Low- and middle-income countries (LMICs) are defined by the World Bank based on gross national income (GNI) per capita. These countries form an incredibly diverse group, including India, China, and many African and South American countries with developing economies. LMIC is a convenient term for healthcare professionals and agencies when considering how to help deliver health care to people who lack optimal care because of resource limitations. However, the authors wish to emphasize their understanding that in many LMICs, the highest standards of burn care, education, and innovation exist. Accordingly, this chapter is directed primarily at informing colleagues in high-income countries (HICs) about strategies to improve burn reconstruction where it is required. It also aims to offer educational advice to healthcare colleagues working in limited-resource settings, while recognizing that within many LMICs, outstanding burn health care is already present. Finally, this chapter presents examples of commonly encountered burn reconstruction problems from LMICs.

Burn injury represents one of the largest causes of morbidity and mortality worldwide, with a global estimate of 11 million individuals requiring burn care each year. More than 95% of burns worldwide occur in LMICs, with the highest rates of burn mortality occurring in Southeast Asia, the eastern Mediterranean, and Africa. Importantly, even in HICs, individuals living in impoverished areas are more likely to experience severe burns necessitating hospitalization, further substantiating the notion that burns disproportionately affect the poor. ^, A lack of policies, infrastructure, and devices contributes to higher per capita thermal injuries in LMICs, including absent smoke detectors, hot water temperature regulators, sprinklers, fire-resistant materials, and infrastructure density regulation. In addition, increased use of illicit substances and alcohol in low socioeconomic areas spawns additional risk. ^,

Beyond the increased likelihood of burn injury in LMICs, decreased access to primary burn care creates significant scar morbidity in the years and decades that follow. ^, International studies have reported rates of hypertrophic scar at the time of hospital discharge to range as high as 38% to 54%. ^, The classic paradigm of early wound closure through surgical intervention is impossible in many LMICs because of limited resources, including supplies, facilities, and trained personnel. Suboptimal burn treatment yields scars that can be life altering in many ways, including disfigurement and physical debilitation. Scar contractures that cause loss of joint function may preclude a return to employment and limit a burn survivor’s ability to complete activities of daily living. ^{, ,} Determinants of disabling scars include injuries to the hand/face, size of burned area, depth of injury, female sex, darker skin tone, and electrical injury.

The goal of scar reconstruction is to restore the form and function of the affected anatomy while limiting donor site morbidity. Within the scope of plastic and reconstructive surgery, these operations and cases are considered some of the most challenging—even in the highest resource settings. Achieving reconstructive goals with limited resources adds another layer of complexity to these cases, which deserves careful consideration and techniques.

Many burns in LMICs are a consequence of various reasons related to infrastructure, social customs, religious beliefs, and medicinal practices. For example, LMIC cooking practices often entail open flames, coal embers, and kerosene lanterns, all of which confer increased burn risk. More granular examples of regional practices include the application of camphor on the palms in religious ceremonies, often leading to full-thickness palm burns; chemical burns caused by the application of crushed garlic as a pain remedy; cupping and coining leading to scald and friction burns; and firework celebrations with resultant hand burns and blast injuries, among others.

Specifically, in LMICs, around a quarter of burns have been reported to result in contractures. A systematic review of global postburn contracture studies found that the most common locations of contracture in LMICs include the hand (52%), followed by the foot (19%), axilla (12%), head and neck (6%), knee (5%), upper extremity (4%), perineum (1%), and trunk/back (1%). Although contracture is a highly morbid condition, lack of access to proper care or inability to receive rehabilitation and/or reconstruction because of financial restraints severely impedes burn recovery in LMICs. In addition, these unhealed contractures subsequently lead individuals with postburn injuries to either be completely unable to work or to receive lower wages compared with those of their nondisabled counterparts.

These disparate gaps in burn care have not gone unnoticed: organizations worldwide are dedicated to solving the global burden of scar contracture. Since 2015, successive meetings of the World Health Assembly have prioritized global surgery as an area for development and passed resolutions accordingly. Also, in 2015, the Lancet Commission for Global Surgery was established, noting “gross disparities in access to safe surgical care worldwide” and setting out a range of proposals to bring surgery to the forefront of the global health agenda. Before this broader commitment to global surgery development, the international burn care and plastic surgery community had already achieved a great deal through a long history of cooperation and philanthropy, including international outreach, training exchange, partnerships for development, and research. Various examples offer templates for healthcare professionals working together to address the inequality of access to burn reconstruction.

Such initiatives include ReSurge International, an organization dedicated to affordably and sustainably training, scaling, and funding the development of reconstructive surgical teams in LMICs. With over 30% of global morbidity resulting from various conditions necessitating surgical intervention and an estimated deficit of five million reconstructive surgeries each year, the goal of ReSurge is ultimately to increase surgical access to a wide breadth of reconstructive care. Similarly, another program, Global Reconstructive Surgery Outreach, is dedicated to financially supporting surgeons, physicians, and nurses, thus enabling them to provide voluntary medical care for impoverished individuals. This organization partners with various plastic and reconstructive surgeons and programs, including Operation Smile, the Pan-African Academy of Christian Surgeons, and Mercy Ships International, to bolster access to surgical care and training in LMICs.

Interburns, an international charity/network originating in the United Kingdom, has developed an integrated program of burns service and burn-care professional development, which includes standards for service assessment: a “Delivery Assessment Tool” process for service assessment, action plans for growth, a wide range of training programs and materials that have been delivered internationally and are available online, and strategies for prevention and research. It also has three training centers in LMICs (India and Nepal). Interburns’ comprehensive model may serve as an example of how the international burn care community can work together to address global inequalities in burn care. It also offers easy, free access to online practical educational material.

In addition, numerous institutions offer global outreach programs for surgical residents and attending physicians to learn and train in various countries worldwide. Although these programs have good intentions to reduce disparities in global reconstructive care, it must be noted that these interventions carry an inherent aspect of imperialism: receiving treatment from foreign surgeons begets foreign dependence. Thus it must be emphasized that a vital principle of any international intervention should be to offer education and service development with a view to sustainable change and not simply to provide treatment. Increasingly, international programs have increased focus on training and empowering local professionals rather than merely providing foreign surgical intervention. An example of one such program is the International Scholar Programs via the Plastic Surgery Foundation, which enables plastic surgeons abroad to study and train at host institutions and subsequently apply their skills and teach other surgeons upon return to their home countries.

The period of the COVID-19 pandemic has been associated with an upsurge in international training efforts using online communications. It is hugely helpful to professionals in LMICs if access to training materials is free of cost, as salaries and expenses resources may be extremely limited. An excellent example of burn reconstruction is the free online material offered by the Swiss charity 2nd Chance, which provides online courses and textbooks. A further example is the Burns Webinar Series organized by BFIRST (British Foundation for International Reconstructive Surgery and Training) and Resurge Africa, available at the Resurge Africa website. These and numerous other international online educational programs show a path by which, in the future, helpful training can be delivered almost anywhere at minimal cost.

The goal at the forefront of initiatives to improve disparities in burns and burn-related scarring is injury prevention. Burn prevention strategies would entail large overhauls in infrastructure and cultural and religious practices. In addition, legislation and education programs could transform burn safety. Although the history of most HICs has shown dramatic improvements in burn prevention, the reality of implementing these changes quickly in LMICs is hugely challenging. For example, in 2010, the National Academy of Burns India recognized the vast need for a “national program for the prevention and management of burns injury” and instituted a program. However, in 2022 an outcome assessment stated that “the scope of the program remains limited.” This is almost certainly replicated in most LMICs, where economic growth demands and wealth distribution problems mean public safety remains a lesser focus than in HICs.

According to the established criteria from the World Bank, for the 2023 fiscal year, the benchmark to qualify as a low-income economy is a GNI per capita of less than USD 1086. Lower middle-income economies have per capita GNIs between USD 1086 and USD 4255, and upper middle-income countries have per capita GNIs between USD 4256 and USD 13,205. These classifications are updated yearly in July based on the following factors: economic growth, inflation, exchange rates, and population growth. In addition, the classification thresholds are adjusted each year based on inflation using the Special Drawing Rights deflator, which represents a weighted average of the gross domestic product deflators of the United States, the United Kingdom, China, Japan, and Euro Asia. In this most recent year, the thresholds were increased because of inflation.

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  Skin rearrangement versus skin deficit: Ascertain whether the contracture is predominantly a linear band, which might be amenable to a local flap or rearrangement procedure, or whether it is a “broadband” contracture with skin deficit, which will require additional skin in the form of a graft or larger flap. If a broadband contracture is surrounded by scarred skin (diffuse broadband contracture), a large amount of skin replacement is almost always required, usually a split-thickness skin graft.

  • Especially in children, do not be tempted to “cheat” and use a Z-plasty type procedure when additional skin is needed in a broadband contracture. Even if a release can be achieved, the scar tightness will recur as the patient grows.

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  The release: When creating a release before skin grafting, create the largest defect reasonably possible to insert as much extra tissue as possible. Sometimes, if a flap of normal skin is used to repair the defect, a slightly less extensive release may be effective, as the flap can stretch with time.

  • Important rule: Keep incising at the margins of the defect. Once you are through the contraction scar’s depth, do not keep incising deeper and deeper in the wound’s center, but incise repeatedly at both margins.

  • It is important to release all subcutaneous scar bands in addition to the evident cutaneous bands. When skin grafting is planned, exercise as much of the wound bed as possible to achieve a well-vascularized bed for your graft. If your grafting fails, the contracture will almost certainly recur.

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  Patient positioning: An essential element of achieving successful intraoperative release of contractures is positioning the patient with the contracture on maximum stretch during the surgery. This is most notable for surgery to release anterior neck contractures when significant efforts to achieve and maintain the neck extension can substantially affect the outcome. Still, it applies to all joints where contractures have been released. The OR team should be prepared with appropriate equipment to position the neck and limbs optimally for surgery. Especially in a limited-resource setting, the patient should be positioned so that the contracture can be released and donor tissue harvested without turning, as this can significantly reduce (valuable) operative time at no cost to the patient. For inappropriately prepared patients, multiple sites may be operated in the same procedure, and consideration should be given to choosing sites and positioning so that these can be done synchronously, saving time.

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  The “best” technique : Have several “workhorse” procedures that you use for different contracts and get to know these techniques. For example:

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    We use Y to V plasties ( Fig. 68.1 ) for long linear bands, except in the neck, where we use Z-plasties.

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    We use a lot of full-thickness grafts for diffuse contractures, especially for diffuse extremity contractures.

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    Around the axilla, we use a lot of local flaps because there is often skin laxity with many adjacent perforators.

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    For severe, wide-band contractures, we often excise a little of the scar margins to maximize an incisional release and try to insert the best-quality skin replacement available. The choice of this skin replacement depends on the defect’s size and contour, especially the individual patient’s characteristics.

    • These are not necessarily the “best” techniques for every indication, but surgeons and patients have an excellent advantage in using a familiar technique with the highest chance of success. Different surgeons will have their own techniques that are most reliable. The highest risk is probably in attempting a challenging local or loco-regional flap stretched to suit the defect. An ambitious and elegant approach that fails can be a disaster for the patient.

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  Markings: Identify and mark the contracture band(s) preoperatively. It is essential to assess the position and posture in which the contracture is tightest under patient instruction preoperatively. Be careful to assess joint and skin contractures and be prepared to operate on joints accordingly (see Case 2 ).

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  Proximal to distal: In the upper limb, when staging procedures, release contractures proximal to distal (e.g., shoulder → elbow → wrist → palm → fingers). Many patients will not rehabilitate and use distal structures if they have a proximal contracture precluding the use of the distal anatomy. For example, if one releases hand contractures but cannot use the arm because of axillary contracture, they likely will not exploit their hand. In addition, it is difficult to operate on a hand when there is a very contracted axilla or antecubital fossa.

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  Split-thickness versus full-thickness graft: Use full-thickness grafts or flaps when reasonably possible rather than split skin grafts (SSGs). Split-thickness skin grafts contract during healing and require more aftercare (splints and physiotherapy) than full-thickness grafts or flaps. However, for the most extensive and severe contractures common in LMICs, SSG is often the only technique that will supply sufficient extra skin to make good the massive deficit. Commonly, after a scar release, the defect for skin grafting will be deeply concave. Use a good-sized graft that contours well into the defect and a tie-over dressing to control the graft. If the bed is irregularly contoured, use a narrow mesh graft to improve take (e.g., axilla; see Case 2 ). If a large, thick SSG is required (e.g., for severe neck or hand contracture), consider overgrafting the donor site for this skin graft with a much thinner adjacent graft to avoid the problem of extreme delay in donor site healing. Even if overgrafting is not undertaken, meticulous donor site care for SSGs is vital in limited-resource settings where the environment may be more conducive to infection and delayed healing that can cause prolonged pain and hypertrophic scarring.

  • In a limited-resource setting, if there is doubt about the choice of technique, a complete incisional release, a good-quality SSG with dermis, and comprehensive postoperative care will deliver a high chance of success for most contracture patients.

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  Microsurgery: Microsurgical tissue transfer is a consideration for broadband contractures with significant regional tissue deficits, especially when the burn is deep and complicated. Not having a microscope will preclude these cases in many LMIC hospitals; however, microsurgeons can perform small vessel microanastomosis with loupe magnification. Even when a microscope is available, the surgeon and perioperative team should be confident in postoperative flap monitoring and able to take a patient back to the OR in case of vessel thrombosis. If there is no OR ability in the middle of the night, then the surgical team should not undertake microsurgery.

  • In limited-resource settings, free flaps should generally be reserved for cases with no other option or where the free flap gives a far superior result to any other technique.

  • One must also consider the amount of time dedicated to treating a single patient with a free flap versus treating many patients with less intensive operations. However, training and skill in microsurgery are invaluable for optimizing the capability and morale of a reconstructive service. Achieving this should be the ultimate aspiration of all significant plastic surgery services (although only some surgeons), even if that would be many years in the future for a limited-resource service.

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  Dermal substitutes and templates: Dermal substitutes and templates will likely not be available in most LMIC settings. Good-quality autograft skin with a significant amount of dermis will provide similar contracture outcomes for most defects. However, the donor sites will likely be less favorable for the patient.

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  Tissue expansion: The availability of tissue expanders is hugely variable in LMICs but will likely be limited. Most services reserve those they can source for the scalp, forehead, and, less often, the breast/chest. However, they can be invaluable for many postburn contracture problems when available.

  • Reusing tissue expanders for different patients has been anecdotally described but would be a major ethical issue for a surgeon visiting from an HIC.

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  Laser burn scar therapies: A significant gap in most LMIC burn reconstruction services is the lack of laser burn scar treatment. Laser has become a standard of care in scar rehabilitation for many services in HICs and is widely accepted. The most reliable alternatives for relatively small hypertrophic scars in LMICs are steroid injections or similar injections such as verapamil. Other strategies for more extensive area scars, such as subcutaneous fat injections or microneedling, have enthusiastic proponents. Still, they do not yet seem to have the breadth of support to be recommended in this context.

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  Hospital stay, follow-up, and choice of surgical technique: A common issue for patients treated in LMIC burn services is that they have traveled far from home to get treatment and cannot readily return for outpatient follow-up. This can occasionally be a factor in HICs, but it is far more significant in LMICs. It is essential to bear this in mind when considering the length of hospital stay and the requirement for aftercare therapy. Often, the cost of a hospital bed is relatively low compared with that in an HIC setting, and it may be better for the patient to remain in the hospital for longer rather than be treated as an outpatient. Similarly, surgical procedures requiring intensive aftercare necessitate careful consideration for patients distant from the reconstructive center. These are factors that should be weighed in the decision-making process.

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  Pain management : Pain management has been identified by the WHO as an issue of concern in LMICs. It is common for pain to be underappreciated and undertreated. Accordingly, this is an essential area for educational and development work to focus on in many LMIC burn services.

  • Infiltration with local anesthetics, regional blocks, and topical local anesthetics on SSG donor sites should all be encouraged, including emphasizing knowledge of safe maximum doses and complications of overdose.

  • Opiates have typically been underused in LMICs compared with HICs. Work to assist with the development of postoperative opiate protocols and education to correct misconceptions about risks of addiction and overdose could significantly reduce suffering in postoperative patients.

  • Excessive pain at the burn scar site remains a meaningful physical sign of postoperative complication, and education of medical and nursing staff about this and about assessing painful wounds is essential.

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  Splinting and positioning: A common knowledge deficiency in inexperienced staff is a lack of awareness of the importance of positioning to prevent edema, keep treated contractures stretched, and avoid skin graft shear. Using the local therapy team as a conduit to educate staff and communicate well with treating ward staff will ensure that optimum positioning practices are developed and maintained. This has the valuable effect of helping nurses understand that they have an important part to play in achieving good patient results.

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  Dressing changes and observations: Good practices should be instituted for postoperative dressing changes, and the use of wound charts to record observations should be encouraged. Educating nursing staff about the appearance of healthy grafts and flaps and complications is essential. For major flaps, observation charts should be used, and the team should be educated on how to assess flaps, record their observations, and when to act.

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  Systemic observations and early warning charts: The use of observation charts (which include an early warning score and recommended actions) should be encouraged to enhance awareness of deteriorating postoperative patients and