Functional and Aesthetic Reconstruction of Burn Patients

532
Functional and Aes thetic Reconstruction of Burned Patients
contractures, however, these measures only serve as
adjuncts to surgical release. Peacock et al. (105) observed
that the need for secondary reconstructive procedures fol-
lowing bum injuries is decreased by the proper attention to
positioning and ranging of joints during the acute phase.
They further observed that the success rates of such
procedures increase in direct proportion to the degree of
motion preserved in these joints before reconstruction.
For the purpose of discussion, it is easier to consider the
contractures of individual joints separately. However, this
should not underscore the fact that multiple joints may be
involved in a single patient with large surface area burns.
Contractures of the Hip Joint
Hip contractures may result from deep bums of the
anterior aspect of the upper thigh, the groin, and lower
abdomen in children or from poor compliance with an
established physical therapy program. The flexion contrac-
ture is usually accompanied by some degree of adduction
as a result of the slight internal rotation that occurs with
flexion at the hip joints. Surgical release may be indicated
in all but the very mild and early contractures where splint-
ing and positioning may constitute adequate treatment.
Z-plasty and its modifications as well as other local trans-
position flaps may be effective in breaking-up and correct-
ing contractures resulting from narrow restricting bands.
However, the contractures frequently encountered are
broad and require more elaborate procedures for correc-
tion (106). The contracture is released with an incision par-
allel to the inguinal ligament through the breadth and
thickness of the scarred tissue. It is important to ensure
completeness of the release intraoperatively. The resulting
defect is resurfaced with thick split- or full-thickness skin
grafts depending on availability and surgeon preference.
Immobilization in extension is essential in the immediate
postoperative period. This may require the use of cross-
leg bars in children. Range of motion exercises as well
as ambulation should be instituted as soon as the skin
grafts take satisfactorily and stability is achieved. Variable
periods of splinting may be required in order to prevent
recurrence of the contracture. The morbidity associated
with the use of skin grafts in the release of these contrac-
tures has endeared the prospects of flap coverage to many
reconstructive surgeons. In fact, the proponents of flap
coverage argue that such difficulties with the use of skin
grafts might have contributed to the development of
the groin contracture in the first instance (106,107).
However, the recent introduction of the vacuum assisted
closure (VAC) technique to improve graft-take in difficult
contour areas such as the groin may address some of these
concerns (108-111).
Flap coverage, however, becomes an absolute necessity
in the rare event of exposure of the femoral vessels and
nerve during the release of severe groin contractures
(106). The large fasciocutaneous flaps popularized by
Ponsten (23) have since enjoyed unprecedented fame in
burn reconstruction of the lower limb (Fig. 37.5).
Described as the “super-flap,” the fasciocutaneous flaps
are easy and quick to raise, can tolerate a length-breadth
ratio of 4:1 and donor defects can usually be closed
directly. The flap can be raised in scarred or grafted skin,
and yet survive transposition due to its fascial component
(106,107). Turley et al. (106) reported the use of the
medial fasciocutaneous flap of the thigh for release of post-
bum groin contractures. They obtained satisfactory
outcome in their series that consisted of four patients
with six severe groin contractures. The vascular supply
and innervation of the flap had previously been described
by Wang et al. (112), who used the same flap laterally
for groin reconstruction and medially for vaginal and peri-
neal reconstructions. Another option, which may be less
versatile for the release of groin contractures is the antero-
medial thigh fasciocutaneous flap described by Hayashi
and Maruyama (113). The perfusion of this flap, like the
medial thigh flap is nonaxial and is dependent on the exten-
sive vascular communications between the supra fascial
and subdermal plexus of the thigh (114).
On rare occasions, the relatively bulky muscle and
myocutaneous flaps may better serve the defect resulting
from the release of groin contractures. The tensor fascia
latae, rectus abdominis, gracilis, and sartorius muscles
have been used either as muscle flaps or myocutaneous
flaps in such circumstances (115,116). Turley et al. (106)
observed that the use of flaps obviate the need for pro-
longed splinting. Mobilization can be started as early as
on the third postoperative day and the patient can be
discharged within 10 days of surgery.
Popliteal Contractures
Postbum flexion contractures of the knee joint, also
known as popliteal contractures, are perhaps the most fre-
quently encountered in the lower extremity. Yet, they are
easily preventable (1). Early surgical intervention as well
as early and aggressive physical therapy programs
should serve to prevent and reduce the incidence of
these contractures. Treatment options for popliteal con-
tractures may correlate with the severity of the contracture
as it affects limb function (Table 37.1). Grade I contrac-
tures may require no immediate surgical intervention.
Functional improvement is expected to follow conserva-
tive measures such as use of pressure garments, silicone
gel inserts, and moisturizing lotions to soften and increase
the pliability of the scars around the knee joint. In grade II
contractures there is a demonstrable tightening of the bum
scar. Patients exhibit full extension but may require release
and lengthening by the use of local transpositional flaps or

Recons truction of Burn Deformities
533
Figure 37.5
(A) A 12-year-old male referred after motor vehicle accident where he sustained an open tibial fracture and arterial repair
(femoral-popliteal bypass) to the right lower leg with exposed hardware. (B) Hardware removed and wound subsequently debrided.
(C) Bilateral fascio cataneous flaps used to cover the defect over the proximal lower leg. (D) Medial view of flaps and skin grafts
used to cover the donor site. (E) Lateral view of flaps and skin grafts used to cover the donor site. (F) Eight-year follow-up with
stable wound coverage.
transverse incisional releases across the axis of the joint
and resurfacing with thick split- or full-thickness skin
grafts. Postoperative immobilization to ensure graft take
and subsequent splinting to prevent recurrence may be
required. The grade III deformity denotes moderate to
severe contracture in which the patient cannot fully
extend the leg. This may be complicated by the presence
of unstable scars and chronic ulcers due to excessive
stretching of the unyielding coverage. Incisional or exci-
sional release and skin grafting is frequently the first line
of therapy with excellent long-term results. Fasciocuta-
neous and fascial flaps, which are devoid of bulk, may
be used as alternatives. Prakash (117) introduced the
concept of the central segment expansion method in the
release of popliteal burn scar contractures that correspond
to the grade III contractures. The technique involves

534
Functional and Aes thetic Recons truction of Burned Patients
Grade I
Symptomatic tightness but no limitation in range of
motion, normal ambulation is preserved
Grade II
Mild decrease in extension with demonstrable
contracting band across the politeal fossa, patient
is able to ambulate
Grade III
Moderate to severe contracture with marked
decrease in flexion-extension arc, patient is able
to ambulate only with a limp
Grade IV
Fixed flexion contracture, patient is unable to stand
or ambulate on affected limb
Table 37.1
Classification o f Poplitea l Burn Scar Contractures
making releasing incisions proximal and distal to the level
of the joint, thereby, creating a bipedicle flap over the
joint. The defects on either side of the flap are then
covered with split-thickness skin grafts. Contraction of
the split-thickness skin grafts is expected to result in the
slow expansion of the flap.
Extensive contractures may require multiple incisions
and therefore multiple bipedicle flaps sandwiched between
skin grafts. The authors advocated excision and coverage
with the superiorly based medial or lateral fasciocutaneous
flap in the presence of unstable scars or chronic ulcers.
They, however, extended the concept of flap expansion
here too by using narrow flaps such that defects above
and below the flap are again resurfaced with skin grafts
(118). The disadvantage of this approach however, is
that it is staged, protracted and yet to be supported by
any long-term follow-up results. More recently, however,
Prakash and Mishra (119) reported the use of the posterior
calf fascial flap in resurfacing popliteal defects after
excision of contractures with unstable scars. They obser-
vedthat the advantages of the technique include its
reliability since the strong fascia ensures satisfactory
graft take thereby preventing recurrence of the contracture.
They also noted that harvesting the fascial flap is asso-
ciated with no functional loss and minimal donor site
defect. Robert et al. (120) had previously described the
use of the same flap in the reconstruction of traumatic
lower extremity defects.
The grade IV contractures, which are fixed flexion
contractures, may require more complex reconstructive
efforts. The potential problems include shortening and
bow stringing of the hamstring tendons, the neurovascular
bundles, and anterior dislocation of the knee. There is also
the need for large amount of soft tissue for coverage when
the contracted structures are released. The goal is to obtain
satisfactory extension and subsequent flexion without com-
promising the perfusion and sensibility of the distal limb
(121). Ahmad and Ashraf (121) reported the use of
Z-lengthening of contracted hamstring tendons and cover-
age with the medial gastrocnemius muscle flap. They
resorted to the use of additional turn over adipofascial
flap to cover residual lateral defect in one of the very severe
cases in their series of five patients with seven severe pop-
liteal contractures. They emphasized the need for post-
operative splinting in plaster cast, followed by regular
physiotherapy and use of pressure garments in order to
achieve complete extension with full range of motion.
The presence of bony ankylosis is an indication for osteo-
tomy to remove the bridging bone and restore joint motion.
Supracondylar extension osteotomy of the femur has been
reported for correction of severe contractures in patients
with neurological deficits such as myelomeningocele and
cerebral palsy. However, this has not been reported in the
correction of postbum contracture deformity (121,122).
The use of the Ilizarov external fixator may be extended
to the correction of these problems.
Contractures of the Ankle Joint
The postburn contractures encountered at the ankle
joint are either in dorsiflexion or in plantarflexion. The
dorsiflexion contracture results from deep dorsal bums
and usually occurs in concert with extension contractures
of the toes due to involvement of the dorsum of the fore-
foot. A transverse incision across the axis of the ankle
joint down to normal subcutaneous tissue may be all that
is required to release the isolated dorsiflexion contracture.
The defect is then resurfaced with thick split- or full-
thickness skin grafts. Postoperative immobilization in
slightly overcorrected position is encouraged. Early range
of motion exercises as well as use of pressure garments are
essential in the restoration of form and function. Correc-
tion of severe contractures requires the excision of dense
contracted scar, which may result in extensive soft tissue
defect and exposure of the extensor tendons. Adequate
release may demand certain measures of tenolysis, teno-
tomies, capsulotomies, and even osteotomies (123). Joint
stabilization with Kirschner’s wires or insertion of
Steinman pins for subsequent skeletal traction may also
be required. Following such extensive release procedures,
the defect may be resurfaced with thick split- or full-
thickness skin grafts (Fig. 37.6). However, where these
are inadequate, flap coverage will be required. Local
fasciocutaneous flap, such as the lateral supramalleolar
fasciocutaneous flap based on the perforating branches
of the peroneal artery is a suitable option if available
(46,47). However, microsurgical transfer of distant
tissues offers the most attractive option in this region.
The free radial forearm fasciocutaneous flap, the lateral
arm fasciocutaneous flap, and the free temporoparietal
fascial flap covered with split skin graft have been used
extensively in this reconstruction where contour preser-
vation is a major concern (51,124,125).
The less common plantar flexion contractures at the
ankle joint are commonly due to Achilles tendon

Recons truction of Burn Deformities
535
Figure 37.6
(A) A 2 -year-old child referred after severe burn to the lower extremities, which were allowed to heal by secondary
intention. (B) Close-up of the left foot. (C) Close-up of the right foot. (D) Bilateral release performed with resurfacing with
thick split thickness skin grafts. (E) Both feet were splinted after graft take. (F) Three months later both feet in neutral position.
(G) Patient shown in first pair of shoes.
shortening where acute care has failed to prevent this
complication. The Achilles tendon shortening is a ubi-
quitous problem in the extensively burned patient with
lower extremity involvement (6,93). Uncorrected, the
progressive shortening is capable of resulting in the
equinus deformity in which the musculoskeletal structures
of the fore foot are secondarily deformed. Surgical correc-
tion is directed at tendon lengthening and the more difficult

536
Functional and Aes thetic Recons truction of Burned Patients
problem of providing suitable coverage. Options for
tendon lengthening include the Z-lengthening and skin-
strip lengthening techniques. Ideal coverage should
provide adequate soft tissue padding to allow healing
and subsequent gliding of the tendon. Yet, it must be
thin enough to preserve the normal contour of the area in
order to permit use of normal footwear (1,6). Local flaps
capable of meeting these requirements are difficult to
come by. The lateral supramalleolar fasciocutaneous flap
has been used for this purpose but again it may not be
available in the severely burned lower extremity. Other
local flaps that have been used include the inferiorly
based de-epithelized turnover flap covered with split skin
graft described by Ramakrishnan et al. (126). They
reported a series of 35 patients in whom the use of this
flap provided satisfactory long-term coverage of the
Achilles tendon area (126). Currently, however, microsur-
gical techniques have allowed satisfactory coverage of
these defects with high quality distant tissues. The free fas-
ciocutaneous and fascial flaps are particularly favored to
preserve the desired contour. Chicarilli et al. (54) reported
the use of a free radial forearm flap in resurfacing the
Achilles tendon area utilizing the posterior tibial vessels
as recipient vessels. They observed that the flap provided
a thin, well-vascularized cutaneous restoration with a
satisfactory aesthetic result and low complication rate.
Contractures of the Forefoot
Deep bums of the dorsum of the forefoot frequently
result in simple extension contractures of the toes. More
severe and extensive dorsal bums, however, may produce
the debilitating deformity in which the toes are hyper-
extended with subluxation or dislocation of the meta-
tarsophalangeal joint. There may be associated loss of
the transverse arch resulting in interdigital contractures
with over-riding of the toes. This deformity may interfere
with normal weight-bearing and ambulation leading to gait
abnormalities. It may also inhibit the use of normal foot-
wear (1-6,15). Pap (127) observed that bums of the feet
could result in significant morbidity with protracted con-
valescence and extended absence from work and school.
They, therefore, advocated that this injury should be
given relatively high priority both in the acute phase and
during the reconstructive phase of management. The
reconstructive goal is to restore normal anatomy that
will permit unimpeded weight-bearing and ambulation as
well as allow the use of normal footwear (2,3).
While mild to moderate linear bum scar contractures of
the dorsum of the foot may be corrected with Z-plasties and
other local transposition flaps, majority of the cases exhibit
extensive soft tissue deficiency requiring release and
replacement with skin grafts or flaps. The deficiency of
soft tissue in the long axis of the foot is frequently
addressed by a transverse releasing incision over the
metatarsophalangeal joints extending from the first to the
fifth and breaking into fishtails at both ends. Excision of
the scar is rarely required as the incision relieves the
tension in the scar thereby enhancing subsequent remo-
deling and flattening of the scar (15). Dissection must be
carried down to normal subcutaneous tissue and adequate
care taken to protect the extensor tendons and neurovascu-
lar structures. On rare occasions, release of severe contrac-
tures may require tenotomies of the long extensors and
closed capsulotomies of the metatarsophalangeal joints
(1). Intermedullary bone fixation with Kirschner’s wires
may be required to maintain joint position. Resurfacing
with thick split- or full-thickness skin graft will usually
suffice. Diligent postoperative splinting and use of pressure
garments and custom-made shoes with silicone inserts
contribute to the overall functional outcome. Despite
these measures, however, the recurrence rate has remained
high, particularly in the pediatric age group. Way mack
et al. (86) reported a 15% recurrence rate within 4 years
in a series of 55 children who had 90 reconstructive pro-
cedures for the treatment of early bum scar contractures
of the feet. They observed that the recurrence rate was
influenced by the diligence of postoperative splinting
rather than the use of either full- or split-thickness skin
grafts. Alison et al. (4), however, observed that the high
recurrence rate following release of foot contractures
might be related to the concomitant soft tissue deficiency
in the transverse metatarsal arch that is often unaddressed
(4). They therefore introduced additional incisional release
on the dorsum of the foot along its long axis as well as mul-
tiple incisions parallel to the plane of the metatarsals into
the web spaces as may be required to completely restore
the transverse arch of the foot (Figs. 37.7 and 37.8). The
latter incisions can in fact be extended to accommodate
simultaneous correction of interdigital contractures. In a
comparative analysis, Alison et al. (4) observed that the
overall recurrence rate in their series of 68 children who
had a total of 146 releases for foot contractures was
35.7% when only the longitudinal arch was released and
the time interval before recurrence averaged 3.50 + 0.41
years. However, with the additional release of the trans-
verse arch, the time interval before recurrence averaged
4.29 ± 1.27 years initially and with improvement in
execution of the technique, they subsequently recorded
no recurrence. Alison et al. (4), however, noted that recur-
rence was influenced by the expansion ratio of the meshed
split-thickness skin grafts used for coverage in the acute
phase of management. They found that the time interval
between injury and the need for the first surgical release
when expansions of 1:2 were used doubled the interval
recorded in the use of expansions of 1:4.
Dhanraj et al. (128) documented the efficacy of simul-
taneous bilateral surgical correction over staged sequential
correction of bum scar extension contractures of the foot in
patients with bilateral deformities. They observed that

Reconstruction of Burn Deformities
537
Figure 37.7
(A) Surgical release of the longitudinal metatarsal
arch by a perpendicular incision over the metatarsal phalangeal
joints. (B) Combined surgical release of both the longitudinal
and transverse metatarsal arches. Additional incisions are parallel
to the plane of the metatarsals. [Reprinted with permission from
Alison et al. (4).]
there is no difference in morbidity between unilateral vs. sim-
ultaneous bilateral correction with Kirschner wire fixation.
However, the latter accords the opportunity to correct
both contractures early and shortens the overall rehabilita-
tion of the patient. They also noted that recurrence might
be as a result of the differential growth of normal tissue
vs. adjacent skin grafts in the growing child. They, there-
fore, recommended simultaneous bilateral correction as
well as a close follow-up program in children presenting
with bilateral dorsal foot contractures.
Webspace contractures of the toes may accompany
both dorsal bums and plantar bums. The associated func-
tional impairment is usually minimal as a result of which
surgical correction is rarely undertaken. However, aesthe-
tic concerns as well as repeated fungal infection may
compel a patient to request surgical correction. The
Z-plasty and its modifications as well as the V-M and the
Y-V transposition flaps are favored because they obviate
the need for skin grafts (1,6,15). Where these measures
prove inadequate, however, routine surgical release, resur-
facing with split skin grafts and immobilization with intra-
medullary pins may become absolutely necessary.
Flexion contractures of the toes frequently follow deep
bums of the plantar surface of the foot. The contractures
can be corrected by incisional release and resurfacing with
split-thickness skin grafts. Postoperative immobilization
is, however, difficult and may be accomplished by the
Figure 37.8
(A) A 13-year-old girl referred for reconstruction of her feet: note severe subluxative at the metatarsal joints and loss of
the transverse and longitudinal arches of the feet. (B) Correction with split thickness skin grafts and k-wire fixature pins left in place for
6 weeks. (C) Three-month follow-up.

538
Functional and Aes thetic Reconstruction of Burned Patients
use of stent-type dressings and insertion of intermedullary
Kirschner wires in severe cases. Maintenance of the
release requires the wearing of shoes 24 h a day preferably
with custom-made inserts to prevent recontracture (6).
Witt and Achauer (6), however, observed that the correc-
tion of these contractures with a variety of local flaps
fashioned from the lateral aspect of the toes tend to
produce more rapid healing and a more lasting correction.
Care must, however, be taken not to compromise weight-
bearing surfaces while using such local flaps.
The reconstructive plan for the correction of the mul-
tiple deformities that may arise from severe burns of the
foot must be based on accurate evaluation and due con-
siderations of the available reconstructive options suited
to the individual patient (Fig. 37.9). In severe deformities
where orthopedic measures as well as physical therapy
expertise are often required, early specialist consultation
should help in the formulation of a reconstructive time-
table from the outset. The role of an adequately informed
physical therapy program in the overall rehabilitation of
the patient cannot be overemphasized.
3.
Amputations
Lower extremity amputations are occasionally required
particularly following high-voltage electrical injuries and
deep thermal burns (129). Acikel et al. (130) noted that
burn injury constitutes a rare but consistent etiology in
lower limb amputations. Although amputation rates
ranging from 32% to 60% have been reported for high-
voltage electric injuries (131,132), the largest study of
major amputations following thermal injuries generally
noted an occurrence rate of 1.5% (133). Factors contribut-
ing to amputations following burns include extensive
involvement of soft tissues and associated open fractures,
which are often accompanied by vascular injuries (129).
Amputations may also be the consequence of failure to
recognize an impending compartment syndrome thereby
overlooking the need to perform timely escharotomy or
fasciotomy on the lower extremity (2,3). Fortunately, inva-
sive bum wound infection, which was once a leading
contributor to lower extremity amputations, have been
adequately contained in the last few decades. Amputations
Figure 37.9
Algorith m for reconstruction o f the burned foot. [Reprin ted with permission from Lyle et al. (1 5).]

Reconstruction of Burn Deformities
539
may be required early in the postbum course, occasionally
as a life-saving procedure or it may become necessary late
in the course of treatment when efforts at limb salvage
have failed. Consultations with the orthopedic and vascular
surgery teams, physical therapist, and the prosthetist have
been found useful when one is faced with the unpleasant
prospect of limb amputation. The primary goal of amputa-
tion surgery is to salvage as much of the limb length as poss-
ible thereby minimizing the functional losses. Efforts must
be directed at preserving uninjured tissues, which can aid
in achieving stable and durable skin cover at the amputation
site so as to minimize the need for future revisions.
Following amputation, physical therapy management is
directed at edema reduction, prevention of contractures
through positioning and range of motion exercises, stump
shaping, both pre- and post-prosthetic fit strengthening
exercises of the limb and trunk and gait training (134).
Psychological concerns must be adequately addressed
as the fear, anxiety, and guilt associated with burn injury
is compounded by the deep sense of limb loss (134).
Though the potentials for rehabilitation depend directly
on the level of limb loss, patient motivation is equally of
paramount importance. Acikel et al. (130) observed that
at least 90% of patients with below-knee amputations suc-
cessfully use prosthesis in contrast to a success rate of
<25% for patients with above-knee amputations. They
noted that the primary factor is the marked increase in
energy required to ambulate with above-knee prosthesis.
They concluded that knee function is so critical to prosthe-
tic rehabilitation that every attempt should be made to
salvage the knee joint (130). Unfortunately, the paucity
of soft tissues at the level of the leg creates a major chal-
lenge to obtaining a below-knee amputation with satisfac-
tory stump qualities in a majority of cases. The classic
posterior myocutaneous flap has been the most widely
used form of coverage for the below-knee amputation
stump. However, other options have been used when this
flap is unavailable either due to the nature or level of the
injury. Yowler et al. (129) described the use of the osteo-
cutaneous pedicle flap of the foot in providing satisfactory
below-knee amputation stumps. Other options include the
use of the laterally based skin flaps, the combination of
anterior and posterior flaps, the posterior muscle flaps
covered by laterally based skin flaps and the use of free
flaps (135-140). Acikel et al. (130) described the use of
gastrocnemius transposition flap covered with thick split-
thickness skin graft to secure bilateral below-knee amputa-
tions in a patient who had suffered severe thermal injury.
With modern prosthetic materials and techniques making
it possible for less-than-optimal skin to tolerate the press-
ures of weight-bearing, more distal amputation levels may
be secured with the use of skin grafts (130).
Generally speaking, with concerted team effort and
adequate patient motivation, a majority of the thermally
injured patients who suffer lower limb losses can be reha-
bilitated to a level of independence and a good number
may be able to eventually return to their preinjury life-
styles (141) (Fig. 37.10).
4.
Recent Advances
The last few decades have witnessed a number of techno-
logical advancements in the field of both acute and recon-
structive burn surgery. Some of these have had direct and
others indirect impact on the outlook for lower extremity
bum reconstruction.
Vacuum Assisted Closure
The high incidence of late complications and deform-
ities associated with severe lower extremity burns may
in part be due to delayed wound healing and poor skin
graft-take occasioned by dependency, complex and unfa-
vorable contours, and shearing during ambulation. These
problems have resulted in the frequent development of
hypertrophic burn scars and scar contractures (1,6,142).
The vacuum assisted closure (VAC) device is a modified
dressing consisting of a sponge and suction tubing that is
secured to the wound with an occlusive dressing. Use
of the suction tubing creates a continuous negative-
pressure dressing (110). Experimental studies have demon-
strated increased oxygen tension, decreased bacterial
counts, and increased granulation tissue formation occur-
ring under the negative-pressure system (108,143,144).
The technique has also been associated with earlier
re-epithelialization and faster healing of burn wounds
and has been used to manage complex wounds success-
fully (145-147). It has been clinically shown to enhance
skin graft-take and healing (43,108,110). Blackburn
et al. (108) further observed that when the VAC device
is used to secure split-thickness skin grafts on rotated
muscle flaps, it decreased edema, improved contour con-
formity, and shortened hospitalization (108). This must
be a welcome development to the use of skin grafts on
muscle flaps in the reconstruction of the weight-bearing
plantar surface of the foot and in securing distal amputa-
tion levels. Scherer et al. reported a retrospective study
comparing the use of VAC device (n = 34) vs. bolster
dressings (n = 27) in securing split-thickness skin grafts
in patients with traumatic and thermal tissue losses.
They observed that the VAC group required significantly
fewer repeated skin grafts (3%) compared to the bolster
group (19%) and that no dressing-associated compli-
cations occurred in the VAC group. They concluded that
though a prospective randomized study is required, the
VAC device provides a safe and effective method for
securing skin grafts and is associated with improved
graft survival (110).

540
Functional and Aes thetic Recons truction of Burned Patients
Figure 37.10
(A) A 16-year-old male referred after high bilateral above the knee amputations. Orthopedic surgery services felt
that remaining femur was too short for a prosthesis. (B) Once wounds closed, external fixator placed for lower extremity distraction
so that patient would be able to wear lower extremity proeteses. (C) Left stump showed erosion of bone through burn scar with distraction.
(D) Coverage of left stump with a free latissimus dorsi myocutaneous flap. (E, F) Final result after fitting of prostheses.

Recons truction of Burn Deformities
541
The VAC technique is likely to have its greatest role of
securing skin grafts in complex contour areas of the lower
extremity such as the groin, the popliteal fossa, and around
the ankle joints. As this technique becomes widely avail-
able, the long-term benefits should include a reduction in
the number of bum wounds undergoing protracted
healing and consequently a decrease in the incidence of
such complications as bum scar hypertrophy and contrac-
tures. Furthermore, the technique is potentially useful in
reconstructive procedures that require the use of skin
grafts to resurface defects created by the release of contrac-
tures and the excision of hypertrophied scars, unstable
scars, and Marjolin’s ulcers. It is expected that the rela-
tively high recurrence rate associated with release of
groin and popliteal contractures when resurfaced with
skin grafts will be addressed by the VAC technique. This
technique, which is undergoing evaluations and modifi-
cations in various centers, may find even more use in the
comprehensive management of the burned patient.
Already, Sposato et al. (109) have introduced a fully
portable, battery-operated unit described as the mini-
VAC device, which allows for early ambulation, reduces
nursing needs and therefore shortens length of hospital stay.
Skin Substitutes
Ever since the introduction of skin substitutes to pro-
vide acute coverage in patients suffering life-threatening
large surface area bums, its clinical uses have conti-
nued to expand beyond this initial concept (148-152).
Perhaps the most widely used skin substitutes in present
day literature include the bilaminar acellular matrix,
Integra® (Marion Laboratory, USA) and the acellular allo-
geneic dermal transplant, AlloDerm® (LifeCell Corp., The
Woodlands, TX) (149,153-156). These materials provide
resurfacing for acute burn wounds at an earlier stage than
would otherwise have been possible. In fact, even low
priority areas such as the lower extremities can now be
resurfaced earlier and without necessarily using widely
meshed skin grafts. The benefits of this innovation
should therefore include a reduction in the incidence of
the complications of bums that are in part due to protracted
healing occasioned by inadequate and delayed closure
of bum wounds (88-90). These complications include
unstable scars and chronic ulcers, and bum scar hyper-
trophy and contractures. Hergrueter and O’Connor (149)
observed that recent clinical reports have offered some
evidence that skin substitutes may heal with less scarring
than conventional skin grafts. This can therefore translate
to less secondary contracture and stiffness, a most desir-
able goal for ambulation and weight-bearing. Early
reports on the use of these skin substitutes have shown
that they provide durable and stable coverage that is
pliable and does not adhere to deeper structures making
them suitable for coverage of areas where mobility of
underlying structures is highly desirable such as the
dorsum of the hand and foot (148,154-156). Lattari
et al. (154) observed that the use of AlloDerm with ultra-
thin autogenous split-thickness skin grafts is associated
with more rapid healing of the donor site, reduced need
for postoperative physical therapy and reduced number
and extent of subsequent surgeries for contracture releases
and cosmetic repair.
Furthermore, the last decade has witnessed anecdotal
reports on successes in the use of skin substitutes in burn
reconstruction. Skin substitutes have been used to resur-
face large defects arising from the release of groin contrac-
tures, popliteal contractures, and foot contractures with
satisfactory functional and aesthetic outcome (148,155).
Tissue Expansion
Tissue expansion offers many advantages over previous
modalities of surgical treatment for burn scars. It allows
one to generate sufficient soft tissue to reconstruct
defects without unduly creating a new disfiguring donor
area. It also obviates the need for transfer of distant
tissues, which on occasions may be a major undertaking.
Color, tone, texture, thickness, and composition of
expanded adjacent skin are aesthetically better matched
than grafted skin or tissue transferred from a distance,
and it also maintains sensibility (95,157-160). Expansion
has, therefore, permitted the elimination of unfavorable
bum scars and replacement with adjacent expanded
tissue with improved functional and aesthetic outcome
(95,158-162). Hudson and Arasteh (157) observed that it
is possibly the greatest advance in bum reconstruction in
recent times. Gottlieb et al. (159) reported a large series
in which tissue expansion techniques were used for the
reconstruction of burns scars. They reported satisfactory
results in 52%, minor problems in 29%, and significant
complications necessitated abandonment of expansion
procedures in 19%. They concluded that in the 81% that
were successfully managed with expansion, the results
were frequently far superior to those possible with avail-
able alternative techniques. They noted that the increased
vascularity in the expanded tissue ensured safety during
transfer and that expansion has decreased the need to
resurface flap donor sites with skin grafts.
Unfortunately, however, the narrow circumference of
the lower extremity has limited the suitability of tissue
expansion in this region where only small-sized expanders
can be used. Yet, the risk of extrusion and infection
remains unacceptably high. Pitanguy et al. (160) reported
a series in which 40 out of a total of 346 expanders used for
the treatment of bum sequela in 132 patients were in the
lower extremity. They obtained satisfactory outcome in a
majority of the patients and reported an overall

542
Functional and Aes thetic Recons truction of Burned Patients
complication rate of 7.5%. Marks et al. (162) observed that
complication rates approaching 35% have been reported in
the use of tissue expanders below the level of the knee
joint. Reporting a series of 45 patients, they remarked
that if patients are selected based on the availability of
relatively healthy expandable skin and the principles of
expansion followed, complications can be kept to a
minimum and successful reconstruction achieved even in
the lower extremity.
The Ilizarov External Fixator
Severe and long-standing postburn contractures and
deformities of the lower extremity tend to affect tendons,
ligaments, joint capsules, and underlying bones. Hitherto,
correction of these deformities had entailed major pro-
cedures such as tendon elongations, capsulotomies, osteo-
tomies, and bone resections. Coverage of the resultant
defect had also demanded the use of flaps, which must
invariably be transferred from distant locations. Arthrod-
esis and amputations had served as last resorts or alterna-
tives to these complex reconstructive procedures (15,163).
In the last two decades, however, the Ilizarov external
fixator has provided an additional option for the correction
of such severe deformities. The morbidity is less and quite
often the result is better. Calhoun et al. (163) were first to
evaluate the Ilizarov external fixator for use in the correc-
tion of chronic burn scar contractures based on their
experience with the use of pin fixation for acute burn man-
agement and the use of the Ilizarov fixator for correction of
other foot deformities. Their result showed that severe
lower extremity burn deformities could be successfully
treated with the Ilizarov fixator (163). They enumerated
the uses and provided details of the use of the fixator
in the correction of the ubiquitous postburn equinus
deformity obviating the need for Achilles tendon release,
elongation, tenolysis or tenotomy. Noting that the fixator
could be applied under general, regional or local anesthe-
sia. The frame consists of two tibial-fibular rings, a calca-
neal ring and a metatarsal ring secured to the bones with
1.5 mm pins. Correction is achieved by pushing the calca-
neus distally while pushing the metatarsals proximally at a
rate of 1-2 mm/day. Periodic radiographs were used to
assess progress. They observed that correction could take
up to 6 weeks after which the limb must be protected in
cast for a further period of at least 6 weeks. They further
noted that the fixator could be used to distract the calca-
neus from the metatarsals in the correction of postburn
cavus deformity of the foot without resorting to fascial
excisions, mid-foot osteotomies, and the complex resurfa-
cing procedures with flaps.
They also reported the use of the Ilizarov fixator in the
correction of severe postburn rocker-bottom deformity to
re-create the longitudinal and transverse arches of the
foot without resorting to osteotomies and fusion as
required by surgical correction. Other uses enumerated
include the correction of complex postbum toe dislo-
cations including hallux valgus and varus, which were pre-
viously treated with bone resection and amputations. The
fixator was also used to lengthen scar tissue by gradual dis-
traction thereby reducing the extent of soft tissue release
required to maintain the corrected position. The use of
the Ilizarov fixator in combination with other surgical
procedures such as tenotomies and tendon elongations
to minimize the complexity of surgery and improve
outcome in complicated deformities was collaborated by
Steinwender et al. (164). They emphasized the fact that
such an approach obviates the need for precarious dissec-
tion of contracted soft tissue in which muscles, tendons,
and neurovascular tissues are interlocked. Calhoun et al.
(163) noted that complications with the use of the Ilizarov
external fixator in the burned extremity are frequent but
manageable. These include pain, infection, nerve and
vessel injuries, and technical problems with the device.
They, however, observed that adequate preoperative plan-
ning is required to minimize the incidence and severity of
these complications. They emphasized the need for ade-
quate evaluation and documentation in preparation for
the use of the device. Appropriate radiographs are required
to establish joint abnormalities such as dislocations, anky-
losis, and heterotopic ossifications (163).
Currently, the Ilizarov external fixator is being adapted
to correct a wide array of postburn deformities in other
parts of the lower extremity and even the upper extremity
(165-167). Ullmann et al. (165) in a case report documen-
ted the use of the Ilizarov fixator in correcting recurrent
postburn fixed flexion contractures (Grade IV) of both
knee joints in a noncompliant patient. They noted that
the complex and lengthy manipulations required of the
Ilizarov technique is justified in patients who cannot
comply with the aggressive and demanding physiotherapy
that may be required with surgical release. Furthermore,
the fixator technique is a viable alternative in patients
whose limited donor skin is required for reconstruction
of higher priority areas. They further observed that the pro-
blems of excessive bulk and scars that accompany distant
flap techniques are not seen with the use of the fixator.
Latimer et al. (166) reported the use of the Ilizarov external
fixator in lengthening below-knee amputation stumps in
order to improve prosthetic fit. The Ilizarov external
fixator has come to stay as far as the correction of lower
extremity burn deformities are concerned. Improvement
in the material and technique of the device points at the
potential for even wider use in the near future.
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(Trang không có chữ)

38
Recons truction of Burn Scar Contractures of Feet
PREMA DHANRAJ
Christian Me dical College & Hospital, Vellore, Tamil Nadu, India
MALACHY E. ASUKU
Ahm adu Bello University Teaching Hospital, Kaduna, Nigeria
I.
INTRODUCTION
The survival of patients with major thermal injuries has
drastically increased in recent years (1). As our ability to
save patients lives increases, the concept of total rehabili-
tation becomes of paramount importance. Bums to the
ankle and foot represent some of the most challenging
problem in acute wound care, subsequent rehabilitation
and reconstruction. Children who sustain large total body
surface area (TBSA) burns with involvement of the
lower extremity frequently sustain injuries of the dorsum
of the feet. Bums of the feet are a very small proportion
— Galveston Unit, Galveston, Texas, USA
of the TBS A. Although, it has not been given importance
by many surgeons, in patients with large TBS A bums, it
continues to cause a major source of morbidity leading
to gait disturbances, growth abnormalities, improper
shoe fit, and recurrent ulcerations (2). Furthermore, the
formation of hypertrophic scars and bum scar contractures
can devastate rehabilitation efforts (3). Thus, these injuries
are categorized by the American Bum Association as
major bums and require careful in-hospital treatment to
avoid complications (4).
Currently, great emphasis is given to proper positioning
and splinting to maintain mobility during the acute and
ROBERT L. McCAULEY
University of Texas Me dical Branch and Shriners Hospital for Children
549
I.
In tro d u c tio n
549
B.
S u rg ic a l
555
II.
An a to m y o f th e Fo o t
5 5 0
C
A m Pu ta tio n
557
III.
Cla s s ific a tio n o f B u m
V -
P h ys io th e ra p y a n d S p lin tin g
557
S ca r Co n tra c tu re s
551
V I.
P itfa lls
559
A.
Do rs a l B u m S car Co n tra c tu re s
551
V II.
Nu rs in g Is s ues
56 0
B.
P la n ta r S u rfa c e B u m
VI I I .
R e h a b ilita tio n Is s ues
56 0
S c a r Co n tra c tu re s
552
IX
Lo n g -Te rm Go a ls
56 0
C.
J o in t De fo rm ity
553
„
,
.
_ .
X.
Co n c lu s io n
56 0
IV .
Tre a tm e n t
555
.
,
___
Re fe re n c e s
561
A.
No n s u rg ic a l
555

550
Functional and Aes thetic Recons truction of Burned Patients
reconstructive phases of care. In spite of this, scarring and
contractures may persist. In part, this is due to the lower
priority given to the foot burns when it is associated
with larger burns. Also, the inherent contractile nature of
scar formation and, in children, growth may accentuate
the development of deformities (5). These factors
combine to increase contractures leading to both func-
tional and aesthetic problems.
The lower extremity is important for static support of
the trunk and ambulation. Burn scar contractures not
only affect gait, but in very severe cases, may even
preclude standing. The human gait pattern is extensively
discussed by various authors (6,7). Goldberg et al. (7)
studied the gait patterns in human and classified gait as
normal, minor gain abnormality and major gain abnormal-
ity. Minor gait abnormality was defined as any insignifi-
cant acquired alteration in either stance or swing phase
of either the injured or uninjured leg. A major gain
abnormality was defined as an alteration that grossly
affects the gait pattern of either leg. Prevention of contrac-
tures is of utmost importance to prevent permanent skel-
etal and functional deformity. The reconstructive goals
for this region are ambulation and weight bearing. This
requires durable stable skin coverage, protective sensation,
and anatomic alignment. Clearly, the challenge in any
reconstructive procedure to the feet is to provide an
outcome where ambulation and weight bearing is painless
and as normal as possible.
Although burns of the foot may have received less
attention, the importance of the foot cannot be overlooked
and the defects that may occur following thermal injury
may produce serious functional impairment. The types
of thermal injuries affecting the foot are flame, scalds,
contact, chemical, and electrical. Even, frostbite also pro-
duces severe foot injuries (8). Foot burns may present a
solitary injury or part of an extended injury. Treatment,
both early and long term, depend on the location of the
bum, the extent of the injury as well as associated life-
threatening problems. In many cases, limitations of avail-
able local tissue may restrict the options available for both
acute coverage and reconstruction.
Burn scar contractures of the foot can cause signifi-
cant morbidity, especially in children. Severe contractures
may be very common in developing countries due to poor
resources and decreased compliance (9). In addition, there
is increased morbidity that results from the multiple oper-
ations to reconstruct the foot. The natural tendency of scars
to contract combined with the normal growth of a child
may accelerate the deformity (10). Also, foot burns can
lead to the most troublesome joint contractures when posi-
tioning is less than optimal posture.
The standard for reconstruction for burn scar contrac-
tures of the feet is restoring the anatomy to normal, then
obtaining
soft
tissue
coverage.
The
timing
of
reconstruction has been questioned. Waymack et al. (10)
supported early release of contractures to prevent growth
abnormalities. Robson et al. (11) suggested possible post-
ponement of reconstruction until scar tissue matures. Yet
regardless of these issues, most agree that if the deformity
is progressive or causing a significant functional deficit,
reconstruction should be initiated. Achieving optimal
results for reconstruction depends in many ways on the
successful management during the acute phase of injury.
Proper splinting, elevation, avoidance of edema, along
with physiotherapy and early surgical intervention helps
to reduce the need for late reconstructive procedures. In
children, release of these contractures and resurfacing
the dorsum of the foot with think split-thickness skin
grafts appears to be adequate. However, these contractures
have been reported to recur in 15-20% of the patients.
Since the mean time to recurrence is more that 2 years,
these recurrences are probably related to growth as
opposed to failure of the skin grafts (12). Waymack
et al. (10) noted that recurrent of contractures requiring
further surgery is probably due to the growth spurt seen
in young children. These tend to worsen with time. Scar
tissues cannot grow at the same rate as that of normal
skin. Clearly, the prevention of contraction is of utmost
importance. However, once contractures occur, it should
be reconstructed as early as possible to prevent skeletal
and functional deformities.
II.
ANATOMY OF THE FOOT
Anatomy of the foot is defined as that area extending distal
to the superior aspect of lateral and medial malleoli. The
various subunits are dorsal surface, plantar surface, and
the ankle. The skin over the dorsum of the foot in thin
and supple to permit gliding movement of the underlying
tendons. The skin over the sole of the foot is firmly fixed
to the deeper structures. The plantar fascia along with
the tarsal bones is very important to stabilize the arch of
the foot. Destruction of this fascia will disrupt the arch
support (13).
The relationship between the anatomy and function is
unique in the foot. The weight bearing properties of the
foot, as well as the particular characteristics of the soft
tissue without intervening muscle between the skeletal
element in the skin, can make coverage of foot injuries a
very difficult and complex problem. Minor alteration in
the normal anatomy can lead to significant dysfunction.
The thinness of the skin, the superficial location of the
tendons, the high ratio of tendinous bony and ligamentous
structures to fatty and muscle tissue make reconstruction
more difficult. The foot permits both rigid and flexible
ranges of motion that enables us to work. This motion is
highly complex and occurs in several planes. The human

Reconstruction of Bum Scar Contractures of Feet
551
foot supports the body when standing and provides a
smooth functional interface between body and ground
during gait. This depends on a complex interaction of
small bones, pain free motion of small joints and an
intact sensate soft tissue envelope (14-16).
III.
CLASSIFICATION OF BURN
SCAR CONTRACT URES
A.
Dorsal Burn Scar Contractures
Blood supply of the dorsum of the foot is mainly by the
dorsalis pedis artery. The nerve supply is from the super-
ficial peroneal nerve, which supplies the dorsum of the
foot, and the deep peroneal nerve, which supplies the
first web space. The sural nerve supplies the lateral
aspect of the foot (Fig. 38.1). The skin of the dorsum of
the foot is thin and loosely connected to the underlying
fascia. The tendons in this region are located superficially.
Bums of the dorsum of the foot can result in distortion of
the skin. The skin is very thin and offers less resistance to
contraction compared to the think skin of the sole. Dorsal
contractures result in tissue shortening, often with enough
force to cause hyperextension of toes and subluxation or
dislocation of the metatarsophalangeal joint. The metatar-
sal heads become prominent on the plantar surface
(Fig. 38.2). The long flexors of the toes result in flexion
at the interphalangeal joints. The accompanying shorten-
ing in the transverse axis often results in narrowing of
the forefoot with overriding of the toes. This type of
deformity occurs either due to the burn wound, which
healed spontaneously or from the previous grafted areas.
Figure 38.2
Burn scar contractures of the feet with significant
dorsal subluxation of the toes on the left.
Inversion contractures of the foot result from contract-
ing bands that extend from the leg to the foot on the medial
side pulling the foot into inversion. Eversion contractures
of the foot occurs when the contracting band from the leg
to the foot is on the lateral side pulling the foot into ever-
sion leading to callous formation and painful gait. This
results in an acquired talus deformity where the scar con-
tractures pull skin into dorsiflexion with eversion of the
foot and shortening of the calf muscles (Fig. 38.3).
Webbing between the toes is a result of contractures.
These dorsal web contractures can occur in burns of the
forefoot resulting in overriding the deviation of toes. This
is managed with release and skin grafting or Y-V advance-
ment flaps, Z-plasty or V-Y flaps. Skin grafts and local flaps
have proven to be satisfactory for reconstructing almost all
bum scars of the foot in children. Heimburger et al. (17)
Figure 38.1
Arterial anatomy of the dorsum of the foot. (Reprinted with permission from Williams PL, Warwick R, Dyson M,
Bannister L, eds. Gray’s Anatomy. 37th ed. New York: Churchill Livingstone, 1989.)

552
Functional and Aes thetic Recons truction of Burned Patients
Figure 38.3
(A) A 10-month-old infant with bums to the dorsal surfaces of both feet with eversion of both feet secondary to scar con-
tractures. (B) Close-up of left foot showing contracture and foot eversion. (C) Close-up of right foot showing eversion and fusion of outer
aspect of the dorsum of the foot to the lower leg. (D) Two-year follow-up after release of contractures and resurfacing with thick split-
thickness skin grafts. (E) Four-year follow-up after initial procedures. One and a half years after second release of both feet during growth
period.
have found that skeletal traction through the distal phalanx
of each digit may facilitate better graft take.
B.
Plantar Surface Burn Scar Contracture s
Blood supply of the plantar surface is by both the medial
and lateral plantar arteries. The lateral plantar artery is
larger than the medial plantar artery (Fig. 38.4). The
plantar arch is formed by the deep plantar branch of the
dorsalis pedis artery and the distal plantar artery. The
nerve supply of the plantar surface is by the plantar
nerves, which consists of medial calcaneal nerve, which
supplies the heel area, medial plantar, and lateral plantar
nerves. The skin on the plantar surface is very thick and
firmly held on to the underlying fascia by the fibrous
septa. The plantar fascia consists of strong fibrous layers
that are oriented in longitudinal, vertical, and transverse
direction. It extends from the calcaneal region to attach

Recons truction of Burn Scar Contractures of Feet
553
Figure 38.4
Blood supply to the plantar surface of the foot. (Reprinted with permission from Williams PL, Warwick R, Dyson M,
Bannister L, eds. Gray’s Anatomy. 37th ed. New York: Churchill Livingstone, 1989.)
to the plantar aspect of the proximal phalanges. The
weight-bearing plantar surface is a challenging area to
achieve soft tissue coverage. Preservation of its sensation
is important for maintaining a stable weight-bearing
surface. The most common type of bums affecting the
sole is electrical exit bum. Although, contact burns,
which occur, can produce significant injury, the other
types of burns are infrequent. This may be due to limited
exposure, the thick layer of the skin and/or protective
effect of the ground and the footwear (Fig. 38.5). Bums
to the plantar surface of the foot rarely lead to full thick-
ness injury. However, if full thickness injuries involve
the plantar fascia, the arch support is disrupted and we
now have a reconstructive challenge.
An important feature of the foot is the longitudinal and
transverse arch. Destruction of these arches occurs in
severe bum scar contractures that can cause a decrease
in the width and length of the foot. Definitive closure of
full-thickness plantar wounds as early as possible is essen-
tial to achieve full rehabilitation.
C.
J oint Deformity
Equina varus deformities occur when scar tissue following
bums results in flexion contractures at the tibiotarsal joint
with heel cord shortening. Later standing scar results in
capsular contractures and eventually joint deformities
causing subluxations and dislocations (17). The joint
assumes abnormal positions due to bum scars. The
changes in bone morphology includes ankle in equines pos-
ition with inversion in the hindfoot and equines varus of the
forefoot. Treatment of heel cord shortening is by tenolysis
of Achillis tendon, tendon lengthening, or tenotomy. The
established equinus deformity of the ankle is corrected by
calcaneal traction or Ilizarov apparatus. Equino varus
deformity can be prevented if ankles are maintained in
neutral position by using either static splints or skeletal
traction (18). Ulceration of the skin and pressure necrosis
are common complications following the use of splints.
Consequently, not only is positioning important but also
padding. Larson et al. (6) have found skeletal traction
uniquely useful in the surgical treatment of bum scars in
extremities because of the force of the contracting scar
and the fragility of the surrounding skin. The other
methods of correcting this deformity have been described
in detail by various authors using the Ilizarov (19). To
facilitate the use of this apparatus, the joint capsule is
released primarily and the soft tissue contracture is gradu-
ally released by using distraction devices. This also permits
elongation of the skin, the blood vessels, and the nerves.

554
Functional and Aes thetic Recons truction of Burned Patients
Figure 38.5
(A) Two-year-old child with dorsal scald burns. (B) Blistering also noted on planter surface. (C) Five days later, plantar
burn shows only superficial partial thickness injury. (D) Full weight-bearing without surgery within 2 months.

Recons truction of Burn Scar Contractures of Feet
555
Rocker bottom foot is seen in patients with bums
involving the dorsal and plantar surfaces resulting in
talus aligning with calcaneum as midfoot and forefoot
are pulled into dorsiflexion resulting in rocker bottom
foot. This is characterized by extensor tendon shortening,
dislocation and subluxation of phalanges and complete
reversal of the plantar arch. Early release and skin grafting,
transosseous pinning, and long-term pressure support can
minimize the deformity (20).
Acquired vertical talus deformity is due to the pull of
scar contractures with dorsiflexion and eversion of the
foot to the shortening of the calf muscles. Early correction
of the contractures either by multiple Z-plasties, skin
grafts or flaps, and lengthening of tendo calcaneus may
avoid such complications, Jackson et al. (5) pointed out
that there was an interactable tendency for the foot to be
drawn into eversion, inversion, and valgus positions by
the burn scar contractures. It was also found out that the
position of the scar contracture in most cases suggests
that the scarring is responsible for the deformity. Silk
and Wainwright (21) believed the condition to be due to
disparity of growth between the muscles and bones of
the leg and that if there was no undue soft tissue tension
they would grow normally. The problem, therefore,
seemed to be one of shortness of the musculotendinous
unit due to scar contracture. Patterson et al. (22) also con-
sidered that it was the tight soft tissue that produced the
bone and joint abnormalities.
IV. TREATMENT
A.
Nons urgical
When the contracture is minimal, either simple skin trac-
tion or Steinmann pins have been used for correction.
Although, this form of treatment alone, is not applicable
to most of the constractures seen in the bum patients.
However, skeletal traction in combination with surgical
releases has been useful. Serial wedging can be used in
conditions where the soft tissue release is limited by
either the tendons or muscles. This method allows the
tissues to gradually stretch the soft tissues before surgical
procedures are attempted (12).
B.
Surgical
Split-thickness skin grafts continue to be the primary
method of coverage in reconstruction of the dorsal foot
burns when the underlying tendons are not exposed. In
conditions where the tendons are exposed, if it is a small
area, then debridement is sufficient to allow for the
development of granulation tissue. Then the use of split-
thickness grafts will allow closure. One must bear in
mind the fact that skin grafts will not take on bare bone,
cartilage or tendon. Dorsal bums can result in extensive
tissue deficiency and require release and resurfacing with
skin grafts, both in the longitudinal and transverse plane.
Alison et al. (23) noted that when only the longitudinal
arch was released the overall recurrence rate was found
to be much higher than when release of both longitudinal
and transverse arches were performed. The release of both
arches also resulted in more natural appearing feet. A
transverse incision across the dorsum of the foot is per-
formed proximal to the fifth metatarsal joint. This maneu-
ver releases longitudinal arch. The transverse arch is
released by making parallel releases to the plane of the
metatarsals, usually in line with the web spaces. If syn-
dactyly is present, then the incisions are carried into the
web spaces. K-wire fixations may be necessary to assure
correct positioning of the metatarsophalangeal joints.
Postoperatively, elevation, and splints are continued until
graft take is insured. Ambulation is started with non-
weight-bearing, initially, and gradually progressed to
full weight bearing. Silicone conformers and pressure
garments are fitted and worn continuously until the skin
grafts mature (Fig. 38.6).
Severe contractures of the dorsum may require joint
capsule releases and/or Kirchner wire in order to maintain
position. These pins are placed through the distal phalanx
of each toe at the time of contracture release and grafting
and left in place for 4 -6 weeks. More severe contractures
affecting the bone and tendons can be corrected by the
Ilizarov external fixator, serial splinting, or casting.
Waymack et al. (10) have suggested early release of
contractures to prevent growth abnormalities. Postopera-
tive immobilization has proven to be responsible for
superior results. Recurrence rate of contraction has been
shown to be 11% in patients with immobilization when
compared to a 30% recurrence rate and graft loss in
patients with no immobilization postoperatively. This
study has shown that splinting is crucial in the postopera-
tive period. Dhanraj et al. (24) elevated the efficacy of
bilateral simultaneous surgical release of the burn scar
contractures, as compared to unilateral correction of
bum scar contractures of the feet. This study showed no
statistical difference in terms of mortality, recurrence of
contractures, the number of reconstructive procedures or
the length of hospital stay. Consequently, patients with
contractures of both feet should undergo simultaneous cor-
rection. Several authors have advocated early ambulation
in both the acute and reconstructive stages of care for
patients with burn to the feet (25-27). Plantar contractures
are rare. This is due to the fact that full-thickness burns to
the plantar surface of the feet are uncommon. However,
split thickness grafts have proven to be satisfactory, even
on the weight bearing portions of the foot, where the
loss is primarily skin with an intact subcutaneous tissue
(28). Harrison and Morgan noted that resurfacing the

556
Functional and Aesthetic Recons truction of Burned Patients
Figure 38.6
(A) A 5-year-old male with severe bum scar contractures of both feet. (B) Lateral view of right foot showing severe sub-
luxation at the metatarsophalangeal joint. (C) Lateral view of left foot. (D) Nine months after simultaneous bilateral release of the con-
tractures and resurfacing with skin grafts. (E/F) Right and left lateral postoperative views.
sole of the foot with skin grafts to be unsatisfactory, as
most patients avoided weight bearing on a resurfaced
area (29). The unique multidirectional fibrous septa of
the skin and subcutaneous tissue of the sole also reduces
flexibility. As a result, flaps are preferred rather than
grafts. Hidalgo and Shaw (30) give importance to preser-
vation of sensation for maintaining a stable weight
bearing surface. However, Kucan and Bash (31) found
that long-term follow-up of gait analysis of patients who
have undergone resurfacing of the weight-bearing area
of the foot with skin grafts or flaps had no significant
difference among the various treatment modalities. Lister
(28) recommended the use of skin grafts to provide sen-
sation to the reconstructed heel.
Reconstruction of the foot using local tissue is limited
by the available skin. However, local random pattern
flaps have been used for coverage of small defects.
Dorsal foot bums with exposed tendon and deeper struc-
tures require vascularized coverage using free tissue trans-
fer. Fasciocutaneous flaps are preferred over muscle flaps
because of their ability to properly contour. Alternatively,
a number of free tissue transfers have been described for
the closure of defects of the foot (32,33).
Plantar bum injuries pose a different challenge. Often
tissues from non-weight-bearing areas are used to transfer
tissue to weight-bearing areas, such as the instep flap. This
flap is ideal when the area to be covered is small (34). The
specialized characteristic of the skin in combination with
relatively poor circulation of the skin in this area limits
availability and mobility of nearby tissue (Fig. 38.7).
Although many types of flaps have been described, they
all lack the normal plantar skin with its unique fibrous
septa (35,36). Heel defects, although rare, can be
covered by using medial plantar flaps based on medial
plantar artery. These flaps can be rotated to cover heel
defects (37). Local subfascial flaps, muscle flaps (i.e.,
the abductor hallucis, flexor digitorum brevis and abductor
digiti minimi muscles) can also be used to cover small
heel defects (38,39). The ideal reconstruction for injuries
on the plantar surface should be aimed at providing
protective and sensate cover (40).
When the injury prevents the use of local flaps, regional
or distant flaps can be used. Random pattern flaps like de-
epithelized turn over flap advocated by Ramakrishnan et al.
(41) are useful. De-epdithelized turn over flap provide a
single flap cover in bums with full thickness defects.
The advantage is that it can be raised either superiorly or
inferiorly based on the site. The defect is debrided into a
rectangular shape. The width of the defect must be equal
to the base of the flap with twice the length. The hinge
should be located about one-third of the distance from
the edge of the defect. When this flap is raised along
with the deep fascia the increased vascular supply provides
a better bed for skin grafts (Fig. 38.8). Several fasciocuta-
neous flaps have been described for coverage of foot
defects. The lateral supramalleolar flap, the sural artery
flap, the lateral calcaneal artery flap, as well as the
reverse dorsalis pedis flap and reverse first dorsal metatar-
sal artery flap have been described (42). Based on the three
major arteries, the peroneal, anterior tibial, and the pos-
terior tibial artery reverse flow flaps are available for
soft tissue defects of the foot. The advantage of using

Recons truction of Burn Scar Contractures of Feet
557
Figure 38.7
(A) A 12-year-old male referred because of tenderness over bony prominence on plantar surface of foot. (B) Delayed
bipedicled skin flap from instep used to resurface the defect with follow-up 5 year later. Patient is completely asymptomatic with full
weight-bearing. (C) Lateral view.
these flaps is that it is a safe single procedure and does not
require immobilization on a long-term basis (43-46).
Muscle flaps, like distally based abductor digiti minimi
muscle flap and the extensor digitorum brevis are most
useful for the Achilles region and is based on the dorsalis
pedis artery pedicle (47,48). One must keep in mind that
flaps never form a normal sole.
Cross-leg flaps are rapidly fading from use. When bum
injury prevented the use of regional flaps, then cross-leg
flaps have been used in past. Although rarely used in the
modem era, they certainly formed an important part of
the armanentarium for recconstructive surgeons (49-51).
Free flaps, when all other options are not possible, micro-
surgical flaps definitely have a place in the reconstruction
of the complex foot injuries. The flexibility of design, the
transfer of composite tissues and the increased vascularity
make it a useful alternative for reconstructing the bum
foot. Various free flaps have been used for the foot depend-
ing on the type of injury and the tissues that need to be
replaced. The more commonly used fasciocutanteous
flaps are radial forearm flap, and the scapular flap (52)
(Fig. 38.9). The commonly used muscle flaps are rectus
abdominis, latissimus dorsi muscle, serratus anterior, and
gracilis muscle. However, these tissues tend to be bulky
and may prevent the wearing of normal shoes. Many
authors prefer the use of microvascular free flaps for
plantar surface (53-58). The advances in microsurgical
technique has made it possible for reconstruction of exten-
sive plantar defects which can provide protective sensation
to the weight bearing surfaces of the foot by using sensory
free flaps. Free flaps offer great flexibility of design and
ability to obliterate deep spaces. Scapular flaps and delto-
pectoral flaps provide good support, especially when
donor site deformity is inconspicuous. Chang et al.
(59,60) have demonstrated sensory reinnervation in micro-
surgical reconstruction of the heel.
C.
Amputation
Appropriate treatment of extensive foot defects is complex.
Despite careful treatment, some patients inevitably require
amputation. In determining the level of amputation, one
must consider the optimal site for prosthetic fitting. The
primary goal should be to salvage as much of the foot as
possible to minimize functional loss. If the injury is
severe resulting in either gangrene or life-threatening
infection, then amputation may be the only choice (61).
V.
PHYSIOTHERAPY AMD SPLINTING
In the management of foot bums, proper positioning is a
critical step in the prevention of joint deformities. The det-
rimental effects of poor positioning and contracture can
result in multiple deformities. Following reconstruction
with skin grafts, there is an urgent need for immediate
and aggressive physiotherapy programs (62). Ambulation
is resumed 1 week postoperatively after application of
Ace wraps to prevent shearing of the skin grafts. Follow-
ing discharge from the hospital, these patients are
advised of graft care and regular use of splints to prevent
further contractures.

558
Functional and Aesthetic Recons truction of Burned Patients
Figure 38.8
(A) A young patient with open wound in heal region. (B) Inferiorly based adipofascial flap raised. (C) Flap turned over to
cover the defect. (D) Split-thickness skin graft placed on top of the turnover flap.

Recons truction of Burn Scar Contractures of Feet
559
Figure 38.9
(A) A 15-year-old female sustained burns as an infant, now complaining of tenderness of left foot scar, which has frequent
ulcerations. (B) Dorsum of the flat plantar surface and ankle resurfaced with a parascapular flap. (C) Frontal view of healed flap. (D)
Comfortable wearing of shoes.
Initially, elasitc bandage support is provided for all
patients with grafts to prevent increased hydrostatic
pressure and graft loss while ambulating. Eventually, all
patients are provided with custom-made pressure gar-
ments, silicone inserts, footplates, and orthopedic shoes
(63). This shoe protects and supports the foot and relieves
painful areas from abnormal pressure. Various shoe cor-
rectors like footpads, metatarsal bars, and foot and arch
supports are often used in combination for comfortable
support. Rayatt et al. (64) have used custom-made ther-
moplastic boot splints for the treatment of bum contrac-
tures of the feet in children following surgical release.
Application of the Unna boot by Baiba et al. and Harnar
et al. (65) has resulted in rapid functional recovery. The
use of splints for 6-9 months is helpful in the preventation
of further contractures. The various types of splinting are
thermoplastic, dynamic, silicone boots, orthopedic shoes,
foot plates, and CASH shoes to maintain a neutral position
and high top boots with supporting metatarsal bars. They
are utilized to maintain the surgically corrected position.
VI.
PITFALLS
Obviously, bums of the foot increase morbidity. Despite
the best care, the magnitude of the original burn may
warrant further operations, or even amputations. Pro-
longed weight bearing with abnormal loading on the

560
Functional and Aes thetic Recons truction of Burned Patients
joints can result in subluxation and joint dislocation. The
pitfalls of surgical intervention include graft loss, joint
pain, and incomplete correction of the initial problem.
Unsuccessful surgery often delays definitive treatment. It
not only reduces the physical activity, but many also
experience foot pain, hyperkeratosis and ulcerations
(66). Over enthusiastic attempts at full correction may
result in damage to the neurovascular bundels. Loss of
flaps may increase the size of the defect causing more
complex problems. Recontractures in children are
common. Inattentive care in postoperative splinting can
lead to pressure sores and joint stiffness.
VII.
NURSING ISSUES
Skin grafts to the lower limb require special nursing care.
It is imperative to make sure that the limb is elevated post-
operatively to reduce edema and subsequent graft failure.
Proper positioning of the splint is checked to avoid
pressure sores. After graft take, dressing changes and the
use of silicone conformers and splints must be taught
prior to discharge. The use of metatarsal bars at night to
keep the feet in plantar flexion is helpful in the prevention
of subsequent contractures. Ultimately, however, the type
of coverage used in the correction of dorsal contractures,
that is, skin grafts vs. flaps may be the ultimate determi-
nant of success.
VIII.
REHABILITATION ISSUES
Survival following extensive burn injury is no longer the
only goal of successful treatment. Advances in the man-
agement of acute bums have resulted in survival of
patients with 90% TBS A. This has resulted in new chal-
lenges for the rehabilitation team in order to achieve
maximum functional recovery. The active planning of
rehabilitation begins with the acute management and con-
tinues as long as satisfactory improvement is achieved
(67,68). However, attention should be given not only to
the physical well-being of the patient, but also focus on
both psychological and social needs.
Physiotherapists and occupational therapists continue
to work with the range of motion and muscle tone by pro-
viding daily exercise. With burns, there is a need for
immediate and aggressive initiation of a rehabilitation
program. The wound itself, as well as compliance can
affect the outcome of an aggressive physical therapy
program. Current means for the prevention of additional
deformities are positioning with splints, exercise to main-
tain range of joint motion and the use of compression
garments.
IX. LONG-TERM GOALS
Although foot bums form a small components of the
TBS A, they require a high ranking on the priority list.
Bums of the foot can result in disabling sequelae, which
can produce chronic, lifelong problems. In the reconstruc-
tion of these patients, all surgical efforts should be made to
overcome severe deformities by restoring the bony foot
anatomy to normal. Second, providing sensate cover
enables the patient to function normally. Third, care is
taken to avoid recurrent ulceration by providing a stable
well-padded cover. The unique architecture of the sole
skin and subcutaneous tissue, which is adapted for
weight bearing, cannot be reproduced. The transferred
tissue does not have the ability to resist the shearing
force produced during normal ambulation. Studies have
been shown that irrespective of proper padding, ulcers
can still occur due to bony abnormalities of poorly
fitting footwear. Yet, even with out best efforts, patients
alter their gait and weight-bearing load on reconstructed
areas resulting in an abnormal gait.
X.
CONCLUSION
The ankle and the foot are specialized structures for main-
taining stability. In order to have proper function, these
structures must be stable and capable of bearing weight.
The need for late reconstruction depends in large part on
the severity of injury and the quality of acute care. Priority
should be given to bums of the foot, as early coverage will
allow earlier ambulation and rehabilitation (69). Large soft
tissue defects present a major reconstructive problem. Skin
loss without exposure of the deeper structure can always
be covered with skin grafts. However, deeper injuries
exposing tendons and bones are best managed with vascu-
larized flaps.
Small defects can usually be closed by local flaps.
Larger defects can be problematic. Micro vascular free
tissue transfer has simplified this problem. The advantage
of muscle flap lies in its vascularity and its ability to with-
stand infection. However, fasciocutaneous flaps conform
to the foot better, making it more acceptable to the recon-
structive surgeon. Bony prominences, inadequate soft
tissue morbidity, and the need for specilized tissue, elim-
inate many of the options available. Primary closure may
not be possible and skin graft may also not be possible
due to exposed bone. This leaves the only option of
distant flaps for coverage. Postoperative splinting has
been shown to be effective in decreasing recurrence in
foot contractures.
Burns to the feet and subsequent contractures continue to
be a long-term problem. The severity and extent of the
injury along with the nature of the acute care given, dictates

Recons truction of Burn Scar Contractures of Feet
561
the need for reconstruction at a later date. Priority treatment
of the foot allows earlier ambulation and rehabilitation.
However, if functional impairment progresses appropriate
release of contractures both in the longitudinal and trans-
verse arches and resurfacing with grafts are appropriate.
More complex wounds require the use of flaps for closure.
The postoperative rehabilitation program is crucial for a suc-
cessful surgical outcome (70). Consequently, patient com-
pliance is the key to maximizing our outcomes and
preventing delayed complications such as recurrence.
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39
The Role of External Fixators in the Correction of the Equinovarus
Deformities in Burn Patients
J ASON H. CALHOUN
University of Missouri-Colum bia, Colum bia, Missouri, USA
KELLY D. CARMICHAEL
University of Texas Medical Branch, Galveston, Texas, USA
DEBRA BENJ AMIN
Shriners Hospital for Children, Galveston, Texas, USA
Bums of the feet are classified as a major burn injury by
the American Bum Association and the American
College of Surgeons and should be referred to burn
centers for specialized care and treatment (1). The feet,
farthest away from the heart and the oxygenated blood
from the lungs, are at risk of slower healing and a longer
period for scar maturation. The feet are also at risk for
increased swelling and inflammation as the normal tissue
support surrounding the lymphatics in the area has
changed with the burn injury and thus may be less success-
ful working against gravity.
Burn scars have long been, and continue to be, a
disabling complication of bum injury. They not only
cause cosmetic disfigurement, but also adversely affect
functional outcome. The burn wound scar, or muscle and
bone loss from the initial injury, can lead to muscle short-
ening and bone structure abnormalities resulting in foot
deformities. Burn scars of the feet can lead to deformities
that compromise ambulation and prevent the indepen-
dence of mobility.
II.
ACUTE MANAGEMENT OF FOOT BURNS
When diagnosing the depth of bum involving the feet, the
characteristics will be similar to those of bum injuries on
other areas of the body. The feet do, however, have a
unique quality of skin coverage. The skin on the
563
I.
Introduction
563
G. Post Surgery Care Following
II. Acute Management of Foot Bums
563
Placement of External Fixator
567
A.
Scarring and Deformities
564
P°st-Hizarov Care
568
B.
Physical Examination
565
^ Follow-up Results
569
C.
Treatment Options
565
J* Dizarov Complications
570
D.
Ilizarov External Fixator
566
Amputation
570
E.
Ilizarov Indications and Treatment
567
HI- Summary
570
F.
Operative Technique
567
References
570

564
Functional and Aes thetic Recons truction of Burned Patients
plantar side of the foot normally has a thick dermis and epi-
dermis, which often protects this portion of the foot from a
deeper injury. In contrast, the dorsal foot tends to have less
subcutaneous tissue and may result in deeper burn injuries
that may require grafting. If grafting of the dorsal foot is
required, it should be done as early as possible to decrease
a local inflammatory response and reduce scarring and con-
tracture formation. If the foot receives only a superficial
bum injury, it may be treated on an outpatient basis. The
patient should be instmcted to keep his feet elevated
above the heart to decrease edema and be educated to
watch for signs of infection and cellulitus. The patient
should also be evaluated for risks of circulation problems
and level of compliance for elevating his feet. If the phys-
ician has any concerns, the patient should be hospitalized
for 24-72 h for observation and treatment.
Passive and active range of motion exercises should
begin immediately with superficial burn injuries, and
within 5-7 days after grafting is performed. Early splint-
ing of the burned foot is necessary to maintain proper pos-
ition. Foot bums that involve the ankle area are prone to
develop an inverted plantar flexion. This is a common
complication seen with foot and ankle bums. Proper posi-
tioning can be accomplished with footboards or foot and
lower leg splints that place the foot at a 90° angle to the
leg. With ambulation, it is important to provide the foot
and leg with proper support. Ace wraps or support hose
are helpful during early recovery to provide support to
the ankle, to provide pressure to the bum scars, and to
improve circulation to an area distant from the heart at
risk of venous stasis. After edema and swelling resolve,
the patient should be fitted with snug supportive shoes.
Silicone inserts may be needed to provide pressure to
specific areas of the foot. Even after ambulation has
begun, it is important to maintain foot position with
splints when the patient is at rest or sleeping.
A.
Scarring and Deformities
The burned foot is an area of the body at greatest risk of
scarring with major deformities. Because of the shape
and various curvatures in the foot, it is difficult to maintain
even pressure for scar control. The requirements of move-
ment for ambulation continually force flexion of the toes
upward without an equal force of the toes toward exten-
sion. As scar forms over the dorsum of the foot, scar con-
traction occurs, which pulls the toes up even more. Bums
around the back of the ankle can lead to scarring and con-
tractures of the skin causing shortening of the Achilles
tendon which produces a plantar flexion of the foot. This
scar tissue can also bind the tendons and even trap bones
and joints to cause major deformities. These deformities
can lead to significant pain and mobility difficulties for
the patient.
Bone deformities of the burned foot have been classi-
fied as simple and complex. This is based on associated
deformities, musculoskeletal function, and the difficulty
associated with correction. Simple deformities are uni-
directional in nature and have relatively normal bone
and soft tissue. They include equinus, cavus, and toe dislo-
cations. These are fairly easy to correct and maintain.
Complex deformities include varus or valgus angulations,
the rocker bottom foot, bone abnormalities, and contrac-
tures due to muscle loss. These deformities are more
difficult to correct and maintain (2).
Toe deformities and dislocations, which are the gross
hyperextension and subluxation of the toes, are the most
common (3). Simple dorsal toe dislocation in burned
patients is due to dorsal soft tissue contracture. Although
functional mobility is usually adequate, toe contractures
often cause problems with shoe fit and chronic friction
ulcerations. More complex toe deformities include hallux
varus and valgus, or metatarsal and phalangeal bone
abnormalities.
A rocker bottom foot is a deformity caused by a dorsal
bum scar contracture or overcorrection of the forefoot for
an equines deformity. Rocker bottom is classified as severe
when the metatarsal-calcaneal angle is >200°.
A cavus deformity is a contraction of the plantar portion
of the foot. It can also occur with an equinus deformity. A
cavus is classified as severe when the metatarsal-
calcaneal angle is <120°.
Equines deformities, which are a shortening of the
Achilles tendon, can be caused by postbum contracture,
anterior muscle loss, improper postburn splinting, and
tibial growth into a rigid scar. If not too severe, this con-
tracture can often be corrected with the release of the
Achilles tendon. Severe equinus (>40°) cannot be cor-
rected with a soft tissue release because of insufficient
soft tissue posterior to the ankle. Simple equinovarus
involves a single deformity that is in one plane and in
one direction. Complex equinovarus, on the other hand,
involves more than one type of deformity. Examples of
complex equinus contracture cases are equinovarus (an
additional medial contraction of the foot) without active
dorsiflexors or caves and equinovarus with bone deform-
ities or a nonfunctional ankle joint. Another complex
equinus is the equinovulgus (an additional lateral contrac-
ture of the foot) (2).
The equinovarus foot deformity makes walking difficult
or impossible and can cause ulcers, infections, and other
deformities. Prevention and treatment of the equinovarus
foot deformity is challenging, particularly in the patient
with multiple injuries and systemic problems associated
with burns. The equinovarus deformity is prevented
though correct positioning of the foot during the acute
phase of bum management. Splints, calcaneal traction
pins, and physical therapy are ways to control foot position.

Correction of the Equinovarus Deformities in Burn Patients
565
All of these methods are used to keep the ankle in the 90°
neutral position while preventing inversion. Burn injury,
compartment syndrome of the leg and foot, and brain
injury can cause loss of muscle control. The peroneals
and anterior tibial and toe extensor muscles are frequently
affected, leading to weakness in eversion and dorsiflexion.
The tricep surae is often spared in peripheral injuries, as its
nerves are more proximal and deep posterior. The tricep
surae is the most powerful muscle acting across the
ankle, so plantar flexion deformity can occur quickly
when other muscle groups are weakened and the patient
can actively plantar flex. When ambulation begins after
an injury, patients often plantar flex or “toe walk,” and
the plantar flexed position becomes more established,
rigid, and extensive. Improper or inadequate bracing
during the period of recovery allows for plantar flexion
and inversion, thus worsening the equinovarus deformity.
B.
Phys ical Examination
The physical examination of the equinovarus deformity
includes an assessment of the position of the ankle, hind-
foot, and forefoot. Disability due to foot and ankle position
is described in the “Guides to the Evaluation of Permanent
Impairment” (4). Impairment due to equinus deformities is
graded as follows: mild plantar flexion (10°-19°) is con-
sidered 7% whole-person impairment, moderate (20°-
29°) is 15%, and severe plantar flexion (>30°) is 21%
(Table 39.1). An ankle in fixed plantar flexion will cause
difficulty with ambulation. Consequences of ankle
equinus include walking with the foot in external rotation,
a “vaulting” type gait as the patient jumps over the plantar
flexed foot, toe walking, and hyperextension of the knee.
The knee is affected by ankle equinus because of the
“plantar flexion-knee extension” couple. In normal gait/
strength, plantar flexion of the ankle is coupled to knee
extension during the gait cycle. Increased plantar flexion
or plantar flexion strength will cause a knee hyperexten-
sion gait. Weak or insufficient plantar flexion is associated
with a crouched knee gait.
Impairment can also include hindfoot varus, which can
be graded as mild (10°-19°), moderate (20°-29°), or
Table 39.1
Ankle Impairment Due to Ankylosis in Plantar
Flexion or Dorsiflexion
Position
Whole person (lower extremity)
[foot] impairment (%)
>20° dorsiflexion
15 (37) [53]
10°-19° dorsiflexion
7 (17)[24]
10°-19° plantar flexion
7(17) [24]
20°-29° plantar flexion
15 (37) [53]
> 30° plantar flexion
21 (52) [74]
Source: From the American Medical Association (1)
severe (>30°). Other forms of impairment can be noted
in the hindfoot, calcaneus, and midfoot (internal rotation),
forefoot, nerves, muscles, and soft tissue. With all these
potential problems, impairment can be up to 50% in a
burned lower extremity with an equinovarus deformity;
the majority (38%) is due to the equinovarus.
Gait abnormalities should be noted during the physical
examination. Other joint abnormalities to quantify are the
degree of plantar flexion and varus. Deformities of the cal-
caneus, midfoot, and forefoot should be noted. Weight-
bearing radiographs of the ankle and foot with the knee
straight should be taken to aid the evaluation of bone or
joint abnormalities. Scarring, with hypertrophy or break-
down, and nerve and muscle function should be noted.
Nerve and muscle dysfunction may be the cause of the
deformity and may also affect any treatments. Weakness
or absence of the peroneal (longus, brevis) and anterior
tibial muscles (tibialis anticus, extensor digitorum
longus, and extensor hallucis longus) can contribute to
the varus. The gastro-soleus muscle is frequently normal,
which leads to increased plantar flexion. Functioning toe
flexors can also contribute to equinus as well as claw
toe. A functioning posterior tibial muscle will contribute
to both plantar flexion and varus.
C.
Treatm ent Options
The treatment goal is to prevent contractures with physical
therapy and splinting. Mild and moderate contractures
may be treated with aggressive physical therapy, splinting
and/or casting, or incisional releases of the soft tissue or
osteotomies. Severe contractures have been treated with
amputations and Ilizarov external fixators.
Equinovarus treatment depends on the severity of the
bum and the severity of the deformity. In the acute
period equinovams deformity responds to physical
therapy. Skeletal traction through the calcaneus can also
be helpful in the patient confined to the bed (Fig. 39.1).
In the chronic phase the bum scar is more rigid and is
not as responsive to physical therapy and traction.
The severity of the bum will influence treatment. Less
severe bums isolated to the lower leg can be treated
more aggressively as the first priority. However, more
extensive bums are limb- or life-threatening and, appropri-
ately, attention to the lower extremities becomes secon-
dary to keeping the patient or extremity alive. As with
impairment rating, it is helpful to “stage” an equinovarus
deformity as mild (<15°), moderate (<30°), or severe
(>30°). The equinovarus can be further identified as
either simple or complex as described earlier. Complex
deformities treated with traditional surgeries often
require staged corrective surgery. One deformity may be
addressed in the first surgery and another deformity in a
subsequent surgery. Releases are often combined with

566
Functional and Aes thetic Recons truction of Burned Patients
subsequent fusions to maintain or further correct
deformities.
Mild equinus or equinovarus with functional nerves,
muscles, bones, and joints can frequently be corrected
with serial casts to the functional position of neutral. Per-
cutaneous Achilles tendon releases (5,6) can be added to
casting to correct moderate deformities. Severe equinus or
equinovarus deformities with functional tissue can be cor-
rected with the Ilizarov circular external fixator (7) or
staged traditional open surgeries. However, in severe
deformities, traditional surgeries are often complicated
by soft tissue tension and wound-healing problems. The
gradual correction obtained by the Ilizarov method was
designed to minimize these complications. Complex
equinus or equinovarus deformities will require the com-
plicating problem to be addressed after correction has
been obtained. With functional nerves and muscles,
especially the anterior tibial muscle, the deformity will
recur unless very aggressive physical therapy and
splints, tendon transfers and releases, or joint arthromeres
are used after correction. With bone or joint abnormal-
ities, then, osteotomies and arthrodeses may be needed
to achieve and maintain correction. Other deformities
such as cavus, calcaneal equines, forefoot and midfoot
inversion, and pes planus and rocker bottom may be
seen as a simple or complicating deformity with
equinovarus.
Contraindications to correction of equinovarus include
poor blood supply, chronic irreversible edema, and insen-
sitivity. These contraindications, if severe enough, may
indicate amputation of the extremity or, at least,
observation, therapy, splints, and special prosthetics for
function.
D.
Ilizarov External Fixator
Professor Gavriil Ilizarov developed the Ilizarov external
fixation system. It allows precise control of bone segments,
including angulation, rotation, translation, lengthening,
and shortening. The system encourages tissue regeneration
through the principles of distraction histogenesis of bone
and soft tissues. The Ilizarov fixator aids in the correction
of bone and soft tissue deformities and defects. The Ili-
zarov and its techniques for use preserve limb function
when properly applied. The Ilizarov external fixator is a
circular frame consisting of (1) implant-grade stainless
steel wires that attach to rings with bolts, buckles, and/or
nuts; (2) rods that interconnect the rings; and (3) connec-
tion plates, supports, posts, hinges, washers, sockets, and
bushings that complete the assembly of the fixator.
Special wrenches and wire tensioners are required for
proper assembly.
In the 1960s the Ilizarov was used for the treatment of
clubfoot and other congenital foot deformities. The Ili-
zarov was first used in 1988, at the Galveston Shriners
Burn Hospital, for the treatment of bone deformities of
the foot from severe scar contractures. For treatment of
foot deformities caused by burn scar, the Ilizarov frame
usually has two tibial-fibular rings, one calcaneal half-
ring, and one metatarsal half-ring. The frames are attached
to the bone with 1.5 mm pins. There are also a set of
Figure 39.1
Calcan eal traction pins used to prevent equ ines.

Correction of the Equinovarus Deformities in Burn Patients
567
distraction rods connecting the rings together to manip-
ulate the position of the foot over time.
E.
Ilizarov Indications and Treatment
The Ilizarov fixator can be used for toe dislocations and also
with hallux varus and valgus deformities. This can be
accomplished with phalangeal pins connecting to half-
rings or outriggers. The bones will be gradually pulled
into place as the scarred skin is stretched and lengthened.
For the cavus deformity in the midfoot area, the Ilizarov
provides correction by distracting the calcaneus and meta-
tarsals in a half-ring frame. The rocker bottom foot can be
treated with the Ilizarov with a frame similar to the cavus
frame except that a midfoot half-ring frame is pulled dor-
sally to re-create the arch. A more complex rocker bottom
foot may need additional frame pieces and wires (2).
A simple equinus deformity can be treated with an
Ilizarov frame consisting of two tibial-fibular rings, one
calcaneal half-ring and one metatarsal half-ring. A complex
equinus deformity involving a varus or valgus contracture
requires a more complex frame to accommodate the
additional twisting of the foot. Risks of complications
also are increased in this more complex treatment.
F.
Operative Technique
The flexible frame can be used for simple, unidirectional
deformities and when bony deformities are not present.
This frame consists of a tibial ring, one calcaneal half-
ring, and one metatarsal half-ring as mentioned earlier
[Fig. 39.2(A) and (B)]. The tibial ring is positioned
approximately at the junction of the middle and distal
third of the leg. It is secured with a single posterolateral
to anteromedial wire and three anterior half-pins attached
with the Rancho cube system (hybrid technique). The
remaining half-rings are connected to bone with 1.5 or
1.8 mm wires (for children and adults, respectively) that
are tensioned to 90 kg of force on the half-rings. The cal-
caneal wire is directed from the medial to lateral side to
avoid the medial neurovascular bundle. The wire is
located relatively proximally and posteriorly in the calca-
neus to prevent wire cutout and increase its biomechanical
advantage. The metatarsal pin is directed medial to lateral
from the first metatarsal to the fifth metatarsal. Only the
first and fifth metatarsals are pinned so that a synostosis
does not develop between adjacent metatarsals. Half-
rings are connected to the calcaneal and metatarsal
wires. The calcaneus half-ring is connected to the tibial
ring with threaded distraction rods, and the metatarsal
half-ring is connected with threaded compression rods.
Calcaneus distraction requires only proximal hinges
without distal hinges to allow posterior translation of the
calcaneus pin as the calcaneus moves plantarly. Metatarsal
dorsiflexion requires hinges on the metatarsal ring and a
rotating post at the tibial ring to allow the metatarsal pin
to translate anteriorly as the deformity is corrected. The
ankle joint must be distracted before other deformity cor-
rection is possible. Distraction is performed at the time of
frame placement. In a simple equinus correction, the ankle
should be distracted 2-5 mm compared with preoperative
radiographs. This limits ankle-joint cartilage compression
and midfoot dorsiflexion deformity (rocker bottom
deformity). Distraction of the hindfoot must be done in a
posteriorly inclined direction. If distraction is performed
in a purely axial direction, parallel to the tibia, the talus
tends to sublux anteriorly (9).
Depending on the cause of the deformity, tendon trans-
fers or joint fusions may be needed to prevent recurrence.
Two technical points of frame application deserve special
mention:
1.
This unconstrained technique, in which the correc-
tion is done around the natural axis of rotation of the joints
and soft tissue hinges (10), is more forgiving than a
constrained technique, in which correction is through a
precisely placed pair of hinges along the defined anatomic
axis of the joint. The two keys to the use of an unconstrained
technique are that distraction must be applied to the ankle
joint before any attempted correction and that posterior
hinges are placed proximally on the tibial ring and distally
on the metatarsal ring to allow translational movement.
2.
Frames for the correction of a simple equinus con-
tracture require much less rigidity than those for bony
instability. It has been the authors’ experience that
frames classically described as equinus frames are also
more rigid than is required. A single tibial ring with a
single wire and three half-pins (hybrid technique) has
proven to be more than adequate proximal fixation. The
use of a footplate or connecting bars between the calcaneal
and metatarsal half-rings has not been needed for simple
equinus correction, but can be added for cavus and
midfoot deformities.
G.
Pos t Surgery Care Following Placement
of External Fixator
Immediately following surgery, the foot or feet with the
Ilizarov(s) should be kept elevated above the level of the
heart to reduce swelling and promote circulation. Appro-
priate pain control should be used for the first few days fol-
lowing surgery, and then Tylenol should be adequate
during the weeks of treatment. Pin sites should be
cleaned with betadine four times a day for 1 week or
until pin sites are dry. After that, pin sites may be
cleaned daily with betadine soaked Q-tips. If sites
become infected during treatment, the wound should be
cultured, and appropriate topical and oral antibiotics
should be administered.

568
Functional and Aes thetic Reconstruction of Burned Patients
Figure 39.2
(A) Galveston frame for equinus correction. Tibial ring is secure with one wire from the fibula to the tibia. The calcaneal
wire and half-ring allow distraction of the calcaneus and ankle joint. The metatarsal and half-ring allow for correction of the equinus.
(B) Clinical photograph of the frame. [Adapted from Calhoun et al. (2), used with permission from Elsevier, 1998 (4).]
Postoperatively, deformity correction is started as soon
as the patient can tolerate it comfortably, which is usually
in 1- 3 days. The Ilizarov fixator will begin its extension to
stretch the foot into position. The calcaneus is pushed dis-
tally and the metatarsals are pulled proximally at a rate of
1-3 mm/day. With a wrench the screws are loosened and/
or tightened as appropriate every 4 -6 h, ~ | - | m m
each time. Because the forefoot lever arm (metatarsal
pin) is further from the axis of rotation (ankle) than the
posterior lever arm (calcaneal pin), a difference in
angular correction occurs if all telescoping rods are dis-
tracted and compressed at the same rate. Theoretically, it
is possible to compensate for this tendency by increasing
the rate of dorsiflexion of the metatarsal ring in relation
to the distraction of the calcaneal ring. In practice,
however, doing so has been unnecessary. The distraction
of the calcaneus is the primary driver of correction and
the dorsiflexion of the metatarsals is of secondary
importance.
Following surgery the patient may begin ambulating as
tolerated with crutches or a walker. This process of stretch-
ing and repositioning the foot with the Ilizarov can take
several weeks. Postoperative radiographs taken at 1, 2, 4,
and 6 weeks are important; they are used to follow deform-
ity correction and to ensure that the ankle remains dis-
tracted
2-5 mm
without
any
subluxation.
After
correcting between 5° and 10° of ankle dorsiflexion, the
frame is left in place for 2 -6 weeks, depending on the
rigidity of the soft tissue.
H.
Pos t-llizarov Care
Following successful treatment it is imperative to maintain
the newly obtained position of the foot. This can be done
after frame removal with a short leg-walking cast, which is
typically applied for 6 weeks. Alternatively, an ankle-foot
orthosis (AFO) can be constructed with 10° of built-in dor-
siflexion that is removed only for range of motion exer-
cises. After cast removal, splints should be made to
maintain position and should be worn while at rest for
several months after the Ilizarov has been removed. The
splints may need to be revised over time with continued
wear and with the child’s growth as the leg will grow
longer, but the scar tissue may stay the same size,
leading to a new equinus. Physical therapy is also extre-
mely important to continue to stretch the skin and scar,

Correction of the Equinovarus Deformities in Burn Patients
569
to develop strength in the muscles of the foot and ankle,
and to maintain range of motion. It is important to note
that additional surgeries may be needed, especially in chil-
dren as they continue to grow, to maintain proper position
or to prevent reoccurrence.
I.
Follow-up Res ults
A follow-up was performed on all patients who had
received treatment with an Ilizarov external fixator.
Twenty-seven children had been treated with the Ilizarov
for bum scar contractures and bony deformities of the
foot, and 36 Ilizarovs were used. Seventy-five percent of
these children had an equinus element to their foot deform-
ity. The mean age at the time of Ilizarov treatment was 10
years, with age ranges between 2 and 18 years. The
average length of time the Ilizarov was used for treatment
was 10.5 weeks. Follow-up was documented on these
patients for an average of 3.6 years. During the 10-year
period that Ilizarov treatment was reviewed, nine of the
patients that had received Ilizarovs needed surgical revi-
sions, and four of the Ilizarovs developed pin-site
infections.
Unfortunately, four Ilizarovs had ended treatment pre-
maturely. Two of the Ilizarovs, the physician removed
early: two due to infection, and one because the parent
requested to have it removed early. Two casts, which are
used after the Ilizarov to maintain position, were
removed early by the patient at home. One of the early
cast removal patients was the same as an early Ilizarov
removal patient. Twenty-three or 68% of the feet treated
with Ilizarovs had no complications or unplanned occur-
rences during treatment (11). An example of the Ilizarov
treatment course is shown in Fig. 39.3(A-F).
Of the 36 feet treated with Ilizarov external fixators, 56%
of the patients had satisfactory results as measured by a gait
within normal limits and a deformity of <25° from neutral.
Thirty-nine percent of the applications ended in a poor
Figure 39.3
(A) Eight-year-old patient before-Ilizarov treatment, demonstrating, severe shortening of the Achilles tendon and equinus
deformity with dorsal subluxation of toes. (B and C) Anterior and posterior view of both feet before Ilizarov treatment. (D) Bilateral
Ilizarov treatment for correction of foot deformities. (E and G) Posterior and lateral view of feet following Ilizarov lengthening of
Achilles tendon. Mild dorsal subluxation of toes still requires attention. (Photos courtesy of Jason Calhoun, MD.)

570
Functional and Aes thetic Recons truction of Burned Patients
result, as measured by a return of the original deformity or a
deviation of >25° from neutral. Of this group of patients,
one required a below-the-knee amputation. Five have had
repeated applications. Three of these now have satisfactory
results, and one with a bilateral application remained in the
poor results group. Three of the patients with poor results
have requested no further surgery at this time. This is not
necessarily an uncommon request of children with major
burn injuries who have gone through years of reconstruc-
tive procedures. Three patients with single Ilizarov appli-
cations did not return for follow-up.
All patients treated with the Ilizarov had successful
results immediately following the removal of the fixator.
It was not, however, expected that perfect position
would be maintained. Children, especially the very
young, have many years to grow, and burn scars do not
always stretch as children grow.
Contractures with growth are expected in children, and
a reoccurrence of the deformity from foot and leg burn
scars is expected. This scenario is thoroughly explained
to the child and their families. They are also told that
because of growth and future scarring, the Ilizarov may
need to be reapplied at a later date.
J .
Ilizarov Complications
Complications of the Ilizarov during the treatment phase
can include pain, pin-site infections, nerve damage, circu-
latory damage, the necessity of surgical revision of the
Ilizarov fixator, and intolerability of the process causing the
patient to request an end to the treatment. Complications
after successful treatment are the return of contractures
limiting functional mobility. Complications following
treatment may be heavily affected by the family dynamics,
including the influence of family and patient/family com-
pliance during treatment.
K.
Amputation
Amputation may be indicated for severe equinovarus
deformities that have contraindications to corrective
surgery and for those deformities that are more debilitating
than a prosthesis. A below-the-knee prosthesis can be less
disabling than a severely burned, contracted, insensate leg.
Most patients and their families, however, are very hesi-
tant to allow an amputation unless the benefits are clear
and obvious. Long, detailed, compassionate discussions
with the patient and their family and caregivers are necess-
ary. No patient with a chronic equinovarus deformity
should be taken to the operating room unless all under-
stand the planned surgery, potential complications, dura-
tion of fixator placement, pain, and difficulties.
III. SUMMARY
Foot bum deformities in the burned patient are best pre-
vented with early grafting, immediate postbum splinting,
and vigorous physical therapy. Treatment of deformity
should be aggressive in the weeks and months after the
burn injury to prevent and resolve mild and moderate
deformities. Equinovarus deformities can also be treated
acutely with calcaneal pins. Severe equinovarus deform-
ities can be treated with external fixators and with tech-
niques to prevent recurrence to avoid amputation.
Successful treatment of severe foot contractures in
burned children continues to be a problem. Ilizarov external
fixators have primarily been used in Galveston, Texas, with
the most severe foot deformities and have been used success-
fully to provide improvement in these patients. Significant
failure still exists; however, the alternative for these deform-
ities may include amputation or being wheelchair bound.
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1.
Committee on Trauma. Guidelines for the Operation of
Bum Units. Resources for Optimal Care of the Injured
Patient: 1999. American College of Surgeons, 1998.
2. Calhoun JH, Evans EB, Herndon DN. Techniques for the
management of bum contractures with the Ilizarov
fixator. Clin Orthop Rel Res 1992; 280:117-124.
3.
Lyle WG, Phillips LG, Robson MC. Reconstruction of the
foot. In: Herndon DN, ed. Total Burn Care. London: W.B.
Saunders Company, 2003:515-519.
4. Cocchiarella L, Andersson GBJ, eds. The Lower Extremi-
ties. Guides to the Evaluation of Permanent Impairment.
5th ed. Chicago, IL: American Medical Association Press,
2001:523-564.
5. Hatt RF, Lamphier TA. Triple hemisection: a simplified
procedure for lengthening the Achilles tendon. N Engl
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6. Waters RL, Garland DE. Disorders of the lower extremity
in the stroke and head trauma patient. In: Jahss MH, ed.
Disorders of the Foot and Ankle. Vol. III. Philadelphia,
PA: W.B. Saunders Company, 1991:2084-2085.
7. Thompson DM, Calhoun JH. Advanced techniques in foot
and ankle reconstruction. Foot Ankle Clin 2000; 5:417-442.
8. Richards Medical Company. The Ilizarov External Fixator,
General Surgical Techniques Brochure. Milan, Italy:
Richards Medical Company, Medical Plastic s.r.l. 1989.
9. Cierny G III. Classification and treatment of osteomyelitis.
In: Evarts CM, ed. Surgery of the Musculoskeletal System.
New York: Churchill Livingstone, 1990:4337-4381.
10. Ciemy G III, Cook WG, Mader JT. Ankle arthrodesis in the
presence of ongoing sepsis: indications, methods, and
results. Orthop Clin North Am 1989; 20:709-721.
11. Benjamin DA, Calhoun J, Evans EB, McCauley RL,
Wolf SE, Desai MH, Herndon DN. Ilizarov external fix-
ators for severe foot deformities in pediatric burn patients.
J Burn Care Rehabil 1998; 19(1 part 2):s210.

Index
Abdomen
scar contractures, 368
tissue expansion, 149
Achilles tendon, 569
lower extremity burn deformities
reconstruction, 527
Adipofascial flap
medial, 527
Adipose tissue
tissue expansion, 143
AlloDerm, 55, 56, 114, 441, 540
Allografts, 106
Alopecia, see also Burn alopecia
scalp, 282
micrografts, 235
tissue expansion, 145
scar
tissue expansion, 83
Amastia, 382-385
Amnion, 215
Anesthesia
airway management, 92-95
burn reconstruction, 95-96
neck tissue expanders, 93
preoperative preparation, 90-92
regional techniques, 95
Angiogenesis, 32-33
Ankle
ankylosis, 565
contractures, 534-536
lower extremity burn deformities
reconstruction, 527
motorcycle bum, 526
Ankylosis
ankle, 565
Anticholinergics, 97
Antideformity burn
hand splint, 497
Antiemetic agents, 97-98
classification, 97
Antifibrotic factors
hypertrophic scars, 188-190
Antihistamines, 97
Apligraf, 114
Apocrine glands, 10, 11
Apoptosis
fibroblasts, 178-179
Arachidonic acid
cascade, 27
metabolism, 28
Argon lasers, 200-201
Arms
burns, 54
troughs, 493
Arnold’s nerve, 303
Arthrodesis
angles, 452
Asian full upper eyelids, 246
Auricle, 302
reconstruction
Tanzer’s method, 302
Autografts, 105-106
Autologous epidermis
hypopigmentation, 169
Axillary contracture reconstmction,
367-377
local flaps, 368-370
preoperative evaluation, 367-368
surgery, 368-375
Back/shoulder soft tissue defects, 359-367
fasciocutaneous flaps, 371-373
intraoperative considerations,
362-363, 375
long-term outcome, 365, 377
microvascular free-tissue transfer, 374
muscle and myocutaneous
flaps, 373-374
nursing, 365, 376-377
pitfalls, 364-365, 375-376
preoperative evaluation, 360-361
rehabilitation, 365, 377
surgery, 361-362
tissue expansion, 374-375
Bard Parker blade, 235
Barrel splint, 502, 503
Basement membrane, 3
Benzodiazepines
comparison, 90
Berkow diagram, 50
Biobrane, 114
Bleomycin, 185
Blood
impaired flow, 36
Blood vessels
tissue expansion, 143
Bone-anchored prosthesis skin incision
surgery, 314
Bone deformities
burned foot, 564
Boutonniere deformities, 430, 453, 454,
494-496, 495-496
digital gutter splint, 501-502
Branchial arch, 302
Breast burns
bilateral, 382-385, 385-386
hypoplastic, 386
mastopexy/reduction mammoplasty,
386-387
operative reconstruction, 82
reconstruction, 381-390
tissue expansion, 148
unilateral, 386-387, 387
Breast ptosis, 387
571

572
Index
Breast reconstruction, 379-390
incidence, 379-380
postoperative pressure therapy, 398, 399
Burn alopecia, 220, 222
classification, 219
tissue expansion, 146-147
complications, 153
Burns, see also specific area
cultured epithelial autografts, 56
depth, 47
dermal equivalents in primary
closure, 54-55
diagram, 86
escharotomies, 45-47
initial wound assessment, 47-48
initial wound care, 44
initial wound management, 48-52
Jackson’s zones of, 24
management, 43-56
mortality, 43-44
operative reconstruction, 79
pathology, 130-131
pathophysiology, 23-25
reconstructive needs, 77-83
resuscitation, 44-47
rule of nines, 49
size, 48
special areas, 52-54
Buttocks burns, 53
Byars’ flaps, 422
Calcaneal traction pins, 566
Calcium channel blockers, 185
Callotasis distraction, 466
Callus distraction, 466
Calmodulin inhibitors, 185
Canalicular obstruction, 266
Canthal hooding
medial, 263, 265
Canthal tendons, 248-250
medial, 250, 251, 257
Capsulopalpebral fascia, 249
Carbon dioxide laser
hypopigmentation, 169
Cardiac arrhythmias
electrical injuries, 61
Cervical bum scar contractures,
347-356
acute care, 347-348
flaps, 351-354
microvascular free-tissue
transfer, 355-356
neck contractures, 351-355
classification, 349-351
reconstmction, 349
skin grafts, 351
Cervical spine
range of motion, 348
Cervicofacial flaps
advancement, 278
Cheek
anatomic layers, 274
anatomy, 270-277
blood supply, 273
hyperpigmentation, 281
sensory nerves, 276
Cheek deformity reconstmction, 269-284
flaps, 279
free tissue transfer, 283-284
methods, 278
skin grafts, 277-284, 279
tissue expansion, 279-282
Chemexfoliation, 161
Chemical bums, 69-75
contact, 70
pigment changes, 70
scar contractures, 407
Chemical depigmentation, 160-161
Chemical peels, 161
Chest
electrical bums, 65
tissue expansion, 149
Chest contractures reconstruction, 393-409
intraoperative considerations, 407-408
long-term outcome, 409
nursing, 408
pitfalls, 408
preoperative evaluation, 393-394
rehabilitation, 409
surgery, 394-401
Chest wall bums
anterior
acute management, 381
Child abuse, 421, 426
Chin
anatomy, 320, 332-334
muscles, 332-333, 333
normal proportions, 335
projection, 334, 341
surface anatomy, 333-334
Chin deformities
classification, 342
Chin reconstmction, 331-345
augmentation, 339-340
flaps, 338-339
skin grafts, 338
surgery, 335-337
tissue expansion, 339
Chondrectomy, 307
Chondritis, 304-305
burned ear reconstruction, 306-307
surgical debridement, 307
Chondrocutaneous advancement flaps, 309
Chondroitin sulfate (CS), 177
Clawed hand, 430
Clonidine, 91
Coagulation factors, 26
Coban fist
with paraffin, 509
Coban glove, 492, 493
Collagen, 6, 7, 176-178
synthesis, 37
Commissure reconstmction, 325-329
electrical bums, 325-327
evaluation, 328
surgical technique, 328-329
Conchal transposition flap, 312
Connective tissue growth factor
(CTGF), 181
Contractures, 179-180. see also individual
contractures
abdomen, 368
ankle, 534-536
classification, 447
conservative therapy, 184-185
hand, 442-444
histopathology and ultrastructure,
174-176
lower extremities, 531-538
pathogenesis, 174-178
surgery, 187
treatment, 183-188
Copper bromide lasers, 201
Copper vapor lasers, 201
Corrective cosmetics
hyperpigmentation, 163
Corticosteroids, 98
intralesional, 185-186
Cosmetic therapy
hyperpigmentation, 161 -164
Cosmetic units, 53
Costal cartilage
surgical approach, 303
Cryotherapy, 185, 199
Cultured skin substitutes, 114
histology, 117
Culture of epidermal autografts
(CEA), 215-216
Cytogenesis, 117
Cytokines, 31, 32
fibrogenic, 180-183
Dacryocystorhinostomy, 255-257
Delta Cast Polyester Conformable
Cast Tape, 506
Dendritic cells, 4, 5
Dermabrasion
hyperpigmentation, 166
hypopigmentation, 168 -169
Dermagraft, 114
Dermal fibroproliferative disorders
prevention, 183-184
Dermal fibrosis
etiology, 178-179

Index
573
Dermapeeling, 161
Dermis, 5, 16
cells, 8
tissue expansion, 142
Dexmedetomidine, 91
Diabetes mellitus
wound healing, 36
Digital cylinder casts, 506
Digital dynamic flexion/extension
splints, 505
Digital gutter splint, 499, 500
boutonniere deformities, 501-502
Digits
shortened
etiology, 465
Dihydroxy acetone
hypopigmentation, 167
Distal digit reconstruction
foot tissues, 483-484
Distal interphalangeal (DIP)
joint, 453-454, 494
Distraction lengthening, 455
Distraction osteosynthesis
finger lengthening, 463-473
Dorsal hand-based resting pan extension
splint, 499
Dorsal metacarpal phalangeal joint block
splint, 500-501, 502
Dorsal wrist splint, 501
Dorsonasal artery, 251
Double bubble technique, 389
Double VI plasty, 388
Drugs
pKa value, 96
Dynamic composite metacarpal
phalangeal / proximal
interphalangeal
joint flexion, 504
Dynamic spring loaded splints, 506
Ear(s)
anatomy, 302-304
anterior displacement, 275
external
structure, 303
operative vs. conservative
therapy, 208-209
Ear burns reconstruction, 301-316
acute care, 305-307
acute care problems, 306-307
aesthetic importance, 304
constricted/contracted ear, 308-309
definition loss, 307
facial bums, 304-305
helical rim defect, 309-310,
311-312
implants, 313-315
osseointegration, 314-316
partial ear defects, 310-313
total ear loss, 312-313, 315
Earlobe, 303
Eccrine sweat glands, 8-10, 10
Ectropions
eyelid, 260, 275, 297
correction, 261, 262-263
lip, 342f
lower lip, 337-338
Edema
burned ear reconstruction, 306
Elastin, 7-8
Elastomer putty
for hand scars, 513
Electrical burns
back/shoulder soft tissue defects, 360
chest, 65
Electrical injuries
acute care, 60-61
cardiac arrhythmias, 61
management, 59-66
ocular, 61
parietal skull defect, 230
pathophysiology, 60
renal complications, 61
wound care, 61-66
Epicel, 114
Epidermal growth factor (EGF), 3, 180
Epidermis, 2-3
autologous
hypopigmentation, 169
cells, 4
tissue expansion, 142
Equines deformities, 564
Equinovarus deformities, 564-565
amputation, 570
external fixators, 563-570
physical examination, 565
treatment, 565-566
Eschar excision
knives, 51
Escharotomy
hand burns, 427, 428
External ears
structure, 303
Extracellular matrix
macromolecular composition, 176-178
tissue expansion, 144
Extremities, see also lower extremities;
upper extremities
burns
operative reconstruction, 82
Eyebrows
operative vs. conservative
therapy, 209-210
Eyelid(s)
anatomy, 242-243, 242-266
Asian full upper, 246
blood vessels, 251
functional deficits, 212
lamella, 249
motor nerves, 251
operative vs. conservative
therapy, 209-210
sensory nerves, 250-251
skin, 243
Eyelid burns
acute management, 260-266
early reconstruction, 261-266
free tissue transfer, 264
local flaps, 264
reconstruction, 241-266
tissue expansion, 264
Eyelid ectropions, 260, 275, 297
correction, 261, 262-263
Eyelid margin
anatomy, 242-245
Eyelid retractors, 244-245
Face
aesthetic units, 270
bony structure, 276
chemical burns, 72-75
five zone subunit classification, 271
hyperpigmentation, 160
lower one-third, 334
muscles, 333
scars, 188, 280
tissue expansion, 147-148
complications, 153
vascular supply, 271
Facial aesthetic units, 82, 83
Facial bums, 276, 277, 282, 293, 294-295
acute, 334-335
aesthetic reconstruction, 212-213
artificial skin coverage, 215-216
compression therapy, 214-215
decision making, 213-214
ear burns reconstruction, 304-305
evaluation, 205-216
functional deficits, 212
future, 216
neglected, 332, 336, 338
operative reconstruction, 79-82
operative vs. conservative
therapy, 206-212
scars, 340
secondary problem prevention, 211-212
skin match, 214
Facial expression
muscles, 273
Facial hair loss
micrografts, 235-237
Facial nerve, 253
Facial reconstruction
visor scalp flap, 339

574 Fasciocutaneous flaps back/shoulder soft tissue defects, 371-373 island, 527 reconstruction, 404, 532 Fasciocutaneous regional flaps, 528 Feet anatomy, 550-551 arterial anatomy, 551 blood supply, 553 contraction, 135 dorsal scald burns, 554 lower extremity burn deformities reconstruction, 527-528 subluxative, 537 cute management, 563-57 econstruction algorithm, 538 scars, 564-565 Feet burn scar contractures reconstruction, 549-561 amputation, 557 classification, 551-555 dorsal, 551-552 joint deformity, 553-555 long-term goals, 560 nursing, 560 physiotherapy, 557-559 pitfalls, 559-560 plantar, 552-553 rehabilitation, 560 splints, 557-559 surgery, 555-557 treatment, 555-557 Fibroblast growth factor (FGF), 180-183 Fibroblast mediated extracellular matrix metabolism modulators, 190-191 Fibroblasts, 8, 34 Fibrogenic cytokines, 180-183 Fibroplasia, 33 Fibroquel hypertrophic scars, 190 Figure 8 swan-neck splint, 501, 502 Finger(s) microvascular free tissue transfer, 475-487 osteoplastic reconstruction, 464 slings, 505 Finger lengthening distraction osteosynthesis, 463-473 advantages, 471-472 age, 467 alternatives, 472-473 amputation level, 466 apparatus, 468 bone length, 466 complications, 471 contraindications, 467 disadvantages, 472 external fixation device, 470 ndications, 466-46 intrinsic release, 47 occupational therapy, 470-471 patient compliance, 467 pin placement, 469 postoperative care, 469-470 preoperative planning surface markings, 468 preparation, 467-468 rehabilitation, 470-471 removal, 470 results, 472 serial x-ray, 470 surgery, 468-469 technique, 467-470 timing, 467 tissue condition, 467 web space, 471 history, 464-465 ingernail Coban hook, 50. 'ingernail hooks, 50: First web C-bar splint, 500 Fistula creation, 259 Flame burns back/shoulder soft tissue defects, 360 breast reconstruction, 405-406 ar contractures, 36 lashlamp-pumped PDL, 20 Fluidotherapy hand scars, 514 Fluorouracil, 185 Foam padding material web inserts for hand scars, 512 Forearm curvilinear incision, 429 radial free flap, 423 Forefoot contractures, 536-538 Foundation hyperpigmentation, 163 Free feline, 528 Free flap reconstruction, 83 Free-hand harvesting skin grafts, 107-108 Free tissue transfer. see also microsurgical free tissue transfer; microvascular free tissue transfer cheek deformity reconstruction, 283-284 eyelid burns, 264 Freezing hyperpigmentation, 161 Index Galia aponeurotica, 228 Galveston frame, 568 Genitalia electrical burns, 66 Genitalia reconstruction, 417-423 cute care, 417-41 filles cocked hat technique, 46. Glands, 8-10 Gay tian, 2oglycan (GAG), 8, 177 Ground substance, 8 Growth factors tissue expansion, 144 Hair, 10-12 Hair follicle, 12 anatomic structure, 11 Hair grafts single eyebrows, 233 Hair growth, 11 Hand anatomy, 476, 494-496 clawed, 430 contractures, 442-444 Hand-based CMC splint, 503 Hand burns, 54 adduction contractures, 448-449 amputations, 454-455 electrical burns, 455-459 initial management, 456-457 nursing, 432-433 osteoplastic thumb reconstruction, 455 pathophysiology, 476-477 pitfalls, 429-432 preoperative evaluation, 425-426 econstruction, 432 - 46 joint deformities, 450-45. car contractures, 442-44 scars, 442 soft tissue deformities, 441-443 volar and dorsal contractures, rehabilitation, 433-434, 489-515 active range of motion, 507-509 amputations, 515

Index
575
capsulotomy, 514
dynamic splints, 503-509
edema management, 491-494
joint mobilization, 510
orthotics, 496-514
passive range of motion, 509
prolonged stretch, 509-510
scars, 510-513
serials casts, 505-507
skeletal suspension, 507
skeletal traction, 507
static splints, 497-503
tendon gliding, 510
skin grafts, 438
skin substitutes, 438-439
surgery, 426-427
syndactyly contractures, 448-449
toe to thumb transfer, 455
web space contractures, 433, 448-449
Hand-driven dermatome
skin grafts, 108
Hand metacarpal phalangeal/
interphalangeal
joint extension splint, 504-505
joint flexion splint, 503-504
Hand sandwich splint, 500
Hand scars
burn rehabilitation, 510-513
elastomer putty, 513
fluidotherapy, 514
foam padding material
web inserts, 512
hard thermoplastic inserts, 513
inserts, 511-513
massage, 514
Otoform KTM, 513
paraffin wax, 513
physical agents, 513-514
pressure garments, 510-511
pressure therapy, 510-511
prosthetic foam inserts, 512
reconstruction, 442-444
rehabilitation, 510-513
silicone elastomer inserts, 512
silicone gel inserts, 512
ultrasound, 513-514
Hard thermoplastic inserts
for hand scars, 513
Hayrake suspension system, 508
Head
burns, 53
inventory diagram, 78
Helical rim defect, 309-310, 311-312
Helix ear framework, 313
Hips
contractures, 532
Histogenesis, 118
Hoffman mini-lengthening device, 468
Hot liquid spill
perineum, 418
Human cadaveric donor skin, 215
Hyaluronic acid (HA), 177
Hydrofluoric acid bums
fingers, 70-71
Hydroquinone, 160-161
Hyoid arch, 302
Hyperglycemia
wound healing, 36
Hyperpigmentation, 158
cheek, 281
dermabrasion, 166
surgery, 165-167
treatment, 159-160
Hypertrophic scars
burned ear reconstruction, 307-308
conservative therapy, 184-185
fibroblasts, 178-179
histopathology and ultrastructure,
174-176
laser therapy, 187-188
pathogenesis, 174-178
pharmacotherapy, 188-191
surgery, 186
treatment, 183-188
Hypopigmentation
dermabrasion, 168-169
suction blister method, 169
surgery, 167-169
treatment, 166-167
Hypoxia
wound healing, 35-36
Ilizarov external fixator, 542, 566-569
complications, 570
Ilizarov technique, 465
Immature bums, 20
Immature hypertrophic red scars
treatment, 169
Implants
ear burns reconstruction, 313-315
osseointegration, 314-316
Medpor, 313-314
Infection
wound healing, 35
Inferior oblique muscle, 247
Inferior tarsal muscle, 245
Injury
immediate response, 25-38
Inserts
for hand scars, 511-513
Insulin-like growth factor-1, 181-182
Integra, 54-55, 114, 439-440, 540
Interferon alpha 2b (IFN alpha 2b)
hypertrophic scars, 188-190
Interferon gamma (IFN gamma), 31
hypertrophic scars, 188-190
Interleukin-1 (IL-1), 31
Interphalangeal (IP)
joint, 494
extension splint, 504-505
flexion splint, 503-504
Intralesional corticosteroids, 185-186
Iontophoresis
chondritis, 306-307
Island fasciocutaneous flaps, 527
Isograft, 106
Jaw
superficial arteries, 254
Jones’ muscle, 252
Jones tube, 260
Karacaoglan’s seven-flap plasty, 370
Keloids
burned ear reconstruction, 307-308
conservative therapy, 184-185
histopathology and ultrastructure,
174-176
laser therapy, 187-188
pathogenesis, 174-178
surgery, 186
treatment, 183-188
Keratinocyte growth factor (KGF), 3
Keratinocytes, 2
Kerrison punch
osteotomy, 258
Ketamine, 91, 93-94
Kirschner wires, 495
Knees
amputation, 540
medial gastrocnemius muscle flap, 525
reconstruction, 524-525
third degree bums, 71
ulcers, 531
Lacrimal anatomy, 253-255
Lacrimal drainage systems, 256
Lacrimal pump, 251-253, 255
Lacrimal sac
tenting, 258
Langerhan’s cell, 4, 5
Laryngeal mask airway (LMA), 95
Laser Doppler, 48
Lasers, see also individual lasers
burn scars, 83
mechanics, 200-203
postburn scars, 199-203
types, 200-203
Laserskin, 114
Lash line, 242
Lateral canthal tendon, 250
Latissimus dorsi myocutaneous flaps
(LDMF)
cervical bum scar contractures, 354

576

Index
Legs
Langer lines, 17
lower
motor vehicle accident, 533
Levator labii superioris alaeque
nasi muscle, 274
Levator palpebrae superioris, 244, 247
Lightning injuries, 66
Lip ectropions, 342
Lips
electrical injuries, 64
functional deficits, 212
muscles, 332-333, 333
normal proportions, 335
operative vs. conservative
therapy, 210-211
surface anatomy, 333-334
Local anesthetics
postoperative pain, 100
Local scalp flaps, 218-219
Lockwood’s ligament, 245, 249
Long-handled spoon, 508
Longitudinal metatarsal arch
surgical release, 537
Lower extremities
amputations, 538-539
inventory diagram of bums, 78
Langer lines, 17
motor vehicle accident, 533
secondary intention healing, 535
tissue expansion, 150-151
complications, 153
Lower extremity bum deformities
reconstmction, 521-542
acute care, 521-523
advances, 539-540
bum scar contractures, 531-538
chronic ulcers, 529-531
early bum scar contractures, 529
early onset functional impairment, 528
hypertrophic burn scars, 528-529
late, 529-542
unstable scars, 529-531
Lower legs
motor vehicle accident, 533
Lower lip
ectropions, 337-338
reconstmction, 331-345
surgery, 335
Lymphocytes, 31
Macrophages, 8, 9, 30-31
Mafenide acetate
ear bums, 305
Mallet deformity finger splint, 502
Mallet finger, 495, 496
Malnutrition
wound healing, 36-37
Mammary hyperplasia, 385-386
Marjolin’s ulcer, 530
Massage
hand scars, 514
Matrix metalloproteinase (MMP), 18
Medial adipofascial flap, 527
Medial canthal hooding, 263, 265
Medial canthal tendon, 250, 251, 257
Medications
pKa value, 96
Medpor Implants, 313-314
Meibomian gland orifices, 242
Melanin, 158
Melanocytes, 1
Melanosomes, 158
Mentalis muscle, 332
Mentolabial sulcus, 337
Merkel cells, 4, 6
Merocrine sweat glands, 10
Metacarpal hand reconstmction, 485
Metacarpal phalangeal (MCP)
joint, 451-452, 494, 496
block splint, 500-501, 502
extension splint, 504-505
flexion, 504
flexion splint, 503-504
Microgenia, 341
Micrognathia, 87
Micrografts, 233-240
cases, 237-240
donor ellipse, 235
donor site, 234
technique, 235-236
Micropigmentation
treatment, 166-167
Microstomia, 64, 87, 322
Microsurgical free tissue transfer,
129-138
advantages, 137
aesthetic considerations, 134
complications, 136
contraindications, 135
disadvantages, 137
flap selection, 136
indications, 132-134
intraoperative considerations, 136-137
limitations, 136
postoperative care, 137
preoperative evaluation, 131-132
rehabilitation, 137
timing, 135-136
Microsurgical toe transfer, 479-485
aesthetic modifications, 482-483
completion, 481-482
functional modifications, 482-483
recipient site preparation, 480-481
toe dissection, 479-480
Microvascular anastomosis, 406
Microvascular free tissue
transfer, 475-487
back/shoulder soft tissue defects, 374
cervical bum scar contractures, 355-356
evaluation prior to, 477-478
finger, 475-487
indications, 477
intraoperative management, 478
options, 478
outcome, 486-487
postoperative care, 485
rehabilitation, 485-486
resurfacing, 478-479
Midazolam, 91
Middle finger
lengthening, 473
Minigrafts, 233-240
cases, 237-240
donor ellipse, 235
donor site, 234
hypopigmentation, 168 -169
technique, 235-236
Minimal tension lines, 20
Modiolus
muscles, 321-322
restoration, 328
Morphine
postoperative pain, 99
Morphogenesis, 117-118
Motorcycle burn
ankle, 526
Mouth
operative vs. conservative
therapy, 210-211
Mucocutaneous margin, 242
Muller’s muscles, 244, 247, 248
Myocutaneous flaps
back/shoulder soft tissue
defects, 373-374
cervical bum scar contractures, 353-354
latissimus dorsi
cervical bum scar contractures, 354
National Tissue Expansion Symposium, 19
Natural dyes
hypopigmentation, 167
Nausea and vomiting
biology, 96-97
Neck
bums, 53
cervical bum scar contractures, 348
contraction, 134
contractures, 187, 351-355
classification, 349-351
functional deficits, 212
inventory diagram of burns, 78
normal contour, 348-349
operative vs. conservative therapy, 211

Index
577
scars, 188-191
tissue expansion, 147-148
complications, 153
youthful, 348-349
Neodymium: YAG lasers, 201
Nesbit tuck procedure, 422
Neutrophils, 29
Nipple-areola complex bums
reconstruction, 387-390
transposition, 407
Nonsteroidal antiinflammatory drugs
(NSAID)
impairing wound healing, 38
postoperative pain, 99
Nose
aesthetic units, 290
adults vs. child, 299
anatomy, 288
bony anatomy, 291
cartilaginous anatomy, 291
operative vs. conservative
therapy, 210
postbum deformity classification, 291
prosthesis, 296-298
surface anatomy, 290
Nose burns
acute care, 288-289
reconstruction, 287-299
historical perspective, 287-288
options, 292-295
postbum in pediatric department,
298-299
scalping flap, 296
Olbrisch’s running Y-V plasty, 370
Olive-tip burr
osteotomy, 257
Oral commissure burns, 64
Oral commissures
natural position, 328
Oral psoralens
hypopigmentation, 167
Orbicularis oculi muscles, 243-244
Orbicularis oris muscles, 321
Orbicular oris muscles, 332
Orbital fat, 244
upper eyelid, 246
Orbital septum, 244, 245, 248
Orcel, 114
Organogenesis, 118
Osteoplastic thumb reconstmction, 455
Otoform KTM
for hand scars, 513
Overgrafting
hypopigmentation, 168-169
Padgett dermatome, 108
Palmar, 497-498
Palmar-based resting pan extension
splint, 498
Palmar bums, 429
bilateral contractures, 133
grafts, 431
Palpebral fissure stenosis, 265-266
Para amino benzoic acid (PABA), 161
Paraffin wax
hand scars, 513
Patient controlled analgesia (PCA)
postoperative pain, 99
Penis
acid bums, 71-72
burns, 54, 419, 420
chemical bums, 72
donor sites, 423
escharotomy, 418
released scar, 422
Pericranium, 228
Perineum
burns, 53
webbing, 420
Perineum reconstmction, 417-423
acute care, 417-419
Peripheral blood fibrocytes, 179
Phalangization, 454
Physical agents
hand scars, 513-514
Pigmentation, 157-170
histology, 159
pathophysiology, 159
treatment, 159-164
Pigment spread phenomenon, 158
Pig skin, 215
Plasma proteins
drug binding, 95
Plaster of paris cast, 507
Platelets, 26-27
Platysma muscle, 275
Pollicization, 454-455, 464
Popliteal contractures, 532-534
classification, 534
Posterior auricular artery, 304
Posterior auricularis, 303
Postoperative analgesia, 98-100
Postoperative nausea and vomiting
(PONV)
after bum reconstructive surgery, 96
treatment, 98, 99
Potassium permanganate
hypopigmentation, 167
Power dermatome, 109
skin grafts, 108
Preaponeurotic fat, 244
Pregnancy
electrical bums, 66
Pressure garments
for hand scars, 510-511
Pressure therapy
for hand scars, 510-511
Prosthetic foam inserts
for hand scars, 512
Proximal interphalangeal (PIP)
joint, 432, 452-453, 494
flexion, 504
Punch grafts
hypopigmentation, 168 -169
Reconstructive burn surgery
airway evaluation, 86-88
anesthesia, 85-100
preoperative diagnostic tests, 89
preoperative evaluation, 86-89
pulmonary evaluation, 88-89
Rectangular expander, 363
Re-expansion, 152
Relaxation incision, 401
Repigmentation, 158
Resting pan extension splint
(Palmar), 497-498
Retroauricular temporal flap, 283-284
Retrognathia, 343-344
Ring sign, 421
Roylan 50/50 Mix elastomer putty
for hand scars, 513
Roylan prosthetic foam inserts
for hand scars, 512
Sandwich splint, 498, 499
Saphenous artery fasciocutaneous flap, 527
Scald bum
back/shoulder soft tissue defects, 361
hands, 426
scar contractures, 404
Scalp
anatomy, 228-229
electrical injuries, 64
expansion, 18
operative vs. conservative
therapy, 207-208
Scalp alopecia, 282
micrografts, 235
tissue expansion, 145
Scalp burns, 53
diagnosis, 230
historical perspective, 227-228
management, 227-232
reconstruction, 217 - 225
acute care, 218
with bony involvement, 221-225
without bony involvement, 218-219
Scar(s), 18-19. see also
Hypertrophic scars
face, 188, 280, 340
formation, 200
hand, 442, 510-513

578
Index
Scar alopecia
tissue expansion, 83
Scar collagen, 35
Scopolamine, 97
Scrotum
burns, 54, 419
Sebaceous glands, 10, 11
Serial casting, 185
Serotonin receptor antagonists, 97-98
Setting powder
hyperpigmentation, 163
Shortened digits
etiology, 465
Shoulder, see also Back/shoulder soft
tissue defects
hypertrophic scars, 364
postburn scars, 362
Silastic conformers, 185
Silicone elastomer inserts
for hand scars, 512
Silicone gel inserts
for hand scars, 512
Silicone gel sheets, 185
Silicone tube
placement, 259
Single hair grafts
eyebrows, 233
Skate flap, 388
Skeletal muscle
tissue expansion, 143
Skin
anatomy, 2-20
appendages, 9
blood supply, 12-14
circulation, 13
components, 116-118
extensibility vs. elasticity, 15
flexible organ, 15
intrinsic aging, 20
nerves, 14
photodamage, 19
properties, 1-20
stress-strain curve, 15
stretched, 16
tissue engineering, 116-118
tissue expansion, 16-18
Skin grafts, 105-110
cervical bum scar contractures, 351
cheek deformity reconstmction,
277-284
chin reconstruction, 338
failure, 109-110
hand burns, 438
harvesting, 107-108
history, 105-107
hyperpigmentation, 165 -166
hypopigmentation, 168 -169
knives, 108
limitations, 132
revascularization, 108 -109
scalp bums, 230
survival, 108-109
technique, 51
Skin substitutes, 440
assessment, 119-120
clinical considerations, 118-120
clinical experience, 121
cost, 120
cultured, 114
histology, 117
cutaneous gene therapy, 123
future, 121-123
hand bums, 438-439
in vitro angiogenesis, 122-123
lower extremity burn deformities
reconstruction, 540
nursing, 119
pigmentation, 122
regulatory issues, 120
requirements, 115-116
surgery, 118-119
Skin surgery, 113-123
objectives, 113-115
Skull
anatomy, 228-229
electrical injuries, 64
Skull burns
diagnosis, 230
historical perspective, 227-228
management, 227-232
pathophysiology, 229
Skull wounds
types, 229-230
Sliding genioplasty, 342
Splash mark burns, 69-70
Splast, 506
Splints, see specific splints
Spoon
long-handled, 508
Squamous cell carcinoma, 186
Steroids
impairing wound healing, 38
Stratum comeum, 4
Stratum granulosum, 4
Stratum spinosum, 3 -4
Suction blister method
hypopigmentation, 169
Sunscreens
topical, 161
Superficial musculoaponeurotic system
(SMAS), 275
Superficial temporal artery, 306
Super-flap, 532
Superior transverse ligament, 245
Supersplint, 505
Supratrochlear artery, 251
Tattooing, 166-167
Thigh
bums, 54
lower extremity bum deformities
reconstruction, 524
Thl/Th2, 182-183
Thumb
adduction contractures, 449-450
lengthening, 472
microvascular free tissue
transfer, 475-487
Thumb reconstruction, 484
osteoplastic, 455
Thumb spica anticupping splint, 500
Tissue expansion, 141-154
abdomen, 149
adipose tissue, 143
back/shoulder soft tissue
defects, 374-375
blood vessels, 143
burned scalp, 219-221
burn reconstruction, 146-151
cheek deformity reconstruction,
279-282
chest, 149
chin reconstruction, 339
complications, 151-153
eyelid burns, 264
face, 147-148
complications, 153
histomorphology, 142
implant type and size, 144
incisions
paralesional vs. remote, 143-144
internal vs. external ports, 144
intraoperative considerations, 146
lower extremities, 150-151
complications, 153
lower extremity bum deformities
reconstruction, 540-541
molecular basis, 143
operative techniques, 146
patient selection, 145-146
postoperative issues, 146
principles, 143-146
rate, 144-145
skin, 16-18
techniques, 145-146
Tissue inhibitor metalloproteinase
(TIMP), 18
Toe deformities, 564
Toe to hand transfer, 464
Toe transfer, see also Microsurgical toe
transfer
clinical experience, 485
Toe wrap-around technique, 464
Topical solutions
hypopigmentation, 167

Index
579
Topical sunscreens, 161
Torso
electrical injuries, 64-65
inventory diagram of bums, 78
Tractors, 321
Tranilast
hypertrophic scars, 190
Transcyte, 114
Transforming growth factor alpha
(TGF alpha), 3
Transforming growth factor beta
(TGF beta), 31, 180-182
Transitional zone, 4
Transparent face masks, 185
Transverse rectus abdominus myocutaneous
(TRAM) flap, 381, 383
Triamcinolone, 185
Trifluoperazine, 185
Trigeminal nerve, 252-253
Tmncal burns, 53
reconstmction, 411-416
incidence, 412
intraoperative, 414
long term outcome, 416
nursing, 415
pitfalls, 414-415
preoperative evaluation, 413
rehabilitation, 415-416
surgery, 413-414
Tumor necrosis factor alpha
(TNF alpha), 31
Tuneable dye lasers, 202
Ultrasound
hand scars, 513-514
Universal cuff, 508
Unna Boot, 523
Upper extremities, see also Arms
inventory diagram of burns, 78
tissue expansion, 149-150
complications, 153
Upper lip
anatomy, 320
defects
scalp visor flap, 325
with vermillion involvement, 325
without vermillion
involvement, 323-324
functional anatomy, 321-322,
322-323
major defects, 325
nasal unit, 321
dimensions, 293
reconstruction, 319-325
acute burn care, 323
surface anatomy, 319-320
Vacuum assisted closure (VAC)
device, 418
lower extremity burn deformities
reconstruction, 539-540
Valve of Rosenmueller, 255
Vancouver Scar Scale, 440
V-beam PDL system, 202-203
Verapamil, 185
Vitamin C
wound healing, 37
Vitamin K
wound healing, 37
Vitiligo, 169
Volar wrist splint, 501
V-Y plasty, 370, 421
Web space syndactyly, 501
Whitnall’s ligament, 245
Whitnall’s tubercle, 250
Wooden dowels
burned hand rehabilitation, 509
Wound healing, 23-38
cell interactions, 30
continuum, 25
factors affecting, 35-38
hemostasis, 27
inflammatory phase, 26-31,
27-29
leukocytes, 29-30
maturational and remodeling
phase, 33-35
metabolism, 55-56
nutritional deficiencies, 37
proliferative phase, 31-33
reparative process, 25-38
Wrist splint, 499, 501
Xenografts, 106
X-Y advancement flap, 395
Youthful neck, 348-349
Zinc
wound healing, 37-38
Zone of coagulation, 23-24
Zone of hyperemia, 24
Zone of stasis, 24
Z-plasty, 17, 421, 449
limitations, 132
Zygomatic major, 274-275
Zygomatic minor, 274

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