Patient-reported scar quality of donor-sites following split-skin grafting in burn patients: Long-term results of a prospective cohort study

Patient-reported

scar

quality

of

donor-sites

following

split-skin

grafting

in

burn

patients:

Long-term

results

of

a

prospective

cohort

study

Catherine

M.

Legemate

a,b,

*

,

Pauline

J.

Ooms

b

,

Nicole

Trommel

b

,

Esther

Middelkoop

a,c

,

Margriet

E.

van

Baar

b,d,e

,

Harold

Goei

b,f

,

Cornelis

H.

van

der

Vlies

b,g

a_{Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Plastic, Reconstructive and Hand Surgery,}

AmsterdamMovementSciences,Amsterdam,TheNetherlands

b_{MaasstadHospital,BurnCentre,Rotterdam,TheNetherlands}

c

AssociationofDutchBurnCentres,RedCrossHospital,Beverwijk,TheNetherlands

d

DepartmentofPublicHealth,ErasmusMC,UniversityMedicalCentreRotterdam,Rotterdam,TheNetherlands

e_{AssociationofDutchBurnCentres,MaasstadHospital,Rotterdam,TheNetherlands}

f_{Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Surgery, Amsterdam Movement Sciences,}

Amsterdam,TheNetherlands

g_{TraumaResearchUnit,DepartmentofSurgery,ErasmusMC,UniversityMedicalCentreRotterdam,Rotterdam,The}

Netherlands

a

b

s

t

r

a

c

t

Background:Skingraftingisthecurrentgoldstandardfortreatmentofdeeperburns.Howpatients

appraisethedonor-sitescarispoorlyinvestigated.Theaimofthisstudywastoevaluatelong-term

patient-reported quality of donor-site scars after split skin grafting and identify possible predictors.

Methods:Aprospectivecohortstudywasconducted.PatientswereincludedinaDutchburn

centreduringoneyear.Patient-reportedqualityofdonor-sitescarsandtheirworstburnscar

wasassessedat12monthsusingthePatientandObserverScarAssessmentScale(POSAS).

Mixedmodelanalyseswereusedtoidentifypredictorsofscarquality.

Results:Thisstudyincluded115donor-sitescarsof72patientswithameanTBSAburnedof

11.2%.Thevastmajorityofthedonor-sitescars(84.4%)wereratedashavingatleastminor

differenceswithnormalskin(POSASitemscore2)ononeormorescarcharacteristicsand

theoverallopinionon80.9%ofthedonor-sitescarswasthattheydeviatedfromnormalskin

12monthsaftersurgery.Theoverallopiniononthedonor-sitescarwas3.22.1vs.5.12.4

ontheburnscar.Ayoungerage,femalegender,adarkerskintype,andlocationonthelower

legwerepredictorsofreduceddonor-sitescarquality.Inaddition,timetore-epithelization

wasassociatedwithscarquality.

Conclusion:Thisstudyprovidednewinsightsinlong-termscarqualityofdonor-sites.

Donor-sitescarsdifferedfromnormalskininalargepartofthepopulation12monthsaftersurgery.

Resultsofthisstudycanbeusedtoinformpatientsonthelong-termoutcomesoftheirscars

andtotailorpreventiveortherapeutictreatmentoptions.

©2020TheAuthors.PublishedbyElsevierLtd.ThisisanopenaccessarticleundertheCCBY

license(http://creativecommons.org/licenses/by/4.0/).

a

r

t

i

c

l

e

i

n

f

o

Articlehistory: Availableonlinexxx Keywords: Scar Scarquality Donor-site Burns POSAS PROM

* Correspondingauthorat:Maasstadweg21,2079DZRotterdam,TheNetherlands.

E-mailaddress:c.legemate@amsterdamumc.nl(C.M. Legemate).

https://doi.org/10.1016/j.burns.2020.12.005

0305-4179/©2020TheAuthors.PublishedbyElsevierLtd.ThisisanopenaccessarticleundertheCCBYlicense(http://creativecommons.

org/licenses/by/4.0/).ThisisanopenaccessarticleundertheCCBYlicense(http://creativecommons.org/licenses/by/4.0/).

Available

online

at

www.sciencedirect.com

ScienceDirect

1.

Background

Inpresentday burncare, excisionandskin graftingisthe

cornerstone inthe treatment of deeper burns to facilitate

woundhealingandprovideagoodfunctionalandaesthetic

scaroutcome[1 3].

On the one hand, skin grafting offers an important

therapeuticoptioninthetreatmentofburnwounds.Onthe

otherhand,donor-sitesthatremainafterskingraftingform

scars,whichmayhealaestheticallydispleasingwith

notice-able depigmentation and hypertrophy [4 6]. Scars of the

donor-sites are rectangular, linear-shaped and commonly

placedonthepatients’thigh,armsorback.Patientsjusthave

toacceptthisextrascarwhilstitmayhaveanimpactontheir

qualityoflife[4,7].

The incorporation of patients’ values and opinions is

endorsedtoensurehigh-qualitypatient-centredcare[8 10].

Althoughscarqualityisoneofthemostimportantoutcomesin

burnsurgerytoday,thereisnoevidencetosupporttherapeutic

decision-makingregardingskingraftingandexpected

donor-sitemorbidity.Inmassiveburninjuries,donor-sitescarring

might be of limited importance. However, when treating

smallerinjuries,othertreatmentoptionsmightbeconsidered

ifsignificantdistressforthepatientisexpectedaftersurgery.

Clinicalobservationsatourinstitutionhave shownthat

caregiversseem tounderestimatethe impactofdonor-site

scarringonpatients[11].Therefore,themainaimofthisstudy

was to evaluatelong-term patient-reported scar quality of

donor-sitesone-yearaftersurgery.Oursecondaryaimwasto

identify factors related to patient-reported scar quality of

donor-sitesinburnpatients.

2.

Methods

2.1. Designandparticipants

The present study is part of an observational prospective

cohortstudy.Strengtheningthe ReportingofObservational

StudiesinEpidemiology(STROBE)guidelineswereadheredto

in this study and manuscript. Patients of all ages who

underwentexcisionandsplit-skingraftingforaburnwound

betweenFebruary2017andFebruary2018intheburncentreof

theMaasstadHospitalinRotterdamwereaskedtoparticipate.

Patientswereincludediftheywereabletocomplywiththe

studyprotocolandsignedinformedconsent.Amaximumof3

donor sites per patient were included. The study was

conductedaccordingtotheprinciplesoftheDeclarationof

HelsinkiandDutchlawsandapprovedbytheregionalEthics

Committee(referencenumberL2016119).

2.2. Treatment

Skingraftswereharvestedatadepthof0.2mm(0.007inch)

withan electricAesculap1 dermatome. Adrenalinesoaked

gauzeswereplacedonthewoundsimmediatelyaftergrafting

to reduce bloodloss. Afterwards, donor site wounds were

covered withanalginate dressing, cottonwool and elastic

bandages,whichwereremoved2weeksaftersurgery.

2.3. Scarqualityassessment

Scar quality was assessed at12 monthsafter burn in the

outpatientclinic.ThepatientpartofthePatientandObserver

ScarAssessmentScale(POSAS)version2.0wasusedtoassess

thescarqualityoftheirdonorsitesandoftheburnscarthat

theyindicatedasmostsevere.Thepatientscoredtheitems

pain,itch,color,pliability,thickness,andrelief.Allitemswere

scoredona10-pointratingscale.Alowerscorecorrelateswith

a better scar, where 1 resembles ‘normal skin’ and 10

resembles‘verydifferentfromnormalskin’.ThemeanPOSAS

scorewascalculatedbysummingupthesixitemscoresand

dividingthisby6.Furthermore,patientswereaskedtogive

theiroverallopinionofthescaronascalefrom1(bestscar

imaginable)to10(worstscarimaginable).Theoutcomesofthe

POSAS were divided into 3 categories: (1) low score, no

differences with normal skin: POSAS item score 1; (2)

intermediate scores, minor differences with normal skin:

POSASitemscore2or3;(3)highscores,majordifferenceswith

normalskin:POSASitemscore4.Thesecut-offpointsare

arbitraryintheabsenceofcommonlyusedcut-offpointsand

intheabsenceofaminimalimportantchangeanalysisofthe

POSAS[12].

2.4. Otherstudyparameters

Otherstudyparametersweredocumentedduringadmission,

surgeryandoutpatientvisits.Thesewerepatient

character-istics:ageatsurgery,gender,skintype,diabetesyes/noand

smokingyes/no.Registeredclinicalcharacteristicswere

burn-related: % total burned body surface area (TBSA), % TBSA

excised,lengthofstay,POSASoftheburnscar,anddonor

site-related:locationonthebody,locationinrelationtotheburn

wound,surfacearea,>2weekstore-epithelization,

applica-tionofpressuregarmentandapplicationofsiliconegel.

2.5. Statisticalanalysis

Wecomparedthemainbaselinecharacteristicsofparticipants

andnonparticipantstodetermineiftherewereanyrelevant

differencesbetweenthegroupsusingtheindependentt-test

orMannWhitneyUtests(forcontinuousvariables)andchi2

test(forcategoricalvariables).Descriptivestatisticswereused

toassesslong-termscarqualityandcharacterizepatientswith

lowandhighPOSASscores.Pearsonstatisticswereusedto

identifythecorrelationbetweenpatientratedPOSASscoresof

thedonor-sitescarandburnscar(i.e.recipientsitescars).

Univariable and multivariable mixed model analyses

were performed to determine the predictive value of

patient-, clinical- and donor-site-related factors for the

meanPOSASscoreandmeanoverallopinionofthePOSAS.

Mixed model analysis was used to take into account the

dependencyofthemultipleobservationswithinthe

partic-ipantsifmorethanonedonorsiteperpatientwasincluded.

Factors with univariable p < 0.20 were selected for

multivariable analyses. A backward selection procedure

was used toobtain the final models for the outcomes, in

whichonlyvariableswithp<0.10wereselected.IBMSPSS

Statistics 23 and STATA version 14 were used for the

3.

Results

Atotalof114patientswerescreenedforeligibilityduringthe

studyperiod.Ofthese,106patientswereeligibletoparticipate

and80patientssignedinformedconsent.At12monthsafter

surgery, 7 patients were lost to follow-up and 1 patient

deceased,resultinginatotalstudypopulationof72patients

with115donorsitescars.Patientsincludedintheanalysishad

ameanageof37.423.0years,23.8%wereaged16years,and

mostweremale(65.3%)(Table1).Mostburnswerecausedby

flames(51.4%).Mean%TBSA burnedwas11.211.4,mean

length of hospital stay was 24.8  23.2 days, and most

participantshadonly1donorsite(62.6%).Mostdonor-sites

wereplacedonthepatients’thigh(76.5%).

3.1. Donorsitescarquality

ThemeanPOSASscore(basedonthesixPOSASitems)was

1.91.2(range1.0 7.2)atone-yearaftersurgery.Eighteen

patients(25.0%)scoredallsixitemsas1,indicatingthattheir

donorsitescardidnotdeviatefromnormalskin(allhad1

donorsitescar).Thesepatientshadameanageof43.124.6

yearsandmost(64.3%)weremale.Thus,fortheother

donor-site scars(n=97, 84.3%),patientsreported atleast minor

differences(i.e.POSASitemscore2)ononeormorescar

characteristics. Six patients (8.0%)with atotalof8 donor

sites (6.1%) reported a relatively high POSAS score (i.e.

POSASitemscore4)forallPOSASitems).Thesepatients

hadameanageof29.723.9yearsandmost(87.5%)were

female.

Theitem‘color’wasappreciatedworst;for41%ofthescars,

majordifferencescomparedtonormalskinwerereportedand

for43%ofthescarsminordifferenceswerereported(Fig.1).For

thescarcharacteristicsitch,pliability,thicknessandrelief8

12% ofthe donorsite scars were rated with high scores

(POSAS item score 4), while73 88% were rated with no

differencescomparedtonormalskin(POSASitemscore=1).

Thelowestratingswerefortheitempain;97%ofthescarswere

ratedas‘nodifference tonormalskin’,resultinginamean

scoreof1.10.6(Fig.1).

Patients’meanoverallopinionoftheirdonorsitescarswas

3.22.2(range1 10)(Fig.2).Twenty-twoscars(19%,in16

patients)wereratedas1(i.e.‘bestscarimaginable’). These

patientshadameanageof38.624.6yearsandmostofthese

patientsweremale(81.3%).Thus,forallotherscars(80.9%)at

leastminordissatisfactionwiththescarwasreported.For40

scars, 27patientsreportedarelativelypooroverallopinion

(i.e.POSASscore4).Thesepatientshadameanageof31.3

21.3yearsand47.5%weremale.Intotal,twopatientsrated4

scarsas10(i.e.‘worstscarimaginable).Thesepatientswere

bothfemaleandhadameanageof35.513.4years.Fig.2

showsthemeanandstandard deviationofthePOSASitem

scoresofthedonor-sitescarandmostsevereburnscar(as

indicatedbythepatient).Theitems‘pain’(1.10.7vs1.9

1.8),‘itch’(1.61.7vs2.72.3),‘color’(3.52.1vs.5.22.4),

and ‘overallopinion’(3.2 2.1vs.5.12.4) itemsdiffered

least.Theitems‘pliability’(1.92.0vs.4.22.6),‘thickness’

Table1–Patientdemographicsandclinicaldata.

Patientcharacteristics No.ofpatients(n=72)

Age,mean(SD,range) 37.43(23.0,0 84) Gender:Male,n(%) 47(65.3%) Fitzpatrickskintype

I 12(10.4%) II 65(56.5%) III 12(10.4%) IV 18(15.7%) V 7(6.1%) VI 1(0.9%) Diabetes,n(%) 6(5.2%) Smoking,n(%) 35(30.4%) Clinicalcharacteristics Burnaetiology Flame 37(51.4%) Scald 18(25%) Other 17(23.6%)

%TBSAburned,mean(SD,range) 11.2(11.4,0.1 55) %TBSAexcised,mean(SD,range) 6.2(7.1,0.1 50) Lengthofstay(days),mean(SD) 24.8(23.2)

Donorsitecharacteristics No.ofDonorsites(n=

115) Location,n(%) Upperback 1(0.9%) Upperarm 12(10.4%) Lowerarm 1(0.9%) Thigh 88(76.5%) Lowerleg 13(11.3%) Samelimbasburnwound,n(%) 56(48.7%) Adjacenttoburnwound,n(%) 39(39%) Surface(cm2_{),mean(SD) 167.5(173.4)}

Timetore-epithelization(>2weeks), n(%)

28(24.3%) Woundinfection,n(%) 8(7.0%) >1timeharvested,n(%) 3(2.6%) Applicationofpressuregarment,n(%) 2(1.7%) Applicationofsiliconegel,n(%) 19(17.3%)

Fig.1–Proportionofdonorsitesforwhichpatientsscored

low,intermediate,andhighscoresforscar-relatedproblems

onitemsofthepatientpartofthePOSASat12monthsafter

surgery.Lowscores,nodifferenceswithnormalskin;POSAS

item score 1;intermediatescores,minordifferences with

normalskin:POSASitemscore2or3;high scores,major

(1.7 1.7 vs.4.4 2.8),and ‘relief’(1.6  1.3vs4.8 2.6)

differedmost.AllitemshadaveryloworlowICC(Pearson’sr

<0.30).

3.2. Predictorsoflong-termdonor-sitescarquality

The results ofunivariable and multivariable mixed model

analysisareshowninTables2and3respectively.Inthefinal

model,ahigheragewasassociatedwithabetterdonor-site

scarquality(i.e.alowermeanPOSASscore(r= 0.01,SE=0.01;

p=0.046)).Femalegender(r=0.76,SE=0.27;p=0.004),ahigher

Fitzpatrickskintype(r=0.27,SE=0.13,;p=0.12)andtimeto

re-epithelizationexceeding2weeks(r=0.66,SE=0.26;p=0.016)

wereassociatedwithapoorerscarquality(i.e.highermean

POSASscore).

Fortheoverallopinion,ahigheragewasassociatedwitha

betterscore(i.e.lowerPOSASscore(r=0.02,SE=0.01;p=0.045).

Female gender(r=1.40,SE =0.48;p=0.045),locationonthelower

leg(r=0.77,SE=0.43;p=0.077)andtimetore-epithelization

exceeding2weeks(r=0.79,SE=0.39;p=0.044)wereassociated

withapooreroverallopiniononthedonor-sitescar.Noneofthe

clinicalcharacteristicswereassociatedwithpatient-reported

donor-sitescarqualityat12months(Table2).

4.

Discussion

This prospective cohort study assessed patient-reported

qualityofdonorsitescarsinaburnpopulationoneyearafter

surgery.Themajorityofthescars(84.4%)wereratedashaving

atleastminordifferenceswithnormalskin(POSASitemscore

2)ononeormorescarcharacteristics.Theoverallopinionon

the majority ofthe donor-site scars (80.9%) was that they

deviatedfromnormalskin.

The overallopinion ofpatients on their donor-sitescar

differed less than 2 points (POSAS 1 10 point scale) and

patient-reported quality ofburn scarsand donor-sitescars

Fig.2–PatientreportedPOSASscoresoftheirdonor-siteand

burnscar 12months aftersurgery. A lower POSAS score

correlateswithabetterscar;ascoreof10reflectstheworst

imaginablescar.*ICC<0.3(verylow),**ICC0.3 0.5(low).

Table2–Univariablemixedmodelanalysisofpredictorsoflong-termdonor-sitescarquality.

Mean6itemPOSASscore Overallopinionscore

Patientcharacteristics Rcoefficient SE p-value Rcoefficient SE p-value

Age(years) 0.01 0.01 0.114 0.02 0.01 0.158 Femalegender 0.78 0.29 0.008 1.28 0.50 0.010 Fitzpatrickskintype 0.27 0.13 0.042 0.35 0.23 0.119

Diabetes 0.38 0.63 0.554 0.43 1.09 0.694

Smoking 0.58 0.31 0.061 0.83 0.53 0.117

Clinicalcharacteristics

%TBSAburned 0.00 0.01 0.824 0.01 0.03 0.908 %TBSAexcised 0.01 0.02 0.526 0.02 0.04 0.537 Totalno.donor-sites 0.18 0.35 0.604 0.34 0.60 0.569 Lengthofstay 0.01 0.01 0.695 0.01 0.01 0.496 Donorsitecharacteristics

Location-Bodypart

Trunk 0.07 0.65 0.911 0.66 1.08 0.541

Upperarm 0.37 0.37 0.320 0.07 0.63 0.914

Lowerarm 0.28 0.65 0.665 1.47 1.06 0.166

Upperleg 0.08 0.21 0.689 0.23 0.35 0.519

Lowerleg 0.02 0.27 0.955 0.84 0.44 0.060

Locationonsamelimbasburnwound(yes) 0.20 0.24 0.401 0.27 0.41 0.513 Locationadjacenttoburnwound(yes) 0.08 0.24 0.750 0.01 0.41 0.987

Surface 0.01 0.00 0.789 0.03 0.01 0.722

Timetore-epithelization(>2weeks) 0.64 0.24 0.008 0.75 0.41 0.066 Woundinfection 0.66 0.40 0.105 0.93 0.68 0.172 >1timeharvested 0.01 0.01 0.391 0.01 0.01 0.441 Useofpressuregarment 0.06 1.22 0.959 1.31 2.07 0.527 Useofsiliconegel 0.74 0.38 0.054 1.04 0.67 0.118

werenotcorrelated,whichmightindicatethattheindividual

opinionofthepatientisofmoreimportancethanbiologicalor

geneticfactors.Ayoungerage,femalegenderandtimeto

re-epithelizationwereassociatedwithreducedscarquality(both

meanPOSASitemscoreandoverallopiniononthescar).In

addition, a darker skin was associated with a poorerscar

quality(POSASitemscore)andlocationonthelowerlegwas

associatedwithapooreroverallopinionofthepatient.

Aformerstudyfromourresearchgroup foundthatthe

agreementondonor-sitescarqualitybetweenpatientsand

caregiversispoorandthatcaregiversseemtounderestimate

theimpactofdonor-sitescarsin asubgroupof-patients.

Manystudieshavebeenperformedondonor-site

manage-ment,rangingfrom differenttypes ofwound dressings to

more innovative (surgical) techniques. However,

patient-reported outcomes were hardly reported [13]. Our results

show that location on the lower leg was a predictor of

reducedpatientsatisfaction,whichmightbeduetothefact

that this area is more often visible than the upper leg.

Harvestingoftheskinfromadifferentlocation(i.e,buttocks

or skull) may lead to a less visible donor-site and might

therefore bea relatively simpleoption toimprove overall

satisfactionofpatients.Theuseofotherharvestingmethods,

likedermalandmincedskingrafting,havebeendescribedto

reducedonor-sitemorbidity[13 16].Also,methodsthataim

toimproveselectivedebridement(e.g.enzymaticor

hydro-surgicaldebridement)ofburntissuemayreducetheneedfor

skingraftingandconsequently,donor-sitescarring[17,18].If

poorpatientsatisfactionregardingscarqualityofa

donor-siteisexpected,thismightbeanargumenttosupportthe

decisiontorefrainfromskingrafting.Local,pedicleandfree

flapsortheuseofaskinstretchingdeviceforprimaryclosure

havebeendescribedassuccessfulinthetreatmentofacute

burnwoundsandeliminatetheneedfordonor-sites[19 21].

Anotheroption,althoughcostlyandtimeconsuming,isthe

use of allogenic skin substitutes or dermal regeneration

productstosupportthewoundenvironmentandautologous

regenerationinsuchway thatskingrafting(andtherefore

donor-sitescarring)maybereduced[17,18,22].Conversely,if

noproblemsregardingdonors-sitescarqualityareexpected,

earlydebridementandskingraftingmayleadtoadecreaseof

thelengthofhospitalstay[23].

Articlesthatreportdonor-sitescarqualityarescarce.Most

investigatedifference incosmeticoutcomeafterthe useof

different types of wound dressings and only a few used

patient-reported outcome measurement instruments [13].

Schulzetal.evaluateddonor-sitescarquality2yearsafter

applicationofBiobraneorDressilkin11patientsandfound

thatpatientsreportedallPOSASitems2fortheirdonor-site

scar.TheselowerPOSASscoresmightindicatethatdonor-site

scarqualityimprovesafteroneyear.Ontheotherhand,the

patients that they included in their study were older, no

children were included and more males were included

compared to our study population. Similar to our results,

colorwasappreciatedworst[24].

To our knowledge, only two studies investigated the

relationshipbetweenpatient-andotherclinicalfactorsand

patient-reportedscarquality ofdonor-sites[25,26].

Karls-sonetal.reportedPOSASresults8yearsaftersurgerythat

were similar to our study results, but did not find a

significant relationship between age, sex, healing time

and patient-reportedscar quality. However, they invited

patientsretrospectively,resultinginastudypopulationof

only 27 patients. McBride et al. studied patient reported

donor-sitescarringinchildren,butdidnotfinda

relation-shipwithageorsex[26].Studiesthatassessedpredictorsof

patient-reported quality of scars after general surgical

proceduresandburninjurieshave,inlinewithourstudy,

reported female gender as a predictor for a worse scar

outcome [12,27,28]. Wallace et al. hypothesized that

immuneandhormoneresponsesmightresultin

hypertro-phicscarringinfemales[29].Nevertheless,otherstudieson

hypertrophic scars did not find female gender as an

independentpredictor[30 32].Garciaetal.statethattheir

clinical observations showed that female burn patients

frequently have greater difficulty choosing a donor-site

location and therefore conclude that scar outcome in

females is moreimportant than in men [5]. This finding

is comparable with a previous study that described that

womenexpressgreaterconcernwiththeirappearancethan

men[33].Moreover,manystudiesonhealthrelatedquality

oflifeafterburninjuryreportfemalegenderasapredictor

ofareducedhealthrelatedqualityoflife[23].Thissupports

thegenderdifferencesinthepatients’opinionfoundinour

study and suggest that this outcome might be based on

culture rather than biological differencesbetween males

andfemales.Onestudythatusedthepatientscale ofthe

POSAS to assess the quality of burn scars also found

Table3–Multivariablemixedmodelanalysisofpredictorsoflong-termdonor-sitescarquality.

Mean6itemPOSASscorea Overallopinionscoreb

Patientcharacteristics Rcoefficient SE p-value Rcoefficient SE p-value

Age(years) 0.01 0.01 0.046 0.02 0.01 0.045 Femalegender 0.76 0.27 0.004 1.40 0.48 0.004 Fitzpatrickskintype 0.21 0.12 0.067

Donorsitecharacteristics

Location 0.77 0.43 0.077

Lowerleg

Timetore-epithelization(>2weeks) 0.66 0.26 0.017 0.79 0.39 0.044

a_{Explainedvariance:32.3%.} b_{Explainedvariance:17.3%.}

differences in age categories on the items pain, color,

pliabilityandthickness[28].Itisimportanttorealizethatin

childrenundertheageof5,parentscompletethepatient

partofthePOSAS.Inliterature,ithasbeenstatedthatthis

mayleadtounderestimationofthetruemagnitudeofthe

problem becausepainandpruritus aredifficult toassess

throughtheparents[30].Ontheotherhand,parentsmaybe

veryconcernedabouttheappearanceoftheangular

donor-sitescarsandhowtheyevolveiftheirchildgrowsandwhat

theymightthinkwhentheygointopuberty.

Animportantstrengthofthisstudyisthatthestudywas

conducted in a dedicated burn centre, and thus reflects

donor-site outcome after specialized (scar) treatment.

Another asset of the study was the prospective design

whichispreferredforthe developmentofassociationand

predictionmodels [34].Becauseofthestrictstudyprotocol

and study conduct there were no missing values in the

patient-, clinical and donor site characteristics. Although

patients signedinformedconsent, they werenotaware of

the predictors that we aimed to investigate and could

therefore not influence the outcome. This study also has

somelimitations.WeusedthePOSAStoassessscarquality

and used arbitrary cut-off points in the absence of a

commonly used cut-off point or a minimal important

changeanalysis ofthe POSAS. Nevertheless, the POSAS is

the only validated scar outcome measure that takes the

opinionofthepatientintoaccount.

5.

Conclusion

Thisstudyprovidesimportantnewinsightsinlong-termscar

qualityofdonor-sitesasstatedbyburnpatients.Evenoneyear

aftersurgerythemeanoverallopinionofpatientson

donor-sitescarswasremarkablyhigh(POSASscore3.2(scale1 10)).

Moreover,37%ofthepatientsreportedapooroverallopinion

onthedonor-sitescar(i.e.POSASscore4).Especiallycolorof

the donor site-scars was judged to remain deviant from

normalskin.Ayoungerage,femalegender,adarkerskintype,

locationonthelowerlegandprolongedtimeto

re-epitheli-zation predict patient-reported reduced donor-site scar

quality.Ourstudyprovidesdatathatcanhelptobetterinform

patientsonthelong-termoutcomeoftheirinjury.

Further-more,preventiveandtherapeuticmeasurescanbetailoredto

furtherimprovelong-termdonor-sitescarquality.

Funding

C.M. Legemate received a grant from The Dutch Burns

Foundation to support this study (grant number: 15.101).

Thefunderhadnoroleinstudydesign,datacollectionand

analysis,decisiontopublish,orpreparationofthemanuscript.

Conflict

of

interest

None.

Allauthorshavenofinancialrelationshipsrelevanttothis

articletodisclose.

Acknowledgments

None.

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