Functional and Aesthetic Reconstruction of Burn Patients

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334
Functional and Aes thetic Reconstruction of Burned Patients
Figure 24. 4 The lower one-third of the face. [Reprinted with
permission from Frodel (13).]
is the distance from the stomion to the mentum (Fig. 24.4).
The upper lip is slightly anterior to the lower lip and is one-
third thinner (13). In evaluating the position of the chin,
two vertical lines are passed from the nasion. The pogo-
nion, or the most anterior portion of the chin, should be
at this line or slightly behind it. Alternatively, chin projec-
tion can be determined by a vertical line from the subna-
sale (Fig. 24.6). The pogonion should be 4 mm behind
Figure 24.5
Measu red h eigh t o f lower two-thirds o f the face.
[Reprin ted with permission from Frodel (13).]
Figure 24. 6 Chin projection. [Reprinted with permission
from Frodel (13).]
the line. It is important to note that the dental occlusion
plays an important role in the assessment of chin deform-
ities. Patients with Angel’s Class II occlusion suggest
overprojection of the maxilla and/or underprojection of
the mandible (13). Lower lip position is influenced by
the inclination of both the maxillary and the mandibular
incisions and the position of the maxilla and the mandible.
Anatomy of the lip can vary based on ethnicity. In many
ways this has been altered with the increase in lip augmen-
tation procedures. However, regardless of the thickness of
the lips, the aesthetic balance between the upper and the
lower lips is desirable. The length of the lips is defined
as being the distance between either both lateral or both
midpupillary lines. The lower lip is one-third wider than
that of the upper lip.
III.
ACUTE FACIAL BURNS
The management of acute facial bums is well described
(14-17). Controversy exists as to the timing for early vs.
delayed excision of partial-thickness injuries. However,
the goal is to minimize the resection of viable tissue and
decrease the need for subsequent reconstructive efforts.
In patients with deep partial-thickness or full-thickness
facial bums, the primary areas of concern are the eyes,
the mouth, and the neck (7,8). These high-risk areas are
prone to the development of contractures which can alter
facial aesthetics and impact function. With respect to the
mouth and the neck, the development of intrinsic or
extrinsic lower lip ectropions can totally alter the aesthetic

Recons truction of the Lower Lip and Chin
335
Figure 24. 7 Diagram of normal proportions in lip and
chin anatomy. [Reprinted with permission from Maillard and
Montandon (18).]
integrity of the lower lip-chin unit (18) (Fig. 24.7). Even
with minimal alterations in this area, the goal is to restore
the balance of the lower one-third of the face with that of
the upper two-thirds. Clearly, principles of aesthetic
surgery are crucial in our decision making process. Once
we incorporate these guidelines, we can now develop a
template onto which our reconstructive efforts in bum
patients may be addressed. Without question, differences
in color match and texture may compromise our aesthetic
results. However, notwithstanding these problems, we
need to approach these areas of reconstruction with
tempered enthusiasm.
IV.
SURGICAL CONSIDERATION
A.
Lower Lip
The lower lip and the mentolabial sulcus is a striking
feature of the lower one-third of the face. Reconstruction
of this region requires a detailed understanding of the
complex contours noted in the lip-chin complex.
Cardoso et al. (19) describe the contour of this unit as
that of a dumbbell. The soft tissues in the region of the men-
tolabial sulcus are condensed to form an isthmus between
the lip and the chin (12). Cardoso et al. (19) also studied
the histological nature of the mentolabial sulcus. It is felt
that the muscles of the lower lip are responsible for the
function and maintenance of the sulcus. In deep burns of
the lower lip, the underlying tissue and the cutaneous inser-
tion of the muscle are destroyed only to be replaced by scar.
The inelastic scar now produces a fixed and altered contour
(19,20). Lower lip ectropion is a sequela of this process as
is loss or blunting of the mentolabial angle.
One of the major concerns with bums to the lower one-
third of the face is the correction of lower lip ectropions.
These problems can be secondary to intrinsic factors or
extrinsic factors. Often in severe cases, the presence of
the lower lip ectropion is a combination of both factors.
Cervical contractures are the primary cause of extrinsic
lower lip ectropions. The contracture of the platysma
muscle has a direct effect on lower lip eversion. The
degree of lower lip ectropion which is intrinsic can only
be determined after correction of the extrinsic problem.
Only then is the lower lip contour re-evaluated and
assessed for correction. In cases where intrinsic lower lip
ectropion is severe, several abnormalities exist: displace-
ment of the commissures inferiority, decrease in the intra-
oral sulcus, increase of the horizontal length of the lower
lip, and possibly an increase in the width of the lower lip
(Fig. 24.8). In these long-standing defects, releasing the
lower lip only will not always correct oral incompetence
if the commissures are not addressed.
In addition, the nonuse of compression facemasks after
the acute injury may accelerate the development of lower
lip ectropions. Consequently, oral incompetence and
exposure of the teeth can also become important issues.
B.
Chin
The chin is an important component of the lower one-third
of the face. Bums to this region can encompass other areas
of the face as well as the neck. These problems are divided
into two categories: soft tissue deformities only and
deformities involving the mandible itself. Soft tissue
deformities are those that result form deep partial- or
Figure 24. 8 After neck release note the interior displacement
of the lower lip, the increased horizontal length of the lip, and the
increased width of the lower lip.

336
Functional and Aes thetic Reconstruction of Burned Patients
full-thickness injuries. The development of hypertrophic
scars and keloids can become problematic. In addition, in
men, this bearded region is prone to the development of fol-
liculitis, which can delay healing. Such injuries can later
have an effect on the contour of the lower lip and chin.
Clearly, associated neck contractures will not only alter
the contour of the lower lip, but can also allow the chin to
become encased in neck scar. Grade IV contractures of the
neck usually involve significant scar contractures of the
chin which subsequently can affect function (Fig. 24.9).
Figure 24. 9
(A, B) Ten-year-old male with neglected facial burns with encasement of chin in scars connected to the anterior chest
wall. (C, D) Normal chin contour after correction of the neck contracture with split-thickness skin grafts and a full-thickness skin
graft to correct the lower lip ectropion.

Recons truction of the Lower Lip and Chin
337
Problems associated with bony deformities of the chin are
divided into two categories: (1) chin deformities that occur
with full-thickness bum injuries and directly involve the
bone and (2) chin deformities which occur indirectly
because of encasement in burn scars or from the treatment
of these scars with compression garments. In either
case, restriction of mandibular growth is believed to be
affected (21,22).
V.
RECONSTRUCTION
A. Lower Lip Re cons truction
1.
Mentolabial Sulcus
Major soft tissue loss of the lower lip after thermal injury
is rare. However, it is possible that electrical injuries can
produce major soft tissue loss. But, more common are
deformities associated with the development of microsto-
mia or ectropions. Even with perfect facial resurfacing
during the acute phase of care, loss of contour in the
lower third of the face can occur. This will detract from
the overall aesthetic results. Blunting of the mentolabial
sulcus not only makes the chin appear smaller, but second-
ary lower lip ectropions, even though mild, can compro-
mise the final appearance (23). Initial methods to correct
this problem with excavation of fat and muscle do not
have uniform success (23,24). Cardoso et al. believe that
projection is lost at a later stage due to gravitational pull
and subsequent sagging. They recommend reconstruction
of the mentolabial sulcus by excision of scar tissue,
lateral flap advancement of the underlying tissues and
resurfacing with skin grafts (19). Feldman believes that
excisional releases and re-contouring of the underlying
tissues gives us the best chance in re-establishing the
normal appearance of the mentolabial angle (24). All of
these factors need to be addressed in order to achieve
successful and aesthetically pleasing results.
2.
Ectropions
The use of local flaps for reconstmction of the lower two-
thirds of the face is well described. However, in facial
burns, this problem is magnified because the surrounding
tissue may also be involved in bum injury. Consequently,
the use of these flaps is prohibited during the acute phase
of injury or even in the early maturation phase of wound
healing. Needless to say, local bum tissue can be safely
moved once wounds have matured (Fig. 24.10). The use
of local flaps is excellent for correction of small lower
lip ectropions. However, in burn patients, the availability
of local tissue for correction of these problems may be
limited.
In patients with severe lower lip ectropions, simply cor-
recting the upper segment of the chin unit by incisional or
Figure 24. 10 Correction of a lower lip ectropion with a local
transposition flap.
excisional release and resurfacing the defect with skin
grafts may not produce the desired results. The commis-
sures, and the increased length and width of the lip may
need to be addressed. A combination of procedures are
often required to correct severe deformities. A complete
release of the lower lip-chin unit is required as a first
step. In long-standing lower lip ectropions, the orbicularis
oris muscle may be attenuated. This problem along with
the inferior displacement of the commissure is addressed
with bilateral commissuroplasties, reconstruction of the
modiolus, and partial vermillionectomy. Tightening of
the orbicularis muscle by advancing the commissures
superiorly and revising the modiolus provides the necess-
ary suspension needed for lower lip function. The
increased width of the lower lip may also be noted after
the above procedures have been performed. The lower
lip is usually one-third more of the width than the upper
lip. Consequently, a partial vermilionectomy may be
necessary in order to achieve lip balance. These pro-
cedures have been shown to achieve significant improve-
ment in lower lip function and aesthetics in the most
dramatic cases of lower lip ectropions (Fig. 24.11).
The use of pedicled flaps has been described for lower
lip reconstmction (25-30). Although many of these tech-
niques have found a place in oncologic reconstmction or

338
Functional and Aes thetic Reconstruction of Burned Patients
Figure 24.11
(A) Young boy with neglected facial burns. (B) Appearance of lower lip after the neck release with split-thickness skin
grafts. Note commissure position after release with inferior displacement. (C) Note lower lip and chin region in the final stages of the
reconstruction approach.
nonburn traumatic injuries, reports of their use in recon-
struction of the burned lower lip is scarce. However,
contour problems and the occasional destruction of the
lip musculature may render these procedures as a second-
ary line of defense in burn reconstruction. Similarly, free-
tissue transfers have also been used to reconstruct complex
deformities of the lip and chin (31-34). But again, most of
the reports do not include bum patients. However, it suf-
fices to say that the sensate composite radial forearm
flap seems to be popular for reconstruction in this region.
B. Chin Recons truction
1.
Skin Grafts
Most burn surgeons contend that facial burns that do not
heal within 2 weeks should be excised and grafted
(14,35). Studies have shown that the incidence of hyper-
trophic scars increases in areas of delayed wound
healing (36). Excision of scars and resurfacing of the
defect as part of the chin subunit or the entire subunit of
the chin can produce excellent results.
2.
Flaps
In adult men, partial-thickness burns to the hair-bearing
regions of the face can be complicated by folliculitis,
thereby increasing the chances for the development of
unsightly scars. In some instances, resection of these
areas and resurfacing with skin grafts may be the only sol-
ution to this problem. However, the aesthetic results may
be less than optimal. Several authors have suggested exci-
sion of these unsightly scars and reconstruction with a
beard (14,36-39). Although several techniques have
been advocated, recent studies by Hafezi et al. (39)
using the bitemporal artery scalp flap has produced excel-
lent results (Figs. 24.12 and 24.13). Although this group

Recons truction of the Lower Lip and Chin
339
Figure 24. 12 Diagram of the use of the visor scalp flap
for reconstruction of the lower one-third of the face as a band.
[Reprinted with permission from Hafezi et al. (39).]
used this flap as a bipedicle visor flap, it can also be used as
a free-tissue transfer for reconstruction of the beard. The
primary limitation of this technique is the orientation of
the hair follicles. In addition, patients who have a strong
family history of male patterned baldness may not be
suitable candidates.
3.
Tissue Expansion
Although visor flaps can produce excellent results in men,
some patients opt for other alternatives. Also, in women
and children alternative methods for the reconstruction
of pronounced chin scars are crucial. Tissue expansion is
a well-accepted method in the reconstruction of patients
with head and neck bums (40-43). The use of expanders
for the correction of cheek and chin defects is still in a
state of infancy (42,44). Nevertheless, dramatic results
can occur without the development of secondary lower
lip ectropions. As noted in principle of tissue expansion,
small incisions are used and the expander is placed in a
subcutaneous pocket. Expansion is typically started 2-3
weeks after surgery and the stitches have been removed.
Once expansion is complete, the expander is removed
and the expanded flap is advanced cephalad with the
neck in slight extension. Tension on the suture line
should be avoided at all costs since the development of a
secondary ectropion is of some concern. Patients are
placed in a loose extended chinstrap to help the flap
contour to the chin and upper neck for the first week
(Fig. 24.14).
Figure 24. 13 (A) Preoperative appearance of patient with
chin scars after burn injury. (B) Postoperative appearance after
reconstruction with the visor scalp flap. [Reprinted with
permission from Hafezi et al. (39).]
4.
Chin Augmentation
Thermal bum injuries involving the central portion of the
mandible, or bony chin, is uncommon (Fig. 24.15).
Although, it is conceivable that such injuries may occur
more frequently in electrical bums, this is not well docu-
mented. Consequently, the effects of these injuries on
growth and development of the chin is nonexistent.
However, to date, several studies have implicated the use
of compression therapy with subsequent underdevelop-
ment of the chin after bum injury (21,22) (Fig. 24.16).
For reconstructive surgeons, this now becomes another
focus in facial reconstmction burn patients. The evaluation
of chin deformities is only part of a comprehensive facial
analysis. McCarthy et al. (45) developed a surgical system
for the correction of bony chin deformities (Figs. 24.17
and 24.18). Although, it is clear that a number of authors
have proposed various systems to evaluate chin size and
shape, McCarthy et al. noted that none are perfect and
surgical decisions should not be solely based on these

340
Functional and Aes thetic Recons truction of Burned Patients
Figure 24. 14 (A) Young girl with facial bum scars. (B) Improvement of bum scars on the cheek regions improved surgically, but
patient unhappy with chin scars, particularly the graft in the upper part of the chin subunit. Tissue expander (100 cm3) placed and over-
inflated. (C, D) Appearance 6 months after removal of chin tissue expander and resurfacing with the expanded flap.
parameters. However, according to Frodel (13), micro-
genia is a term that describes a recessive or short chin in
the sagittal and vertical dimensions. Retrogenia is essen-
tially microgenia in the sagittal plane. In burn patients,
the most commonly seen chin deformity is retrogenia.
The etiology of this deformity has been attributed to
bum injuries to the lower one-third of the face in
combination with compression therapy. Although the
exact incidence of this problem in bum patients is
unknown, retrogenia is the most common chin abnor-
mality noted in the overall population. Vertical microgenia
is commonly a reflection of retrognathia with Class II
malocclusion. Patients may have a deepened labiomental
sulcus and a procumbent lower lip.

Recons truction of the Lower Lip and Chin
341
Figure 24. 15
(A) Infant with facial bums with full-thickness burns to the chin with extensive debridement of tissue over the chin.
(B) Early indications of a small chin in vertical and horizontal dimensions 5 years later. (C) As a teenager, the lack of chin projection
is more pronounced.
Guyuron et al. (46) introduced a practical classification
of chin dysmorphology in an analysis of 2879 patients over
a 10-year period. The most common dysmorphism noted
was microgenia (63.8%). It is clear that the acceptable
methods of chin augmentation are the sliding genioplasty
or augmentation with alloplastic implants. In 2001,
Chang et al. (47) reviewed their experience with sliding
genioplasty for correction of retrognathia. In the eight
Figure 24. 16 (A) Young boy with microgenia. (B) Four-year-
old follow-up demonstrating pronounced chin deformity.
patients requiring chin reconstruction, the average
advancement was 8 mm. Their follow-up of 6 months to
5 years (2.3 years mean) showed excellent aesthetic results
with minimal complications. In 1985, Thomson (48)
described the sagittal genioplasty which has been effec-
tively shown to perform reduction, augmentation, push-
back, and advancement genioplasties. A lower labial
incision is made through the mucosa. The dissection is con-
tinued downward with division of the mentalis muscle and
division of the periosteum to expose the chin. A horizontal
subapical cut through the mandible is performed avoiding
the apices of the teeth and both mental nerves. Rigid func-
tion is obtained with the use of lag screws. Thomson
reported minimal complications as a result of this versatile
approach for the correction of chin dysmorphology. Vuyk
(49) reviewed his experience in the treatment of chin retru-
sion with silicone implants. In his review of 40 patients
who underwent augmentation genioplasty, bone resorption
was noted in 13 patients (61%) (49). However, the majority
of these patients (8/13) experienced minimal resorption.
Interestingly, Peled et al. (50) reported his experience
in the use of silicone implants in children with Downs syn-
drome. In his series of 50 patients with a mean age of 9, all
underwent augmentation of the nose, cheek, and/or chin
with silicone implants. Of the 12 patients who underwent
chin augmentation, 9 patients (75%) developed crater-like
bone resorption. All implants were subsequently removed
with bony regrowth back to its preoperative status. To

342
Functional and Aes thetic Recons truction of Burned Patients
Figure 24. 17 Classification of chin deformities without occlusion problems. [Reproduced with permission from McCarthy et al. (45).]
Figure 24. 18
Sliding Genioplasty. (A) Osteotomy made in
plane parallel to the occlusal surface. No significant change,
in the vertical dimension. (B) Lag screws provide fixation.
[Reproduced with permission from McCarthy et al. (45).]
date, a large series of burn patients undergoing genioplasty
either by advancement or with alloplast implants does not
exist. However, from these reports, several points are
important to note. First, chin implants in children or even
young adults appear to have an increased risk of bone
resorption. The younger the patient, the greater the resorp-
tion. Second, although relapse occurs with advancement
genioplasties, this seems to be a reliable alternative
(Fig. 24.19). Needless to say, in bum patients any type of
advancement genioplasty requires the presence of soft
regions that are pliable in the upper neck and chin, to
ensure the success of the procedure.
VI.
CONCLUSION
Clearly, much is to be learned about reconstruction of the
lower one-third of the face in burned patients. The correc-
tion of lower lip ectropions needs to be addressed only
after correction of cervical contractures, which may con-
tribute to the severity of the problem. In long-standing
ectropions an increase in the horizontal and the vertical
dimensions of the lower lip may be noted. Here, after cor-
rection of all extrinsic components, a complete release of
the lower lip combined with bilateral commisuroplasties,
reconstmction of the modiolus, and a partial vermilionect-
omy may be considered. Approximation of the normal aes-
thetic balance of the lips is possible with preservation of
function. The correction of soft tissue defects of the chin
is a function of the extent of the depth of the injury.
Although resurfacing of these defects appears to be ade-
quate with the use of skin grafts, sculpturing of the labio-
mental crease prior to placement ensures a more natural
appearing result. Bony defects of the chin rarely occur in

Recons truction of the Lower Lip and Chin
343
thermal injury. However, burns to the chin and the associ-
ated use of compression therapy have been implicated in
the development of retrognathia. However, to date, no
extensive epidemiologic studies have been performed to
compare the incidence to that of the normal population.
Regardless of this issue of incidence, the correction of
this problem with advancement genioplasty or alloplast
implants will most likely require the placement of
additional tissue in the chin-upper neck region. Reported
long-term follow-up of these procedures in burn patients
Figure 24. 19
(A and B) Fifteen-year-old child with retrognathia; anterior and lateral views. (C) Preoperative lateral cephalogram.
(D) Preoperative planning model, (see page 344 for E -I) (E) Preoperative planned movement of mandible by 8 mm and chin advancement
by 10 mm. (F and G) Postoperative follow-up after surgery, anterior and posterior views. (H) Lateral postoperative cephalogram.
(I) Postoperative panorex. (Courtesy of Elgene Manious, MD, Chief, Division of Maxilliafacial Surgery, University of Texas Medical
Branch, Galveston, TX.)

Figure 24.19
Continued.
344
Functional and Aes thetic Recons truction of Burned Patients

Recons truction of the Lower Lip and Chin
345
appears to be currently lacking. Nevertheless, we should
remain ever vigilant in our efforts to restore all aspects
of facial bum injuries to their normal parameters.
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Gullane PJ, Maring GC. Minor and major lip reconstruc-
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Warpeha RL. Resurfacing the burned face. Clin Plast Surg
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Neale HW, Billmire DA, Carey JP. Reconstruction
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Guillan PJ, Martin GC. Minor and major lip reconstmction.
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Thorak P. Anatomy in Surgery. 2nd ed. Philadelphia:
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Zide BM, McCarthy J. The mentalis muscle: an essential
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Feldman JJ. Reconstruction of the burned face in children.
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Surgery. St. Louis: Mosby, 1984:522-632.
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Frodel JL. Evaluation and treatment of deformities of the
chin. Facial Plast Surg Clin N Am 2002; 10:221-232.
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Hunt JL, Purdue GF, Spicer T, Gennett G, Range S. Face
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Jonsson CE, Dalsgaard CJ. Early excision and skin grafting
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Fraulin FOG, Lllmayer SJ, Tredget EE. Assessment of
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Voinchet V, Bardot J, Echinard C, Aubert JP, Magalon G.
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18.
Maillard GF, Montandon D. Reconstmctive surgery of deep
burns of the lips. Clin Plast Surg 1984; 655-668.
19.
Cardoso ERL, Amondo-Kuofi HS, Hawary MB. Postbum
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Cardoso ERL, Amondo-Kuofi HS, Hawary MB. Mento-
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21. Fricke NB,
Omnell L, Dutcher KD, Hollender LG,
Engrav LH.
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Omnell L, Dutcher KD, Hollender LG,
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24. Feldman JJ. Facial bums. In: McCarthy JG, ed. Plastic
Surgery. Philadelphia: W.B. Saunders, 1990:2153-2236.
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Yoshida T, Sugihara T, Ohura T, Minakawa H, Igawa H.
Double cross lip flaps for reconstmction of the lower lip.
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Bayramicli M, Numanoglu A, Tezel E. The mental v-y
island advancement flap in functional lower lip reconstmc-
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reconstmction. Br J Plast Surg 1999; 52:232-235.
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Yotsuyanagi T, Nehei Y, Yokoi K, Swada Y. Functional
reconstmction using a depressor anguli oris musculo-
cutaneous flap for large lower lip defects, especially for
elderly patients. Plast Reconstr Surg 1999; 103(3):850-856.
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Moschelia F, Cordova A. Platysma muscle cutaneous flap
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Özdemir R, Ortak T, Kocer U, Celebioglu S, Sensoz O,
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Jeng S-F, Kuo Y-R, Wei F-C, Su C-Y, Chien C-Y.
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33. Serletti JM, Tavin E, Moran SL, Coniglio JU. Total lower
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37. Argrawal K, Panda KN. Moustache reconstruction using an
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54:159-161.

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38. Datubo-Brown P, Khalid NK, Paul LL. Tissue expanded
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32:205-208.
39. Hafezi F, Naghibzzdeh B, Nouhi AH. Facial reconstruction
using the visor flap. Bums 2002; 28:679-683.
40. McCauley RL, Oliphant JR, Robson MC. Tissue expansion
in the correction of bum alopecia: classification and methods
of correction. Ann Plast Surg 1990; 25(2): 103-115.
41. Weislander JB. Tissue expansion in the head and neck.
Scand J Plast Reconstr Hand Surg 1991; 25:47-56.
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44. McCauley RL, Owiesy F. Aesthetic reconstruction of
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genioplasty for correction of chin abnormalities. Arch Fac
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49. Vuyk HD. Augmentation mentoplasty with solid silicone.
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Maxillofac Surg 1986; 44:346-348.

25
Correction of Cervical Burn Scar Contractures
ROBERT L. McCAULEY
University of Texas Medical Branch and Shriners Hospital for Children— Galveston Unit, Galveston, Texas, USA
I.
INTRODUCTION
Facial and neck burns present quite a challenge for recon-
structive surgeons. Whereas the incidence of neck burns
vary, they remain an integral part of acute bum care.
Under most circumstances, deep partial-thickness burn
injuries and full-thickness burn injuries are tangentially
excised and resurfaced with split-thickness skin grafts.
Superficial partial-thickness wounds are allowed to heal
secondarily. In either case, early wound closure and the
prevention of neck contracture is crucial. The use of
neck splints and physical therapy are part of the postopera-
tive regimen to prevent subsequent contractures. However,
even under the best circumstances, bum scar contractures
of the neck can occur. The degree and severity of the con-
tractures have been classified according to their effects on
the range of motion in the neck (Table 25.1). Neck motion
is classified into these areas: flexion, extension, rotation,
and lateral flexion (Table 25.2). All of these movements
are crucial to performing our activities of daily living
(ADLs). Of these four movements, extension seems to
inhibit function the most in burn patients and certainly is
the focus of our efforts in defining bum scar contractures
of the neck. Grade II contractures or greater not only
affect neck extension and lateral rotation, but may also
distort facial features. The combination of these forces
often produces significant facial distortion complicated
by limitations in performing ADLs. The reasons for
development of significant neck contractures are easily
dissected. The concavity of the neck, the thinness of the
skin, and its increased mobility all contribute to the
propensity for the development of neck contractures.
However, treatment of these problems is complex.
Long-term follow-up is scarce.
II.
ACUTE CARE
Early excision and grafting of burn wounds is a well-
accepted concept in the management of patients with
347
I.
Introduction
347
D.
Grade IV Contractures
350
II.
Acute Care
347
V.
Skin Grafts
351
III.
Normal Neck Contour
348
VI.
Flaps
351
A. Reconstruction
349
VII.
Microvascular Free-Tissue Transfer
355
IV.
Classification of Neck Contractures
349
VIII. Conclusion
356
A.
Grade I Contractures
349
References
356
B.
Grade II Contractures
349
C.
Grade III Contractures
350

348
Functional and Aesthetic Recons truction of Burned Patients
Grade I
Symptomatic; no limitations in range of motion;
no facial distortion
Grade II
Symptomatic; may have mild limitations in neck
extension and/or rotation; distortion of lower
one-third of face may be noted on extension
Grade III
Symptomatic; cannot extended head past neutral
position; limited extension; distortion of lower
one-third of face
Grade IV
Symptomatic; loss of cervicomental angle; severe
facial distortion; possible fusion of chin to
anterior chest wall
Table
25.1
Bu m
Scar
Contractu res
o f
the
Neck—
Classification
major thermal burns. However, relative to the head and
neck, even the most aggressive of acute bum surgeons
may temper their approach. Although the concept of
early excision offers the advantages of early wound
closure, the prospect of decreased hypertrophic scarring,
and improved aesthetics, one main problem exists. What
is considered early excision? A review of the literature
indicates that early excision can occur within 24 h of
bum injury to nearly 3 weeks after bum injury (1-3). In
each of these studies, however, early excision of bum
wounds was touted to be effective in decreasing hyper-
trophic scarring and improving aesthetics. Yet, the
concept of timing for early excision remains elusive. As
we look closer at the acute management of cervical
bums, yet another dimension is brought to light. In 1995,
Voinchet et al. (4) reported their series of early excision
and grafts of anterior neck bums (within 24 h) as com-
pared to patients who underwent delayed excision (after
5 days, but within 3 weeks) (4). These authors noted that
the incidence of hypertrophic scars and subsequent scar
contractures of the neck were lower in the early-excision
group. In addition, subsequent revisions were more
common in the early-excision group. Similar to previous
studies, Voinchet et al. (4) supported the concept of
early excision of acute neck bums noting its impact
on subsequent reconstructive procedures. However, it
should be noted in this study that the extent of neck
bums and the frequency in which meshed skin grafts
were utilized within each group were not addressed. The
use of meshed split-thickness skin grafts or thin-sheet
grafts may affect the subsequent development of
cervical contractures. In addition, postoperative compli-
ance is also a factor in the prevention of these problems.
However, even with these issues factored in, early excision
in facial and neck burns seems to be favored.
When acute cervical bums require coverage of the soft
tissues with split-thickness skin grafts (STSG), insuring
graft survival is cmcial. The intraoperative techniques of
obtaining hemostasis and insuring contact of the graft to
the concave recipient bed are crucial for graft survival.
Postoperatively, the prevention of graft shearing may be
accomplished by placement of a tie-over bolster. Ideally,
patients are positioned supine on a short mattress so that
the neck is in extension. The head of the bed is put on
shock blocks to simulate the reverse Trendelenberg pos-
ition to facilitate oral intake. A full liquid diet is instituted
for a few days in cases where large grafts are used to
resurface the neck. Prism glasses are important to
improve visualization of the surroundings while in this
position. If bolsters are used, grafts are exposed in 5-7
days. Once graft take is deemed acceptable, patients are
placed in hard neck collars to maintain neck extension
between 90° and 105°. This collar is worn during the
day. At night, the short mattress supine position is encour-
aged. Alternatively, the neck collars can be worn at night
but they tend to be less comfortable. Physical therapy is
instituted during this time to maintain and improve range
of motion. Yet, in spite of these measures, cervical bum
scars continue to be problematic.
III.
NORMAL NECK CONTOUR
The recreation of the youthful neck has been a topic in
plastic surgery for years (5-9). Over time, various tech-
niques have been devised to improve the aging neck and
return it to its youthful appearance. Today, most
approaches to this operation have utilized variations
of transection or plicatiar of the platysma muscle to
achieve this goal. In addition, submental fat resection or
liposuction has become a standard adjunct to rejuvenate
the neck. Ellenbogen and Karlin (8) produced five visual
criteria for the youthful neck. These criteria include: (1)
a distinct mandibular border from mention to angle; (2)
a subhyoid depression which gives the neck the appear-
ance of being long and thin; (3) a visible thyroid cartilage
bulge; (4) a visible, anterior border of the sternocleidomas-
toid muscle; and (5) a cervicomental angle between 105°
and 120° (Fig. 25.1). These criteria are important par-
ameters to keep in mind when reconstmcting patients
with severe cervical bum scar contractures. In burned chil-
dren, the type of operation performed will affect neck
contour later. In order to achieve as normal a contour as
possible, aside from prominence of the thyroid cartilage,
these measurements approximate what we would like to
achieve in the correction of severe cervical contractures.
Table 25.2
Degrees of Normal Cervical Spine Range
of Motion According to American Association of
Orthopedic Surgeons (AAOS)
Flexion
0-45
0-30
Extension
0-45
0-30
Lateral flexion
0-45
0-40
Rotation
0-60
0-30

Correction of Cervical Burn Scar Contractures
349
Figure 25.1
Criteria for the youthful neck: (1) distinct inferior
mandibular border, (2) subhyoid depression, (3) visible thyroid
cartilage bulge,
(4) visible anterior stemoclesidomastoid
border, and (5) SM-SM angle of 90° (cervico-mental angle
between 105° and 120°). [Reprinted with permission from
Ellenbogen and Karlin (8).]
In Grade II cervical contractures or greater, scar excision is
necessary to obtain a complete release of the neck. Tran-
section of the platysma muscle here is routine. Protection
of the overlying fascia adjacent to the submandibular
gland is often overlooked in this type of surgery.
However, it is crucial that the fascial layer here remains
intact. Violation of this fascia will produce glandular
ptosis and compromise the final aesthetic results. Cur-
rently, a number of procedures are described to correct
severe cervical bum scar contractures. They range from
the use of skin graft to free-tissue transfers (9). The
decision as to how one should proceed to correct these dif-
ficult problems should be guided by tissue availability,
patient circumstances, and our visualization of the resul-
tant neck aesthetics.
A.
Recons truction
The surgical management of cervical contractures is
dependent on the severity of the contracture, the avail-
ability of acceptable donor sites, and the compliance of
the patient. The support of the family to encourage the
patient to follow through with the postoperative plan is
also crucial. In addition, the availability of local resources
to assist with physical therapy may have an impact on the
choice of tissue used for reconstruction. For the surgeon,
the goal is to provide stable soft tissue coverage which cor-
rects facial deformities, returns range of motion to normal,
reconstructs the cervicomental angle, and blends in well
with patient’s color and skin texture. Needless to say,
the reconstructive choice should provide normal contour
to the neck. To date, these ideals are not uniformly accom-
plished in the reconstruction of cervical deformities.
Current methods used to address cervical contractures
range from the use of skin grafts and local skin flaps to
complex reconstruction with expanded pedicled myocuta-
neous flaps and free-tissue transfers. Needless to say, the
experience of the surgeon plays a large role in determining
the choice of procedure. The choice as to which recon-
struction to proceed with is influenced by all of the
above factors.
IV.
CLASSIFICATION OF NECK
CONTRACTURES
All cervical bum scar contractures are not equal. Conse-
quently, their management differs. It may be useful to clas-
sify these contractures based on their effects on range of
motion as well as their effects on the production of second-
ary facial distortion. Although it is clear from the literature
that a multitude of procedures exist for the correction of
these problems, analysis as to which procedure is appropri-
ate is lost since the degree of contracture is either omitted
or presented as a case report or in a limited series. In
addition, long-term follow-up is often missing.
A.
Grade I Contractures
Grade I cervical contractures are mild contractures.
Usually, the patient has full extension, but complains of
tightness in the neck. Facial distortion on full extension
is not present. However, on physical examination, neck-
bands of varying widths are present. Narrow neckbands
can be corrected with multiple Z-plasties, which lengthens
the neck tissue and reorients the scar. Rarely are skin grafts
necessary to correct this problem (Fig. 25.2).
B.
Grade II Contractures
Grade II cervical contractures are moderate contractures in
which patients are able to extend the neck, but facial dis-
tortion is noted. The range of motion is past 90°, but
may fall short of full extension. This indicates that there
is a significant soft tissue deficit. Occasionally, the neck
extension will also cause cephalad migration of the
nipple-areola complex in female patients. Correction of
the contractures may require large transportation flaps.

350
Functional and Aes thetic Recons truction of Burned Patients
Figure 25. 3 Grade II neck contracture. Near complete exten-
sion is noted; however, lower lip ectropion with inferior displace-
ment is noted on the right side.
tissue coverage of defects in Grade III contractures has
sparked utilization of a variety of surgical procedures, all
with purported superiority over the standard technique of
resurfacing with skin grafts (Fig. 25.4) (10-14).
D.
Grade IV Contractures
Grade IV contractures are described as those in which
patients are unable to reach the neutral position.
Figure 25.2
(A) Grade 1 neck contracture: full extension: no
facial distortion but a central band is present making patient
symptomatic. (B) Blunting of cervicomental angle is noted.
[Reprinted with permission from Ellenbogen and Karlin (8).]
Large cervical flaps, either alone or in combination with
other cervical flaps, may be used for closure (Fig. 25.2).
Alternatively, the use of full-thickness skin grafts
(FTSG) provides adequate correction, if available. If
FTSG are unavailable, thick STSG may be used.
However, when skin grafts are used, splinting is crucial
in the postoperative phase to prevent recurrence.
C.
Grade III Contractures
Grade III cervical contractures are diagnosed when neck
extension past the neutral plan of 90° cannot be achieved.
Facial distortion is usually present (Fig. 25.3). These
patients require extensive neck releases, not only of the
skin, but also of the underlying platysma muscle. Soft
Figure 25. 4
Grade III neck contracture; limited range of
motion; patient unable to extend beyond neutral position.

Correction of Cervical Burn Scar Contractures
351
Figure 25. 5
(A and B) Grade IV neck contracture with patient unable to extend neck to neutral position. (C) Grade IV neck contracture
with fusion of chin to the anterior chest wall.
Occasionally, such patients can present with fusion of the
neck to the anterior chest wall (Fig. 25.5). These patients
have fixed neck contractures with severe impairment in
ADLs. Needless to say, facial distortion is always
present. Although airway obstruction does not appear to
be present, the quality of life for these patients is dismal.
Similar to patients with Grade III neck contractures,
various methods for correction have ranged from the use
of skin grafts to free-tissue transfer. Yet, regardless of
which techniques are utilized, functional and aesthetic
considerations must be taken into account.
V.
SKIN GRAFTS
To many investigators, the time-honored use of skin grafts
remains the standard method of treatment for severe men-
tostemal contractures. The advantage of this procedure is
the ability to resurface large areas of the neck, the ease
of the procedure, and the ability to restore aesthetics of
the neck. However, recurrent contractures are a common
concern unless a protracted course of splinting is followed.
McCauley et al. (15) retrospectively evaluated the use of
STSG vs. FTSG in the management of Grade IV cervical
bum scar contractures in 18 children referred to his insti-
tution. Ten patients with a mean age of 7.6 years under-
went STSG with a mean thickness of 17/1000 in. These
patients were compared to eight children with a mean
age of 9 years who underwent an FTSG placement for cor-
rection of Grade IV cervical contractures. The mean time
from injury to reconstruction was ~18 months for all
patients. Although 7 out of 10 patients with STSG required
additional revisions with STSG at ~17 months, only 3 out
of 8 patients with FTSG required additional releases at
2^-years. Although splinting was required from 3 to 6
months, all patients ultimately had successful outcomes
(Figs. 25.6-25.8). It is important to recognize that the
use of STSG in these patients were not failures. This
study does emphasize the fact that STSG are not always
able to keep up with the growth of children. However,
FTSG appear to be better suited.
VI.
FLAPS
Grade III and IV burn scar contractures of the neck usually
involve the anterior neck, lateral neck, and submental
region. The earliest use of flaps to address this problem
was reported by Mutter in 1842 (10). This flap is a
cutaneous skin flap oriented over the lateral shoulder and
is believed to have been limited, since neither fascia nor
muscle was included in the pedicle (11). Arufe referred
to this cervicoacromial flap as the epaulette flap and suc-
cessfully used it to resurface defects after the release
of bum scar contractures of the neck (16). In a series of
286 cases, the procedure was performed in stages, one of
which included a delay procedure. Several investigators
recognized the value of this flap in the correction of cervi-
cal burn scar contractures (17,18). They also recognized
from Arufe’s experience that there were limitations in
width and length. Consequently, the use of the expanded
version of this flap has been reported on several occasions
(17,18). In a series of 12 patients, Almeida et al. (18)
reported the use of the expanded cervicoacromial flap in
an attempt to minimize limitations of length and width.
The complication rate from exposure of the expanders
was only 8.3% (one patient). However, the correction of
dog-ears at the base of the flap was frequent (67% of

Figure 25. 6
(A, B) Seven-year-old male with Grade IV neck contracture; severe facial distortions noted. (C, D) Five years later after
two operations to the neck using split-thickness skin grafts and one operation using a large Z-plasty to correct contour problems: no oper-
ative intervention in 2\ years; note full neck extension. (E, F) Pre- and postoperative right lateral view: note normal neck contour.
(G, H) Pre- and postoperative left lateral view: note normal neck contour.

Correction of Cervical Burn Scar Contractures
353
Figure 25. 7 (A, B) A 6-year-old female with Grade IV neck contracture. (C) Patient underwent excision of burn scars with allograft
placement. Four days later, patient returned to the operating room for allograft removal and resurfacing with FTSG taken from the
abdomen. (D) Two-year follow-up with contour of the neck maintained. Patient 1 week earlier, underwent Z-plasties within the
FTSG to correct lateral bands.
patients). The author noted that expansion not only
allowed for an increase in flap width, but also provided a
thinner flap with better contouring of the neck.
Aranmolate utilized the bilobed skin flap to correct
Grades III, IV contractures of the neck. This procedure
is offered as an alternative to the use of skin grafts (19).
In nine patients, most of who were children, the prerequi-
site for use of this flap was a scar-free shoulder, including
the lateral two-thirds of the clavicular region. The flap is
designed and transposed in a fashion similar to multiple
modified Z-plasties with excellent results initially. Early
results show excellent neck contour, re-creation of the
normal cervicomental angle, and a reasonable range of
motion. However, long-term follow-up for this promising
procedure is not available.
The use of myocutaneous flaps in correction of cervical
bum scar contractures is controversial. Several pedicled
myocutaneous flaps have been described, not all with
ideal designs or outcomes (11-14,20). Isenberg et al.
(11) described the use of the longitudinal trapezius

354
Functional and Aes thetic Recons truction of Burned Patients
Figure 25. 8
(A) A 6-year-old child with Grade IV lateral neck
and shoulder contractures. (B) Three and a half years of follow-
up, 2 years since the last release of contractures of neck and
shoulder with STSG (two operations required).
fasciocutaneous flap for correction of severe burn scar
contractures of the neck. This flap is based on the trans-
verse cervical artery. Although length may not be a
problem, flap width is limited and may not fully correct
the neck contracture. Long-term follow-up for this pro-
cedure is absent. The latissimus dorsi myocutaneous flap
(LDMF) was originally described as a fasciocutaneous
flap by Tolhurst and Haesecker in 1982 (12). At that
time, it was advocated for correction of axillary contrac-
tures. The inclusion of the latissimus dorsi muscle into
this flap has been used for the correction of anterior neck
contractures (14). Wilson et al. (13) described the use of
the LDMF in six patients with Grade IV neck contractures.
Although this flap corrects the defect in a single stage, they
admit that the dissection is difficult, the size of the skin
Figure 25. 9 (A, B) A 15-year-old male referred to our
institution after correction of cervical contracture using a
parascapular flap. Obliteration of cervicomential angle is
noted. Although the flap survived, aesthetics were severely
compromised.
paddle is limited, and partial necrosis of the skin, although
minor, is common. However, again, long-term follow-up
is lacking. In addition, it is unclear as to whether complete
correction of these contractures was obtained (14). Aesthe-
tically, the cervicomental angle was not fully corrected
with this technique. One of the major problems associated
with the use of myocutaneous flaps for cervical reconstruc-
tion is its bulkiness and color mismatch. Ohba et al. (20)
described the extended serratus anterior myocutaneous
flap as a thin, reliable pedicled flap, which maintains the
contour and aesthetics of the neck. However, some limit-
ations exist. The width of the skin paddle should be
<10 cm in an adult. This makes reconstruction of the
entire neck difficult. Consequently, only contractures in
the upper half of the neck are recommended for correction
with this flap.

Correction of Cervical Burn Scar Contractures
355
VII.
MICROVASCULAR FREE-TISSUE
TRANSFER
The use of free flaps in the correction of cervical contrac-
tures has been extensively reported (21-26). Most com-
monly, the scapular or parascapular fasciocutaneous
free flap has been used owing to its increased size to
cover large skin defects (21-23). With free-tissue trans-
fers having a >95% survival rate, safety is usually not
an issue (24,27). What is of concern is aesthetics. These
flaps may require multiple revisions to obtain definition
of the cervicomental angle as well as improve lower
neck contour (25) (Fig. 25.9). Yet, without the proper
design of flap width, disasters can occur even with flap
survival (Fig. 25.10). Recently, Yang et al. (26) also
recognizing the problem of the neck contour with free-
tissue transfer, described the use of the anterolateral
thigh flap, combined with cervicoplasty, to correct
cervical burn scar contractures. This group was the first
to compare preoperative and postoperative range of
Figure 25. 10 (A) A 12-year-old male referred for correction of Grade III cervical contracture. (B) Near complete scar excision
necessitated a large (10 x 20 cm) parascapular free flap for coverage. (C) Insetting of parascapular flap: head is at the top. (D) Final
result after three procedures to debulk the flap.

356
Functional and Aes thetic Recons truction of Burned Patients
motion measurements. The mean extension in this group
of patients preoperatively was 95° (almost Grade III
neck
contractures).
Postoperative
improvements
in
extension and lateral rotation were noted although
follow-up was only 5 months. However, width limitations
prevent the use of this flap for resurfacing of the entire
neck.
Tissue expansion has found a permanent place among
the reconstructive options available to surgeons. It is
not surprising that it has found a place in the recon-
struction of bum patients with head and neck defor-
mities. Expanded free-flap transfers have been reported
in the correction of cervical contractures (25,28,29). In
an attempt to further provide thin vascularized tissue
to the neck for correction of cervical contractures,
Woo and Seul (28) reported the use of the expanded
arterialized venous free flap. The pre-expansion of this
flap in three patients, eliminated problems of flap
necrosis and provided a large, thin segment of vascular-
ized tissue for resurfacing of the neck. Celikoz et al. (29)
utilized the expanded sensate radial artery free flap for
resurfacing of cervical contractures. However, this flap
is of limited size, although its thinness and pliability
are ideal for the neck. With a variety of techniques
reported for the reconstmction of cervical bums, very
few comparative studies exist. Recently, Adant et al.
(30) reported the long-term follow-up of a study which
compared skin grafts, tissue expanded flaps, and free-
tissue transfer in the correction of cervical contractures
(30). Although the series is small, five patients within
each group, with follow-up of at least 1 year, produced
some interesting observations. Apparently, all patients
had Grade III/IV neck contractures. In a comparison of
morbidity, skin elasticity, skin sensation, color match,
and scar recurrence, the use of full-thickness skin grafts
appears to be preferred.
VIII.
CONCLUSION
The management of cervical bums during the acute phase
of injury, along with rehabilitation efforts, can avoid major
bum scar contractures. However, most circumstances are
not ideal and bum scar contractures still occur. Our
approach to the reconstmction of these problems
depends on both severity and tissue availability. Most con-
tractures are mild or moderate (Grade I or II), and are
easily corrected with local flaps or skin grafts. As contrac-
tures become more severe, the methods used for correction
become more diverse. The use of split skin grafts con-
tinues to deliver excellent results. However, postoperative
splinting is necessary. In addition, in children, frequent
revisions using skin grafts are negative aspects of this pro-
cedure. FTSG may be of better benefit. Pedicled flaps, both
expanded and nonexpanded, have shown some promise
(10-14,16-20). The use of free-tissue transfers, both
expanded and unexpanded, has also been successful
(21-23,25-31). However, with respect to achieving aes-
thetic contours of the neck and restoring the cervicomental
angle, multiple revisions after free-tissue transfer includ-
ing defatting and Z-plasties are required (25,26). The use
of arterialized venous free flaps may help minimize
these problems (28). The results from the use of tissue sub-
stitutes are early. Yet, some results have been less than
optimal (32). Still, it appears that the standard for correc-
tion of cervical contractures by which all techniques are
judged may be of use for skin grafts. Here, the extent of
coverage is not limited to the anterior neck as noted with
many other techniques. With FTSG, a two-stage approach
may be required for the resurfacing of extensive neck
defects. A complete incisional or excisional release is
carried out in stage 1, followed by autografting at stage
2 (15). However, in spite of the report by Adant et al.
(30), which indicates that the skin grafts may be preferred
to tissue expansion or free-tissue transfers, these patients
will require a protracted course of splinting. Yet, the
results can be outstanding. As we continue to search for
ideal methods for the reconstmction of cervical bum scar
contractures, the restoration of the cervicomental angle
and providing contour for the lower neck region should
be the focus by which to direct our surgical intervention.
Many of the described techniques were developed and
utilized in the neck to address these issues. Although
there may be a place for all of these techniques, the
severity of the contracture, donor site availability,
patient compliance, and expected aesthetic results will
help in the selection of the most appropriate procedure.
REFERENCES
1.
Hunt JL, Purdue GF, Spicer T, Bennett G, Range S. Face
bum reconstmction—does early excision and autografting
improve results. Bums 1987; 13:39-44.
2.
Jonsson CE, Dalsgaard CJ. Early excision and skin grafting
of selected bums of the face and neck. Plast Reconstr Surg
1991; 88:83-94.
3.
Fraulin FOG, Lllmayer SJ, Tredget EE. Assessment of
cosmetic and functional results of conservative vs. surgical
management of facial bums. J Bum Care Rehab 1996;
17:19-29.
4.
Voinchet V, Bardot J, Echinard C, Aubert JP, Magalon G.
Advantages of early bum excision and grafting in the treat-
ment of bum injuries to the anterior cervical region. Bums
1995; 21:143-146.
5.
Webeter RC, Smith RC, Smith KF. Face lift, part 2:
etiology of platysma cording and its relationship to treat-
ment. Head Neck Surg 1983; 6:590-595.

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6. Newman J, Lolsky RL, Mai ST. Submental liposuction
extraction with hard chin augmentation. Arch Otolaryngol
1984; 110:454-457.
7. Connell BF. Neck contour deformities—the art, engi-
neering, anatomic diagnosis, architectural planning, and
aesthetics of surgical correction. Clin Plast Surg 1987;
14(4):683-692.
8.
Ellenbogen R, Karlin JV. Visual criteria for success in
restoring the youthful neck. Plast Reconstr Surg 1980;
66(6):826-837.
9. Stamatopoulos C, Panayotou P, Tsirigotou S, Ioannovich JD.
Use of free flaps in the aesthetic reconstruction of face and
neck deformities. Microsurgery 1992; 13:188-191.
10. Mutter TD. Cases of deformities from bums relieved by
operation. Am J Med Sei 1842; 4:66-80.
11. Isenberg JS, Price G. Longitudinal trapezius fascio-
cutaneous flap for the treatment of mentosternal bum scar
contractures. Bums 1996; 22:76-79.
12. Tolhurst DE, Haesecker B. Fasciocutaneous flaps in the
axillary region. Br J Plast Surg 1982; 25:430-435.
13. Wilson IA, Lokesh A, Schubert A, Benjamin CJ.
Latissimus dorsi myocutaneous flap reconstmction of
neck and axillary bum contractures. Plast Reconstr Surg
2000; 105:27-33.
14. Argarwal R, Chandra R. Latissimus dorsi myocutaneous
flap reconstmction of neck and axillary bum contractures;
correspondence and brief communication. Plast Reconstr
Surg 2000; 106:1216-1217.
15. McCauley RL, Owiesy F, Dhanraj P. Management of Grade
IV neck contractures in children. Proc Am Bum Assoc
2001; 22:89.
16. Amfe HN, Cabrera VN, Sica IE. Use of the epaulette flap to
relieve bum contractures of the neck. Plast Reconstr Surg
1978; 61:707-714.
17. Karacaoglan N, Uysal A. Reconstmction of post burn scar
contractures of the neck by expanded skin flaps. Bums
1994; 20:547-550.
18. Almeida MF. Expanded shoulder flap in bum sequela. Act
Chir Plast 2001; 43:86-90.
19. Aranmolate S, Attah AA. Bilobed flap in the release of
postbum mentosternal contractures. Plast Reconstr Surg
1989; 83:356-361.
20. Ohba S, Inoue T, Ueda K, Takamatsu A. The pedicled,
extended serratus anterior musculocutaneous flap for
cervical contracture release. Ann Plast Surg 1995;
35:416-419.
21.
Tseng WS, Cheng, Tung TL, Wei FC, Chen HC. Micro-
surgical combined scalpular/parascapular flap for recon-
struction of severe neck contractures case report and
literature review. J Trauma Inj Infect Crit Care 1999;
47:1142-1147.
22.
Angrigiani C, Grilli D. Total face reconstmction with one
free flap. Plast Reconstr Surg 1997; 99:1566-1575.
23. Xu J, Li SK, Li YQ, Ma XB, Li SY. Superior extension of
the parascapular free-flap for cervical bum scar contracture.
Plast Reconstr Surg 1995; 96:58-62.
24.
Wei FC. Overview of microvascular surgery. In: McCauley
RL, ed. Aesthetic and Functional Reconstmction of Bums.
New York: Marcel Dekker, 2005.
25.
Fan JC. Post-transferred tissue expansion of a musculo-
cutaneous free-flap for debulking and further reconstruc-
ture. Ann Plast Surg 1997; 38:523-526.
26. Yang JY, Tsai FC, Chana JS, Chuang SS, Chang SY,
Huang WC. Use of free thin anterolateral thigh flaps
combined with cervicoplasty for reconstmction of post
bum anterior neck contractures. Plast Reconstr Surg
2002; 110:39-46.
27. Inigo F, Jimenez-Murat Y, Arroyo O, Martinez A,
Ysunza A. Free flaps for head and neck reconstmction in
non-oncological patients: experience in 200 cases. Micro-
surgery 2000; 20:186-192.
28. Woo SH, Seul JH. Pre-expanded arterialised venous free
flaps for bum contracture of the cervicofacial region. Br J
Plast Surg 2001; 54:390-395.
29. Celikoz B, Sengezer M, Guler MM, Selmanpakoglu N.
Reconstmction of anterior neck contractures with sen-
sate expanded radial forearm free flap. Bums 1996;
22:320-323.
30. Adant JT, Bluth F, Jacquemin D. Reconstmction of neck
bums. A long-term comparative study between skin
grafts, skin expansion and free flaps. Acta Chir Belg
1998; 98:5-9.
31. Angrigiani C. Aesthetic micosurgical reconstmction of
anterior neck bum deformities. Plast Reconstr Surg 1994;
93:507-518.
32. Hunt JA, Moisidis E, Haertsch P. Initial experience of
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(Trang không có chữ)

26
Correction of Soft Tis s ue Defects of the Back and Shoulders
NELSON SARTO PICCOLO
Instituto Nelson Picolo and Pronto Socorro para Queim aduras, Goiánia, Goiás, Brazil
I.
INTRODUCTION
Bum wounds of the back and shoulders can be an isolated
injury or part of a more complex, larger bum. In the pedi-
atric population, younger children frequently have deep
and extensive injuries, caused by scalding liquids, com-
monly involving the head, neck, shoulders, and back.
Flame burns are only responsible for about 8% of all
our burns, but they are the most frequent cause of major
burns in adults. Although rarer in Brazil, but very frequent
in the United States and Europe, the wounds generated in
these accidents are usually very deep, large burns, which
require aggressive surgical treatment (Fig. 26.1).
The surgical management will be dictated not only by
the depth of injury, but also by the extent of the injury.
In addition, the experience or method with which the treat-
ing burn team is acquainted influences outcome. The
choice and timing of treatment may influence both
functional and aesthetic results in the immediate and in
the long term since backs may be grafted later or with
“lesser quality” meshed skin in major burns. Better
quality skin grafts are typically used to cover more critical
areas, such as face, hands, and major joints.
Since scald burns are not all treated the same way by the
various services, particularly in children, the reconstruc-
tive surgeon may also be faced with patients who
present with hypertrophic scars as a result of nonexcised,
nongrafted areas. These sequelae are generally accom-
panied by various degrees of functional deficit, which
may influence the surgeon to take a more immediate
approach for the patient’s reconstruction, even before
complete maturation of the scar tissue has occurred.
More recently, the advent of bioengineered skin substi-
tutes, has allowed earlier closure of bum wounds. Accord-
ingly, this has led to earlier hospital discharge and
rehabilitation procedures in most burn centers (1-3). In
the vast majority of bum patients, the sequelae of major
burn injuries involve the skin and scar contractures. In
most cases, then, planning a reconstructive procedure
rests on how to promote the substitution of scarred skin
with healthy, normal looking skin. Obviously, injuries
involving deeper tissues, such as electrical bums, will
have to be reconstructed accordingly (4,5) (Fig. 26.2).
Whatever the method chosen for the surgical correction
of these soft tissue defects, the operating surgeon should
provide a timely procedure, which will yield a profitable
359
I.
Introduction
359
VI.
Nursing Issues
365
II.
Preoperative Evaluation
360
VII.
Rehabilitation Issues
365
III.
Surgical Options
361
VIII.
Long-Term Outcome
365
IV.
Intraoperative Considerations
362
IX.
Conclusion
365
V.
Pitfalls
364
References
366

360
Functional and Aes thetic Recons truction of Burned Patients
Figure 26.1
Patient with extensive flame burn, also involving
the back and shoulders.
result for the patient. The results should not only be func-
tional and aesthetic, but also reflect positively on the
patient as a whole to improve self-esteem and his or her
abilities to relate socially and to function better in his/
her activities of daily living (ADLs). The ultimate goal
for the reconstructive team then is to bring the patient
back to his preinjury status, which, unfortunately, cannot
always be achieved.
II.
PREOPERATIVE EVALUATION
Although preoperative assessment must be performed to
not only identify functional deficits, but also address
patient’s complaints. Planning for an operative procedure
for a specific patient will obviously be influenced by the
injury as a whole. But, for the purpose of this chapter,
we will present considerations on the treatment of burn
sequelae of the back and shoulders only. Although one
may have significant functional deficits as a result of
back bums, impairment may be more important as a
result of shoulder burns. Hypertrophic scarring and con-
tractures are the main cause of poor functional results.
However, patient compliance with occupational therapy
and physical therapy (OT and PT) can influence the
outcome. This aspect of care must always be closely
followed.
Continuity of the treatment offered to the patient may
require an even larger commitment of all involved. As
the burn team and the patient initially pursued survival
during the acute phase of injury, all who were engaged
in this process must now pursue the same direction with
a broader view. Here, the goals are restoration of function,
Figure 26. 2
(A) Electrical injury to the left trunk and back. (B) Same patient, postexcision. (C) Same patient, after skin grafting.
(D) Same patient, after skin grafting, posterior view.

Correction of Soft Tis sue Defects of the Back and Shoulders
361
improvement in the cosmetic aspect of the burn scar,
and adaptation of the patient to a new image and a new
life (6). Compliance with the use of pressure garments
and frequent visits to the PT/OT department all influence
the outcome of the surgical procedure. The patient must
be aware that a similar or even better performance
at the PT/OT suite will be requested of him in the
immediate postoperative period to insure the success of
the operative procedure. Important considerations are
the continuation of the rehabilitative program initiated
early, during the acute phase of treatment, with continu-
ous and progressive active range of motion in all joints
and proper positioning at rest. In addition, avoiding tech-
niques that unnecessarily immobilize the patient or body
parts is essential (7).
The bum injury may have left a severe, disfiguring as
well as functionally crippling scar. The patient may
be depressed or undergoing psychological counseling,
which will require continuous support toward the plan-
ning, execution, and result of the proposed surgical
treatment. In our institution, the patient is evaluated by
the surgeon, the physiotherapist, the occupational thera-
pist, and the psychologist. As a result of this evaluation,
his or her complaints are noted and his or her needs are
prioritized in accordance with the degree of disability or
severity of the disfigurement. The entire team involved
in the treatment of the patient must be aware of the
patient’s case as well as acquainted with him or her per-
sonally. A thorough evaluation of the patient’s psycho-
logical status may be the single most important step of
the preoperative evaluation. Although the adult, male
patient is more frequently concerned with functional
aspects, cosmesis may be the stronger issue in the cases
of children and female patients. The patient must deal
with realistic expectations for an already difficult situ-
ation. The injuries or disfigurements may be severe and
he may be experiencing difficulty in coping with his
everyday life. This issue may be even more complex
when the patient is a child. Here, parents may feel
guilty about the initial event, and may be obtrusive rela-
tive to following the usual sequential treatment in rehabi-
litation, willing to “burn steps” and go immediately into
surgery. The other end of this complex spectrum is rejec-
tion of the patient by one or both parents. Forced seclu-
sion, not allowing the child to go to school, play, or
participate in social activities with his or her peers is a dif-
ficult challenge (8). The surgeon may also have to enforce
proper timing of the procedures when regional habits and
custom influence the requests for reconstmction. This is
frequently the case in Brazil, where the weather is
always hot, and female patients will very often ask for
immediate reconstmction of the bum sequelae concerning
the back, so they can soon go back to sun tanning and
wearing light or minimal clothing.
When considering how to correct back and/or shoulder
soft tissue defects, the surgeon will soon realize that in
most cases, wound closure was attained with skin grafts
acutely. The exception usually happens in electrical
bums, or deep friction bums, when deeper tissue injury
is the rule and skin or muscle flaps may have to be used
(9) (Fig. 26.3). The method of acute treatment will, of
course, influence the method of reconstmction. Local
tissue may have already been spent for the initial injury
problem, and there may be different types of tissue cover-
ing the posterior trunk. Local tissue may have been utilized
as pedicled flaps to reconstmct more mobile, extensile
parts like the neck or the axilla. In cases where the back
and/or shoulder injury has been an isolated injury, with
normal skin in the periphery of the sequela, the treatment
of choice will be tissue expansion (Fig. 26.4). Tissue
expansion has been widely used all over the world, in all
age brackets, for removal of bum scars. It is a very versa-
tile technique, with an infinity of implant shapes and sizes.
Better results are generally obtained when the scar tissue is
already mature and the patient comprehends the sequence
of treatment required in this technique. The learning curve
is relatively short and swift, for both the surgical team and
the patients. The later benefits are that these patients can be
taught to expand the implants themselves, at home (10,11).
In cases where tissue contraction has resulted in func-
tional impairment in an area within a larger scar, it may
be necessary to surgically correct the lack of local tissue,
usually with incision and grafting, and/or with Z-plasties,
when there are contracture bands. Other options may
include the rotation of skin or composite flaps, and,
more rarely, even the transfer of distant tissue by micro-
surgical techniques (12) (Fig. 26.5).
In the rarer cases where skin grafting was placed onto
deeper stmctures like periosteum or deep muscle layers,
peripheral soft tissue can be expanded compositely,
III.
SURGICAL OPTIONS
Figure 26.3
Scald bum.

362
Functional and Aes thetic Recons truction of Burned Patients
Figure 26. 4 (A) Patient with postburn shoulder scar. (B) Tissue expander inflated. (C) Postoperative appearance after removal of burn
scar and resurfacing with expanded flap.
advancing skin, subcutaneous layer, fascia, and/or
muscle. The surgeon must not forget that all soft tissue
above the expander is expanded, including vessels and
nerves, and he should take advantage of these facts when
planning an adequate reconstruction for a particularly
difficult problem.
IV.
INTRAOPERATIVE CONSIDERATIONS
Most procedures in these areas are done under general
anesthesia in an intubated patient. Complete control of
the
airway
is
imperative
in
back
and
shoulder
reconstructive procedures due to the fact that awkward
positioning may result in respiratory obstruction if an
airway is not properly secured.
Skin markings for the placement of implants or expan-
ders, indicating the shape and rotation of a flap, should be
performed immediately before surgery, with the patient
awake and standing. Whenever possible, the natural skin
lines and creases should be respected. Failure to do so
may result in uneven anatomical placement of incisions
and, subsequently, unsightly scar lines.
Special care should also be taken when considering
using the normal skin of the axilla for the posterior
shoulder flap, particularly in the prepubertal patient,
Figure 26. 5
(A) Patient with severe restriction of shoulder movement, being expanded for full-thickness expanded skin graft, to be
placed on both axillas for bilateral shoulder release. (B) Patient 8 days postremoval of tissue expanders, partial scar removal and full-
thickness expanded skin grafting to both axillas. (C) Same patient with full functional recovery of shoulder movement.

Correction of Soft Tis sue Defects of the Back and Shoulders
363
when this area is hairless. These flaps can rarely be
advanced further than a few centimeters, because of the
risk of transferring hair-bearing tissue to a non-hair-
bearing area, such as the posterior inferior shoulder.
Although tissue expansion is probably the most widely
used technique for reconstruction in burn care today,
there are several issues to be considered and the seasoned
surgeon will take several precautions to minimize the
incidence of complications. A common misjudgment in
planning, at the time of ordering or choosing the tissue
expander, is that although the expander is presented as a tri-
dimensional implant with height, width, and length in the
catalog, when it is placed in the dissected surgical
pocket, it is placed flat or with minimal volume within.
Thus, its base now has an increased dimension on each
side. The implant now is much larger than the measures
described on its label. Consequently, it is most important
when creating the pocket for the tissue expander that one
considers the size of the base of the implant (width and
length) plus the folded sides, which will also be a part of
the flat cookie shape of the expander (Fig. 26.6). Implants
with a thick base should be reserved for areas with thicker
overlying tissues like the paramedian back area. Thinner
prosthesis should be the choice, to be placed on the
shoulders, and on or around the base of the neck. Beware
of the placement of an expander with a stiff base over a
curved surface like an upper arm or leg in a child. The
stiff base may project up into the skin as the base straight-
ens out increasing the risk of expander exposure. We often
inject a small amount of volume into the expander, through
the skin, into the expander port, after it is in its place, under
healthy or scar tissue. This will insure that the connection is
working properly. In addition, this provides a certain
massaging/buffer effect to the underlying tissue as the
patient moves or is moved in the immediate postoperative
period. Failure to consider the issues mentioned earlier may
cause folds or edges of the still flat expander to project into
healthy tissue or suture lines, which may result in local
discomfort, tissue necrosis, contamination of the surgical
pocket, and premature extrusion. If the surgeon chooses
to place continuous vacuum drainage for the first
24-48 h, as we usually do, the drain should be placed
before the expander to avoid its displacement or folding,
which may occur if the drain is forced within the surgical
cavity after the expander is already in place. The drain
should never be brought out through healthy, scarless
tissue, but via a stab wound in a neighboring scar. When
considering shoulder expanders, dissection should be
limited to the size and shape of the compressed expander.
Wider pockets in this area may facilitate “to and fro”
movements of the continuously growing implant, and it
may dislocate with gravity, into the lateral arm. This will
result in less tissue being expanded in the desired area,
where the tissues are firmer and thicker (Fig. 26.7).
Figure 26. 6
(A) Rectangular expander with “full” volume, seen from the side. (B) Same expander without any volume, “flat,” as it is
usually placed into the surgical cavity. Note the height of the empty prosthesis. (C) Rectangular expander with “full” volume, seen from
the top. (D) Same expander, “flat.” Note the larger area taken by the folded sides.

364
Functional and Aes thetic Reconstruction of Burned Patients
Figure 26. 7 (A) Patient with hypertrophic shoulder scar. (B) Same patient with expanders placed on left shoulder, being held up, on
the original surgically placed position. (C) Same patient, when expander is not held up, demonstrating the effect of gravity on the filled
prosthesis, on the looseness of the soft tissue in young patients. (D) Immediate postop result, demonstrating the lesser resection at
shoulder level, from where the prosthesis has been “taken” by gravity.
V.
PITFALLS
Although most plastic surgeons involved in bum recon-
struction have collected a vast experience with different
techniques of reconstmction, one must be aware of the
complications related to each technique and be prepared
for the occasional poor result. The patient and/or his or
her families must be made aware of these possible occur-
rences. A bum survivor may be under a varied load of
stress, and dealing with frustration could be very difficult,
when compared to other plastic surgery patients.
The surgeon must be honest with the patient and the
patient’s family, discussing the surgical plan, its expected
outcome, and possible complications and pitfalls. Patients
with a failed surgical procedure will rarely blame the sur-
gical team if they were made aware of this possibility
beforehand. The surgeon must also assure the prospective
patient that even though complications occur, the surgical
team is prepared to deal with them accordingly, taking the
appropriate measures in due time. It is widely accepted to
show pictures of unidentifiable patients with previous
similar cases, to give an idea of the expected results. The
author is personally against the use of computer images
that are modified on the screen to give an idea of the
expected results. Such images may not be representative
of the true results.
In our experience, the most frequent complication,
when considering tissue expansion, is the formation of
striae, followed by scar widening and implant dislocation.
Other failures are usually due to unrealistic surgical expec-
tations, as in the rare case where the surgeon may think
that more tissue can be removed. The resulting tight

Correction of Soft Tis sue Defects of the Back and Shoulders
365
suture line closure may result in dehiscence of the suture
line. This can produce a long-lasting wound where
previously only a scar existed. This may have happened
to several of us, generally, in earlier years of surgical
practice, when the eagerness to please the patient was
greater than common sense and the geometric reality
would dictate.
VI.
NURSING ISSUES
The nursing staff as an integral part of the bum team must
be intimately involved in the direct care and treatment of
the bum patient or victim who is planning to undergo sur-
gical reconstruction. Understanding the reconstructive
plan will allow for a smoother postoperative period,
when appropriate actions will be taken at the correct
time. Positioning may be a major issue and the nursing
staff will be working closely with the PT/OT group to
ensure the success of the operative procedure. Also, the
nursing staff may bring important input on how the
patient behaved after previous acute or reconstructive pro-
cedures. This helps the surgeon to recommend a more rea-
listic approach to certain patients who were considered
problem patients or difficult patients. Compliance with
positioning is absolutely necessary in the postoperative
care of most procedures in the back and shoulders. The
staff must be completely informed about each and every
case, and the requirements relating to their care and
expected outcome.
VII.
REHABILITATION ISSUES
The physiotherapist and the occupational therapist work
very closely in the recovery of the bum patient as a
whole. Since admission for the care of an acute burn,
these professionals control important issues which will
influence the outcome and result for that particular
patient. It is no different when reconstruction is con-
sidered. The patient who is a candidate for surgical treat-
ment of burn sequelae must be cleared by the
rehabilitation team in relationship to timing, necessity,
and compliance for the planned operation. The presence
of the PT or OT in the operating room is as routine nowa-
days as the presence of the circulating or scrub nurse,
anesthesiologist, or surgeon. Most splints are made
during or right after the procedure to insure proper posi-
tioning of the joints or extremities. This is frequently
necessary when considering shoulder or back procedures.
The patient as a whole is very important because most
splints may engage several parts of the body. Conse-
quently, the influence of support or motion to other body
parts must be taken under consideration. Preoperative con-
sultation with the rehabilitation team members will clear
any doubt as to where to reconstruct first, based on orthesis
placement, pressure garment requirements, and physio-
therapy progress.
VIII. LONG-TERM OUTCOME
Good results are undoubtedly the goal of any operative
procedure. Planning for sequential procedures in a bum
survivor is relatively standard procedure, since most
patients have several problems that cannot all be dealt
with simultaneously. In the usual case, the patient or the
parents will be made aware of the planned procedures
and how one previous procedure influences the next one.
Shoulders are generally treated earlier than backs, as the
patient may also have other areas that were prioritized in
the sequence of reconstruction.
Complete scar removal may be obtained with one or
more operations in the case of localized shoulder or back
scars, but pressure garments may have to be worn for
months or even more than 1 year after the procedure. If
scar widening still occurs, a revision may be in order.
Scar removal may not be the objective in some cases
where functional restriction is the concern. The patient
will be submitted to the technique that will fit the need.
Usually, incisions of the retraction area and thick split-
skin graft or full-thickness skin graft application may be
necessary. Alternatively, rotation of a local pedicled flap
may be the procedure of choice. The result here may be
appreciated earlier, and the patient may be back to his
usual function in a matter of weeks or months. Whatever
is the case, long-term good results are more prevalent
when the surgeon insures adequate, sequential procedures,
and the patient is realistic in his or her expectations.
IX.
CONCLUSION
As with any other part of the body which may have been
injured during a bum accident, the shoulder and the back
may have residual scarring and consequently functional
and aesthetic disabilities may ensue. The patient must be
prepared to face the challenges of reconstruction in order
to return to normal life as possible. This may require
psychological support as well as rehabilitative support.
However, these support systems must be put in place as
early as possible. There are a wide array of possibilities
at hand for the reconstructive surgeon who will obviously
choose the ones he or she is most acquainted with using.
Although complications may occur, the patient must be
assured that the bum team as a whole is prepared to deal
with whatever problem or difficulty he or she may have.

366
Functional and Aes thetic Recons truction of Burned Patients
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1.
Heimbach D, Heimbach D, Luterman A, Burke J,
Cram A, Herndon D, Hunt J, Jordan M, McManus W,
Solem L, Warden G. Artificial dermis for major bums: a
multicenter randomized clinical trial. Ann Surg 1988;
194:413-428.
2.
Tompkins RG. Increased survival after massive thermal
injuries in adults: preliminary report using artificial skin.
Crit Care Med 1989; 17:734-740.
3.
Fitton AR, Drew P, Dickson WA. The use of a bilaminate
artificial skin substitute (Integra) in acute resurfacing
of bums: an early experience. Br J Plast Surg 2001;
54:208-212.
4.
MacKinnon C, Klaassen M, Widdowson P. Reconstruction
of a severe chest and abdominal wall electrical burn injury
in a pediatric patient. Plast Reconstr Surg
1999;
103(6): 1775-1777.
5.
Foyatier JL, Comparin JP, Masson CL. Skin flaps and
extended full-thickness skin grafts. Indications in the
repair of bum sequelae. Ann Chir Plast Esthet 1996;
41(5):511-532.
6.
Petro JA, Salzberg CA. Ethical issues of bum management.
Clin Plast Surg 1992; 19(3):615-621.
7.
Boswick JA Jr. Comprehensive rehabilitation after burn
injury. Surg Clin N Am 1987; 67(1): 159-166.
8.
Patridge J, Robinson E. Psychological and social aspects of
burns. Bums 1995; 21:453-457.
9.
Xu X, Zhu W, Wu Y. Experience of the treatment of severe
electric bums on special parts of the body. Ann NY Acad
Sci 1999; 888:121-130.
10.
Manders EK. Soft tissue expansion. Concepts and compli-
cations. Plast Reconstr Surg 1984; 74:495-507.
11.
Hudson DA, Grobbelaar AO. The use of tissue expansion in
children with bums of the head and neck. Bums 1995;
21:209-211.
12.
Ono I, Tateshita T. Reconstruction of a full-thickness defect
of the chest wall caused by friction bum using a combined
myocutaneous flap of teres major and latissimus dorsi
muscles. Bums 2001; 27:283-288.

27
Recons truction of Axillary Contracture
J UI-YUNG YANG
Chang Gung Mem orial Hospital, Taipei, Taiwan
I.
INTRODUCTION
Axillary burn scar contractures are common problems
after deep thermal burns involving the upper trunk or
extremities because they are neither easily positioned
initially nor easily rehabilitated later. The contractures
can produce both functional and anatomical deformities.
A vicious cycle, caused by both repeated ulcers after exer-
cise and scar contracture after wound healing, frequently
develops during the rehabilitation stage. Surgical inter-
vention is usually needed if contractures are established.
However, surgical correction for axillary contractures
is still a challenge because the axilla is a unique
three-dimensional pyramid-shaped hollow formed by the
junction of the upper extremity and trunk (1). Thus, a
satisfactory reconstruction needs detailed preoperative
evaluation of the anatomy of axilla involved by scar
contracture and prioritizing available donor tissues.
II.
PREOPERATIVE EVALUATION
Axilla contractures are characteristically divided into two
groups: those involving the hairy dome and those that
do not. Grishkevich classified the contractures into two
types: edge contractures caused by a tight web and strip
contractures caused by a wide scar (2). Achauer (3) classi-
fied them into four types, namely, type 1, anterior or pos-
terior axillary fold only; type 2, both anterior and posterior
fold with the apex spared; type 3, the entire axilla; and type
4, scars of the axilla and the adjacent areas. Hallock’s (4)
classification of axillary contractures is modified from
Salisbury and Bevin (5) and also divided into four types:
(1) solitary anterior or posterior web; (2) scar bands
adjacent to axilla; (3) anterior and posterior webs with
the cupola spared; and (4) total axillary obliteration. The
key point of the classification of the axilla contracture is
to differentiate whether the dome of the axilla is involved
367
I.
Introduction
367
IV.
Intraoperative Considerations
375
II.
Preoperative Evaluation
367
V.
Pitfalls
375
III.
Surgical Considerations
368
VI.
Nursing Issues
376
A. Local Haps
368
yil.
Rehabilitation Issues
377
B.
Fasciocutaneous Flaps
371
v m
Long-Term Outcomes
377
C.
Muscle and Myocutaneous Flaps
373
D.
Microvascular Free-Tissue Transfer
374
e erences
E.
Tissue Expansion
374

368
Functional and Aes thetic Recons truction of Burned Patients
or not. If the dome is spared and most of the axillary hairs
exist, the reconstructive procedure may be aimed at the
release of contracture utilizing local cutaneous tissue
such as Z-plasty, etc. If the dome was already destroyed,
the reconstructive procedure may be aimed at the replace-
ment of the entire scar tissue utilizing local or distant
flaps or skin grafts.
Besides the local tissue condition, the abduction func-
tion of the upper limb should also be considered. Huang
et al. (6) used the range of motion and defined the severity
of the contracture as follows: mild, <25%; moderate,
25-50%; and severe, >50% (6). Usually a releasing pro-
cedure, using local tissue is enough for the mild cases and
a tissue replacement procedure is needed for the severe
cases. The surgical considerations for the moderate cases
depends on the local tissue condition.
III.
SURGICAL CONSIDERATIONS
The use of skin grafts is the basic technique to correct the
contracture. A full-thickness skin graft (FTSG) is the first
choice for replacement of the scar tissue if the graft donor
site is available. Less secondary contraction will occur
with FTSG than with split-thickness skin grafts (STSG).
However, the donor site of the FTSG should be closed pri-
marily or grafted with STSG. The shortage of graft donor
site is the main limitation in using FTSG for burn scar axil-
lary contractures. The use of STSG, although more donor
sites may be available, will have more secondary contrac-
tion. Prolonged immobilization initially and splinting later
is needed after application of STSG for the correction of
these scar contractures. The advantage of the use of skin
grafts in correcting burn scar contractures of the axilla
is that the reconstruction is also suitable, from minor
contractures to total obliteration of the axilla (Figs.
27.1-27.3). Recently, artificial dermis has been applied
to the reconstruction of bum scar contractures of the
axilla, especially when skin graft donor sites were not
available or a greater underlying dermal tissue cushion is
needed such as in the axilla or in the elbow (7,8).
However, this new technique requires a two-stage oper-
ation and is cost-ineffective. The postoperative rehabilita-
tion such as pressure therapy is still needed.
A.
Local Flaps
In the mild cases of scar band deformity, local Z-plasties
may be enough for the release of the contracture.
Examples in Figs. 27.4 and 27.5 show how a simple
Z-plasty can solve the problem of scar band deformity in
the anterior axilla. Sometimes, multiple Z-plasties may
be needed to correct a longer linear contracture band
(Figs. 27.6-27.9). In this case, the scar bands extended
from the elbow across the axilla to the upper chest and
Figure 27. 2 Release contracture with thick STSG taken from
the abdomen. Two years’ follow-up showed satisfactory results.
Figure 27.1
Severe scar contracture of the neck, axilla, and
elbow after flame bum since childhood.

Reconstruction of Axillary Contracture
369
caused limitations in extension of the upper limb. Various
directions of the Z-plasties not only solve the problem but
also provide the chance to excise some redundant scar
tissue. The Hirshowitz’s five-flap procedure is also very
effective in the release of the scar band deformities
(9,10). The triangular flaps of two opposite Z-plasties
and a Y -V advancement flap constitute the five flaps
(Figs. 27.10-27.13).
Figure 27. 3 Follow-up for 5 years showed good function of the shoulder function.
Figure 27. 4 Multiple scar bands in anterior axilla and arm.
Z-plasties were applied for release of contracture.
Figure 27. 6 Long linear scar bands involving elbow, axilla,
and upper chest.
Figure 27. 5 Effective release of the axillary contracture.
Figure 27. 7 Multiple different directions of Z-plasties were
applied.

370
Functional and Aes thetic Recons truction of Burned Patients
Figure 27. 9 Follow-up for one more year revealed satisfac-
tory results.
Figure 27.11
Design of a five-flap plasty for anterior scar fold
in the axillary region.
The V -Y plasty may also be used for correction of burn
scar contractures of axillary fold or adjacent areas (Figs.
27.14 and 27.15). The triangular flap was advanced and
rotated to achieve a greater release and avoid a linear
scar in the axillary fossa. Olbrisch’s running Y -V plasty
can be applied to longer scar band deformity like the
multiple Z-plasties (11).
Karacaoglan’s seven-flap plasty may be used in patients
with linear postburn axillary contracture (12). The geome-
try of the seven-flap plasty consists of two half Z-plasties
and one W -M plasty. Vaubel’s V flap designed for correc-
tion of the axillary defect can also be used for reconstruc-
tion after scar excision and the release of contracture (13).
The V-flap is a combination of V -Y advancement and two
Limberg transposition flaps.
Whenever healthy local tissue is available, the scar
shape should be taken into consideration to make a
better design in the reconstructive procedure. A specially
designed square flap applied to a patient with scar band
deformity in the posterior axillary fold is useful
(Fig. 27.16). The square flap method basically consists
of a square flap and 45° and 90° angled triangular flaps.
After joining these flaps, an elongation rate of +180% is
obtained (14). The effect of the release of contracture is
Figure 27. 12 The result of five-flap plasty after interpolation
of the flap.
Figure 27. 8 Immediate results of transposition of skin flaps of
those Z-plasties and excision of some redundant scar tissues.
Figure 27. 10 Interior scar fold deformities caused limitation
of arm abduction and shoulder elevation.

Reconstruction of Axillary Contracture
371
Figure 27. 13 Follow-up 1 year later revealed satisfactory
results.
Figure 27. 14 A big scar band in the anterior axillary fold that
caused contracture.
Figure 27. 15 The scar tissue was nearly matured and could be
used as an advancement and rotated flap in a modified V -Y plasty.
greater than with the Y -V advancement flap because the
head of the flap is a square not a triangular shape. The
advancement of the square flap also can provide more
chances to excise more scar tissue (Fig. 27.17).
Figure 27. 16 A square flap was designed for scar band
deformity in a patient with posterior axillary fold contracture.
B.
Fas ciocutaneous Flaps
When extensive adjacent scar tissue or even dome oblit-
eration is noted in axillary contractures, local cutaneous
flaps such as the Z-plasty is usually not enough for a
complete release. In this situation, larger local pedicle
flap such as fasciocutaneous flap is a better choice. The
most local random patterned transposition flap is elevated
at a safe base-length ratio of 1:1. However, the raising
of fasciocutaneous flaps with ratios of 1:3 or more can
survive (10,15). The blood supply to the deep fascia is
rich enough to support this flap so that the presence of
burned skin or grafts on part of the flap is not a contrain-
dication for use (16). Usually this flap is designed along
the lines of the contracture. Wherever possible, the flap
should be in an area where there is low tension in the
tissue at right angles to the scar axis so that the secondary
defect can be closed primarily (17). This flap may be elev-
ated from the lateral chest, the lateral back, or the para-
scapular, cervicohumeral, or thoracoacromial regions. In
addition, the posterior upper arm and inner arm can be
used depending on the relationships between the scar
tissue and the available donor site (17-22). A schema
for a reasonable flap selection process has been devised
based on the relative severity and anatomic location of
the axillary burn scar contracture (5) (Figs. 27.18-27.21).

372
Functional and Aes thetic Reconstruction of Burned Patients
These photographs document a young man with a scar
contracture involving the entire axilla including the dome
being treated with a fasciocutaneous flap with good results.
The range of motion of the shoulder improved from 70° to
~180°. Figures 27.22-27.24 document a scar contracture
not only in the axillary dome but also in the anterior shoulder.
A long fasciocutaneous flap, 5 cm x 18 cm, was elevated
from the lateral back and transposed 90° to cover the defect
in the axilla and anterior shoulder after releasing the contrac-
ture. The donor site can be easily closed primarily. The results
showed that the flap is well suited for this situation.
Most of the fasciocutaneous flaps were designed as
pedicled flaps. They may have dog-ears at the pedicle
after transposition. The movement of the flap is limited
due to the pedicle attachment. The island flaps may
solve this problem. For example, the scapular island flap
utilizing the circumflex scapular artery, a branch of the
subscapular artery, as its vascular pedicle can be rotated
180° on this pedicle to insert into the axillary defect
after contracture release (23-25).
Depending on the three cutaneous branches of the cir-
cumflex scapular artery, the scapular flap is designed hori-
zontally in the middle scapular region, the parascapular flap
obliquely in the lower scapular region, and the ascending
scapular flap vertically in the upper scapular region. All
can be used for axillary reconstruction (23,26,27).
Figure 27. 19 A big fasciocutaneous flap, 8 x 24 cm, was
designed in the lateral back.
Some modifications of the island flaps have been noted
to minimize the residual contractures or to increase the
width of the flap for coverage. A posterior arm fasciocuta-
neous flap with its feeding vessels from the brachial
vessels can also be elevated as an island pedicle flap to
increase the arc of rotation to cover the axillary defect
(21). The parascapular flap may be folded on to itself in
a “U” shape to double the width of the flap for greater cov-
erage (26) (Figs. 27.25 and 27.26). An axial bilobed flap,
based on the transverse and ascending branches of the cir-
cumflex scapular artery, is also successfully used to recon-
struct severe bum scar contractures of the axilla (28). The
primary flap may have greater width up to 12 cm and the
Figure 27. 17 The postoperative results of advancement of the
square flap after excision of the most severe scar tissue and
release contracture.
Figure 27. 18 Scar contracture with total obliteration of axil-
lary dome after flame bum.

Reconstruction of Axillary Contracture
373
Figure 27. 20 Complete release of the contracture and the
defect was covered by transposition of that flap. The donor site
was closed primarily.
Figure 27.21
Follow-up for two more years revealed satisfac-
tory results.
secondary defect can be closed primarily without tension.
Recently, the thoracodorsal perforator-based cutaneous
island flap was successfully used for extensive axillary
burn scar contractures (29). This flap offers some advan-
tages over other island flaps such as scapular or subscapu-
lar flaps. The exit points of the perforators are usually far
from the bum injury and the length of the vascular pedicle
permits the design of a large flap. In addition, the donor
site is easy to close primarily.
Figure 27. 22 Patient sustained scar contracture in axillary
dome and anterior shoulder. A long fasciocutaneous flap,
5 x 1 8 cm in size, was designed at the lateral back.
Figure 27. 23 The flap was transposed 90° to cover the defect
after complete release of contracture.
C.
Mus cle and Myocutaneous Flaps
The muscle or myocutaneous flaps, sometimes, are an
alternative choice for correction of extensive bum scar
contractures of the axilla. After releasing of the contrac-
ture, the lateral portion of the latissimus dorsi (LD)
muscle is chosen to transpose and fill the defect in axillary
area. Skin grafts are placed over the muscle (30). In
unusual
circumstances,
when
simple
options
are

374
Functional and Aesthetic Recons truction of Burned Patients
Figure 27. 24 Follow-up for several months showed satisfac-
tory results.
Figure 27. 25 A patient with scar contracture involving the
entire axilla was reconstructed with the folded parascapular flap.
Figure 27. 26 The flap totally survived and the shoulder
function was restored.
unavailable, the skin-grafted long head of the triceps
muscle flap may serve admirably as another vascularized
flap alternative for releasing of either anterior or posterior
axillary web contractures (31). The LD myocutaneous flap
is part of the armamentarium to reconstruct the axillary
region after wide releases of burn scar contractures (32).
The main disadvantage of using the LD myocutaneous
flap is its bulkiness. Dividing the thoracodorsal nerve
will, over time, reduce the bulkiness of the flap secondary
to muscle atrophy.
D.
Microvas cular Free-Tis s ue Trans fer
Microvascular free-tissue transfers, especially the free
perforator flaps, are now more popular. The ultrathin
cutaneous flap based on either septal or intramuscular
perforators, such as the anterior lateral thigh flap, is a
good choice to reconstruct the deformities in concavity
area such as the neck or axilla (33).
E.
Tis s ue Expans ion
Tissue expansion is a very useful technique for aesthetic
replacement of postburn scar deformities. It provides
skin flaps around the affected region with similar color,
texture, and composition for reconstruction (34,35). This

technique also provides minimal donor site morbidity.
Figures 27.27 and 27.28 show a tissue expander being
placed in the shoulder area. The scar tissue was excised
and the contracture was corrected. The resultant defect
was covered by advancement of the expanded skin flap.
IV.
INTRAOPERATIVE CONSIDERATIONS
Usually, the scar in the axillary dome should be totally
excised and then the residual underlying fibrotic bands
should be cut to achieve complete release for the patients
with total obliteration of the axillary dome. Care must be
taken not to injure the brachial plexus and greater
vessels during the procedure. The brachial plexus may
also be injured by exerting too much stretch on the
plexus when extending the upper arm during the release.
In addition, it should be mentioned that every effort
must be made not to disturb the axillary hairs during trans-
position of the local flaps for those patients with anterior or
posterior axillary scar bands. Multiple Z-plasty or continu-
ous VY-plasty with moderate-sized skin flaps may have
less possibility to disturb the axillary hairs than a single
large Z-plasty or VY-advancement flap. When fasciocuta-
neous flaps are used for reconstruction, care must be taken
to include the deep fascia in the flap dissection or the
Reconstruction of Axillary Contracture
Figure 27. 27 A boy complained of scar contracture in the
anterior axilla. A tissue expander was placed at the shoulder
near the scar tissue.
375
Figure 27. 28 The scar was excised and contracture relieved
after reconstruction with expanded skin flap. There was no
donor site morbidity.
circulation might be compromised. Because of scar con-
tractures, the skin and the subcutaneous tissues are
thicker in the back and the adjacent tissues surrounding
the axilla are usually thinner than normal tissue. Thinned
flaps such as thinned musculocutaneous perforator-based
flaps are recommended by some authors (36).
V.
PITFALLS
Waiting for scars to mature before the correction of axillary
contractures is not always necessary. Because these con-
tractures will cause functional impairment, especially for
the pediatric patients, early intervention is necessary (37).
If the axillary dome is spared in the burn scar contracture,
the axillary hairs are better preserved during the reconstruc-
tion. The male patient may complain more if the axillary
hairs are displaced. Figures 27.29-27.32 show a patient
who complained of malposition of his axillary hairs after
local flap reconstruction for the axillary contracture was
performed at another clinic. The original axillary hairs
were located at the lower axilla but not at the dome. A
large Z-plasty to elevate the entire hair-bearing skin flap
to the middle axilla was performed during a secondary
reconstruction. The final result showed correct position of
axillary hairs and the patient felt satisfied.

376
Functional and Aes thetic Reconstruction of Burned Patients
Figure 27. 29 A patient with malposition of the axillary hairs
after transposition of a fasciocutaneous flap.
Figure 27. 30 A big Z-plasty to elevate the hair-bearing skin
flap was performed.
In addition, one should mention that the burned or
grafted skin over the fasciocutaneous flap usually causes
no problems if the skin is mature or stable. In the early
stages of the bum injury or with immature skin grafts,
gentle manipulation of this tissue is required to avoid super-
ficial necrosis of the overlying of the skin when raising fas-
ciocutaneous flaps. Because the vascular pedicle in the flap
is easily kinked or compressed after transposition to the
axilla, proper position to avoid these conditions is very
important to prevent partial flap necrosis.
VI.
NURSING ISSUES
Postoperative immobilization is very important. The tie-over
dressings for graft skin should be kept clean and dry post-
operatively. The splint if any should be kept in place. Fre-
quent check-up of the dressings and change, if necessary,
is needed to prevent maceration of the surrounding skin.
Poor hygiene of the axillary area frequently causes wound
infection and subsequent loss of skin grafts.
Sometimes tip necrosis of a Z-plasty can be prevented
after releasing the tension by removing one or two stitches
around the tip. In cases where flaps are used for correction
of axillary contractures, one should watch out for impaired
Figure 27.31
The axillary hairs were moved to the axillary
dome after transposition of the hair-bearing flap.

Recons truction of Axillary Contracture
377
Figure 27. 32 Two more years of follow-up showed satisfac-
tory results.
circulation of the entire flap. Artery insufficiency causes
the flap to look pale and venous congestion produces a
dark-reddish appearance to the flap. Poor function of the
drainage system may possibly cause hematoma formation
beneath the flap. Postoperative follow-up at the outpatient
service and the rehabilitation unit should be arranged for
every patient who receives this type of reconstructive
surgery.
VII.
REHABILITATION ISSUES
It is very important to understand that postoperative reha-
bilitation after correction of the burned axillary contrac-
tures is crucial to achieve the best results. Traditionally,
airplane splints have been used after reconstruction
(37.38). The airplane splint is used from 5 days to 2
weeks for postoperative immobilization. Following immo-
bilization, using the splint at night is routinely rec-
ommended for 3-6 months (39). The figure-of-eight soft
brace applied for scapular positioning can also be used
for the postgrafted pressure therapy in the axillary region
(38.39). The combination of free abduction splinting, use
of pressure garments, and adequate physiotherapy is advo-
cated as a satisfactory method for postoperative care after
treating axillary bum scar contractures (40).
Because the bum axilla in a child is a difficult area to
immobilize during the postgrafted stage, a device, called
the “papoose,” was designed by Macdonald et al. (41)
for this situation. The papoose, which is made of 4 in.
thick foam, fixes the child with the arms in 20° horizontal
abduction and 90-160° shoulder abduction, according to
the patient’s needs. This position is maintained by the
use of foam axillary wedges and velfoam straps attached
to the papoose and secured around the arm, waist, etc.
However, the axillary splint is difficult to keep in
place and may be uncomfortable for those patients who
have some daily activities. A salute splint designed by
Abhyankar (42) has the same results as other splints but
may be more easy to use and more comfortable for
patients. The splint is made of a narrow-width cotton
fabric and consists of four straps to help stabilize the
arm in abduction during surgery, to place the hand on
the forehead while the patient is lying down, and to put
the hand on the head while the patient is ambulatory.
While splinting is emphasized after the use of skin
grafts, exercise of the shoulders should not be neglected.
Routine follow-up to receive evaluation and comments
from the physical and occupational therapists is very
important. When flaps are used, a shorter period of immo-
bilization is required. The decreased incidence of second-
ary contractures and the greater extensibility of the flap is
an advantage over the use of skin grafts.
VIII.
LONG-TERM OUTCOMES
Complete release of the scar contracture with postopera-
tive rehabilitation will result in good outcomes even
after long-term follow-up in patients who underwent
local flap reconstruction for severe axillary contractures
(Figs. 27.6, 27.21, and 27.32). Local cutaneous flaps
such as Z-plasties are useful for longitudinal scar bands,
while fasciocutaneous transposition or island flaps are
useful for more extensive scar contractures in the axillary
region. From a review of the literature and the evidence-
based results in this article, we know why Donelan (43)
recommends that it is advantageous to correct axillary
contractures by rearranging local tissues as flaps whenever
possible (11-29).
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2.
Grishkevich V. The basic types of scar contractures after
bums and methods of eliminating them with trazezplasty
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3.
Achauer BM. The axilla. In: Achauer BM, ed. Bum Reconstruc-
tion. New York: Thieme Medical Publishers, 1991:87-99.

378
Functional and Aesthetic Reconstruction of Burned Patients
4. Hallock GG. A systematic approach to flap selection for the
axillary bum contracture.
J Burn Care Rehabil 1993;
14(3):343-347.
5. Salisbury RE, Bevin AG. The axilla. In: Salisbury RE,
Bevin AG, eds. Atlas of Reconstructive Burn Surgery.
Philadelphia: W.B. Saunders, 1981:108-111.
6.
Huang TT, Blackwell SJ, Lewis SR. Ten years of experi-
ence in managing patients with burn contractures of
axilla, elbow, wrist, and knee joints. Plast Reconstr Surg
1978; 61:70-76.
7. Moiemen NS, Staiano JS, Ojeh NO, Thway Y, Frame JD.
Reconstructive surgery with a dermal template: clinical and
histologic study. Plast Reconstr Surg 2001; 108(1):93-103.
8.
Chou TD, Chen SL, Lee TW, Chen SG, Cheng TY, Lee CH,
Chen TM, Wang HJ. Reconstruction of burn scar of the
upper extremities with artificial skin. Plast Reconstr Surg
2001; 108(2):378-385.
9. Hirshowwitz B, Karev A, Levy Y. A 5-flap procedure for
axillary webs leaving the apex intact. Br J Plast Surg
1977; 30:48-51.
10.
Kurtzman LC, Stern PJ. Upper extremity burn contractures.
Hand Clin 1990; 6(2):261-279.
11.
Olbrisch RR. Running Y -V plasty. Ann Plast Surg 1991;
26:52-56.
12.
Karacaoglan N, Uysal A. Use of seven-flap plasty for the
treatment of axillary and groin postburn contractures.
Burns 1996; 22(l):69-72.
13.
Vaubel E. The V flap. A combination of V- Y advancement
and two Limberg transposition flaps. Ann of Plast Surg
1991; 26(l):64-69.
14.
Hyakusoku H, Fumiiri M. The square flap method. Br J
Plast Surg 1987; 40:40.
15.
Tolhurst DE, Haeseker B. Fasciocutaneous flaps in the
axillary region. Br J Plast Surg 1982; 35:430.
16.
Achauer BM, Spenler CW, Gold ME. Reconstruction of
axillary burn contractures with the latissimus dorsi fascio-
cutaneous flap. J Trauma 1988; 28:211-213.
17.
Roberts AHN, Dickson WA. Fasciocutaneous flaps for burn
reconstruction: a report of 57 flaps. Br J Plast Surg 1988;
41(2):150-153.
18. Tiwari P, Kalra GS, Bhatnagar SK. Fasciocutaneous flaps for
burn contractures of the axilla. Burns 1990; 16(2):150-152.
19. Hallock GG. Regional fasciocutaneous flaps for the burned
axilla. J Burn Care Rehabil 1991; 12(3):237-242.
20. Hallock GG, Okunski WJ. The parascapular fasciocuta-
neous flap for release of the axillary bum contracture. J
Burn Care Rehabil 1987; 8:387-390.
21. Elliot D, Kangesu L, Bainbridge C, Venkataramakrishnan V.
Reconstruction of the axilla with a posterior arm fasciocuta-
neous flap. Br J Plast Surg 1992; 45(2): 101-104.
22. Budo J, Finucan T, Clarke J. The inner arm fasciocutaneous
flap. Plast Reconstr Surg 1984; 73:629-632.
23. Diamond M, Barwick W. Treatment of axillary burn scar
contracture using an arterialized scapular island flap. Plast
Reconstr Surg 1983; 72:388-390.
24. Teot L, Bosse JP. The use of scapular skin island flaps in the
treatment of axillary postburn scar contractures. Br J Plast
Surg 1994; 47(2): 108 -111.
25.
Nisanci M, Er E, Isik S, Sengezer M. Treatment modalities
for postburn axillary contracures and the versatility of the
scapular flap. Burns 2002; 28(2):177-180.
26.
Yanai A, Nagata S, Hirabayashi S, Nakamura N.
Inverted-U parascapular flap for the treatment of axillary
bum
scar contracture.
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76:126-129.
27.
Maruyama Y. Ascending scapular flap and its use for the
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28.
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29.
Kim DY, Cho SY, Kim KS, Lee SY, Cho BH. Correction of
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30.
Knowlton EW. Release of axillary scar contracture with a
latissimus dorsi flap. Plast Reconstr Surg 1984; 74:124-
126.
31.
Hallock GG. The triceps muscle flap for axillary contrac-
ture release. Ann Plast Surg 1993; 30(4):359-362.
32.
Wilson IF, Lokeh A, Schubert W, Benjamin Cl. Latissimus
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105(l):27-33.
33.
Yang JY, Tsai FC, Chana JD. Use of free thin anterolateral
thigh flaps combined with cervicoplasty for reconstruction
of postbum anterior cervical contractures. Plast Reconstr
Surg 2002; 110(l):39-46.
34. Marks MW, Argenta LC, Thornton JW. Bum management:
the role of tissue expansion. Clin Plast Surg 1987;
14(3):543-548.
35.
Yamamoto Y, YokoyamaT, Minakawa H, Sugihara T. Use of
the expanded skin flap in esthetic reconstruction of postbum
deformity. J Bum Care Rehabil 1996; 17(5):397-401.
36.
Kim DY, Jeong EC, Kim KS, Lee SY, Cho BH. Thinning
of the thoracodorsal perforator-based cutaneous flap for
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37. Greenhalgh DG, Gaboury T, Warden GD. The early release
of axillary contractures in pediatric patients with burns.
J Burn Care Rehabil 1993; 14(l):39-42.
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39.
Leman CJ. Splints and accessories following burn
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Whitaker J, Lamberty Ma BGH. Pressure garments in the
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1981; 67(l):5-7.
41.
Macdonald LB, Covey MH, Marvin JA et al. The papoose:
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42.
Abhyankar SV. The salute splint for axillary contractures.
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Philadelphia: W.B. Saunders, 1990:5452.

28
Recons truction of the Burned Breast and Nipple-Areolar Complex
ROBERT L. McCAULEY, GARRY W. KILLYON
University of Texas Me dical Branch and Shriners Hospital for Children— Galveston Unit, Galveston, Texas, USA
KANIKA BOWEN
University of Texas Me dical Branch S chool of Medicine, Galveston, Texas, USA
I.
INTRODUCTION
Thermal injuries to the anterior chest wall can have severe
psychological impact because of scarring and contractures.
In adult female patients, such injuries, which can be severe
in nature, can lead to severe distortion of the involved
breasts. In children, breast development becomes an import-
ant issue. Thus, deformities related to scar contractures in the
developing breast can be significant and surgical intervention
may be necessary. In the prepubescent female, the manage-
ment of the bum injury during the acute phase of treatment
is of paramount importance. Previous studies have documen-
ted development of breasts in female adolescent patients even
in the absence of the nipple-areola complex (NAC) (1).
Needless to say, these patients underwent conservative man-
agement of their initial injuries after demarcation of eschar
with tangential excision of bums on the anterior chest wall
or blunt eschar separation (epluchage) with subsequent
coverage with a split-thickness skin graft. In both types of
treatment, preservation of the underlying breast bud was of
primary concern. In a review of 28 patients treated in such
a fashion, McCauley et al. (1) showed that all patients sub-
sequently developed breasts. To date, numerous studies
have documented the psychological impact of thermal inju-
ries and their subsequent deformities in bum patients
(2-5). These problems very well may be accentuated in
female patients with such injuries who develop significant
breast deformities. As reconstructive surgeons, our goal is
to transform, as much as possible, significant breast deform-
ities to the ideal breast shape that is desired within our society.
II.
INCIDENCE
In recent years, patients have continued to survive increas-
ingly large total body surface area bums. In general, this
379
I.
Introduction
379
2-
Bilateral Breast Burns:
II.
Incidence
379
Mammary Hyperplasia
385
TTT
,, _
3.
Unilateral Breast Burn
386
III. Acute Management ol Burns to
.
TT
t ^
^
.
.
.
°
4.
Unilateral Breast Burn:
the Anterior Chest Wall
381
^Breast Ptosis
387
IV. Reconstruction of the Burned Breasts
381
R p Pmnctnirrinii of
A. Reconstruction of ,he Burned
B'
^
"
1
Complex
387
Breast Mound
381
^
„
V.
Conclusion
390
1.
Bilateral Breast
Bums: Amastia
382
References
390

380
Functional and Aes thetic Recons truction of Burned Patients
increased survival has been attributed to better resuscita-
tion, control of bum wound sepsis, improved support of
the hypermetabolic response and early closure of the
bum wound. Burvin et al. (3) evaluated 421 female patients
admitted to their institution over a 3-year period, focusing
on female patients with breast burns. Of the 138 female
bum patients identified, only 9% had nonisolated breast
bums. Although the overall total body surface area bum
was not identified, 66% of the breast bums were secondary
to scald injuries (6). In 1989, Brou et al. (7) evaluated 25
patients with a mean total body surface area bum of
71%. In this series of patients, 512 reconstructive problems
were identified. In the trunk and perineal regions, 70 pro-
blems were identified. In 1993, Bums et al. (8) analyzed
reconstmction issues associated with 28 patients who sur-
vived bums of at least 80% of the total body surface
area. In this series, 564 reconstructive problems were
noted. In each series, ^20 reconstructive problems iden-
tified per patient. In the series by Bums et al. (8), the
trunk was the most frequently injured area in the torso/
lower extremity section. Interestingly enough, the trunk
Figure 28.1
(A) A 5-year-old girl after conservative debride-
ment of burns to the anterior chest wall involving both nipple-
areolar complex: subsequent split-thickness skin grafts placed
over the chest wall. (B) Breast development noted in teenage years.
was only second to the hand with respect to the most fre-
quently injured anatomic section. In addition, the breasts
were the most frequently injured region within the
truncal/perineal region. McCauley et al. (1) noted that
subsequent analysis of the donor sites usually revealed
that the tissue available for reconstruction was usually
less than optimal. Without question, these issues are of sig-
nificant concern since it has been recognized that 71 % of
female patients with bums to the anterior chest wall with
involvement of the NAC will require surgical intervention
to assist with breast development (1) (Figs. 28.1 and 28.2).
Figure 28.2
(A) An 8-year-old girl, 1-year after a 30% total
body surface area bum involving both nipple-areolar complex
after constmctive debridement and coverage with split-thickness
skin grafts. (B) Ten-year follow-up, breast development after
additional release using split thickness skin grafts. [Reprinted
with permission from McCauley et al. (1).]