexuality and sexual function.

Future developmentsHair transplant surgery is currently the only per-manent treatment for hair loss, a solution which is limited by the availability of donor hair. The future of alopecia treatment may be in using cell therapy. Culturing of trichogenic cells in vitro has been tried in the past with limited success. However, newer culturing methods have shown that hair follicle cells maintain their ability to regenerate hair in vivo when re-implanted.16

Although general patient wellbeing (which may be impacted by hair loss issues) will be cap-tured in burn-specific quality of life and patient reported outcome measures currently, there are no globally accepted outcome measures for hair transplant surgery that can be applied to hair resto-ration for burn scar alopecia. This, along with the development of more specific patient satisfaction measures for hair transplantation in burn scar alo-pecia, should be a focus of research in the future.

ConclusionBurn scar alopecia may add to the appearance issues suffered by burn survivors and contribute to lowered self-esteem and sense of wellbeing. A vari-ety of non-surgical and surgical methods are employed to achieve hair restoration to areas of burn scar alopecia. The suitability of performing a hair transplant procedure is dependent on suffi-cient availability of donor hair to address the area of hair loss, as well as a receptive recipient area as determined by scar tissue that is sufficiently mature and has adequate subcutaneous tissue to allow the insertion of grafts through the scar.17 Hair trans-plantation can restore completely natural looking hairlines, cover small to moderate sized areas of scalp burn scar alopecia, and recreate destroyed beards and moustaches. Eyebrows can be restored, as can upper eyelashes and other hair bearing parts of the body in selected cases. At the present time there are no globally accepted outcome measures for hair transplant surgery that can be applied to hair restoration in burn scar alopecia. This, along with the development of patient satis-faction measures for hair transplantation in burn scar alopecia, should be a focus of research in the future. Engagement and collaboration with health service commissioners would be valuable to

increase availability of hair transplantation for burns survivors.

Declaration of conflicting interestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

FundingThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Ethical ApprovalThe authors confirm that the necessary written, informed con-sent was obtained from patients for this article.

References 1. Barrera A. The use of micrografts and minigrafts for the treat-

ment of burn alopecia. Plast Reconstr Surg 1999; 103(2): 581–584. 2. Okuda S. Clinical and experimental studies on hair transplant-

ing of living hair. Jpn J Dermatol Urol 1939; 46: 537–587. 3. Tamura H. Concerning hair transplantation. Jpn J Dermatol

Urol 1943; 53: 76. 4. Headington JT. Transverse microscopic of the human scalp.

A basis for a morphometric approach to disorders of the hair follicle. Arch Dermatol 1984; 120: 449–456.

5. Rassman WR, Bernstein RM, McClellan R, et al. Follicular unit extraction: minimally invasive surgery for hair transplantation. Dermatol Surg 2002; 28(8): 720–728.

6. Bernstein RM and Rassman WR. Follicular transplantation: patient evaluation and surgical planning. J Dermatol Surg 1997; 23(9): 77–84.

7. Shapiro R. Creating a natural hairline in one session using a systemic approach and modern principles of hairline design. Int J Cosm Surg Aesth Dermatol 2001; 3(2): 88–99.

8. McCauley RL, Oliphant JR and Robson MC. Tissue expansion in the correction of burn alopecia: classification and methods of correction. Ann Plast Surg 1990; 25(2): 103–115.

9. Ellis JA, Sinclair R and Harrap SB. Androgenetic alopecia: pathogenesis and potential for therapy. Expert Rev Mol Med 2004; 4: 1–11.

10. Rushton DH, Ramsay ID, Norris MJ, et al. Natural progres-sion of male pattern baldness in young men. Clin Exp Dermatol 1991; 16: 188–192.

11. Kaufman KD, Olsen EA, Whiting D, et al. Finasteride in the treatment of men with androgenetic alopecia. J Am Acad Dermatol 1998; 39: 578–589.

12. Olsen EA, Weiner MS, DeLong E, et al. Topical minoxidil in early male pattern baldness. J Am Acad Dermatol 1985; 13: 185–192.

13. Norwood OT. Male pattern baldness: classification and inci-dence. South Med J 1975; 68: 1359–1365.

14. Barrera A. The use of micrografts and minigrafts in the aes-thetic reconstruction of the face and scalp. Plast Reconstr Surg 2003; 112(3): 883–890.

15. Gandelman M. A technique for reconstruction of eyebrows and eyelashes. Semin Plast Surg 2005; 19(2): 153–158.

16. Farjo B and Farjo N. Follicular regeneration. Montagna Trichology Vol II 2013, pp. 1125–1130. Madrid: Grupo Aula Medica.

17. Rose P and Shapiro R. Transplanting into scar tissue and areas of cicatricial alopecia in hair transplantation. In: Unger WP and Shapiro R (eds) Hair Transplantation. 4th ed. New York, NY: Marcel Dekker, 2004, pp. 600–606.


Editor-in-Chief: Professor Kayvan ShokrollahiMersey Regional Centre for Burns and Plastic Surgery, Liverpool UK Edge Hill University, Ormskirk [email protected]

Managing Editor: RuthAnn FanstoneChelsea and Westminster Hospital, London, [email protected]

Scars, Burns & Healing is a new peer reviewed, open access journal bringing together the specialist focus of scar and burns research with the breadth of the science and medicine related to healing.

A truly multi-disciplinary journal, Scars, Burns & Healing seeks to publish suitable material relevant to all clinical specialties related to scar and burn care, ranging from basic science (including genetics, immunology, nanotechnology and tissue engineering) to clinical practice.

The journal breaks new ground in a number of areas:

It is the only international journal which includes a specialist focus on scar research

Its content is designed in such a way to have relevance to a lay audience as well as a clinical and scientific one

It is fully peer reviewed and published open access to ensure maximum dissemination; all published content is freely available to view, ensuring the greatest visibility and impact for research in the areas of scars, burns and healing

It is the only burns-related journal which guarantees full colour publication for all articles

A free language editing service can be provided for articles from non-English speaking regions

A considerable amount of targeted PR activity will help promote and disseminate the works of authors and institutions in both scientific and mainstream media

Affiliation with The Katie Piper Foundation ensures a wide and varied audience for research

Open for SubmissionsPlease visit https://mc.manuscriptcentral.com/sbh to upload your manuscript and view the guidelines

Commercial SalesFor information on advertising, reprints and supplements please contact Neil Chesher [email protected]

Further InformationFor further information about Scars, Burns & Healing, please contact the Publishing Editor, Jovie [email protected]

This is a print-on-demand copy of content from a SAGE online journal. Please visit www.sagepublications.com and follow the journal links for full details of this title including editors, editorial board, submissions procedures, subscription information and more.

© SAGE Publications Ltd (issue compilation); individual articles, © The Author(s) or as otherwise indicated


Editorial Board

Baljit Dheansa, Queen Victoria Hospital, East Grinstead, UKWilliam Dickson OBE, South West Burn Operational

Delivery Network, UKPeter Dziewulski, St. Andrew’s Centre for Plastic Surgery

and Burns, Broomfield Hospital, Essex, UK & Anglia Ruskin University

Dale Edgar, Health Department Western AustraliaNicolas Frasson, Cliniques Ster, Saint Clément de Rivière,

FranceGerd Gauglitz, Ludwig Maximilian University, Munich,

GermanyC. Scott Hultman, UNC School of Medicine, North Carolina,

USAFredrik Huss, Burn Center, Department of Plastic and

Maxillofacial Surgery, Uppsala University Hospital, SwedenJorge Leon-Villapalis, Chelsea and Westminster Hospital,

London, UKWei Liu, Department of Plastic and Reconstructive Surgery,

Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, P.R. China

Koen Maertens, Organisation for Burns, Scar After-Care & Research, Antwerp, Belgium

Peter Moorgat, Organisation for Burns, Scar After-Care & Research, Antwerp, Belgium

Ciaran P O’Boyle, Nottingham University Hospitals NHS Trust & The University of Nottingham, UK

Sarah Pape, Royal Victoria Infirmary, Newcastle upon Tyne, UK

Susan Peirce, Cedar, Cardiff University School of Engineering, Cardiff, UK

Alan Phipps, Pinderfields General Hospital, Aberford Road, Wakefield, West Yorkshire, UK

Warren Matthew Rozen, Department of Surgery Monash University, Victoria, Australia

Ascanio Tridente, Whiston Hospital, St Helens’ and Knowsley NHS Trust, Prescot, UK & Sheffield University, Sheffield, UK

Marcela Vizcaychipi, Chelsea and Westminster Hospital, London, UK

Stuart Watson, Canniesburn Plastic Surgery Unit, Glasgow Royal Infirmary, Glasgow, UK

Iain S. Whitaker, Swansea University Medical School & Welsh Centre for Burns and Plastic Surgery, Swansea, UK

Amber Young, The Healing Foundation Children’s Burns Research Centre and South West Children’s Burns Centre, Bristol, UK

SBH_Cover.indd 2 04/12/2015 6:19:12 PM

http://sbh.sagepub.comISSN 2059-5131

This reprint was supported by an educational grant from LumenisUltraPulse®

The Most Powerful CO2 Laser in Aesthetic Dermatology

DeepFXTM | ActiveFXTM Fractional Modesgreat versatility for all your resurfacing needs

Deepest Impact with SCAAR FXTM Mode up to 4mm in a single pulse

Best Ablation/Coagulation ratio for optimal clinical outcomes

Shortest Pulse Duration for maximum patient safety and comfort

Stretching the limits of performance


The Starting Point to Your Success

Everything You Have Ever Desired The New Generation of Hair Removal Systems

Gold Standard 805nm diode laser

Fast and comfortable

Intuitive and upgradable

Portable and affordable

Highest return on investment

NEW



Lumenis (UK) LtdTelephone: 020 8736 4110e-mail: [email protected]

SBH_Cover.indd 1 04/12/2015 6:19:11 PM

everything you have ever desired the new generation of hair … · great versatility for all your...

Documents