Reconstructive burn surgery

22 Reconstructive burn surgery

Timing of reconstructive procedures

The timing of reconstructive procedures vary; they could occur relatively early in the post-injury period (i.e., weeks), years or even decades, following injury. By and large, surgery on burn scars should typically occur once the scar has matured. The scar maturation process can take up to 1 year or longer. Allowing scars to fully mature could reduce or, in some cases, eliminate the need for burn reconstructive procedures altogether. As a general rule, the body should be given every chance to try and improve on its own without surgery. There are certain exceptions to waiting for scar maturation to occur including severe debilitating early contractures, severe eyelid contractures, unstable wounds and exposed vital structures.

There are several critical prerequisites that need to be met prior to embarking on any reconstructive endeavor. First and foremost, the patient must want the procedure performed and be psychologically prepared for the procedure. Unlike acute surgeries which may be life-saving, reconstructive procedures are usually elective and many patients may not be readily prepared to undergo more surgeries and to comply with postoperative splinting, garment wearing and the rigorous exercise regimens needed to achieve optimal results. In addition, many patients may not be psychologically ready to come back into the hospital for an inpatient stay. Children must also be included in the surgery decision-making process. Favorable outcome will require children to cooperate with postoperative plans and, therefore, in the cases of school-age children and adolescents, we make an effort to ensure that the patients themselves want a procedure and it is not just the desire of the parents. The cooperation of the child in terms of wearing splints, garments and performing physical therapy is critical to the success of reconstructive procedures and if the child does not want to have surgery performed, there is a high risk of poor postoperative compliance.

It is also critical that patients have realistic expectations regarding what can be achieved with reconstructive surgery. Many patients come to the burn clinic wanting their scars removed as soon as possible and many may have the unrealistic expectation that defects can be easily and rapidly fixed – that scars can simply be “erased”. Expectation-reality matching must be achieved and the concept that scars cannot simply be erased must be clearly articulated. It is also crucial to explain to patients that several procedures are often needed in order to address all reconstructive needs. When possible, procedures should be grouped, yet this needs to be done cautiously. For example, a procedure that requires early mobilization of a joint, such as a capsulotomy or capsulectomy, should not be performed at the same time as a procedure that might require immobilization of an adjacent joint. Similarly, performing procedures on either both upper or lower limbs simultaneously should be avoided, so the patient will still be able to provide self-care following surgery. Unfortunately, there are deformities for which there may be no good reconstructive options or that the risks involved in a procedure may exceed the potential benefit. This too must be explained clearly to the patient but an effort should also be made to provide some hope that new techniques or technologies may one day provide a solution.

Hypertrophic scars and contractures

Hypertrophic scarring remains the most significant source of pain, discomfort, and misery for burn survivors and constitutes the chief complaint of the majority of patients seeking burn reconstruction (Fig. 22.1). Despite the frequent occurrence of these scars – estimated to be as high as over 50% – still little is known about the causative factors and, therefore, a cure or effective prevention strategy remains elusive. Risk factors for hypertrophic scarring include delay in wound closure, infection and race (i.e., patients with pigmented skin are believed to be at higher risk of forming hypertrophic scar).2 There have been several proposed prevention and treatment strategies for hypertrophic scars, including steroids, oral anti-inflammatory agents, pressure garments and silicon, and all have been reported to have varying levels of effectiveness. Steroid injection into scars and topical silicon sheeting can be used during the period of scar maturation to alleviate symptoms of pain and itch and potentially improve scar appearance. However, scar injection may be difficult to perform in children and is seldom useful for broad areas of hypertrophic scar.

Wound contraction is a natural process that occurs in all healing tissues and in all skin grafts. The amount of contraction may vary based on thickness of tissue (i.e., full thickness skin grafts contract less than split thickness grafts due to the presence of more dermis). Contractures result when contraction occurs over a mobile joint and leads to functional compromise; they are negative sequelae of the natural process of contraction and often require surgical correction. Contractures can involve the skin as well as underlying tissues such as muscle and tendons. Limited contractures may be overcome with aggressive range of motion and splint immobilization. However, more significant contractures will require release and subsequent grafting or flap coverage. Even after contracture releases, patients must be aware that prolonged periods of intense range of motion exercises is required as is the use of splints in order to prevent the recurrence of contractures.

Other burn injury complications can be due to mismatch in color (hypopigmentation or hyperpigmentation), texture and hair loss as well as problems of chronic pain, itch and temperature regulation.

Overview of techniques for reconstructive surgery

Scar release

Contracture release is usually achieved by incising the scar band at its point of maximal tension. Given that contracture bands typically exist in a sea of surrounding scar, full release requires incision beyond the scar band itself. In addition, in the axilla and eyelids, we typically include a superior and inferior dart at either end of the scar incision line in order disrupt the scar pull. The incision should be carried down through the scar to healthy appearing tissue. In some cases, release of the subcutaneous tissue and muscle fascia may also be required to achieve full release. This is often the case in the neck and axilla. Long-standing deformities of the digits may also require tenolysis or, in some cases, tendon lengthening or transection, as well as joint capsule release. The surgeon must be aware of the potential need to divide these underlying structures and challenges in covering the subsequent defect, since skin grafting is not possible on exposed tendon, bone and joint.

In some cases, total scar excision is necessary and practical. This is particularly true for smaller or discrete areas of scar. There are two general approaches to scar excision: intralesional and extralesional. When performing intralesional excision, a rim of scar is left in the wound and subsequently closed. The purported benefit of intralesional excision is that there will be no new tissue injury – the incision is made through previously scarred tissue only and therefore the process of scar formation has already occurred in this tissue and is unlikely to recur (Fig. 22.2). This is in contradistinction to extralesional excision, in which the incision is made in the healthy tissue surrounding the scar so the entire scar can be removed. The relative risks and benefits of each approach should be discussed with the patient prior to surgery. Many scars are too large to be removed in one setting and often require several “serial” excisions. We typically wait 8–12 months between serial excisions in order that the tissue can sufficiently heal and soften so that it can be optimally mobilized again to achieve closure.

Wound closure

Plastic surgeons often utilize the reconstructive ladder as a way to approach reconstructive procedures. The ladder represents a list of procedures from simple to more complex for surgical management and forms an appropriate framework for approaching burn reconstructive procedures. Below is a discussion of the most common approaches to wound closure.

Local flaps

There exists a veritable alphabet soup of local tissue rearrangement flap options that have been described, including Z-plasty, Y-V-plasty, V-Y-plasty and W-plasty. Each has its distinctive geometric properties, as well as relative benefits. We most commonly use Z-plasties (Fig. 22.3) and Y-V-plasties to address scar bands (Fig. 22.4). It is critical to understand that these procedures are most appropriate for scar lengthening and are not the solution to all reconstructive problems. Areas with even moderate degrees of missing tissue will be inadequately addressed by a Z-plasty and require the addition of soft tissue either in the form of a skin graft or a flap. The principal drawback to Z-plasty use is that transposition and advancement of the Z-limbs requires extensive undermining and this often means undermining scar that can result in partial flap ischemia. For this reason, in many cases we prefer to use Y-V plasties because they require minimal flap undermining in order to achieve the desired advancement.

Feb 21, 2016 | Posted by in General Surgery | Comments Off on Reconstructive burn surgery
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