This article is based on the Mumbai NABICON Research Award 2012 oration which I delivered an oration at Vadodara in January 2013 during NABICON 2013. It traces my journey over about 25 years in the field of burn care. I have tried to share the thought process and the efforts involved in contributing meaningfully to some areas in this field. There is a lot more to be done to improve the quality of acute care of burnt patients in our country. With the large number of burnt patients that we still continue to face, it is a major challenge and I strongly feel that all the research and new developments in this field should henceforth be coming from us - Indians. I fervently hope that this article stimulates at least a few to think, innovate and apply and contribute to clinical research addressing our problems.

In major burns in the pediatric age group, there is a very narrow transition between life and death. Amongst deaths due to pediatric trauma, burns rank the second highest in India. Emergency management of each pediatric burn requires knowledge of normal physiology and its changes with age as this is important in planning management for the burnt child. We have to keep in mind that children with burns have a higher morbidity and mortality. Hence, an advanced life support course must be popularized for pediatric burns.The advanced pediatric life support (APLS) in burns would be the care given over the first 24 h to the burnt child.

The burn unit at Lokmanya Tilak Municipal Medical College and General Hospital was established in 1983 and since then continues to be an integral part of the Department of General Surgery. It has been recognized as the center of excellence in western region of India by The Association of American Physicians from India and it has several firsts to its credit and has undergone some metamorphosis over the years. The focus has always been to provide comprehensive, quality-of-care to the burn victims.

Respiratory burns are caused by the aspiration of heated gases or toxic products of incomplete combustion. The extent of damage is determined by the temperature of the inhaled gases, their composition and the duration of exposure. Along with age and size of full-thickness burn injury, the presence of respiratory burns is one of the most powerful predictors of poor outcome in patients admitted to burn centers. There are three types of respiratory burns: (a) Inhalation of systemic asphyxiants such as carbon monoxide. (b) Thermal damage to airway above vocal cords. (c) Injury to tracheobronchial tree and pulmonary parenchyma by inhaled toxicants. The goals of initial management of the airway and breathing are to protect the patency of the airway to prevent suffocation and to ensure adequate ventilation and oxygenation. High levels of inspired oxygen are necessary to treat carbon monoxide poisoning. Intubation and mechanical ventilator support with low tidal volumes is required to treat subglottic respiratory burns. Because there are no known antidotes to the poisonous effects of inhaled smoke, treatment of respiratory burns is protective and supportive.

Radiation dermatitis is the commonest side effect encountered during definitive radiotherapy. Radiation depletes the basal cell layer of skin and initiates a complex sequence of events leading to dose-dependent acute or late sequelae. The incidence and severity of radiation dermatitis depends upon multiple patient and treatment related factors. With the use of megavoltage radiation and implementation of conformal radiotherapy, the incidence of severe radiation dermatitis has reduced significantly. Treatment interruptions due to severe reactions may affect outcome. Prevention and management of radiation dermatitis requires a multidisciplinary approach. For acute radiation dermatitis, maintaining hydration which will eventually promote epithelialization is the key; while for moist desquamation, prevention of infection and facilitation of epithelialization are important. Barrier dressings like human amniotic membrane and hydrocolloid dressing are useful as they prevent trauma and infection, trap moisture, and thus facilitate healing. Late radiation dermatitis presenting as a difficult to treat long standing chronic radionecrotic ulcer is seen rarely in the current practice. Radionecrosis refractory to hyperbaric oxygen therapy (HBOT) may require surgical intervention to restore function and alleviate pain. Although there is lack of robust data to define strict policies for management of radiation dermatitis, the current practices are based on institutional protocols and personal experiences.

Introduction: The rehabilitation of the burn patient is difficult, time consuming and yet an undeniably integral part of their management. The long-term effects of burns are wide ranging; from permanent scarring and debilitating contractures and deformities, to deep psychological trauma, which often results in fear of social exclusion, depression and suicidal ideation. Methods: The successful rehabilitation of the burn survivor requires the involvement of a multi-disciplinary team from the 1 ^st day in order to meet the patient's complex needs. Following this, the burns team ensures the continuation of rehabilitation of the patient before and after discharge of the patient from the hospital. Finally, the patient is encouraged to join social networking activities to help regain confidence. Objectives: A burns unit must utilize all the skills and resources it has available to it, in order to provide the burn survivor with the best possible outcome. However, in hospitals located in resource-limited areas across India, the professions and resources required for this task may not be readily available to support the burns patient. The team must be able to reflect on itself and consider how best to continue to improve the provision of burns rehabilitation in the future so as to further reduce morbidity and improve quality-of-life. Conclusion: Nothing short of a multidisciplinary burn team that is dedicated to securing the patient's physical, psychological, social and spiritual wellbeing is required to ensure that a burn victim can return to their families, their work and their society and lead a long and fulfilled life.

Introduction: The aim of the reconstructive burn surgeon is to remove all the scar tissue in the affected area and resurface the area with supple tissue, which allows proper movement of the neck and is esthetically pleasing. We present our series of 10 patients of burn neck contracture, primary and recurrent, who were treated with free flap reconstruction. Patients and Methods: A retrospective review of all the data of the patients was done and the demographic data, preoperative and postoperative examination findings, surgery offered, results and follow-up details were tabulated and analyzed. Results: All the flaps survived completely. Two flaps showed postoperative congestion on day 1 and were taken to the operating room to be reexplored. All patients showed marked improvement in the degree of neck extension, lateral flexion, and rotation which remained unchanged with successive follow-ups. Conclusion: The results of free flap reconstruction of the burn neck contracture area appear to be better than other methods in terms of functional and esthetic restoration of the normal anatomy. The postoperative morbidities for the patient are also reduced and patient comfort is enhanced. The authors feel that in centers where microsurgical expertise is available, the patients of burn neck contractures may be offered the option of complete scar excision and free flap reconstruction as a primary option instead of scar release and split skin grafting.

Post-burn neck contracture (PBC) is one of the most common burn sequela. These contractures affect the patient significantly causing both functional limitations and esthetic disfigurements. Hence, the reconstruction of this area is a challenge to surgeons who must choose a technique, which restores the function and also improves the esthetic appearance. Aims: The aims of this study are to provide a simple classification of PBC and offer surgical solutions for each section of our classification. Materials and Methods: This retrospective study was carried out on 140 patients with PBC neck who were classified according to the functional defect and the anatomical type of scar. Results: We offer a simple classification system for PBC neck depending on the degree of contracture into mild, moderate and severe and also according to the type of the scar into linear, band or broad type.

Introduction: In the majority of pediatric burns mortality and morbidity results from simple domestic accidents that are preventable. Aim: A prospective study of pediatric burns was carried out at our burns unit to outline the epidemiology and management of the pediatric burns problem. Materials and Methods: Epidemiological data collected included age, sex, seasonal variation, place of burn, family size, economic status, period of time between the accident and admission to hospital. The cause and mode of burns, management of burns, relationship between mortality and age, cause and extent of burn was also noted. Results: A total of 72 pediatric patients of burns were admitted to our unit over a 3 years period. The highest incidence of burns was seen in the period of winter months between October and March. Males were affected more commonly as compared with females. The majority of the burns occurred at home. Most of the patients belonged to the low socio-economic strata and were members of medium or large size families. The most common type of injury was scald burns in children under 6 years of age and flame burns in the older children (6-12 years). The overall mortality was 13.88%. Conclusions: Burns injuries could be prevented by improving the home environment and socio-economic living conditions. Prevention can be achieved by education of adults as well as children about preventable aspects of burns.

Background: Post-burn contracture (PBC) of the neck is a challenging problem for reconstructive surgeons in view of not only functional and esthetic considerations but prolong physiotherapy and splintage as well. The aim of this study is restoration of form and function with special attention to functional and esthetic considerations in reconstructing such defects. Materials and Methods: Total 40 numbers of patients with PBC of anterior neck were studied from 2009 to 2011 in the Department of Plastic Surgery. All the patients were assessed for degree of the extension (cervicomental) angles, the nature of scar tissue, and the available normal skin surrounding the contracting band. The PBC of neck was divided into three categories according to the degree of extension to type-1(mild) when extension angles were >90°, type-2 (moderate) when extension angles were ≤90°, and type-3(severe) with mentosternal synechiae. Contractures with narrow band were treated with Z-plasty in type -1 and Z-plasty along with skin grafting in type-2. Contractures with broad band were treated with flap surgeries with or without skin grafting in type-1 and 2. Contractures in type-3 were treated with only skin grafting. The flaps were local advancement flaps, expanded flaps, and supraclavicular flaps. Results: All type-1a patients were treated with only Z-plasty. One patient in type-1b was treated with expanded flap; the other patient was treated with unilateral supraclavicular flap along with full thickness skin grafting. Seven patients in type-2a contracture were treated with Z-plasty. Here one patient was treated with only Z-plasty, and six patients were treated with Z-plasty along with full thickness skin grafts. Seven patients in type-2b contracture were treated with flap surgery. In type-3, all contractures were released with excision of the scars; and the defects were resurfaced with split thickness skin grafts. The esthetic quality of the neck was judged by the patient, operating team, and patient's relative. The result of postoperative scar neck was also found esthetically fair to good. The cervicomental angle of 100-125° was attained in our cases.

Introduction: Severe burns in the elderly have a much higher mortality in comparison to the younger population. The most complicated problem in burn therapy is in the treatment of patients with deep burns especially those who are elderly. Aim and Methodology: To study the different surgical treatments and test the intermediary metabolism in elderly deep burns admitted to our unit over a period of 11 years including patients from 1999 to 2009. Results: In our burn center in Uzbekistan, skin grafts were performed in 356 patients (age range, 60-92 year) with deep burns (107 in the early post-burn period of 7-15 days, plus 249 over granulating wounds). Skin grafts in extensive burns were performed in 32 patients for the purpose of achieving early closure of the burn area. In these 32 cases, a stamp graft procedure was used in 17 patients and Moule-Jackson method of skin grafting in 15 cases. Testing intermediary metabolism indicators in 102 patients before and after free skin grafting provided interesting findings. We identified common scenarios of elderly patients, which helped in treatment.

Background: With increasing use of electricity in our day-to-day life the incidence of electrical injuries is increasing. Incidence is higher in developing countries where people are less acquainted to proper and safe use of electricity in contrast to developed countries. Objectives: (1) To study the clinical profile of high voltage injuries to the head and neck region (2) To know the reason for the higher incidence of such injuries and find out various preventive measures to reduce such injuries in future (3) To launch an awareness program among the electrical department workers about electrical injuries and their prevention. Materials and Methods: All patients with high voltage electrical injuries to the head and neck region reporting to our center were included in the study. The study was conducted retrospectively from January 2001 to May 2008 and prospectively from June 2008 to December 2010. A total of 54 patients were included in the study. Results: Involvement of head and neck region was seen in 25.35% of high voltage electrical injury victims. The most common age group was 20-30 years with a mean age of 29.13 ± 8.37 years. Incidence was higher in rural population 75.93% compared with urban 24.07%. Incidence was higher in winter months. Electricians comprised 59.26% of victims. The most common mode of injury was touching the live wire directly or indirectly and was seen in 74.07% patients. Average total body surface burn was 16.32 ± 8.13%. An average of 2.91 surgical procedures per patient were performed. Reconstructive procedures were required in 85.18% of patients. Average hospital stay was 26.81 days. Conclusions: High voltage injuries are not uncommon in Kashmir valley and electric department workers are at a greater risk. The incidence of high voltage injuries would not have been so high had the electric workers been properly trained, hazards of high tension lines explained and use of safety equipments made mandatory.

During a neck contracture reconstructive surgery, author successfully implemented earlobe reconstruction with a post-burn scarred skin tissue flap. Since this flap is difficult it is generally avoided. But in this case author obtained consent with risk, prior to the surgery. Design was similar to the flap described by Zenteno. Flap base was broad and during the operation, there was good bleeding at the distal end of the flap probably due to supple nature of the mature burnt skin, its proximity to ear, neck and face region and good blood supply. Post-operative result after 6 weeks revealed an aesthetically pleasant neck, proportionate, soft, aesthetic, sensate ear lobule with ability to wear earrings of her choice.Ear lobule reconstruction was achieved using post-burn scarred skin tissue flap safely. Author recommends its use for its advantage of good aesthetic and sensate lobule so achieved.

Author reports a case of disfigurement of the face, due to concentrated sulfuric acid burns, treated with early dermabrasion and collagen dressing which achieved quick esthetic restoration, mental satisfaction, and early rehabilitation without any complications. Concentrated sulfuric acid usually causes deep burns and scarring, but in this case the interplay of the injuring agent, host, environment, and the immediate and appropriate first aid, helped to limit the resultant burn depth to superficial dermis. Author attributes success in this case to favorable burn depth, quick and appropriate first aid, host and environmental factors, and early diagnosis and appropriate treatment in the form of early dermabrasion.