The trunk constitutes 36% of the total body surface area (TBSA) and, as such, commonly requires reconstruction after a burn injury. Anterior chest and breast burns are encountered frequently, either from thermal injury going up clothing or scald burns from hot liquid pulled down. This is often seen in adults and the pediatric population. Due to anatomic proximity, a burn injury to the chest often means a burn injury to the abdomen. Contractures can compromise function and mobility because the trunk links the head, neck, and limbs. Additionally, within the trunk, critical structures need specific attention, such as the breasts or genitals, and most importantly, crucial viscera need coverage.

The International Society for Burn Injuries 2016 created practice guidelines based on the best evidence and research regarding the acute management of burns. ^, Summarizing these guidelines for the management of trunk reconstruction, the most salient points are as quoted directly:

• ■

  Thermally injured patients should be evaluated systematically to identify the greatest threat to life.

• ■

  Evaluation of burns should estimate TBSA using a standardized method and delineate characteristics that require immediate attention from a designated burn center.

• ■

  Appropriate resuscitation should be initiated promptly and tailored based on patient parameters to avoid over- and underresuscitation.

• ■

  Adult patients with burns greater than 20% TBSA and pediatric patients with burns greater than 10% TBSA should be formally resuscitated with salt-containing fluids; requirements should be based on body weight and percentage burn.

• ■

  Abdominal escharotomy should be performed when circumferential or near-circumferential eschar is associated with evidence of intraabdominal hypertension or signs of abdominal compartment syndrome (ACS).

• ■

  Early surgery for small- to moderate-sized deep burns (less than approximately 20% TBSA) speeds recovery, might improve outcome, and is cost-effective.

• ■

  Tangential excision is the standard method of burn-wound excision. Fascial excision may be indicated in very deep burns and high-voltage electrical conduction injuries.

• ■

  Burn- wound excision and grafting can be undertaken without undue blood loss by using some or all the following: subcutaneous infiltration of burn wound and donor site, topical application of epinephrine solutions, or both; tourniquets for limb surgery; fascial-type excision using electrocautery; other topical hemostatic agents such as thrombin and fibrinogen; prevention of hypothermia; compression dressings; limb elevation; and staged burn excision.

• ■

  After excision or debridement of the deep burn wound, it is essential that the wound is covered with autograft skin or an appropriate skin substitute.

• ■

  Deep dermal burns (wounds that heal in >3 weeks) require aggressive and monitored scar prevention therapies augmented with appropriate pain relief and combined with early positioning regimens and physiotherapy for joint mobilization to prevent hypertrophic scarring and joint contractures.

• ■

  All extensive hypertrophic burn scars should receive pressure therapy with silicone therapy as the first line of treatment. Restraint should be applied in opting for the surgical modality before scar maturation unless the scar is functionally limiting because of a developing contracture.

Therefore the following four clear burn care phases are considered:

• ■

  Initial evaluation and resuscitation

• ■

  Wound excision and initial skin cover

• ■

  Definitive skin closure and rehabilitation

• ■

  Reconstruction and reintegration into society

Ultimately, reconstruction of the trunk and perineum begins at the time of initial resuscitation and acute burn care, as all reconstruction should.

The priority list in these areas is as follows:

• 1.

  Reestablishment of body compartments and protection of the viscera

• 2.

  Early wound closure

• 3.

  Establishment of sufficient tissue laxity for mobility

• 4.

  Reconstruction of major aesthetic subunits

• 5.

  Improvements in cosmesis and skin envelopes

Generally, the first two points are considered a part of the acute phase; the latter three points are aspects of the reconstructive phase. Although delineating priorities is practical in medicine, it is critical to consider the best steps toward a long-term outcome at every phase of care. In plastic surgery, the reconstructive ladder describes a stepwise approach to achieving wound coverage and reconstruction ( IMAGE ). This concept potentially predates the ancient Egyptians. However, climbing the ladder’s rungs sequentially may yield less-optimal functional and aesthetic results for the patient, so the concept of the reconstructive elevator was introduced in 1994. The purpose was to suggest that the simplest is not always best and that moving more freely along the rungs may ultimately provide better patient outcomes. Although it has been argued that the reconstructive elevator is an outdated paradigm, the need for a protocolled approach to reconstructing deficits from burn insult remains.

In practice, this looks akin to a reconstructive time machine, whose goal is to provide the best reconstruction the patient’s recovery will accept to buy time until their reconstruction can be optimized. This approach allows the surgeon to determine the best reconstructive course based on patient risk, available materials, and techniques (e.g., grafting vs. acute microsurgery), leaving a balance between technical approach and physiology. For example, the preferred treatment for a typical patient with an exposed sacrum after a burn excision might be a gluteal artery rotation flap. However, skin grafting might be preferable to minimize operative time, optimize therapy, and reduce overall wound burden in a massive burn wound. In this example, when a sacral pressure ulcer develops later in the patient’s care, it can be more easily reconstructed after recovering from the massive burn wound.

No current protocol exists to prevent burn-wound conversion. ^, Care taken in the excision of burn wounds, when possible, will improve long-term outcomes. When excising chest burns in prepubescent females, it is important to avoid injury or resection of the breast buds if anatomically practical. However, even in the absence of damage to the breast bud (which is deep in the subcutaneous tissues and often spared even in full-thickness burns), significant contracture and restricted breast development occur and require a longitudinal approach to care. ^, In the male perineum and genitalia, care must be taken to preserve the bulbous urethra and spermatic cords. Care must be taken when excising perianal burns to preserve the anoderm for fecal sensory function.

The first reconstructive priority is to reestablish body compartments. In some major burns and traumatic injuries, the continuity of the visceral cavities is lost. Thankfully, these defects are rare and even more rarely massive. They can occur traumatically due to an avulsion injury, thermally with a fourth-degree injury, electrically causing necrosis of part of the chest or abdominal wall, or most commonly, iatrogenically from a decompressive laparotomy. Regardless of the mechanism, assiduous care must be taken to cover and protect the viscera. The best reconstruction to apply is arrived at through consultation with an experienced surgical team, considering both available donor tissue and the patient’s physiology.

In addition to debridement and reconstructive planning, it is important to note dressings. Although the goal is to attain tissue coverage, this is often a staged intervention, and, in the meantime, dressings are necessary to prevent infection, manage exudate, minimize fluid losses, and promote healing. The number of dressing materials available is numerous and overwhelming. An entire chapter could be devoted to listing the options, especially when topical agents are added to the conversation. Often, the dressing choice relies on familiarity and availability for the operating surgeon.

Long-acting, silver-based dressings, such as silver sodium carboxymethylcellulose (Aquacel Ag; ConvaTec, Greensboro, NC) and silver-containing soft silicone foam (Mepilex Ag; Mölnlycke Health Care, Gothenburg), have become widely accepted into practice for partial-thickness burns due to their ease of use (requiring less frequent changes) and cost-effectiveness. Smaller TBSA burns can help transition patients from inpatient management to outpatient care with weekly visits. However, no literature has proven silver-containing agents/dressings promote wound healing or prevent infection. In addition to dressings, many short-acting topicals are often employed with dressing changes. Literature comparing these topicals is also usually minimal and of poor quality. Although silver sulfadiazine is the most commonly used topical worldwide, a Cochrane review in 2013 concluded that it produced poorer healing outcomes than biosynthetic (skin substitute) dressings, silver-containing dressings, and silicon-coated dressings. Studies suggest that honey-based treatments may have efficacy in partial-thickness burns. Ultimately, there is no one correct answer; the goal of the dressing should be reducing fluid losses, protecting from the environment, and making application and removal easy.

In preserving life, reconstruction of the chest wall and reestablishment of a negative-pressure pleural space is critical for pulmonary physiology. Completion of resection to healthy tissue is essential to prevent infectious complications. If resection of the chest wall is required, it is possible to resect two ribs and, in select cases, three ribs (<5 cm in diameter of total chest wall resection) without functional consequences. Beyond this, reconstruction is recommended. There is some evidence that concurrent visceral resections are more closely associated with postoperative complications than the size of the resection. However, given the rarity of these types of injuries in burn patients, most literature on chest wall reconstruction derives from the oncologic literature. This includes functional outcomes that suggest larger resections result in greater and lasting impairment, which should be taken into consideration in patients with concurrent inhalation injury. ^,

The pleura can be reconstructed with Vicryl, Prolene, polytetrafluoroethylene (PTFE), or an acellular dermal matrix sutured to the ribs to reestablish the pleural cavity in conjunction with a tube thoracostomy to aid in apposition of the lung to the chest wall. Each of these materials has a different profile for tensile strength, infection risk, seroma/hematoma formation, and long-term cosmetic outcomes. In practice, we often rely on PTFE or acellular dermal matrix given the constraints of the acute burned patient. Specifically, needing to reestablish a continuous chest wall while acknowledging the high risk of a contaminated field and the possible need for reintervention, future reconstruction, and altered pulmonary physiology in the setting of massive fluid resuscitation, greatly complicates chest wall reconstruction in the acute burn patient. There are many more complex chest wall reconstruction strategies available, especially for large defects, that attempt to recreate the durability of the chest wall with osteosynthetic materials like methyl methacrylate and titanium; ^, however, these approaches do not translate well into the acute phase of the burn patient where the risk of developing infectious complications can be prohibitively high.

When dealing with larger defects, ideally, local tissue flaps can be mobilized to gain complex closure or local random pattern flaps over the underlying chest wall reconstruction. Without suitable local tissue, the patient’s physiology will not allow for a more extensive reconstruction. Negative-pressure wound therapy (NPWT) over the prosthetic mesh can temporize these wounds until regional or free tissue transfer is medically appropriate and rarely may be used as destination therapy awaiting future reconstruction. Many pedicled flaps can be used for acute chest wall defects, including latissimus dorsi, pectoralis major, omental, or transverse rectus abdominus myocutaneous flaps, to name a few. However, choosing these depends on each patient’s burn injury pattern and overall disease burden.

Given the proximity of these structures, a defect in the chest wall can sometimes mean a defect in the abdominal wall. Abdominal wall defects can occur from a wide range of mechanisms, such as massive electrical injuries or cooccurring blunt/penetrating traumatic injuries in burn patients. Still, the loss of a full-thickness abdominal wall is a rare event. The first priority in abdominal wall defects is to resect necrotic tissue for source control, a central tenet of burn surgery. However, the most common abdominal wall defect arises from decompressive laparotomy to treat ACS.

In patients where the intraabdominal compartment has not been violated or after restoring abdominal wall continuity, ACS can be a rapidly lethal complication. Patients with severe burns are at risk for developing ACS due to the large volume of resuscitation fluid that is infused, abdominal wall compliance, and capillary leakage due to increased permeability. This subsequently reduces blood flow to the abdominal viscera and may lead to bowel ischemia, multiorgan failure, and death if not adequately addressed. Medical management of this condition includes nasogastric decompression, increased sedation or paralysis to improve abdominal wall compliance, and correcting positive fluid balance, which is often difficult in the acute burn setting.

Although many of these medical management options can help slow the progression of ACS, a decompressive laparotomy is the current gold standard of surgical care. Once a decompressive laparotomy is performed, patients are still at high risk of mortality, which has been reported as high as 50%, and for survivors, this is a severe physiologic insult. An open abdomen adds significant complications to those due to the extent of the burn. The longer an abdomen remains open, the greater the loss of domain and the more difficult closure becomes. Simultaneously, the open abdomen adds increased challenges to fluid balance, results in intraabdominal adhesion development, and can produce long-term complications like enteric fistula. Once an abdomen is open, the goal is to close it as soon as it is clinically reasonable.

In the interim, the use of NPWT for temporary abdominal closure, such as the KCI Abthera system, is recommended. These systems can be used to temporize the patient for any injury or procedure that has violated the abdominal compartment. However, a unique challenge arises in burn patients as the occlusive drapes will often not adhere to the surrounding burnt skin. Sealing compounds such as ostomy paste can allow seal in these challenging scenarios. More classic solutions, such as the Bogota bag, are often needed when this is impossible.

For minor defects, such as those from a decompressive laparotomy, secondary closure after judicious diuresis often allows the normal peritoneal cavity to reestablish. It is important to note that routine hernia closure techniques, such as component separation, are not contraindicated in burn patients, even in the setting of deep pattern injuries. A component separation is performed by dissection between the external and internal oblique muscles of the abdomen, with care taken to maintain the perforating vessels and advancement of the rectus muscles and fascia to close the midline defect. In larger defects with patients able to tolerate a more extensive surgery, rectus abdominus flaps and component separation can allow a wider closure. In massive defects with a patient able to take a more extensive reconstruction, regional pedicled flaps of the rectus femoris, tensor fascia lata, or a lumbar-based latissimus dorsi can also provide robust tissue for reconstruction of large abdominal wall deficits. In a patient unable to tolerate such an extensive repair, commonly, the viscera can be constrained with an adsorbable matrix such as Vicryl mesh or an acellular dermal matrix, followed by the skin grafted with a plan for a more extensive reconstruction when the patient’s physiology will tolerate.

Many of the topics for chest wall and abdominal reconstruction apply to injuries in the back with methods for treating herniated contents and restoring the pleural cavity. However, there are a few unique topics that should be mentioned. Burn injuries impacting the scapula can damage shoulder mobility, which is discussed further in the chapter on the axilla. Given the durability of the soft tissues with thickened skin and extensive muscle coverage, sustaining a burn injury to the back, which extends to the spinal column, is extraordinarily rare but not impossible, especially in electrical burns. Coverage of an exposed spinal column and nerve roots should be paramount. Dissemination of contaminants into the spinal column can be a devastating complication. In practice, latissimus dorsi turnover flaps have provided a sufficient reconstruction option, and the neurosurgical literature employs this technique for selected wound complications in addition to paraspinal and trapezius flaps.

Acute perineum defects are also rare due to the protective nature of undergarments. Burns to genitalia, perineum, and buttocks increase the risk of death. Beyond issues of early skin coverage, physiologic considerations of urinary drainage and stool elimination must be considered. Urinary drainage via a Foley catheter is a primary goal in managing the acutely burned patient. In acute perineal burns, the catheter can serve as a functional means of maintaining genitourinary patency during reconstruction. Rarely a suprapubic drainage catheter is needed. Similarly, patient defecation or fecal management systems are generally sufficient for acute perianal burn injuries, with only a rare need for surgical fecal diversion. In male patients, maintenance of the anatomic location of the testicles below the penis can be accomplished with scrotoplasty and skin grafting or skin substitution. ^, Although flap procedures and, if appropriate tissue is available, thigh pouches are viable options for coverage, a split-thickness skin graft can often have a positive cosmetic outcome due to the contracted skin similarity to the natural rugae of the scrotum. In females, conjugated estrogen (Premarin) cream is trophic for the mucosa and can help to achieve mucosal healing with the reduction of strictures. Finally, when acutely reconstructing perineum burns, it is essential to maintain sufficient lower-extremity laxity so that the lower extremities have an acceptable range of motion. This is accomplished with adequate grafting, aggressive physical therapy, and positioning.

Early wound closure completes the acute phase of burn care and the beginning of reconstruction. It is accomplished, as discussed throughout this textbook, with skin grafting. Using allografts for temporary closure can allow the physician to assess the wound bed for the readiness of autograft skin while offering temporary coverage in tissues where the viability of the wound bed is a concern. In select wounds, where there is sufficient excess healthy local tissue, a complex closure or adjacent tissue rearrangement can gain early wound closure without grafting. For example, panniculectomies of the burn pannus or even a reverse abdominoplasty can gain rapid closure in these areas with good functional and aesthetic outcomes.

As the patients’ care priorities transition from major wound area coverage and critical care to functional recovery and outpatient care, we cross into the bulk of the reconstructive phase. Although preparation and forethought from the outset often offer the best outcomes, the final reconstructive plan is a moving mark for each patient’s unique physiology and injury course. This strategy design increases in priority as the patient gets under the 20% TBSA open-wound threshold, and it becomes the main priority once the patient is fully covered with skin grafts. The benchmark is the preservation of function; however, good cosmesis can significantly improve quality of life and decrease the psychological burden from such a massive and disfiguring injury. A framework for designing this strategy is establishing tissue laxity, establishing aesthetic subunits, and improving the skin envelope.

The first priority when approaching long-term reconstruction strategies is to achieve sufficient soft tissue laxity for a functional outcome—scars contract and decrease in size over time. Myofibroblasts play a significant role in elevation of scar tissue. Although these cells provide mechanical support and integrity to healing injured tissues, their presence in a wound bed can be considered a marker of fibrosis or scarring, which ultimately leads to the phenomenon known as contracture, a cause of morbidity in burn injuries. Scar contracture bands can be released with local tissue rearrangements such as Z-plasties. In large-area burns, tissue expanders can be used during reconstruction to increase skin availability for flaps and grafts. However, it should be noted that complications are more likely to develop from expanders placed in extremities versus in the trunk. Additionally, there is a correlation between the number of expanders used and complications.

One of the oldest tools in the armamentarium of reconstructive surgeons, the Z-plasty has proved indispensable due to its versatility in correcting defects and burn scar contractures. Opposing Z-plasties can be used when available tissue is limited. Functional skin deficiencies on the trunk, such as those causing chest or abdominal tightness, can compromise diet or exercise tolerance. In these settings, incisional release of the scarred skin with skin grafting with or without a dermal matrix can alleviate these symptoms and improve tissue laxity.

Aesthetic subunits are distinct, anatomically defined facial or body regions treated separately during surgical procedures. These subunits play a crucial role in achieving natural-looking results, as they help preserve the harmony and balance of a patient’s features. For example, in rhinoplasty, the nasal tip and dorsum are often considered separate subunits, allowing for precise adjustments to maintain facial symmetry. Understanding and respecting aesthetic subunits is essential for plastic surgeons to achieve optimal outcomes and patient satisfaction. If reconstructing half of a subunit or greater, it is preferable to reconstruct the entire subunit.

The anatomic subunits of the chest are as follows: the clavicles, the sternum and notch, the pectoral muscles, the breast, and the inframammary folds.

Special consideration of the chest are the breast and the nipple. Most breast burns occur in the pediatric population, so long-term and regular follow-ups are necessary to optimize reconstruction. Due to a low amount of subcutaneous fat and thin dermis, reconstruction is often difficult in the breast area. Deformities after a burn injury can include obliteration of the inframammary fold, altered skin texture, deformity or absence of the nipple-areola complex (NAC), and extrinsic scar contractures that can alter breast orientation, or prevent the development of breast mound. Asymmetry of breasts can result from unilateral defects, affecting cosmetic and emotional outcomes. In children, burns can result in amastia, whereas in postpubescent females, compromise of lactiferous ducts may contribute to an inability to breastfeed. Attention to the reconstructive plan to maximize aesthetic and potential functional results is necessary.

The complicated nature of burn wounds often means multiple strategies need to be employed for an excellent cosmetic outcome. Abnormal burn scarring during puberty results in compromised breast growth and displacement of the NAC, the breast mound, and the inframammary fold. ^, Particularly in prepubescent young females, the absence of a nipple is a noticeable concern. Nipples can be reconstructed with C-V flaps, which can offer good cosmesis. As children mature into adults, scarring can result in malformation of the breast with flattened and disfigured breast mounds and displacement of any nipple reconstruction, potentially necessitating multiple reconstructions spread over decades. Generally, most surgeons wait to reconstruct the breasts of patients burned before or during puberty until after complete breast development with regular follow-up of the patient during puberty. Scar management to increase tissue pliability before reconstruction can include laser treatments, Z-plasties to release scar contractures, and compression garments, among other procedures. To decrease the tension on the breast mound, extrinsic scar contracture releases should precede any intrinsic procedure on the burned, deformed breast. ^,

Intrinsic breast reconstruction can include the use of flaps or tissue expanders and implants. Due to the contributions of the oncologic field, many strategies are employable in burn reconstruction. Developed for oncologic patients, lipofilling (fat grafting) can be a viable option if scar patterning is amenable or in treating more minor defects. It is important to note that resorption rates ranging from 25% to 80% have been reported from fat grafting in reconstructive surgery. Strong et al. theorize that serial fat transplant sessions may be required to improve scarred recipient sites. However, all approaches can be challenging in the burn patient due to limited skin quality and unavailability of donor sites (abdomen, back, buttock, thigh). In patients with amastia, free flaps or pedicled flaps are options. Abdominal flaps can be an excellent aesthetic match but may be compromised due to abdominal burn scars from injury to lack of skin laxity from contractures of the breast. Alternatives include the transverse myocutaneous gracilis flaps or the thoracodorsal artery perforator flap. The flap must be designed to provide optimal aesthetic and functional results, and surgeons have turned to unconventional designs to mitigate constraints from the unavailability of donor sites.

Breast and nipple reconstruction in pregnant or lactating females can present unique considerations. During pregnancy and lactation, hormonal changes and breast tissue alterations can impact reconstructive outcomes. It is important for the surgeon to assess the timing of reconstruction, and delayed reconstruction is a safer option to minimize obstetric and fetal complications, typically after weaning or once hormonal stability is achieved.

Although much of the current literature focuses on cosmesis and its impact on self-image after breast disfigurement, it is imperative to discuss the functional aspect of the breast. Full-thickness injuries or damage to the NAC can result in an inability to lactate. Unfortunately, no reconstructive options will restore this function if lost. Careful consideration needs to be made in counseling this population both after an injury has occurred and when considering reconstruction options in a nondefinitive case.

For the remaining subunits of the chest, skin grafts can be reliable for reconstructing postburn contractures. Given the smooth planes of the sternum and clavicles, pressure dressings can be used to good effect in conjunction with a split-thickness skin graft or a flap to restore function in patients with limited donor sites. ^,