Preoperative planning: A holistic approach to burn reconstruction

General considerations

This chapter is intended to shift the focus of burn reconstruction from the provider to the burn survivor’s needs and hesitations as opposed to repeating general principles of burn reconstruction outlined in Chapter 42 . As providers, we often forget that we are caring for individuals, their caretakers, and their social support network, who have spent significant time in the hospital. Survivors often have undergone multiple surgical procedures during their acute care stay, leaving them with posttraumatic stress disorder (PTSD) that includes denial, depression, and many other psychological sequelae further described in Chapter 55 . Their immediate concerns may be very different from ours. Whereas providers are trying to restore the physical entity “person” to a functional level, the survivor may struggle with the concept of having a physical impairment in the first place. Interventional fatigue may be prevalent in one survivor, whereas another survivor may be overanxious to “get things fixed.” It is important to recognize the survivor’s needs at any moment of their reconstructive journey and to see the person as a whole before planning and executing any particular reconstructive procedure. An ongoing case study illustrates the considerations addressed in this chapter.

Case study: Christa’s journey (name changed)

Christa is a 36-year-old female treated at a different burn center after a suicide attempt, with 36% total body surface area (TBSA) burned. Her medical history includes developmental delay, several psychiatric diagnoses, and diabetes. She was seen for burn reconstruction 3 months after discharge from acute care. She had no scar treatments or follow-up visits in the interim ( Figs. 46.1–46.4 ).

A photo of a distressed person with severe facial injuries and burns. A close-up photo of a person's face shows significant damage to the facial skin, with darkened areas and open wounds throughout as patches. The eyes are also shrunken. There is a partial open left eye and almost fully shrunken right eye. Eyelids are damaged and cheek area is fully shrunken on the right and partially bulged on the left. — Fig. 46.1

A side-view photo of a person in a hospital setting taken from the right with facial injuries and greying of front hair. The photo shows redness, swelling, and peeled skin. Eyes are fully shrunken. — Fig. 46.2

A photo of a person's torso and raised hand with heavy scars and peeled skin in large patches. The photo shows only the left hand and shoulder region uncovered next to it while the rest of the body is covered by cloth. One patch covers the shoulder and humerus part. One peeled skin is around the elbow. Another patch extends from the wrist to the digits on the palmar side. — Fig. 46.3

A photo of a surgical procedure being performed on the eyelids of a person with external burns. The person's eyes are closed and shrunken. The eyelids are misaligned or partially absent. The lips are raised on one side. Suture threads are laid throughout the left cheek, both eyes, and forehead. A person operates on the patient using a forceps and scissors. — Fig. 46.4

Establishing goals

As elaborated upon in all other chapters in this book, the goal of burn reconstruction is to reconstruct (or restore) the preinjury state. However, this is a dangerous assumption because a complete preinjury state will never be achieved. The perception of many burn survivors, fueled by social media and “reality” television series such as Extreme Makeover , is that whatever scars they encounter can be fixed with plastic surgery. When scars are mentioned during a burn surgery consent conversation, the survivor will often ask: “But I can get plastic surgery for it later, right?”—meaning “I can have it fixed later, right?” Without being discouraging, it is important for the provider to make the survivor and their partners, parents, children, and friends understand early that a scar is a scar and will remain a scar forever (at least when this book was published). Reconstructive plastic surgery and other interventions can make a scar look and behave very similar to normal skin, but complete “regeneration” or restitutio ad integrum is currently not available if the full-thickness wound measures more than 2 mm to 4 mm in diameter, with the exception of fetal wound healing. Therefore reconstruction goals must be discussed carefully with the survivor seeking intervention. Unless the scar is small enough to excise primarily (which is not the case for most burn scars), a staged intervention plan needs to be outlined. This includes preparation and follow-up procedures. The provider must describe the best achievable result in detail. Sometimes this is best achieved by using demonstrative images. Even if the scar is small enough to excise, a burn scar is replaced with a surgical scar. This fact needs to be emphasized.

Goals of care follow a hierarchy, starting with life or organ preservation (e.g., exposed cornea, invasive infection), function, and aesthetics. In this hierarchy, the survivor may have very different goals than the provider. So, always ask: “What bothers you most about your scars?” and create a reconstructive plan accordingly.

Case study

Christa’s problems: Severe microstomia impeding feeding, ectropion, neck contracture, ear deformities, upper-extremity contractures (unable to perform activities of daily living [ADLs]), open wounds on scalp and neck, no personal hygiene, severe hypersensitivity, impaired mentation, communication via screaming and grunting only
Goals for Christa: Pain control, sedation for cleaning of all wounds and range of motion assessment, and correction of ectropion and microstomia urgently (see Figs. 46.1 and 46.2 )

Timing

The timing of reconstructive interventions is crucial. It needs to consider the intervention’s urgency, the scars’ maturation status, and the survivor’s psychological and social situation. Corneal exposure caused by ectropion or complete occlusion of body orifices is the only true, universally accepted reconstructive emergency. Wait for scar maturation before performing surgical scar or contracture releases if possible. In the interim, use scar modulation techniques, such as noninvasive scar treatments, laser, or relaxing Z-plasties within scars. Performing releases too early has a very high recurrence/recontracture rate. ^,

Remember that scarring is a 5-year process. Many acute scar issues resolve with sufficient time and conservative scar treatment. Also, remember that burn reconstruction is a lifelong process for most burn survivors because new issues develop with burn scars throughout the life cycle, from growing bones causing ongoing contractures, to hormonal changes and hair growth causing ingrown hair and additional scarring, to aging issues causing more friable skin and open wounds. ^,

Burn reconstruction program patient care plan (staging plan)

A form titled burn reconstruction program and a subtitle patient care plan. A label on the top reads, burn reconstruction program patient care plan (staging plan). The form has the following input fields to be filled. Injury date, age, Sex with M and F checkboxes, date plan completed, stage 1 procedure, number of hours, stage 2 procedure, number of hours, stage 3 procedure, and number of hours. Plan discussed with has checkboxes for patient, recon surgeon, acute burn surgeon, and multidisciplinary team. Physician signature, date, and time fields are at the bottom. The bottom left is partitioned like a box and labeled reconstruction patient care plan with date 03 slash 02 slash 2022 and page 1 of 2. The bottom right is partitioned and labeled Patient label.

A form titled burn reconstruction program and a subtitle patient care plan. The form has the following diagrams. The top section has 2 human body diagrams from the front and back views with arms outstretched. They are labeled R and L on the right and left leg, respectively. The first part of the second section part has diagrams of feet labeled L and R and palmar view of hands on the right labeled L and R. The bottom left part of the second section has a person's front view of face with no hair on the head and face. It is labeled L and R. The bototm right of the second section has a dorsal view of the hands labeled L and R. The bottom left is partitioned like a box and labeled reconstruction patient care plan with date 03 slash 02 slash 2022 and page 2 of 2. The bottom right is partitioned and labeled Patient label.

Matching reconstructive means to the problem

In the 21st century, multiple options are available for any reconstructive problem. From minimally invasive options, to skin graft to dermal template plus skin graft to local flaps to locoregional flaps to free tissue transfer, every possible procedure on the reconstructive ladder has been used for every burn reconstructive problem. However, considering the proportionality of the means to the problem is crucial. Consider a 60% TBSA burn survivor: there are only a few unscarred areas on their body, which they covet! And there are only so many free flaps on any human body. ( Fig. 46.5 shows the result after the use of a free anterolateral thigh [ALT] flap for neck contracture release. The reconstructive goal clearly was not achieved.)

A photo of the lower face and shoulder region of a patient lying in bed. The photo has the appearance of alternating patches of redness in elevated skin flaps and plain areas of the inner layer without flaps. These inner layer areas are in the neck and shoulder while a flap extends from face to chest via the neck. — Fig. 46.5

Case study

Christa had no tolerance for extensive and complicated procedures. She barely participated in physical therapy (PT) or occupational therapy (OT). She refused to wear a mouth splint after microstomia correction or a neck brace after neck contracture release. She developed massive hypertrophic scars at the full-thickness skin donor sites ( Fig. 46.6 ).