Reconstruction of burn deformities: An overview

Chapter 50 Reconstruction of burn deformities


An overview



Lars Peter Kamolz, Ted Huang


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The severity of burn injuries is usually assessed, if not by patient survival, by the consequence of burn injuries, i.e. scar hyperplasia/hypertrophy, scar contracture, and structural deformities due to loss of bodily components. Since the bodily deformity is closely related to the magnitude of injuries, restorative procedures are seldom indicated if the depth of injury is superficial and the burned area limited (Fig 50.1) but are required for deep burns (Fig 50.2).


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Figure 50.1 (a) An 8-year-old boy sustained flash flame burns of the face. The depth of injury was judged to be superficial. (b) The wounds healed spontaneously. The scar formed was judged to be minimal 5 years later.


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Figure 50.2 (a) A 4-year-old boy sustained flame burns involving 75% of his total body surface. (b) The injury was extensive; the wound required staged debridement and skin grafting, resulting in extensive scarring.


The possibility of surviving burn injuries has changed dramatically over the past 30 years, attributable singularly to an aggressive approach in surgical treatment of burn wounds, i.e. early wound debridement and wound coverage.1–3 It is ironic that the success attained in burn treatment has resulted in a higher number of patients who will need to undergo reconstruction because of an aggressive ‘life-saving’ surgical treatment.


Formation of scar tissues at a wound site and contraction of the scar tissues are the normal consequence of an injury. Although the exact mechanisms accounting for the sequential changes in wound healing and scar formation remain incompletely understood, wounds with infection and/or those allowed to heal spontaneously, for instance, tend to result in a thickened scar that is contracted circumferentially; an observation suggestive that various fibrogenic cytokines such as transforming growth factor β could play an important role in the pathogenesis of otherwise clinically undesirable consequences.4,5


Thickened and contracted scar tissues, i.e. the changes that are ‘normal’ and ‘expected’ consequence of the wound healing processes, are microscopically composed of collagens arranged in whorls and nodules. The changes may be observed as early as 3–4 weeks following the injury and they are cosmetically unsightly and functionally disturbing (Fig. 50.3).


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Figure 50.3 (a) Scarring formed around the injured sites became apparent within 3 weeks. (b) Thickening of the scar continued during the subsequent 5–6 months. Contraction of scars caused difficulty in the closing and opening of the eyelids and mouth.



Reconstruction of burn deformities



General principles


Burn injuries are a traumatic illness resulting in aberrant body physiologic processes caused by thermal destruction of the skin. The altered physiologic processes will affect not only the healing of the original burn wounds but also healing processes of the secondary surgical procedures aiming to restore the consequence of the original injuries. The treatment, under an aberrant physiologic circumstance, should aim to repair the burn wounds first. Attempts to restore deformities should be delayed until recovery from the initial phase of injury is complete.6



Early treatment of deformity


Of the consequences of burn injuries, hyperplasia and contracture of resultant scars at wound sites and the contraction of mobile bodily parts, i.e. eyelids, neck, axilla, elbow, hands-fingers, groin, knee and ankle-foot, are two most common problems that are in need of attention. The regimen of applying pressure upon scar tissues and of immobilizing joint structures has been advocated to minimize the undesirable consequences of scarring and scar contracture (Fig. 50.4).


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Figure 50.4 The use of splints over the mobile joints and pressure garments is an essential component of patient management.


Although the true efficacy of a non-surgical regimen to control the deformities has not been established, the frequency of secondary joint release among individuals who ‘endured’ the morbidities associated with proper joint splinting for a period of no less than 6 months has been noted.7,8 The use of pressure dressing, especially in the areas such as upper and lower limbs, with proper splinting of the hand and fingers is strongly recommended soon following the injury. The regimen of non-surgical management of burn deformity must include daily physiotherapy and exercise to maintain joint mobility and to prevent muscle wasting.



Assessment of burn deformities


Objective assessment of deformities by the patient is neither physically nor psychologically possible soon after the accident. Restoration of physical changes resulting from the injury, in addition to the need of obtaining relief of pain and discomfort, are the primary concerns of the patient. Medical assessment of physical problems caused by scarring and scar contracture will require a detailed understanding of the extent of original injury and the precise treatment approach used to manage the burn wound. Formulating a realistic plan to restore physical problems and to alleviate pain and discomfort in the area of injury requires an in-depth analysis of the physical deformities and psychological disturbance sustained by the patient. Psychiatric, psychosocial, and physiotherapeutic care, in this sense, must be continued while the surgical treatment plan is instituted.



Indication and timing of surgical intervention


For a surgeon, making a decision of ‘how’ to operate on a patient with burn deformities is quite simple. In contrast, deciding ‘when’ to operate on a patient with burn deformities can be difficult.


The basic principle of restoring bodily deformities that impose functional difficulties before surgical efforts are directed to restoring appearance should be followed. The surgeon’s efforts should be concentrated upon restoring the deformed bodily parts essential for physical functions. An exposed skull or a calvarial defect, contracted eyelids, constricted nares, contracted major joints, and a urethral and/or anal stricture in individuals with severe perineal burns, are the prime indications for early surgical intervention. In contrast, restoration of contour deformity can be delayed. In fact, reconstruction of the nose and the ear, for instance, should not be initiated until its growth pattern has reached the growth peak; ear reconstruction may be initiated once the child has reached 6–8 years of age, while nasal reconstruction should be delayed until 16–18 years.


Although the exact scientific basis remains unclear, it has been advocated that attempts at reconstructing burn deformities should be delayed for at least 2 years post-burn injuries; the time needed for scar maturation. During the interim, the use of pressure garments and splinting is recommended to ‘facilitate’ scar maturation and to ‘minimize’ joint contracture. The true efficacy of pressure garments in ‘facilitating’ scar maturation remains undefined. Lack of a reliable method to determine various stages of scar maturation and personal difference in assessing scar appearance could account for the controversy. Splinting a joint imbedded in burned scars with an external device to maintain a proper joint angulation, on the other hand, was found to be effective in reducing the need for re-operation to achieve joint function. However, this was possible only if the patient would wear the splint faithfully for a minimal period of 6 months. A physical exercise regimen to provide vigorous movements of a burned joint was found to be effective in reducing the need for surgical intervention.


The 2-year ‘moratorium’ on early burn reconstruction, in some ways, is justifiable. Operating on an ‘immature’ scar characterized by redness and induration is technically more cumbersome; hemostatic control of the wound is difficult and inelasticity and lack of tensile strength noted in scar tissues render tissue manipulation more difficult. A high rate of contracture noted in instances where a partial-thickness skin graft is used for releasing a wound showing active inflammatory processes may further support the advocacy of two years of delay in initiating burn reconstruction.9


Our recent change in handling individuals who were in need of reconstruction followed the finding that contracted bodily parts can be effectively reconstructed in the first 2 years post-burn if skin flap, fasciocutaneous flap or musculocutaneous flap techniques are used. Reconstruction is initiated in individuals as early as 3–6 months following the initial injury. The approach is well-suited for those encountering functional difficulties because of scarring and scar contracture.10



The techniques of reconstruction


There are several techniques routinely used to reconstruct bodily deformities common to burn injuries, i.e. unsightly scar, scar contracture, and joint contracture. Principally, they are: (1) excision of scars with primary closure technique; (2) wound closure following scar excision with a piece of free skin grafting technique with or without the use of dermal template; (3) an adjacent skin flap technique; (4) an adjacent fasciocutaneous (FC) flap technique; (5) an adjacent musculocutaneous (MC) flap technique, and (6) a distant skin, fasciocutaneous (FC) flap, or musculocutaneous (MC) flap via microsurgical technique.



Primary wound closure technique


Excision of an unsightly scar with layered closure of the resultant wound is the simplest and the most direct approach in burn reconstruction. The technique is also useful in handling scars that are hyperesthenic and pruritic.


The margins of scar requiring excision are marked. It is important to determine the amount of scar tissue that can be removed, yet the resultant defect could be closed directly. ‘Pinching’ the edge of scar at three or four different sites along the length of scar to determine the mobility of the wound edges is the simplest yet most reliable method to determine the amount of scar tissues that can be removed safely. Leaving a rim of scar tissue is generally necessary unless the size of scar is so small that removal and direct closure of the resultant wound would not lead to contour deformity. A circumferential incision is made in the line marked and is carried through the full thickness of the scar down to the subcutaneous fatty layer. While the outer layer of the scarred tissue is excised, 4–5 mm of collagen layer is left attaching to the base. The conventional approach of wedged scar excision will result in depression along the site of scar excision, an iatrogenic consequence that could be difficult to amend secondarily. In order to minimize vascular supply interference along the wound edges, undermining of scar edge should be kept minimal. Synthetic sutures are preferred for wound closure (Fig. 50.5).

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Mar 14, 2016 | Posted by in General Surgery | Comments Off on Reconstruction of burn deformities: An overview

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