CME

Acute Burn Care

Michael Bezuhly, F.R.C.S.C.
Joel S. Fish, F.R.C.S.C.
Halifax, Nova Scotia, and Toronto,
Ontario, Canada
Learning Objectives: After studying this article and accompanying Supplemen-
tal Digital Content, the participant should be able to: 1. Explain current burn-
prevention strategies and criteria for referral to a burn center. 2. Summarize the
current advances made in the critical care of acute burn patients. 3. Outline the
recent developments in burn depth assessment and burn wound dressing tech-
nology. 4. Describe the common psychosocial aspects of postburn rehabilitation.
Summary: Burn patients require interdisciplinary care in which the plastic surgeon
plays a prominent role. Appropriate referral, assessment, treatment, and posttreat-
ment supports are essential to achieving favorable outcomes following burn injury.
The authors reviewed the current literature on epidemiology, prevention, referral
criteria, critical care, wound assessment, wound dressings, and psychosocial aspects
of burn injury. Recent advances in burn care are highlighted and have been made
possible through ongoing collaborative epidemiologic, clinical, and basic biomed-
ical research. A systematic interdisciplinary approach to the evaluation and
treatment of acute burn injuries is pivotal to providing patients with the greatest
chance of functional recovery. Plastic surgeons treating burn patients must remain
current in a wide variety of areas, ranging from critical care to psychosocial
rehabilitation. (Plast. Reconstr. Surg. 130: 349e, 2012.)

B
urn patients require interdisciplinary team
care. This has led to the establishment of
specialized burn centers around the world.
This article serves as a general update on recent
advances in the different aspects of burn care for
plastic surgeons who may not be members of a
specialized burn program but who, as plastic sur-
geons, must nevertheless have an appreciation for
the complex issues involved in caring for severe
burn patients.
EPIDEMIOLOGY
The incidence of major burn injuries in North
America continues to decrease. Despite falling
numbers of major burns, multi-institutional re-
views of major burn injuries continue to bear fruit
because of the National Burn Repository, a data-
base established in the early 1990s that draws data
from participating North American burn centers.
The National Burn Repository allows for individual
centers to have comparison population-based data
such as morbidity and mortality statistics, and facil-
itates collaboration with other centers.1 Although
the general prevalence of major burns continues to
decrease, since 2001 there has been a worldwide
increase in the incidence of burn injuries among
elderly patients accompanied by a decrease in the
mortality rate for older burn patients.2,3
BURN CARE DELIVERY
Major burn patients represent one of the most
severe examples of trauma and, as such, require
highly specialized care. Such care has been cen-
tralized into burn care centers around the world.
In North America and Australia, clear guidelines
have been established in terms of burn care de-
livery and the organization of burn centers.4 Burn
center verification criteria have been in place
since 2006, with centers in North America and
Disclosure: The authors have no financial interest
to declare in relation to the content of this article.

From the IWK Health Center, Division of Plastic and Re-

constructive Surgery, Dalhousie University, and the Hospital
for Sick Children, Division of Plastic and Reconstructive
Surgery, University of Toronto.
Received for publication March 10, 2011; accepted January
24, 2012.
Copyright ©2012 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0b013e318258d530
Related Video content is available for this ar-
ticle. The videos can be found under the “Re-
lated Videos” section of the full-text article, or,
for Ovid users, using the URL citations pub-
lished in the article.

www.PRSJournal.com 349e
 Plastic and Reconstructive Surgery • August 2012

Australia participating.5 This review sets standards PREVENTION

for the organization, personnel, resources, and
services required for a burn center. It is not cur-
rently mandatory for all burn centers to be veri-
fied; however, it is likely that this will become an
expected mark of distinction as was seen with
trauma program verification over the past decade.
Not all burn programs are created equal, and for
the nonspecialist looking to refer cases, knowing
what regional burn centers have passed verifica-
tion is invaluable information. Verified centers
tend to have survival rates comparable to those of
nonverified centers, despite the fact that they tend
to admit more patients and more severely injured
patients.6 Governments and third-party payers are
also aware of this change and are preferentially
looking to accredited facilities that provide high
standards of care. As shown in Table 1, the Amer-
ican Burn Association has established burn center
referral criteria to help guide decisions regarding
triage and transfer based on patient age, injury
mechanism and extent, and other factors that may
complicate burn wound management.7 Despite
these clear criteria, in a recent study by Carter et
al. of 952 burn patients treated in nonburn cen-
ters, 48 percent met criteria for transfer to a burn
center. Patients with Medicare were more likely
not to be referred to a burn center despite meet-
ing referral criteria.8
The falling incidence of major burn injury in
developed countries is in part attributable to pre-
vention efforts that include fire-safe cigarettes, leg-
islation for prevention of methamphetamine lab-
oratories, and fused leads for multimeters.9 (See
Video, Supplemental Digital Content 1, which
shows use of multimeters to prevent electrical in-
juries, including a demonstration of where pre-
vention has had an impact in reducing or almost
eliminating electrical flash injury among electrical
workers. Available in the “Related Videos” section
of the full-text article on PRSJournal.com or, for
Ovid users, at http://links.lww.com/PRS/A526.)
Worldwide, burn injury is still a major source of
death and disability and remains a disease of low-
and middle-income populations. A disproportion-
ate number of burn injuries occur among racial
and ethnic minorities. Socioeconomic status,
more than cultural or educational factors, ac-
counts for most of this apparent increased suscep-
tibility, particularly in pediatric burns (Fig. 1).
Burn survivors of low socioeconomic status are
frequently from poor communities without finan-
cial means to pay for surgery and treatments for
aesthetic improvement (Fig. 2).
The past decade has finally witnessed effective
prevention using education, engineering changes,
enforcement of legislative protection, and environ-

Table 1. Burn Center Referral Criteria*

1. Partial-thickness burns ⬎10% of the total body surface
area
2. Burns that involve the face, hands, feet, genitalia,
perineum, or major joint
3. Third-degree burns in any age group
4. Electrical burns, including lightning injury
5. Chemical burns
6. Inhalation injury
7. Burn injury in patients with preexisting medical
disorders that could complicate management, prolong
recovery, or affect mortality
8. Any patients with burns and concomitant trauma
(such as fractures) in which the burn injury poses the
greatest risk of morbidity or mortality. In such cases, if
the trauma poses the greater immediate risk, the
patient’s condition may be stabilized initially in a
trauma center before transfer to a burn center.
Physician judgment will be necessary in such situations
and should be in concert with the regional medical Video 1. Supplemental Digital Content 1, demonstrating the
control plan and triage protocols
9. Burned children in hospitals without qualified use of multimeters to prevent electrical injuries, including a dem-
personnel or equipment for the care of children onstration of where prevention has had an impact in reducing or
10. Burn injury in patients who will require special social, almost eliminating electrical flash injury among electrical work-
emotional, or rehabilitative intervention
ers, is available in the “Related Videos” section of the full-text
*From the American College of Surgeons Committee on Trauma.
Guidelines for the Operation of Burn Units: Resources for Optimal Care of the article on PRSJournal.com or, for Ovid users, at http://links.lww.
Injured Patient. Chicago: American College of Surgeons; 2006. com/PRS/A526.

350e
Volume 130, Number 2 • Acute Burn Care

Fig. 1. Photographs showing pediatric burn caused by scald that was treated with dressings for 3 months (the child was
aged 3 years) in an underdeveloped country. Now aged 12 years, the patient has fully mature secondary contractures of
(left) ears and (right) upper limb that now require staged reconstruction. The social impact for this child is impossible to
measure and includes living in a new country to obtain reconstruction and having grown up with a physical deformity that
is largely correctable and now has become an issue with the onset of early adolescence.

Fig. 2. Photograph showing pediatric scald burn sustained

while the child was wandering in the kitchen during cooking
and with the adult unaware that the child was nearby. Prevent-
able accidents such as this represent a significant percentage of
the pediatric scald burns still occurring worldwide.
mental modifications. A poignant example of this is
the Acid Survivors Foundation of Bangladesh, which
has been working to reduce acid attacks for the past
10 years (Fig. 3). It has also successfully fostered
advocacy and lobbied governments and enforce-
ment agencies in Cambodia, India, Pakistan, and
Uganda.10 Another exciting development in world-
wide acute care has been the partnering of the In-
ternational Society of Burn Injuries with the World
Health Organization to create a 10-year plan.11
Fig. 3. Acid burn to the face resulting from a marital disagree-
ment resulting in loss of vision and severe permanent facial scar-
ring. Prevention of this cause has been successful through lob-
bying efforts to increase global awareness of this issue.
BEST PRACTICE RESEARCH
COLLABORATION
To provide “best practice” data required to
advance the specialty, the American Burn Associ-
ation has established the Multicenter Trials
Group. To date, the majority of studies published
by the Multicenter Trials Group have been retro-

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 Plastic and Reconstructive Surgery • August 2012
spective reviews that have reported on the status of
burn care in North America. More recently, how-
ever, the Group has initiated a number of pro-
spective studies examining topics including blood
transfusion triggers, outcomes of military person-
nel and civilians after burn injury, scar contrac-
ture, and rehabilitation treatment. (See Video,
Supplemental Digital Content 2, which shows the
Multicenter Trials Group, whose work constitutes
an up-to-date accounting of the first series of mul-
ticenter trials for burn care and will have a pro-
found effect on the delivery of burn care over the
next 10 years. Available in the “Related Videos”
section of the full-text article on PRSJournal.com
or, for Ovid users, available at http://links.lww.com/
PRS/A527.)
CRITICAL CARE
Although the majority of plastic surgeons do
not practice in critical care, there have been many
advances in burn care related to the critically in-
jured burn patient. The changes in critical care as
they relate to the burn patient require additional
specialized training that is beyond the required
scope of most plastic surgery residency programs.
Improved survival from major burn injury has re-
sulted from a number of recent advances in critical
care.
Tight glycemic control has been shown to de-
crease rates of sepsis and mortality. It is currently
Video 2. Supplemental Digital Content 2, which shows the Mul-
ticenter Trials Group, whose work constitutes an up-to-date ac-
counting of the first series of multicenter trials for burn care and
will have a profound effect on the delivery of burn care over the
next 10 years, is available in the “Related Videos” section of the
full-text article on PRSJournal.com or, for Ovid users, at http://
links.lww.com/PRS/A527.
352e
being actively researched both in burn patients
and in critically ill patients.12,13
Rates of blood transfusion have generally
dropped with the knowledge that outcomes of
critically injured patients are improved with con-
servative treatment. Guidelines in the critical care
literature have been adopted in many burn units.
There is no current literature that supports an
ideal “transfusion” threshold. In addition to this,
the use of tumescent solutions and tourniquets to
limit blood loss continues to draw interest and
support. (See Video, Supplemental Digital Con-
tent 3, which shows the tumescent technique for
burn excision. A discussion of blood-conserving
strategies that are safe and practical is included.
Available in the “Related Videos” section of the
full-text article on PRSJournal.com or, for Ovid
users, available at http://links.lww.com/PRS/A528.)
The technique of surgical excision of the burn
wound using tourniquets and/or tumescence re-
quires an organized approach. The clinical guides
for the depth of tangential excision have been
described as the three “Ps”: pale yellow fat, pearly
white dermis, and patent vessels.14 (See Video,
Supplemental Digital Content 4, which shows the
three “Ps” of surgical excision of burn eschar and
a demonstration of the surgical technique to eval-
uate burn depth excision under tourniquet con-
trol, available in the “Related Videos” section of
the full-text article on PRSJournal.com or, for
Ovid users, at http://links.lww.com/PRS/A529.)
There is evidence for the use of steroid-based
medications in the management of acute burn
Video 3. Supplemental Digital Content 3, demonstrating the
tumescent technique for burn excision, and including a dis-
cussion of blood-conserving strategies that are safe and
practical, is available in the “Related Videos” section of the
full-text article on PRSJournal.com or, for Ovid users, at http://
links.lww.com/PRS/A528.
Volume 130, Number 2 • Acute Burn Care
Video 4. Supplemental Digital Content 4, which shows the
three “Ps” of surgical excision of burn eschar and demonstrates
the surgical technique to evaluate burn depth excision under
tourniquet control, is available in the “Related Videos” section of
the full-text article on PRSJournal.com or, for Ovid users, at http://
links.lww.com/PRS/A529.
injury. In two prospective, randomized, double-
blind, placebo-controlled trials, oxandrolone, a
synthetic testosterone derivative, administered in
the acute postburn period to patients with mod-
erate to large burns (20 to 70 percent total body
surface area burn) demonstrated significantly
lower net weight and nitrogen losses, and shorter
length of hospital stay and time to wound healing.
A mild asymptomatic elevation of liver function
tests has been reported in approximately half of
patients treated with oxandrolone.15,16
Burn resuscitation has resulted in the phe-
nomenon of “fluid creep,” which describes in-
creased fluid volumes required for resuscitation,
possibly secondary to sedation/analgesia. These
increased fluid volumes have led to an increased
incidence of abdominal compartment syndrome in
the past decade.17,18 The concept of fluid creep has
further fueled the ongoing debate over the use of
crystalloid versus colloid resuscitation. Modern re-
suscitation parameters include more than just
urine output, blood pressure, and mental aware-
ness as originally practiced. There is a host of
literature that supports the use of many additional
parameters more readily available in the critical
care unit, such as base deficit, central venous pres-
sure, hematocrit, and bladder pressure. The con-
cept of “closed loop resuscitation” for burns has
also been introduced. Although not yet applied
clinically, the research in this area and its appli-
cability to mass casualty situations make it likely to
become a clinical reality.19
TELEMEDICINE
In parts of the world with few and relatively
inaccessible regional centers, telemedicine has
had a positive influence. Telemedicine allows for
patients to be accurately triaged to limited facili-
ties and to be followed closer to home while still
receiving monitoring from experts for potential
reconstruction and ongoing rehabilitation.20 Sim-
ilarly, in a military setting, telemedicine can facil-
itate timely and consistent triage of burn patients
from remote front-line medical providers in aus-
tere environments to rear-based specialists.21
BURN DEPTH ASSESSMENT
The ability to quickly and accurately diagnose
burn depth will likely represent the next paradigm
shift in improving burn care.22 Currently, the de-
termination of burn depth based on clinical ex-
amination is only 70 percent accurate, making it
difficult to effectively stratify burn wounds and
thereby evaluate new wound care technologies in
reproducible ways. The use of laser Doppler scan-
ning shows promise in improving burn depth ac-
curacy, with reports indicating that “machine” is
better than “man.” (See Video, Supplemental Dig-
ital Content 5, which shows burn depth assessment
and includes a review of accurate burn depth as-
sessment using laser Doppler technology and
newer technologies, is available in the “Related
Videos” section of the full-text article on PRSJour-
nal.com or, for Ovid users, at http://links.lww.com/
PRS/A530.) The technology remains expensive
and can also be difficult to learn and incorporate
into a busy practice. The nonspecialist practitio-
ner would benefit from a simpler, less expensive
device that would accurately predict deeper injury.
TOPICAL ANTIMICROBIAL BURN
WOUND DRESSINGS
Topical antimicrobial agents are an integral
part of burn injury treatment. For superficial
burns, the antimicrobial dressing should facilitate
reepithelialization by providing a moist, clean en-
vironment. For deeper burns that will require ex-
cision and grafting, the intention of the burn
wound dressing is to reduce bacterial colonization
until grafting occurs. The reader is referred to a
number of excellent reviews of the numerous oint-
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 Plastic and Reconstructive Surgery • August 2012
Video 5. Supplemental Digital Content 5, which shows burn
depth assessment and includes a review of accurate burn depth
assessment using laser Doppler technology and newer technol-
ogies, is available in the “Related Videos” section of the full-text
article on PRSJournal.com or, for Ovid users, at http://links.lww.
com/PRS/A530.
ments, creams, and dressings available to achieve
these goals.23,24
Silver-based dressings have a long history and
remain a mainstay of topical burn treatment.25
Silver ions disrupt DNA replication and the elec-
tron transport chain, resulting in bactericidal ac-
tivity against a broad spectrum of microorganisms
including Gram-positive and Gram-negative bac-
teria, fungi, and some viruses.26 –28 Silver sulfadia-
zine remains the best known and most widely used
silver-based antimicrobial agent for burns.29
In recent decades, there has been a prolif-
eration of dressings that elute nanocrystalline
silver. Nanocrystalline dressings have better an-
timicrobial activity (including against methicillin-
resistant Staphylococcus aureus) than earlier formu-
lations such as silver sulfadiazine because they
provide rapid, sustained delivery of silver ions to
the biological site.30 These newer formulations are
manufactured with nanocrystalline silver embed-
ded in high-density polyethylene mesh (Acticoat;
Smith & Nephew, Hull, United Kingdom), hydro-
fiber (Aquacel AG; ConvaTec, Princeton, N.J.), or
soft silicone foam (Mepilex AG; Mölnlycke Health
Care, Dunstable, United Kingdom). All of the var-
ious choices allow for the selection of a product to
be placed on the wound and left for several days,
making them financially sound despite higher
product costs. Several studies have demonstrated
that such formulations are equally effective in pre-
venting infections than older formulations but al-
354e
low more rapid reepithelialization.31–35 Moreover,
a longer interval of time between dressing changes
leads to improved patient comfort and decreased
total costs. Dressing selection should be based on
local wound and patient factors, and local nursing
knowledge and ability to support the use of a par-
ticular product. In the case of an exudative wound,
for example, Aquacel AG is particularly effective
because of hydrofiber properties.36 This product
has had impact on the very common scald burn,
particularly among children. (See Video, Supple-
mental Digital Content 6, which shows the use of
Aquacel AG for burn wounds, including a discus-
sion of one particular technique of a closed dress-
ing technique used for the most commonly en-
countered scald burn, available in the “Related
Videos” section of the full-text article on PRSJour-
nal.com or, for Ovid users, at http://links.lww.com/
PRS/A531.)
The practical use of the many products
brought to market can be confusing, and compa-
nies sometimes attempt to extrapolate. The use of
a specific dressing requires the knowledge, not
only of the plastic surgeon but also of the entire
inpatient and outpatient nursing and support
staff. Recently, there has been renewed interest in
honey, a topical agent with a history as old as that
of silver.37 Honey likely inhibits bacterial prolifer-
ation by means of its high osmolarity and through
direct antimicrobial activities. In several trials, mi-
nor burns treated with honey showed shorter heal-
Video 6. Supplemental Digital Content 6, which shows the use
of Aquacel AG for burn wounds and includes a discussion of one
particular technique of a closed dressing technique used for the
most commonly encountered scald burn, is available in the “Re-
lated Videos” section of the full-text article on PRSJournal.com or,
for Ovid users, at http://links.lww.com/PRS/A531.
Volume 130, Number 2 • Acute Burn Care
ing times compared with conventional dressings
such as silver sulfadiazine.38,39 Systematic reviews of
these and earlier studies have similarly shown the
use of honey to accelerate healing of minor
burns.40,41 Although these findings are provoca-
tive, the studies included in the systematic reviews
were generally of poor quality because of a failure
to state the method of randomization.
SKIN SUBSTITUTES
Excised burn wounds can usually be covered
quickly, safely, and permanently using skin au-
tografts. Under some circumstances, however, au-
tologous skin grafting is not advisable. Such in-
stances include the presence of a grossly infected
or nonviable wound bed, the absence of adequate
donor skin, or when the patient is too ill to tolerate
the additional morbidity of a donor site. In such
cases, skin substitutes may prove invaluable to
maintain the viability of the wound bed and to
decrease infection, pain, and metabolic stress.
Skin substitutes may be temporary or perma-
nent. Temporary skin substitutes must eventually
be replaced by autologous skin grafts in immuno-
competent patients. The criterion standard for
such skin substitutes is fresh human cadaveric al-
lograft. Given the limited shelf life of fresh allo-
graft, however, most tissue banks instead carry
cryopreserved allograft that may be stored indef-
initely and thawed when needed. Other tempo-
rary skin substitutes include xenografts (also
known as heterografts), most commonly porcine
in origin. Amniotic membrane helps to reduce
bacterial counts and provides excellent homeo-
stasis to wound beds but is rarely used because of
its limited availability, fragility, and high cost, and
because of concerns over disease transmission.42
Biobrane (Smith & Nephew) is a cost-effective
dressing composed of a silicone membrane fused
to a nylon fabric coated with porcine dermal col-
lagen that is particularly useful for short-term
coverage.43 Its main drawback is susceptibility to
infection.44
There are several products that may be used to
assist in permanent wound coverage. The most
widely used product for permanent wound cover-
age is Integra (Integra LifeSciences, Plainsboro,
N.J.). This bilaminar “artificial skin” is composed
of an inner layer of bovine collagen and chon-
droitin-6-sulfate and an outer layer of silicone
sheeting. After approximately 2 weeks, the outer
layer is removed and replaced by a thin split-thick-
ness autograft. Although it has been shown to
reduce scarring and pruritus, Integra has failed to
become the standard of care in most centers, likely
because of its high cost and occasionally severe septic
complications.45,46 Another permanent wound cov-
erage product is AlloDerm (LifeCell Corp., The
Woodlands, Texas). This acellular human dermal
allograft replaces part of the missing dermis, thereby
reducing scarring. Like Integra, it too must be cov-
ered by a thin split-thickness autograft.
Cultured autologous epithelial cells, also
known as cultured epithelial autograft, have been
used by burn surgeons for over 30 years and are
used to provide permanent skin coverage of mas-
sive burns.47 The grafts are grown from a full-
thickness skin biopsy specimen into thin, fragile
sheets using standard tissue culture techniques
and then attached to petrolatum gauze carriers to
facilitate handling. The major drawbacks of cul-
tured epithelial autografts are high cost, poor en-
graftment, and poor long-term durability. Most of
the limitations of cultured epithelial autografts are
attributable to the absence of an underlying der-
mis and epidermal-dermal attachments. To im-
prove their success, cultured epithelial autografts
have been applied or even directly cultured over
vascularized dermal allograft or over a variety of
collagen-glycosaminoglycan scaffolds.48 –51
With the increasing costs of acute burn care
and the explosion of newer wound care products
and skin substitutes, in 2009 the American Burn
Association published the so-called White Paper.52
This document was “intended for Medicare and
Medicaid contractors, nongovernmental third
party payers and interested professionals outside
healthcare reimbursement with a current, author-
itative clinical reference.” It clearly outlines what
falls within the standard of care for burn wounds
and is particularly useful in an environment where
practitioners are facing increasing administrative
pressure to justify their choice of wound care prod-
ucts or skin substitutes that are expensive and may
not be routinely used but are still appropriate.
PSYCHOSOCIAL ASPECTS OF
BURN INJURIES
Psychological morbidity is extremely common
following severe burn injury, with clinical evidence
of acute stress disorder, posttraumatic stress dis-
order, or depression observed in up to 45 percent
of adult survivors.53–56 Predictors of psychiatric
morbidity include increased total body surface
area burned, premorbid affective and anxiety dis-
orders or anxious personality traits, and female
sex.55,56 In the acute stage of burn treatment, the
major objectives of psychosocial support are to
prevent delirium, optimize pain control, and re-
duce sleep disturbances.53 (See Video, Supple-
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 Plastic and Reconstructive Surgery • August 2012
mental Digital Content 7, which shows pain con-
trol and hypnosis in acute burn care, including a
discussion of the treatment of pain in burns and
new technology uses of virtual reality hypnosis that
are available, available in the “Related Videos”
section of the full-text article on PRSJournal.com
or, for Ovid users, at http://links.lww.com/PRS/
A532.)
A number of studies have examined long-term
functional outcomes in burn patients. Burn pa-
tients tend to have diminished health-related qual-
ity of life.55,57 Predictors of poor long-term health-
related quality of life include a premorbid
psychiatric disorder, longer hospital stay, and am-
putation. The visibility of burn scars has not been
shown to predict poorer function.58 Long-term
psychosocial treatment should be multifaceted
and address concerns regarding return to work,
family dynamics, and sexual dysfunction. Modal-
ities include outpatient counseling, support
groups, peer counseling, and vocational and social
retraining. Although many patients face a long
period of rehabilitation, as many as 90 percent
return to work by 24 months after burn.59
CONCLUSIONS
A systematic interdisciplinary approach to the
evaluation and treatment of acute burn injuries is
pivotal to providing patients with the greatest
chance of functional recovery. Plastic surgeons
treating burn patients must remain current in a
Video 7. Supplemental Digital Content 7, which shows pain
control and hypnosis in acute burn care, including a discussion of
the treatment of pain in burns and new technology uses of virtual
reality hypnosis, is available in the “Related Videos” section of the
full-text article on PRSJournal.com or, for Ovid users, at http://
links.lww.com/PRS/A532.
356e
wide variety of areas, ranging from critical care to
psychosocial rehabilitation.
Joel S. Fish, M.D., M.Sc.
Hospital for Sick Children
555 University Avenue, Room 5410
Toronto, Ontario M5G 1X8, Canada
joel.fish@sickkids.ca
PATIENT CONSENT
Parents or guardians or the patient provided written
consent for use of the patients’ images.
ACKNOWLEDGMENTS
The authors recognize the contributions of Drs. Rob-
ert Cartotto (University of Toronto), Jeffrey Saffle (Uni-
versity of Utah), and David Patterson (University of
Washington) for willingly providing them with their
original work in the form of presentations/videos to en-
hance this CME article.
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