Functional Burn Reconstruction
David A. Billmire
Kim A. Bjorklund
The hallmark of burn injury in children is burn scar and burn scar contracture.
The tendency toward hypertrophic scarring in children is a major challenge.
Hypertrophic scars tend to develop in wounds that require greater than 3 weeks to close.
These scars are raised, red, tight, hard, and often itchy.
Hypertrophic scarring after burns is common and creates a wide range of cosmetic and functional problems.1
Contractures (inability to perform full range of motion) result from factors such as limb positioning, duration of immobilization, and muscle, soft tissue, and bony pathology.2
Scars result in restriction in movement, particularly when they cross a joint, and increase the likelihood of contracture development.
A similar burn injury in an adult that requires only initial resurfacing of the wound may require repeated releases and other procedures during subsequent growth and development of a child.
Growth can be affected with restriction, distortion, and, in some cases, elongation.
Heterotopic ossification (HO) resulting from ectopic bone formation in the soft tissue around joints can significantly affect extremity motion and function.
Functional issues are frequently coupled with aesthetic concerns regarding loss of structures, obliteration, and distortion of normal anatomy.
Major problems tend to occur across joints and sites of active movement.
The shoulder, elbow, and hand are most commonly affected by contractures.2
In normal acute wound healing, myofibroblasts provide collagen and fibronectin deposition and aid in wound contraction over approximately 7 to 10 days.3
However, the presence of myofibroblasts following a burn injury can result in excessive extracellular matrix deposition leading to a pathologic contracture and hypertrophic scarring.3
Although in adults scars typically mature within 12 months, in children, the scarring diathesis may take years to resolve.
The natural history of a burn wound is to heal with re-epithelialization in superficial partial-thickness burns within 10 to 14 days.
Deep partial-thickness or full-thickness burns heal by combination of contracture and re-epithelialization and are unlikely to heal within 14 days.
Accordingly, burn wounds that are unlikely to re-epithelialize by 2 weeks should be treated with early operative intervention for excision and split-thickness skin grafting (STSG).
Sheet grafts should be used in critical areas such as the face and hands.
Less cosmetically sensitive areas can be covered by mesh graft techniques.
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