Functional and Aesthetic Reconstruction of Burn Patients

382
Functional and Aes thetic Recons truction of Burned Patients
Figure 28. 3
(A) A 13-year-old girl with early breast development and entrapment of right breast in burn scar with inferior
displacement. (B) Proposed outline of a fasciocutaneous flap along with proposed incised release. (C) Transposition flap with place.
(D) One-year follow-up.
Figure 28. 4 (A) 6-year-old girl after recovery of anterior chest wall burns treated with conservative debridement and coverage with
skin grafts. (B) Six years later with breast development, patient required bilateral inframammary releases and coverage with skin grafts.
(C) Symmetric breast development noted 2 years later.
scars over the breast mound itself is carried out to improve
breast contour. If the deformity is minimal and located in
the inframammary region the use of local fasciocutaneous
flaps are an option (Fig. 28.3). However, extensive burns
over the breast mound may require excisional release
and resurfacing with thick (15-20 times one-thousandths
of an inch) split-thickness skin grafts (Fig. 28.4). In
some cases of bilateral breast entrapment, an inverted
T incision is required to separate the developing breasts
and relax the scar tissue over the breast mound.
1.
Bilateral Breast Burns: Amastia
As previously stated, patients who have sustained injuries
to the underlying breast bud will not develop breasts.
During the adolescent years, this becomes a significant

Reconstruction of the Burned Breast and Nipple-Areolar Complex
383
issue to young girls. The use of the TRAM flap for recon-
struction may not be an option because of the lack of
tissue bulk. The latissimus dorsi myocutaneous flap is an
option with implant placement. The author’s approach
has been to release the scar contractures using thick
split-thickness skin grafts with an inverted T incision.
Once the new grafts have matured, a transaxillary
approach is then used for placement of submuscular
tissue expanders. Once expansion is completed, the
expanders are removed and breast implants are then
inserted using the transaxillary approach. The use of the
transaxillary incision avoids problems which may
develop with wound healing if the inframammary
approach is undertaken (Figs. 28.5 and 28.6).
Figure 28. 5 (A) A 15-year old patient who survived a 60% total body surface area burn but necessitated fascial excision of deep
burns over anterior chest wall. Note lack of breast development. (B) Inverted “T” incision performed to release chest contractures.
(C) Trans axillary approach used for insertion of tissue expanders (200 cc expanders). Expanders placed under poctoral muscle and
over inflated six months after inverted “T” release of anterior chest wall tightness. (D) Final appearance after removal of expanders,
insertion of saline implants and bilateral revision of lateral redundant tissue over the breasts. (E) Right oblique view.

384
Functional and Aesthetic Recons truction of Burned Patients
Figure 28. 6 (A) A 14-year-old girl with fascial excision over anterior chest wall and resurfacing of the defect with meshed skin
grafts. (B) Final appearance after placement of tissue expanders using the trans axillary approach and replacement with saline implants.
(C) Left lateral view showing projection of implants for breast enhancement.
The use of tissue expansion and placement of an
implant is employed in reconstruction of the burned
breast when it is believed that there is adequate skin to
result in primary coverage of the prosthesis after place-
ment. Becker (25) introduced the permanent breast expan-
der implant in 1984. Tissue expanders are placed in the
subglandular or submuscular plane and are expanded
incrementally until the desired growth is obtained (16).
In burned patients, who have undergone fascial excisions,
placement in the submuscular plane is the only option.
Some authors have recommended that reconstruction be
delayed several months to allow for scar softening to
take place (15). Afterwards, the expander can be tem-
porarily deflated to assess tissue laxity (18,26). At this
point, insertion with a subpectoral breast implant pro-
portional in volume to the tissue expander provides a
Figure 28. 7 (A) A 17-year-old female with bums to the right breast. Previously, skin grafts were used to assist breast development.
Now patient complains of breast asymmetry because of the larger more ptotic left breast. (B) Six months postoperative appearance after
reconstruction of the right areola with a full-thickness skin graft from the inner thigh and a left-sided mastopexy.

Reconstruction of the Burned Breast and Nipple-Areolar Complex
385
breast mound that is not under tension. Some common
complications that are seen with the use of tissue expander
and implants include exposure of the injection port, infec-
tions, spontaneous deflation, and capsule formation (26).
2.
Bilateral Breast Burns: Mammary Hyperplasia
Although uncommon, mammary hyperplasia can occur in
the postburn breast (27). This condition may occur unilat-
erally in which a reduction mammoplasty may be required
for breast symmetry (Figs. 28.7 and 28.8). Alternately,
bilateral reduction mammoplasties may be required if
both breasts are hyperplastic. Thai et al. (27) have estab-
lished certain principles in the management of such
patients. First, the release of all contractures prior to
embarking upon a procedure which reduces breast
volume is recommended. Second, reduction mammoplasty
using the inferior pedicle technique is quite safe in these
patients. In their series, six patients (10 breasts) underwent
removal of 454 g of tissue per breast without major
Figure 28. 8 (A) A ten-year-old girl with unilateral right breast bums with preservation of the nipple areolar complex. (B) Same patient
at age 17 with unilateral macromastia on the left. Note normal breast shape without ptosis on the right side. (C) Postoperative appearance
after left unilateral reduction mammaplasty. (D) Four-month follow-up. (E) Patient is satisfied with results being able to wear a brassiere
for adequate support for both breasts.

386
Functional and Aes thetic Reconstruction of Burned Patients
complications noted. It is important to note that only
patients with split-thickness skin grafts over the breasts
were included in this series. El-Khatib (28) also confirmed
the safety and reliability of the inferior pedicle technique
in postbum breast reduction (28).
3.
Unilateral Breast Burn
The Hypoplastic Burned Breast
Correction of the hypoplastic breast is challenging.
When burn injury is involved, reconstruction becomes
increasingly difficult. In bum patients, it is unclear as to
whether the event would have occurred without injury or
if it happened because of partial loss of the breast bud.
Reconstruction of the hypoplastic breast, ideally, is under-
taken at the time of complete breast development. Tissue
expanders, implants, and myocutaneous flaps have been
used to augment the hypoplastic breast (Fig. 28.9). Correc-
tion of this defect is important in maintaining a symmetri-
cal appearance of the reconstructed breast mound. The
TRAM flap and the latissimus dorsi flap has been used
in the reconstruction of the hypoplastic breast. When
tissue expansion with subsequent placement of an
implant is the treatment plan, a period of over expansion
is advised not only to achieve a more naturally appearing
breast, but to also possibly reduce capsular contracture
(29-32). Subsequent reduction mammoplasty of the unin-
volved breast may be required to achieve symmetry.
Mastopexy/ Reduction Mammoplasty
Symmetry of the burned breast is desired and should be
the driving force behind breast reconstruction. Correction
of asymmetry is complicated and must address skin con-
tractures, nipple dystopia and volume asymmetry (33).
The most difficult technical problem has been that of
achieving volumetric and geometric equality (34). Assess-
ment of proper volume status between the two breasts can
be closely approximated perioperatively, but geometric
equality will change over time.
In patients with unilateral breast bums, the uninjured
breast serves as a guide for shape and symmetry. Unfortu-
nately, in some patients achieving breast symmetry may
be challenging. Occasionally, even as breast development
proceeds with the injured breast, its subsequent development
Figure 28. 9
(A) A 17-year-old female with right-sided breast burns with a slightly smaller right breast noted. Skin grafts were used
in the past to assist right-sided breast development. (B) Left pericresant mastopexy performed to lift the nipple-areolar complex with
right-sided augmentation. The right nipple areolar complex reconstructed with a skate flap and inner thigh full-thickness skin graft.
(C) Two-year follow-up. (D) Note projection still of the skate flap.

Reconstruction of the Burned Breast and Nipple-Areolar Complex
387
may still pose a problem with respect to shape and size when
compared to the normal breast. The choices of reduction
mammoplasty or a mastopexy on the uninjured breast vs.
augmentation of the injured breast depends on the extent
of the asymmetry and the patient’s desires (Fig. 28.10).
Sometimes different procedures may be required on each
breast to achieve symmetry.
4.
Unilateral Breast Burn: Breast Ptosis
Bums to the breast even after extensive releases with skin
grafts maintain a very strong outer envelop for breast
support. Thai et al. (27) noted that the thick inelasticity
of skin grafts creates a sling that does not become ptotic
with age. In patients with unilateral breast bums, over
time, the contralateral uninjured breast may become
ptotic when compared to the reconstructed burned breast
(Fig. 28.10). In cases where at least a grade II ptosis is
present, a mastopexy of the uninjured breast may be
necessary. This procedure not only improves breast
symmetry but also improves superior pole fullness.
Reconstruction of the NAC constitutes the second stage of
breast reconstruction. The literature has numerous articles
to address this issue (35-39). The NAC reconstruction is
often delayed until the reconstructed breast mound has
had time for scars to mature. This may be 9-12 months
after breast mound reconstruction. In general, reconstruc-
tion of the NAC is undertaken when the breasts have fully
developed. In the reconstructed breast, several problems
may exist: malpositioning of the NAC and partial or
total absence of the NAC. In cases of malpositioning of
the NAC in the burned breast, Mohmand and Nassan
(35) suggested the use of two double U-plasty for
correction. This technique is quite similar to a Z-plasty
in which the NAC is transposed inferiorly or superiorly
to match the contralateral unbumed breast (Fig. 28.11).
Of course, the technique can only be performed in patients
with no evidence of breast contraction and in patients
in which there is minimal displacement of the NAC.
B.
Recons truction of the
Nip p le-Areo la Complex
Figure 28. 10 (A) A 19-year-old woman complaining of breast asymmetry. Note left-sided breast burn with preservation of the nipple
but loss of the areola. Grade III ptosis noted on right side. (B) Outline for proposed right-sided mastopexy and reconstruction of the left
areola. (C) Inner thigh full-thickness skin graft used for the left areolar at time of right-sided mastopexy. (D)Final results at 6 months.

388
Functional and Aesthetic Reconstruction of Burned Patients
Figure 28.11
Diagram of the double V plasty. [Reprinted with
permission from, Mohmand and Nassan A. (35).]
Reportedly, there is minimal interference with the sen-
sation of the NAC with this technique.
In situations where the nipple is present but the areola is
partially or totally lost treatment alternatives differ. Partial
loss of the areola can be addressed with tattooing of the
region to blend in with the color of the remaining areola.
In situations where the entire areola is lost, tattooing of
the areola or resurfacing with full-thickness skin grafts
are useful. The upper inner thigh as a donor site produces
excellent contrast with the surrounding tissues in this situ-
ation (38). In unilateral breast burns, the technique utilized
may be guided by the color match of the unaffected side.
However, in bilateral breast bums with areola loss, either
technique provides acceptable results.
Total loss of the NAC presents a difficult problem in the
burned patient. Although numerous techniques are avail-
able, their role in the reconstruction of the burned breast
has yet to be fully evaluated (35-37). In the absence of
the native NAC, a nipple can be constructed from numer-
ous composite graft donors, including toe pulp, postauricu-
lar cartilage and skin, or the opposite nipple (11). The use
of labial skin to reconstruct the NAC has been replaced
with more current procedures. Reconstruction of the
NAC using auricular skin and cartilage can be used in
patients where nipple sharing is not an option and yields
fair to good results (40). The conchal cartilage is used to
simulate Montgomery glands. Free toe pulp grafts as
well as composite grafts taken from the second to fourth
toe has been utilized in NAC reconstruction. Pensler
et al. (36) reviewed different results of various techniques
in reconstmcting the burned NAD. They recommended the
use of full-thickness skin grafts from the superomedial
thigh for reconstruction of the areola. This group also
Figure 28. 12
(A) Design of the skate flap as described by
Little with elevation of the pedide. (B)Design of the skate flap
as described by Little with reconstruction of the areolar and cov-
erage with a full thickness skin graft. [(Reprinted with permission
from, Little (41).]

Reconstruction of the Burned Breas t and Nipple-Areolar Complex
389
recommended the use of the quadrapod flap for nipple
reconstruction if there is adequate surrounding dermis
(36). This technique appeared to be superior to the compo-
site grafts and the “double-bubble” technique over a 1-year
period. Several authors have been skeptical with respect to
the use of skin flaps in reconstruction of the NAC (11).
Since these flaps require normal dermal elements and sub-
cutaneous tissue to maintain viability to the skin, it was felt
that the role of skin flaps in the reconstruction of the NAC
in the burned patient was limited. In 1984, Little described
the “skate” flap for NAC reconstruction (Fig. 28.12) (41).
Its use in reconstruction of burn patients has received little
attention. However, McCauley and Robson (42) reported
the successful use of the “skate” flap in reconstruction of
the nipple in the burned breast (Fig. 28.13). This finding
clearly demonstrates the re-establishment of an adequate
subdermal plexus in burned patients after resurfacing
with skin grafts. Virtually all techniques that involve the
projection of a nipple will succumb to some degree of
flattening. Several factors have been cited for this
Figure 28. 13 (A) A 20-year-old girl with immature scars with open drainage over the anterior chest wall: patient was treated conser-
vatively. The nipple-areolar complex was absent bilaterally. (B) After wound maturation of an inverted “T” incision was performed to
assist breast development. (C) Three years later, bilateral “skate” flaps were utilized to create the nipple. (D and E) Excellent projection
noted at 4 months. (F) Seven-month follow-up: patient still has projection of the nipples, but loss of contrast around the areola.

390
Functional and Aes thetic Recons truction of Burned Patients
6.
Watson EJ, Johnson AM. The emotional significance of
acquired physical disfiguration in children. Am J Ortho-
psychiatry 1958; 28:85.
7.
Brou JA, Robson MC, McCauley RL, Herndon DN,
Phillips LG, Ortega M, Evans EB, Alvardo MI. Inventory
of potential reconstructive needs in the patient with bums.
J Burn Care Rehabil 1989; 10(6):555-560.
8.
Burns BF, McCauley RL, Murphy FL, Robson, MC.
Reconstructive management of patients with greater than
80 per cent TBS A burns. Burns 1993; 19(5):429-433.
9.
Herndon DN, Barrow RE, Retan RL, Rutan TC, Desai, MH,
Abston, S. A comparison of conservative versus early
excisional therapies in severely burned patients. Ann Surg
1989; 209(5):547-553.
10.
Herndon DN, Parks DH. Comparison of serial debridement
and autografting and early massive excision with cadaveric
overlay in the treatment of large burns in children. J Trauma
1986; 26:149-152.
11. MacLennon
SE,
Wells
MD,
Neale
HW.
Recons-
truction of the burned breast. Clin Plast Surg 2000;
27(1): 113 —119.
12.
Al-Qattan MM, Zuker RM. Management of acute burns of
the female pediatric breast: delayed tangential excision
versus spontaneous eschar separation. Ann Plast Surg
1994; 33:66-67.
13. Kunert P, Schneider W, Flory J. Principles and procedures
in female breast reconstruction in the young child’s burn
injury. Aesth Plast Surg 1988; 12:101-106.
14.
Guan W, Jin Y, Cao H. Reconstruction of post-burn female
breast deformity. Ann Plast Surg 1988; 21(l):65-69.
15.
Pakhomov SM, Dmitriev GI. Scar deformities of the
mammary glands—surgical treatment. Acta Chir Plast
1984; 26(3): 150-157.
16. Versaci AD, Balkovich ME, Goldstein SA. Breast recon-
struction by tissue expansion for congenital and burn
deformities. Ann Plast Surg 1986; 16(l):20-30.
17. Kalender V, Aydim H, Karabulut AB, Özcan M,
Amiraslanov A. Breast reconstruction with the internal
mammary artery pedicle fasciocutaneous island flap:
description of a new flap. Plast Reconstr Surg 2000;
106(7): 1494-1498
18.
McCauley R. Reconstmction of the trunk and genitalia.
In: Herndon DN, ed. Total Burn Care. Philadelphia, PA:
Elsevier Ltd., 2001:707-709.
19. Ozgur F, Gokalan I, Mavili E, Erk Y, Kecik A. Recon-
struction of post-burn breast deformities. Burns 1992;
18(6):504-509.
20. Psillakis JM, Woisky R. Burned breasts: treatment with a
transverse rectus abdominis island musculocutaneous flap.
Ann Plast Surg 1985; 14(5):437-442.
21. Slator RC, Phil D, Wilson GR, Sharpe DT. Post-burn breast
reconstruction: tissue expansion prior to contracture
release. Plast Reconstr Surg 1992; 90(4):668-674.
22. Bishop JB, Fisher J, Bostwick J. Ill The burned female
breast. Ann Plast Surg 1980; 4(l):25-30.
23. Spence RJ. Bilateral reconstruction of the male nipple. Ann
Plast Curg 1992; 28:288-291.
24. Lewis JR. Reconstruction of the breasts. Surg Clin of North
Am 1971; 51:429-440.
phenomenon including surface tension of skin, lack of
normal infrastructure, and centrifugal forces (26,29,30).
V. CONCLUSION
Reconstruction of the burned breast encompasses a
number of complex issues. Management of such burns in
prepubescent females during the acute phase of injury is
extremely important in determining the need and ultimate
outcome of subsequent reconstructive procedures. The use
of skin grafts and/or fasciocutaneous flaps to assist breast
development and prevent deformities is crucial. The use of
tissue expansion and breast implants play an important
role in the reconstruction of patients with significant
breast asymmetry or in patients who do not develop
breasts because of fascial excision. Problems associated
with breast asymmetry may require augmentation or
even a reduction mammaplasty depending on the extent
of the deformity and patient’s desires. Clearly, the litera-
ture demonstrates the reliability and safety of these pro-
cedures in the burned breast. Macromastia of the burned
breasts is also safely addressed with reduction mammo-
plasties. The NAC requires multiple procedures to com-
plete the reconstructive efforts. Intradermal tattooing of
the areola or the use of full-thickness skin grafts provide
acceptable results. The successful use of the “skate” flap
in reconstruction of the nipple is the authors’ preferred
method. It is reliable and safe.
Regardless of the type of reconstructive procedure
utilized in the burned breast, the goal of the recon-
structive surgeon is to provide symmetric breasts which
should be as aesthetically pleasing as possible. Such
efforts are rewarded as we come closer to the reintegration
of burned patients into our society with positive self-
images.
REFERENCES
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McCauley RL, Beraja V, Rutan RL, Huang TT, Abston S,
Rutan TC, Robson MC. Longitudinal assessment of breast
development in adolescent female patients with burns
involving the nipple-areolar complex. Plast Reconstr
Surg 1989; 83(4):676-680.
2.
Cahners SS. Young women with breast burns: a self-help
“Group by Mail”. J Burn Care Rehabil 1992; 13:44-47.
3.
Burvin R, Robinpour M, Milo Y, Tamir G, Wolf Y,
Hauben DJ. Female breast burns: conservative treatment
with a reconstructive aim. Israel J Med Sci 1996;
12:1207-1301.
4.
Bernstein N. Emotional Care of the Facially Burned and
Disfigured. Boston, MA: Little, Brown and Co., 1976.
5.
Stoddard FJ. Body image development in burned children.
J Am Acad Child Adolesc Psychiatry 1982; 21:502.

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25.
Becker H. Breast reconstruction using an inflatable breast
implant with detectable reservoir. Plast Reconstr Surg
1984; 73:678-683.
26.
Loss M, Infanger M, Kunzi W. The burned female breast:
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27.
Thai KN, Mertens D, Warden G, Neale HW. Reduction
mammaplasty in postburn breasts. Plast Reconstr Surg
1999; 103(7): 1882-1886.
28.
El-Khatib HA. Reliability of inferior pedicle reduction
mammaplasty in burned oversized breasts. Plast Reconstr
Surg 1999; 103(3):869-873.
29.
Kneafsey B, Crawford DS, Khoo CTK, Saad NM. Correc-
tion of developmental breast abnormalities with a perma-
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Becker H. The permanent tissue expander. Clin Plast Surg
1987; 14:519-527.
31.
Becker H. Expansion augmentation. Clin Plast Surg 1988;
15:587-593.
32.
Persoff MM. Expansion-augmentation of the breast. Plast
Reconstr Surg 1993: 91:393-403.
33.
Payne CE, Malata CM. Correction of post-burn deformity
using the Lejour mammoplasty technique. Plast Reconstr
Surg 2003; 111:805-809.
34.
Corso PF. Plastic surgery for the unilateral hypoplastic
breast. Plast Reconstr Surg 1972; 50:134-141.
35. Mohmand H, Nassan A. Double U-plasty for correction
of geometric malposition of the nipple-areola complex.
Plast Reconstr Surg 2002; 109(6):2019-2022.
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Pensler JM, Haab RL, Perry SW. Reconstruction of the
burned nipple-areola complex. Plast Reconstr Surg 1986;
78(4):480-485.
37. Adams WM. Labial transplant for correction of loss of the
nipple. Plast Reconstr Surg 1979; 4: 295-298
38. Broadbent PR, Woolf RH, Metz PS. Restoring the
mammary areola by a skin graft from the upper inner
thigh. Br J Plast Surg 1977; 30:220-222.
39. Becker H. Nipple-areola tattooing using intradermal
tattooing. Plast Reconstr Surg 1988; 81:450.
40. Brent B, Bostwick J. Nipple-areolar reconstruction
with auricular tissues. Plast Reconstr Surg 1977; 60:
353-361.
41. Little JW. Nipple-areolar reconstruction. Clin Plast Surg
1984; 11:351-364.
42. McCauley RL, Robson MC. Reconstruction of the nipple-
areola complex in the burned breast using the ‘skate’ flap.
Proc Am Burn Assoc 1994; 26:14.
43. Neale HW, Smith GL, Gregory RO, MacMillan BG. Breast
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(Trang không có chữ)

29
Recons truction of Ches t Contractures
J UI-YUNG YANG
Chang Gung Mem orial Hospital, Taipei, Taiwan
I.
INTRODUCTION
Bum injuries of the chest are not uncommon. Flame bums
with ignition of clothes, scald bum due to pouring hot
water over upper trunk, chemical bums with direct or
indirect involvement of the chest; friction burns or electri-
cal injuries to the chest can frequently produce deformities
of the chest. Sometimes, the electrical bum involves
deeper tissue injuries than others (1,2). However, no
matter what kind of injury is involved, the most serious
complications may occur in the female chest (3).
The significance of breast development to women is not
only for nursing but also a symbol of sexuality. It could be
a disaster when the breast is destroyed in any accident
including bums. Thus both functional restoration and aes-
thetic reconstruction should be taken into consideration
during correction of burn breast deformities. In this
chapter, the literature about bum breast reconstruction is
reviewed. The principles of conservative debridement in
the acute stage and complete scar release in late stage
along with nipple areolar complex (NAC) reconstruction
and proper choice of replacement tissue are still valid for
burn breast reconstmction. Free flaps including trimmed
perforator flap reconstmction is also discussed.
II.
PREOPERAT IVE EVALUATION
In the acute stage, the depth of the injury should be care-
fully evaluated. Possible involvement of the ribs should
be kept in mind in deep bums especially in electrical
bums. The choice of reconstruction procedure is related
to the extent and depth of injures. Involvement of NAC
in bum injury should also be assessed.
In the delay reconstmctive stage, any possibility of
developmental limitation is usually a high priority. Exten-
sive chest scar contractures may result in kyphosis. The
scars in the pediatric female breast can possibly cause
hypoplasia or even aplasia of the breasts. The status
of NAC should be cited in the chart. The breast deformities
may be classified into several groups including: 1—caudal
contracture, which might results in marked asymmetry and
restriction of breast contour; 2—lateral contracture, which
causes displacement of the breast; 3—loss of breast
volume and destruction of the NAC, which usually is
due to direct bum injury to the breast; and 4—NAC
deformities, either distorted or completely destroyed (4).
The classification may be simplified as: (1) adjacent scar
contracture, which causes a disfigured breast; (2) volume
decrease with or without NAC destruction; and (3) isolated
393
I.
Introduction
393
VI.
Nursing Issues
408
II.
Preoperative Evaluation
393
VII.
Rehabilitation Issues
409
III.
Surgical Options
394
VIII. Long-Term Outcome
409
IV.
Intraoperative Considerations
407
References
409
V.
Pitfalls
408

394
Functional and Aes thetic Recons truction of Burned Patients
NAC destruction. The preoperative evaluation of the
relationship between breast deformities and surrounding
available healthy tissues is very important for decision-
making about the reconstructive timing and procedure.
III.
SURGICAL OPTIONS
In the acute stage every effort should be made to preserve
the breast tissues. Skin grafts after spontaneous eschar
separation or after delayed tangential excision when
wound demarcation is clear for the burns of the female
pediatric breast makes no difference in later breast develo-
pment (5). In spite of the significant thermal injury to
the anterior chest wall with involvement of the NAC,
no patient failed to develop breasts. This is a finding
of McCauley et al. (6) in 28 patients with long-term
follow-up of 15 patients. Initial conservative treatment
with preservation of breast buds for burned female chil-
dren is recommended. By recognizing that the breasts
are specialized structures and that bums to the breast,
especially if lactating, delayed tangential excision and
cessation of lactation by using bromocriptine were
suggested to achieve successful reconstruction (7). Thus,
conservative management of the acutely burn breast in
children, especially girls, to preserve breast buds is the
first choice of surgical options (8,9).
Deep thermal bums involving chest and/or breasts
may be reconstructed with conservative debridement and
skin grafts. However, a full-thickness chest wall defect
following high-voltage electrical injury requires prompt,
secure, and stable repair. Immediate reconstruction with
flaps such as latissimus dorsi myocutaneous flap is better
than skin graft after granulations appeared (10). If the
defect is located at the upper chest accompanied by
costal bone exposure, the cervicohumeral flap has been
described for reconstruction. It can be raised undelayed
with a length-to-width ratio of 2:1 or 3:1 and transposed
to cover the anterosuperior chest wall (11). Sometimes
costal bones or cartilages involved in deep burns should
be aggressively excised to ensure subsequent reconstruc-
tion successful (12). Reconstruction of a full-thickness
defect of the chest wall caused by friction burn using a
combined myocutaneous flap of teres major and latissimus
dorsi muscle has been reported (13).
In the late stages the goals of reconstruction are aimed
at complete release of contractures to prevent or to correct
the deformities especially the female chest. Complete
release of the scar contracture by means of scar revisions
with Z- or VY-plasty, proper replacement of tissue
defects utilizing skin grafts, local flaps (i.e., square flaps
and slide-swing plasty, fasciocutaneous flaps, myocuta-
neous flaps), tissue expansion, free flaps, or combined util-
ization of these methods are advocated by some authors
(3,8,9,14-29). Some methods of NAC reconstruction are
also proposed (30-35). All the aforementioned methods
are reasonable to achieve the goals of both functional
and aesthetic reconstruction for burn breast deformities
(36-39). The surgical options and clinical examples are
noted in the following text.
Case 1:
This case involves a young girl with multiple
burn scars in her chest and abdomen with caudal contrac-
ture of the left breast (Fig. 29.1). Excision of scars and
reconstruction with a Limberg flap from the abdomen
and V-Y plasty for the left breast were performed to
correct all contractures (Fig. 29.2). Seven years later the
breast started to develop without any contracture (Figs.
29.3 and 29.4).
Case 2:
This deals with a lateral burn scar contracture
of the breast, which resulted in lateral deviation of the
NAC (Fig. 29.5). The deformity was corrected by scar
excision and a V-Y advancement flap (Fig. 29.6).
Case 3:
This case relates to a 5-year-old girl who sus-
tained a third degree flame burn over the entire chest-
abdomen with destruction of the NAC (Fig. 29.7). In the
acute stage, every effort was made to preserve the breast
buds. The breast areas were the first priority for sheet
skin graft (Fig. 29.8). Seven years later at adolescent
age, the development of the breasts was restricted by
scar contracture around the chest (Fig. 29.9). Complete
release of scar contracture was achieved by means of mul-
tiple Z-plasties and scar revisions (Fig. 29.10). A 4-year
follow-up of the patient showed good development of
both breasts with acceptable symmetry. A comparison
can be made between pre- and postoperative appearances
as shown in Figs. 29.11 and 29.12, respectively. The
patient did not desire NAC reconstruction.
Case 4\
Upper and lateral scar contracture with dis-
tortion of the left breast occurred in a woman who sus-
tained a flame burn in her childhood (Fig. 29.13).
Excision of the scars, complete release of contracture by
means of cutting the underlying fibrotic bands, and resur-
facing with a thick split-thickness skin graft (STSG) were
performed (Fig. 29.14). Postoperative pressure therapy
was done to prevent secondary graft skin contraction
using custom-made garments (Fig. 29.15). The breasts
were restored to their natural contour and symmetry
(Fig. 29.16).
Case 5\
This case relates to a 22-year-old female, who
sustained a flame burn since childhood. A severe caudal
scar contracture with underdevelopment of both breasts
especially the left side, which was retracted down to the
abdomen, was noted (Fig. 29.17). Complete scar release
with preservation of the breast mounds was achieved by
means of wide incisions and cutting of fibrotic bands.
The resultant extensive defect was covered by thick
STSG with tie-over suture (Fig. 29.18). Postoperative
compression garment was applied to prevent secondary

Recons truction of Ches t Contractures
395
Figure 29.2
Scar excision and V-Y advancement flap for the
left breast.
Figure 29. 3
Follow-up for 3 years showed satisfactory
results.
Figure 29. 4
The lateral view shows nipple projection being
started without limitation.

396
Functional and Aesthetic Recons truction of Burned Patients
Figure 29. 6 A V-Y advancement flap was applied for release
of contracture to allow unlimited development of the breast.
Figure 29. 7 A 5-year-old girl suffering from third degree
flame bum over the entire chest-abdomen with destruction of
the nipples.
Figure 29. 8 Conservative debridement with preservation of
breast buds and proper sheet STSG.
contracture of the skin graft (Fig. 29.19). Follow-up of the
patient at 1year showed a satisfactory result. For compari-
son, the pre- and postoperative appearances are shown in
(Figs. 29.20-29.23). Augmentation mammoplasty was
suggested but not accepted.
Case 6:
This involves a 14-year-old girl with a
deformity of her right breast due to bum scar contracturea
around the inframammary area. For reconstruction, design
of an inferior-based fasciocutaneous flap from her flank
was performed (Fig. 29.24). A relaxation incision was
placed along the inframammary fold. The contracture
was released as much as possible and the breast mound
was well preserved but not undermined (Fig. 29.25).
Immediate postoperative result of transposition of the fas-
ciocutaneous flap showed good release of the contracture
(Fig. 29.26). A 2-year follow-up showed good projection
of the right breast from lateral view (Fig. 29.27).
Figure 29.5
A patch of scar tissue over the left chest with
lateral retraction of the breast.

397
Figure 29. 9 Seven years later at adolescent age, development
of the breasts was restricted by scar contracture around the chest.
Preoperative appearance of her chest at puberty showed
marked distortion and hypoplasia of the right breast
(Fig. 29.28). However, after reconstruction with a local
flap, the development of both breasts seemed rather sym-
metric and the contour of right breast was satisfactory
(Fig. 29.29).
Case 7:
This case presented a 10-year-old girl, who
developed a bum scar contracture over the entire chest
with restricted development of both breasts. The nipples
were destroyed but could still be identified (Fig. 29.30).
Combined use of local fasciocutaneous transposition
flaps from the flanks to the inframammary fold and a
full-thickness skin graft (FTSG) for the intermammary
area was done before puberty. Three years later, develop-
ment of both the breasts is noted (Fig. 29.31). The pre- and
postoperative lateral views are shown in Figs. 29.32 and
29.33, respectively. The third degree bums sustained,
severe scar contracture after wound healing, limitation of
breast development, and the corrected deformities after
Figure 29.11
Preoperative oblique view before reconstruction
for comparison.
Figure 29. 10 Complete release of scar contracture was
achieved by means of multiple Z-plasties and scar revisions.
Figure 29. 12 Four-year-follow-up of the patient showed well
development of both breasts with acceptable symmetry. Patient
had no desire to do NAC reconstruction.
Reconstruction of Chest Contractures

398
Functional and Aes thetic Reconstruction of Burned Patients
Figure 29. 13 Upper and lateral scar contracture of the chest
with distortion of left breast in a woman after flame burn.
Figure 29. 14 Thick STSG was used to cover the defects after
scar excision and complete contracture release.
local fasciocutaneous flap reconstruction are shown in
Figs. 29.34-29.37, respectively.
Case 8:
This is a case involving a 6-year-old boy, who
sustained a scald burn over his chest and abdomen 1 year
before reconstruction. Some kyphosis of the trunk and
asymmetry of both nipples is noted (Fig. 29.38). Tissue
expansion was used and most of the scar tissue was
excised (Fig. 29.39). The location of the nipples was regu-
lated during each time of reconstruction, which finally
resulted in symmetry (Fig. 29.40).
Case 9:
This case reports a 44-year-old female, who
sustained flame burns over her chest (Fig. 29.41). Conser-
vative debridement with preservation of the NAC was
done in the acute stage. A right breast deformity secondary
to scar contractures is later noted (Fig. 29.42). Combined
use of tissue expansion and a free flap reconstruction
was planned (Fig. 29.43). The scar tissue was excised
with preservation of the NAC. The breast mound after con-
tracture release is noted (Fig. 29.44). A free anterior lateral
Figure 29. 15 Postoperative pressure therapy with custom-
made garment worn for 6 months.
Figure 29. 16 The oblique view shows symmetric breasts.
thigh flap, 25 x 9 cm2 in size, based on the descending
branch of the lateral femoral artery, in her right thigh
was designed (Fig. 29.45). The flap was harvested as a chi-
meric perforator flap (Figs. 29.46 and 29.47). The donor
site was closed primarily (Fig. 29.48). The flap was
divided into two segments based on the separated perfora-
tors and trimmed according to the size of the defect
(Fig. 29.49). The microvascular anastomosis between
donor vessels, recipient vessels,
and the internal
mammary vessels was performed (Fig. 29.50). Follow-up

Reconstruction of Ches t Contractures
Figure 29. 17
Severe scar contracture and resultant under-
development of both breasts, especially the left side, of a lady
due to flame bum during childhood.
Figure 29. 18 Complete release of the scar contracture with
preservation of the breast mound was achieved by means of infra-
mammary incisions and thick STSG.
399
Figure 29. 19 Postoperative
compression
garment
was
applied to prevent secondary contracture of the graft skin.
Figure 29. 20 Preoperative picture shows severe scar contrac-
ture with hypoplasia of both breasts especially the left breast
located almost at the abdomen.

400
Functional and Aes thetic Reconstruction of Burned Patients
Figure 29.21
Follow-up 1-year later showed satisfactory
result. Augmentation mammoplasty was suggested but not
accepted because patient thought that it was not necessary.
Figure 29. 23 Postoperative lateral view shows restoration of
original breast mound.
Figure 29. 22
Preoperative lateral view shows flat and dis-
located breast.
Figure 29. 24 A 14-year-old girl with deformity of her right
breast due to bum scar contracture received local flap reconstruc-
tion. Design of an inferior-based fasciocutaneous flap from right
flank is shown in the picture.

Recons truction of Ches t Contractures
401
Figure 29. 25 The relaxation incision was put along the infra-
mammary fold. The contracture was relieved as much as possible
and the breast mound was well preserved but not undermined.
Figure 29. 27 Two-year follow-up shows good projection of
the right breast from lateral view.
Figure 29. 26 Immediate postoperative result of transposition
of the fasciocutaneous flap.
of the patient 8 months later showed a satisfactory aes-
thetic result (Figs. 29.51 and 29.52).
There are many methods of NAC reconstruction includ-
ing composite graft for the nipple and skin graft for the
areola, tattooing for the areola nipple sharing with the
healthy nipple, transposition of the remaining NAC,
correction of the malpositioned NAC by transposition of
subcutaneous pedicled flap, local flap such as double-
bubble technique of Bunchman, wrap around technique
of Silversmith, or the skate flap of Pensler (19,30-35,39).
Case 10:
A patient with scar contracture over entire
chest after a chemical bum with destmction and malposi-
tion of the NAC (Fig. 29.53) is reported here. Scar revision
and repositioning of the residual nipple was done with
satisfactory results (Fig. 29.54).
Case 11:
This is another case of a young girl, who
sustained bum scar contracture over her chest after scald
bums. Most of the scars were removed by tissue expansion
leaving the NAC undisturbed before puberty (Fig. 29.55).
Figure 29. 28 Preoperative picture of a patient at puberty
showing marked distortion of the right breast. It looks like
hypoplasia.

Figure 29. 29 After reconstruction with local flap, the breast
development
seems
rather
symmetric
and
the
contour
satisfactory.
Figure 29. 30 Scar tissues over the entire chest with restriction
of the development of both breasts.
Figure 29.31
Local fasciocutaneous flaps for the inframam-
mary contracture and FTSG for the inframammary area was
done before puberty. A 3-year follow-up picture reveals satisfac-
tory breast development.
Figure 29. 32 Preoperative oblique view shows limitation of
breast development.
402
Functional and Aes thetic Recons truction of Burned Patients

Recons truction of Ches t Contractures
403
Figure 29.33
Postoperative oblique view shows good develop-
ment of breasts with minimal donor site scar along the scar margin.
Figure 29. 34 Extensive third degree burn over the chest and
abdomen of a young girl. Complete escharectomy but careful
preservation of the breast mound was done.
Figure 29. 35
Severe scar contracture noted after wound
healing.
Figure 29. 36 Limitation of breast development and caudal
retraction of both breasts were noted seven years later.

404
Functional and Aes thetic Recons truction of Burned Patients
Figure 29. 37 The deformities were corrected by local fascio-
cutaneous flap reconstruction.
Figure 29. 38
Scar contracture of the chest and abdomen with
kyphosis noted in a young boy after scald burn.
Figure 29. 39 Most of the scar tissues were removed by tissue
expansion technique step by step.
Figure 29. 40 The relieved contracture and the corrected
kyphosis. The nipples were also preserved after reconstruction.

Reconstruction of Chest Contractures
405
Figure 29.41
A 44-year-old female suffering from flame bum
over the chest and upper limbs. Conservative debridement with
preservation of the right nipple and breast mound was done in
the acute stage.
Figure 29. 42 Deformity of the right breast due to scar con-
tracture was noted later although breast mound was preserved
as much as possible initially.
Figure 29. 44 The thick scar tissue was removed and revealed
that the breast mound still existed after contracture was relieved.
The NAC was preserved and put onto the correct position.
Figure 29. 45 A free anterior lateral thigh flap, 25 x 9 cm2 in
size, designed as a chimeric flap based on two perforators in the
patient’s right thigh was done.
Figure 29. 43 The scar tissue around the breasts were excised
step by step by means of tissue expansion technique 1 year later.
Figure 29. 46 The flap was elevated and the perforators can be
seen clearly.

406
Functional and Aes thetic Reconstruction of Burned Patients
Figure 29. 50 Immediate postoperative result of free flap
reconstruction.
Figure 29. 47 The flap was trimmed according to the defect
area and properly arranged in good direction.
Figure 29. 48
The donor site was closed primarily.
Figure 29. 49 Microvascular anastomosis between descend-
ing branch of lateral femoral vessels and internal mammary
vessels.
Figure 29.51
Follow-up 6 months later shows good aesthetic
breast contour. The patient was satisfactory.
Figure 29. 52 The oblique view compared to Fig. 29.43 shows
much improvement.

Reconstruction of Ches t Contractures
407
Figure 29. 53
Scar contracture of the breasts after a chemical
burn in a lady’s chest. The ring nipple was destroyed.
The NAC was transposed to proper location during
advancement of the expanded skin. After the breasts
were well developed, the NAC in both breasts looked
rather symmetric (Fig. 29.56).
IV.
INTRAOPERATIVE CONSIDERATIONS
Any burn injury involving the chest of a girl or a young
female patient should be carefully managed considering
Figure 29. 55 Transposition of the NAC was done before
puberty for a 17-year-old girl who sustained a scald burn in child-
hood when the scar tissues were replaced by expanded skin.
the ongoing development of the breasts. Conservative deb-
ridement with preservation of the breast buds for further
breast development is recommended by many authors
(3-6). McCauley et al. (6) reviewed 28 female patients
with burns to the anterior chest wall involving NAC and
found that in spite of significant thermal injury, all patients
developed breasts. The key point is careful tangential exci-
sion to the viable tissue and preservation of the underlying
tissue as much as possible if surgery is necessary. Even in
the full-thickness burns to lactating breasts, surgical tan-
gential excision was delayed (5). This principle is also
advocated by other authors and noted in our own experi-
ence (Figs. 29.7, 29.8, 29.12, 29.30, and 29.31).
It is clear that different problems occur between child-
hood and early adulthood in female patients who have sus-
tained thermal burns over the anterior chest wall. The main
concern, however, is the status of breast development. In
the adult group, the most frequent causes of bum injury
Figure 29. 54
Scar revision and transposition of the remaining
nipple was done with acceptable results.
Figure 29. 56 The final results of reconstruction were
satisfactory.

408
Functional and Aes thetic Reconstruction of Burned Patients
are chemical injuries or flame bums. The most common
problems are scar contractures with distortion or asym-
metry of the breasts (Figs. 29.13, 29.42, and 29.53). The
most important reconstmctive procedure utilized is the
release of these scar contractures by excision of the bum
scars. The well-developed breast mounds usually still
exist even in third degree bums (Figs. 29.14 and 29.44)
(14). However, scar replacement using skin graft, tissue
expanders, or flaps is sometimes needed (Figs. 29.14,
29.44, and 29.47).
The most frequent cases of bum injury in children are
those due to scald injuries and flame bums. The most
common problem is scar contracture over the chest. In
pediatric female patients, underdevelopment or even
aplasia of the breasts may subsequently occur. In this
group, for mild postbum breast deformities, scar release
by V-Y- or Z-plasty before puberty may provide enough
release for breast development (Figs. 29.2, 29.6, 29.10,
and 29.12). Scar release by skin graft or by transposition
of local flaps such as fasciocutaneous flap is sometimes
needed in this group (Figs. 29.26 and 29.31). For severe
postburn deformities with underdeveloped mammary
glands, breast reconstmction can proceed if the surface
area of the breast is restored by means of tissue expansion
and a breast prosthesis is substituted for the absent par-
enchyma (21,22). The myocutaneous flaps such as latissi-
mus dorsi (LD) or transabdominal myocutaneous (TRAM)
flap are frequently used for severe destmction of the
breasts either in young girls or adult groups (18,36).
NAC reconstmction always needs later reconstmction in
this situation. This means that more careful initial manage-
ment of the bum wound and early scar release before ado-
lescence is needed for the child with thermal bums in the
anterior chest.
V.
PITFALLS
Considering the reconstmction principles, first of all, com-
plete release of the scar contracture cannot be overempha-
sized (15,19). Usually the incision line is placed in the
inframammary fold from the flank to the sternum leaving
the breast tissue intact without any undermining (Figs.
29.18, 29.25, and 29.44). Successful resurfacing of the
defect using skin graft, local flaps such as slide-swing
plasty or fasciocutaneous flap, and expanded skin nearby
should be achieved for restoring the breast contour (Figs.
29.14, 29.21, 29.26, 29.31, 29.39, and 29.55) (17,24).
Good immobilization of graft skin can be achieved by
means of a tie-over dressing, avoiding circulation compro-
mise in flap surgery by proper design (by keeping the
length-to-base ratio at 3:1 for fasciocutaneous flap).
Careful elevation of the flap to include the fascia, and
secured vessels anastomosis in free tissue transfer should
be kept in mind to achieve good results (Fig. 29.18).
The second important principle is delayed reconstmc-
tion of the NAC because the definite position of the
NAC usually cannot be ensured until full development
of the breast and final stage of the reconstmction.
Besides, unreliable blood supply of the local flap for
NAC reconstmction usually exists if the initial bum
injury involves the dermis (15). Pigments used in the tat-
tooing technique for the areola in burn breast reconstmc-
tion may fade away later, possibly because the injured
dermis cannot keep the pigments longer and hence the
technique is not advised by some authors (30). It is
better to arrange the NAC reconstmction in the last pro-
cedure, if possible, for bum breast reconstmction after
scar maturation and contour restoration.
The third key point is not to do any harm. Injury to the
sensory nerves toward the breast tissue should be avoided
when reconstmctive procedure is performed around the
lateral chest (4).
VI.
NURSING ISSUES
Acute stage wound care for the bum chest is the same as
for other thermal bums. The nurses may find that the
necrotic tissues around the NAC are not removed after
debridement. This may reflect a policy of conservative
treatment of surgeons. Therefore, bedside debridement
during dressing changes is not performed.
The patient should acquire a full understanding of the
methods available for reconstmction of the breast and
NAC (4). Informed consent and explanation should be
given preoperatively. When reconstruction is carried out
on a lactating breast, care must be taken not to let the
wound become contaminated by lactation. Tie-over bol-
sters are used to ensure skin graft adherence. The dressing
should be kept clean and dry in the subsequent postopera-
tive days to avoid infection.
When flaps are used for reconstmction, the circulation
must be monitored frequently, especially in the first two
postoperative days. The appearance of the flap, capillary
refill, surface temperature, and transcutaneous oxygen
levels should be recorded frequently in the first 24 h post-
operatively. One should bear in mind that the development
of a hematoma is a frequent cause of skin graft or flap
failure. Consequently, a drainage system, either penrose
or vacuum drain, should be kept effective. When an
implant, such as tissue expander or breast prosthesis is
used, perioperative antibiotics are usually recommended.
The importance of postoperative pressure therapy for
skin grafts or a specially designed device to maintain the
breast contour and control of chest deformities should be
provided for all patients (40).

Reconstruction of Ches t Contractures
409
VII.
REHABILITATION ISSUES
The tie-over bolster dressings are kept in place for 6 or 7
days. After removal of the dressings, a plaster-of-Paris
slab is suggested for application to the grafted area and
for the breast to maintain its shape and contour (38). A
device consisting of a Plastizote molded two-piece body
jacket which incorporates a full neck and chin conformer
was recommended by Becker to control chest deformities
including kyphosis due to bum scarring (40). This device
can also be used in the postreconstructive stage.
Custom-made compression garment worn for 6-12
months after breast release is recommended by most
plastic surgeons and physical or occupational therapists.
Custom-made openings in pressure garments allow for
nipple and breast mound projection. Silicone inserts
placed in the concave area help scar maturation after
reconstmction (Fig. 29.19) (19,41,42). Postoperative
splinting combined with regular exercise is recommended
by many authors for the prevention of disfigurement and
for maintaining range of motion (43-45).
VIII.
LONG-TERM OUTCOME
From 1982 to 2000 there were 37 female patients suffering
from bum injury with breast deformity and received surgi-
cal reconstmction at Linkou Bum Center in Chang Gung
Memorial Hospital. The age at injury ranged from 2
months to 50 years with an average of 16.6 years.
Among this group, there were 19 children (51.4%) under
the age of 12. The remaining 18 patients were adults
(48.6%) with a mean age of 31.7 years. In the adult
group, 50% of the patients sustained chemical bums. In
children, scald burns were the most common cause of
injury. The most common method for correction of the
resulting defects was the use of Z-plasties, although skin
grafts, tissue expansion, fasciocutaneous flaps, and myo-
cutaneous flaps were also used for reconstmction. The
use of local tissue dominated this process. For NAC recon-
stmction also, Z-plasties were the most frequently used
method. In children, all the breast mounds were restored
after various kinds of reconstmctive procedures. Four
patients with NAC destmction or distortion due to pre-
vious burn injury received transposition of residual NAC
showing acceptable results. Two patients with total
destmction of the NAC did not receive further reconstruc-
tion. Among those patients who received fasciocutaneous
flap reconstmction, only one had partial flap tip necrosis.
No other serious complication occurred in this group. In
the adult group, all patients regained breast mound after
reconstmction. Two patients had marked hypoplasia of
the breast even after total release of the scar contracture.
Three patients with NAC involvement also were satisfied
by means of local cutaneous flap reconstruction or transpo-
sition of residual NAC. There were also no serious compli-
cations in this group.
There are some long-term follow-up noted (Figs. 29.12,
29.23, 29.31, and 29.37). Breast development and contour
restoration can be satisfactory if the timing and modality
of reconstructive procedures can be done properly.
Consequently, several conclusions can be drawn. Satis-
factory aesthetic results for burns, chest and breast deform-
ity reconstmction can be obtained by means of following
principles: (1) conservative treatment in the acute stage;
(2) prevention of postbum deformity; (3) complete scar
release with as much preservation of breast mounds as
possible; and (4) aesthetic reconstmction for established
deformity in chronic stage using skin grafts, local flaps,
free flaps, tissue expansion and transposition, or composite
grafts for the NAC. It is especially worthwhile to perform
reconstruction for any female with a burned breast
deformity.
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1997; 50:331-334.
33. van Straalen WR, van Trier AJM, Groenevelt F. Correction
of the postburn malpositioned nipple-areola complex
by transposition of subcutaneous pedicled flaps. Br J Plast
Surg 2000; 53:406-409.
34.
Bunchman HH, Larson DL, Huang TT, Lewis SR. Nipple
and areola reconstruction in the burned breast. Plast
Reconstr Surg 1974; 54:531-536.
35.
Silversmith PE. Nipple reconstruction by quadripod flaps.
Plast Reconstr Surg 1983; 72:422.
36. Ozgur F, Gokalan I, Erk Y, Kecik A. Reconstruction of
postburn breast deformities. Burns 1992; 18:504-509.
37. Neale HW, Smith GL, Gregory RO, MacMillan BG.
Breast reconstruction in the burned adolescent female
(An 11-year, 157-patient experience). Plast Reconstr Surg
1982; 70:718-724.
38.
Sawhney CP. The correction of post-burn contractures of
the breast. Br J Plast Surg 1977; 30:291-294.
39. Neale HW,
Kurtzman
LC.
Reconstruction
of the
burned breast and abdomen. In: Achauer BM, ed. Burn
Reconstruction. New York: Thieme Medical Publishers,
1991:148-164.
40. Becker BE. Hypertrophic burn scarring: control of chest
deformities with a new device. Arch Phys Med Rehabil
1980; 61:187-189.
41. Cooper R, Hall S. Occupational therapy and physiotherapy.
In: Settle JAD, ed. Principles and Practice of Burns Manage-
ment. New York: Churchill Livingstone, 1996:453-464.
42. Cooper R, Fenton OM. Disfigurement and disablement. In:
Settle JAD, ed. Principles and Practice of Burns Manage-
ment. New York: Churchill Livingstone, 1996.
43. Leman CJ. Splints and accessories following burn recon-
struction. Clin Plast Surg 1992; 19:721-731.
44. Evans EB, Alvarado MI, Ott S, McElroy K. Prevention
and treatment of deformity in burned patients. In:
Herndon DN, ed. Total Burn Care. London: W.B. Saunders,
1996:443-454.
45. Jordan RB, Daher J, Wasil K. Splints and scar management
for acute and reconstructive burn care. Clin Plast Surg
2000; 27:71-85.

30
Recons truction of Truncal Burns
NELSON SARTO PICCOLO
Instituto Nelson Picolo and Pronto Socorro para Queim aduras, Goiânia, Goiás, Brazil
I.
INTRODUCTION
As the trunk is usually covered by clothing on most every-
day activities, it is proportionally less injured than the
exposed areas of the body. Although clothing may act as
a protective barrier against certain types of burn accidents,
that is, against cooking gas explosion, it may also be a
“complicating” item when it gets soaked with a hot or a
chemical agent, or when caught on fire. In these situations,
the chances of a deeper burn are increased. This may result
in a larger incidence of burn scar sequelae in this region
of the body (Fig. 30.1). Excision and grafting has been
widely accepted as the treatment of choice for full-thickness
bums (1). Although some patients will not seek reconstruc-
tion of grafted areas, removal of scar tissue, previously
grafted or not, is a very common desire among our patients.
Reconstruction of truncal burns may face restrictive
scars around the axillae, base of the neck, and upper extre-
mities, as well as in relatively vast areas of scar tissue
around the thorax and abdomen. Functional reconstruction
is a priority in all areas of the body, and improvement of
shoulder and neck movement can be achieved with
truncal procedures alone or combined with more caudal
or cephalad procedures. Flat areas of scar tissue, which
result in no retraction, may be progressively removed
after complete maturation.
In the case of female patients, the tissue damage will be
more significant, if the breast or the area of future breast
development is injured and subsequently scarred. Assur-
ance that reconstructive procedures can, and will, be done
is a must for psychological comfort and to improve compli-
ance with pressure garments and physiotherapy. Pro-
cedures around these areas of the trunk usually have to be
started early. As the breast bud starts to grow, multiple pro-
cedures may be required until development is complete.
Absence of landmark anatomic structures as a result of
a deep burn involving the nipple areola complex (NAC) is
of significance to both sexes. The same is true for the
umbilical scar. The acute burn surgeon will not usually
remove these areas upon excising burn lesions, but deep
burns may result in their loss regardless of the acute
careful surgical technique. Enforcement of proper timing
of reconstruction may be difficult and sometimes painful
for the surgeon and the patient, who may wish for earlier
reconstructive procedures [Fig. 30.2(A-C)]. In our
country, patients of both sexes will usually ask to
411
I.
Introduction
411
VI.
Nursing Issues
415
II.
Preoperative Evaluation
413
VII.
Rehabilitation Issues
415
III.
Surgical Options
413
VIII.
Long-Term Outcome
416
IV.
Intraoperative Considerations
414
IX.
Conclusion
416
V.
Pitfalls
414
References
416

412
Functional and Aes thetic Reconstruction of Burned Patients
Figure 30.1
Incident of burn lesions according to body region—truncal bums = 18.4% (in a sample of 50,243 bums).
Figure 30. 2
(A) Patient with full-thickness bum to the entire trunk and upper extremities. (B) Same patient postexcision, with the attempt
of preserving the location of the nipple areola complex (NAC). (C) Same patient, after complete loss of the NAC, and sheet grafting.

Recons truction of Truncal Burns
413
reconstruct the upper portion of the trunk first. These areas
are commonly exposed daily. Most female patients will
agree that “return to femininity,” as some will say, can be
greatly improved with early reconstruction of the anterior
upper thorax.
Since the main goal of any procedure is to obtain a good
result, the surgeon, of course, will accommodate the
patients wishes, as long as they are realistic and within
his armamentarium of surgical options.
II.
PREOPERATIVE EVALUATION
As in any other surgical procedure, planning for the oper-
ations will require a thorough preoperative assessment to
identify functional deficits as well as aesthetic concerns.
A complete patient evaluation may include being seen
not only by the surgeon but also by the psychologist, the
physiotherapist, and the occupational therapist. After
these visits, the patient’s wishes are needs are prioritized
and the reconstructive procedures planned accordingly.
The surgical plan is then widely discussed with the
patient and/or the patient’s family. Very frequently, the
patient will initially present with a severe functional com-
plaint. As the treatment plan is outlined, he or she will
demonstrate the desire to reconstruct areas for a esthetical
reasons. Functional procedures, as a rule, are performed
first [Fig. 30.3(A-C)]. One must always realize that
most patients with severe bum scar contractures may not
only have difficulties with everyday life activities, like
brushing their teeth or putting their shoes on, etc. but
also have severe psychological difficulties coping with
their new appearance and a new different self. An honest
and straightforward evaluation may help in the planning
of realistic reconstruction options. However, the surgeon
in charge will have to consider all aspects of recovery, if
the patient is to benefit from the treatment (2).
If the patient is a child, this task is even more difficult.
There may be a lot of guilt involved, with parents reacting
in a very wide spectrum of attitudes. Overprotection is the
rule, but rejection can also happen. Both will impair ade-
quate preoperative care, such as physiotherapy and the
use of pressure garments. This can lead to the blurring of
proposed treatment options and postoperative manage-
ment issues. Strong psychological support and/or treat-
ment may be necessary for several months after the
wound has healed (3). After deciding upon the elected
procedure and operation dates, the entire team should be
briefed about the proposed treatment and become
acquainted with the patient. Thus, when the child is
admitted, adequate care will be provided. Knowing the
patient’s case may be influential in the immediate post-
operative care, when the difference between inadequate
and adequate positioning may signify the success of the
surgical procedure.
III.
SURGICAL OPTIONS
As any other pathology that requires surgical treatment,
bum sequelae to the tmnk are present in such a varied
spectrum of sizes and shapes that one must evaluate
each case as a different case, and the options for treatment
must be chosen accordingly.
Closure of the acute wound may be done with meshed
or sheet grafting, artificial or bioengineered skin substi-
tutes or even with local or distant flaps. Contraction will
usually occur across scar tissue, but it may also occur in
Figure 30.3
(A) Patient with truncal sequelae and severe restriction of shoulder range of motion. (B) Same patient being expanded.
(C) Same patient, 1-year follow-up postadvancement of expanded tissue, with significant functional and aesthetical result.

414
Functional and Aesthetic Recons truction of Burned Patients
grafted wounds. Alternatively, scar tissue may connect to
healthy skin, with subcutaneous scar tissue cords or bands
sometimes present in the anterior chest linked to the upper
extremities. This may result in impaired movement from
the shoulders and upper arms (4,5).
The functional deficits are usually treated first, although
the most frequent reason for these are contractures, signifi-
cant tissue deficits may occur; there may also be a lack of
adequate skin donor sites for correction of the problem.
Incisional release and resurfacing with grafts on Z-plasties
are frequently performed as curative procedures for con-
tracture bands in the upper lateral thorax and base of the
neck. Another frequently available option are rotation
flaps of lateral posterior thorax tissue for treatment of pos-
terior axillary retraction.
If the patient presents with normal tissue in the periph-
ery of the defect, or if he accepts more than one procedure
to gain the proposed result, the treatment of choice, in our
opinion, will be normal tissue expansion and advance-
ment. Yet, there is already enough evidence that suggests
that future treatment may consist of the replacement of
scar tissue by artificial skin. Tissue expansion has been
widely used all over the world to treat burn scars. The
implants now come in various shapes and sizes, and the
learning curve is relatively short, usually with the
surgeon understanding the benefits and the incidence of
complications when still relatively inexperienced. The
best results are achieved when the scar tissue is already
mature and the more pliable tissue chosen to be expanded
is around the defect (6) [Fig. 30.4(A and B)]. Expansion
may also be used as a way of “expanding” donor area
skin or to save possible scarring in distant virgin donor
areas. The periphery of the sequelae is expanded, and
full-thickness skin is removed, with “reattachment” of
the residual expanded skin to the defect, without any
local cosmetic loss. There is minimal to no donor site mor-
bidity as seen with contractures treated by incision and
full-thickness skin grafts. Composite tissue expansion is
also a possibility, with muscles, nerves, and vessels all
being included in the expansion process, when the defect
presents with more than just the absence of normal skin.
IV.
INTRAOPERATIVE CONSIDERATIONS
Since burn scars and scar contractures of the trunk may
involve one or both sides, and the back, most patients
are treated under general anesthesia. Adequate positioning
is imperative if the surgeon is rotating a flap or advancing
local tissue. The surgeon must be aware of local tissue
resistance to advancement and repositioning on the surgi-
cal table. Improper positioning can result in advert traction
at the suture line or at the base of the flap, when the patient
is placed back into the supine position in the immediate
postoperative period.
Figure 30. 4
(A) Preoperative planning for placement of
expander for partial removal of abdominal scar. (B) Expanders
in place, matching the defect.
Preoperative planning should always include careful
planning of incisions and noting that if flap rotation is
necessary, suture lines will be placed in natural skin
lines or creases to diminish the incidence of unsightly
surgical scars.
V.
PITFALLS
The expected results for the surgical technique are
presented for the patient or for the patient’s family.
The occurrence of complications must also be discussed.
The experienced surgeon will choose established tech-
niques with which he has acquaintance, so he may expedi-
tiously treat any complications related to the procedure.
Modesty upon scar removal may be the single most import-
ant factor upon doing these procedures along major joints
and round structures, like the lateral region of the trunk,
where tension on the advanced flap may be more geometri-
cally demanding. The surgeon must be prepared to act
acutely if complications develop, in order to minimize

Recons truction of Truncal Burns
415
Figure 30. 5
(A) Patient 1 year after severe bum to the anterior trunk. (B) Same patient, lateral views. (C) Same patient, after the first
expansion. (D) Same patient, after the second expansion. (E) Same patient, on her third expansion. (F) Same patient, after the third expansion.
the chance of total failure. Surgical planning based on
inadequate judgment may be the cause of incomplete or
unsatisfactory results. A though evaluation of the patient
with a comprehensive interview will clarify any doubts
there may be about the proposed procedure. Bum patients
who seek reconstruction may deal with disfigurement in
several different ways. Consequently, information about
the technique and disclosure about previous results in
similar but unidentified cases may inform the patient or
the patient’s family about expected results and possible
complications (7).
complementing the success of the procedure with the rec-
ommended postoperative care. Knowledge about the per-
formed procedure and how the care should be provided
after surgery is paramount to attain the proposed goal. As
positioning is very important in most truncal reconstruc-
tion cases, the Physiotherapist/Occupational Therapist
(PT/ OT) group will work together with the nursing staff
to guarantee this aspect of postoperative care.
VII.
REHABILITATION ISSUES
VI.
NURSING ISSUES
The burn team members will be completely informed about
each patient’s case, so they can play their role accordingly,
As in the acute burn care, the physiotherapist’s and the
occupational therapist’s work will contribute to the post-
operation rehabilitation of the patient. All procedures are
explained in detail and the issues to treatment of compli-
ance are identified as it relates to the expected outcome.

416
Functional and Aes thetic Recons truction of Burned Patients
Planning of subsequent procedures is based on the func-
tional gain perceived by the therapists. These professionals
will then communicate to the reconstructive team that the
patient is ready for the next intervention. In purely
aesthetic procedures of scar removal, the use of pressure
garments and orthotics is also influential in the final result.
VIII.
LONG-TERM OUTCOME
Outcome is determined by a series of factors. Although the
reconstructive procedure is only one of them, the surgeon
should involve the entire bum team in the patient’s
treatment. Staged procedures are usually the rule in bum
reconstruction. There may be several areas that require
simultaneous treatment. Sequential surgical planning
should also include the patient’s wishes in a realistic
manner. Thus, he or she can note that the progress is
already being achieved by the initial procedures. In
some cases, reconstmctive procedures may have to be
delayed until full development has been achieved
[Fig. 30.5(A-F)].
In some functional cases with major contractures, there
may be an actual “gain” of scar tissue area, as the release in
performed. Information about the expected result and the
changes to be expected with the scar red area will diminish
anxiety. Long term evaluation of actual results, can also be
anticipated. The planning of future operations for removal
of scar tissue may then be assessed (8). The patient must be
aware of the importance of the use of pressure garments
after each stage of reconstmction to achieve the best
results with decreased changes of scar hypertrophy at the
suture line of advanced flaps or even partial or complete
scar removal.
IX.
CONCLUSION
Although the trunk is only injured in about one-fifth of the
bum accidents, it is a very frequent site for reconstmctive
procedures. Thorough and comprehensive planning will
insure a larger number of satisfactory results. Unless, a
severe functional deficit is present, an operation should
only be performed after complete hypertrophic scar matu-
ration. In addition, there must be a complete evaluation by
the bum team, which includes the surgeon, physical and
occupational therapists, and, if necessary, a psychologist.
There must be a continuum of supportive treatment from
the acute phase of injury though reconstruction, with
long-term planning disclosed as soon as possible. Obtain-
ing the patient’s cooperation and “enrolment” into the
stages of the treatment is probably the single most
important factor in all aspects of bum care.
REFERENCES
1.
Still JM, Law EJ. Primary excision of the bum wound. Clin
Plast Surg 2000; 27(l):23-47.
2.
Fauerbach JA. Barriers to employment among working-aged
patients with major bum injury. J Bum Care Rehabil 2001;
22(l):32-34.
3.
Moss BF, Everett JJ, Patterson DR. Psychologic support and
apin management of the bum patient. In: Richard RL,
Staley MJ, eds. Bum Care and Rehabilitation—Principles
and Practice. Philadelphia: F.A. Davis Company, 1994.
4.
Fémadez-Palocios J, Bayón PB, Sánchez OC, Duque OG.
Multilevel release of an extended postbum contracture.
Bums 2002; 28(5):490-493.
5.
Ono I, Tateshita T. Reconstmction 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(3):283-288.
6.
Youm T, Margiott M, Kasabian A, Karp N. Complications of
tissue expansion in a public hospital. Ann Plast Surg 1999;
42(4):396-401.
7.
Pisarski GP, Mertens D, Warden GD, Neale HW. Tissue
expander complications in the pediatric bum patient. Plast
ReconstrSurg 1998; 102(4): 1008-1012.
8.
Berton RR. Applying what bum survivors have to say to
future therapeutic interventions. Bums 1997; 23(l):50-54.

31
Recons truction of the Perineum and Genitalia
LAWRENCE J. GOTTLIEB
University of Chicago, Chicago, Illinois, USA
MARK A. GREVIOUS
University of Illinois, Chicago, Illinois, USA
I.
Introduction
417
III.
Reconstruction
419
II.
Acute Care
417
References
423
I.
INTRODUCTION
Bum injury of the genitalia and perineum, like burns of the
face, hands, and feet, may result in physical and psychoso-
cial scars and dysfunction out of proportion to the percen-
tage of total body surface area injured (TBSA). Hence, the
American Burn Association classifies these bums as major
bums. Recovery from perineal burns is a difficult physical
and mental challenge. The physical pain that wound care
entails is obvious to the most casual observer. Likewise,
the psychologic consequences of these injuries should
not be overlooked and cannot be overemphasized. The
repetitive invasion of the patients’ most personal anatomic
region tends to erode their sense of modesty as well as self-
respect. Fear of sexual dysfunction or unattractiveness
may cause depression, increasing the likelihood of the
patient’s fear of dysfunction coming to fruition. In fact,
25% of all adult burn patients experience a loss of libido
or orgasmic dysfunction (1). Direct injury to the genitalia
increases the number of patients who have sexual dysfunc-
tion to a significantly higher level.
Most burns of the genitalia and perineum are superficial
flame or scald injuries. Isolated bum injuries to the
genitalia and perineum are infrequent and usually the
result of a child spilling hot food or liquid on themselves
(Fig. 31.1). These bums are usually partial-thickness inju-
ries. Deep perineal burns are usually associated with either
large TBSA flame bums or immersion injury. Rarely,
high-voltage electrical injuries cause devastating injuries
to this area. Most of the severe genital injuries occur in
males, for the anatomy of the female genitalia does not
leave it as vulnerable to significant injury. The best treat-
ment of any bum scar deformity is prevention by appropri-
ate care of the acute injury. The management of burns of
the genitalia and perineum can be especially challenging
to the bum care team. The high bacterial load endogenous
to the region as well as its unique anatomy necessitates
meticulous and knowledgeable pre- and postoperative
care.
II.
ACUTE CARE
Although certain qualities of the perineum and genitalia
require special care, wound management in this region is
similar to that in other areas of the body. Minimization
417

418
Functional and Aes thetic Recons truction of Burned Patients
Figure 31.1
Scald burn secondary to hot liquid spill.
of scars and deformity requires adherence to burn wound
management principles.
Superficial burns are most efficiently managed non-
operatively with topical antimicrobials, maintaining bac-
tériologie balance (<105 organisms/g of tissue), while
epithelialization occurs. Moderately deep partial-thickness
injuries are more likely to heal with unfavorable scars,
therefore consideration should be given to early closure
with a biologic dressing (Fig. 31.2). Small deep wounds
of the perineum and buttocks should also be treated with
topical antimicrobials, taking advantage of the fact that
perineal wounds tend to rapidly contract and close
rapidly by secondary intention. Larger deep wounds are
Figure 31.2 Burn injury debrided with a combination of
manual dermabrasion and tangential excision. Mons area and
labia majora closed with synthetic biologic dressing (Biobrane);
right thigh required grafting. The graft was secured with fibrin
glue (Tisseal) and the Biobrane was secured with tissue adhesive
(Indermil).
treated with tangential excision and immediate split-
thickness skin graft coverage. The grafts may be meshed
to accommodate the irregular contour of the region, but
should not be expanded if possible. The perioperative
management of the grafts (whether done acutely or
during reconstruction) is crucial. The grafts require a
well-vascularized wound bed in bacteriologic balance,
stabilization with sutures, staples, or fibrin glue, and pre-
vention of postoperative shearing. Nylon mesh secured
over the graft may help to prevent shearing. If there is ade-
quate uninjured skin surrounding the wound a vacuum
assisted closure (VAC) device may be placed over the
graft to assist in stabilization. Postoperatively, legs should
be positioned in abduction for wounds that traverse the
groin crease.
Concerns regarding contamination by stool is unnecess-
ary and unwarranted if the wound bed is devoid of non-
viable tissue, well vascularized, and adequately dressed.
A diverting colostomy is unnecessary in most cases.
Treatment of burns of the penis is similar in many
respects to that of hand burns. Superficial bums may be
treated with topical antimicrobials or biologic dressings.
Deep circumferential bums of the penis should be decom-
pressed via escharotomy when vascular compromise is
suspected (Fig. 31.3). Tangential excision and grafting
should be performed when the patient is hemodynamic ally
Figure 31.3 Escharotomy of circumferential burn of the penis
secondary to an electrical injury.

Reconstruction of the Perineum and Genitalia
419
able to tolerate the procedure. Although meshed grafts are
frequently used in the rest of the perineum, nonmeshed
grafts are preferred on the penis in order to obtain a
superior aesthetic result. If possible, efforts should be
made to salvage the superficial fascia (Dartos) of the
penis with its rich venous network. This loose areolar
layer is analogous to the areolar layer on the dorsum of
the hand. If it is preserved, there is little problem with
distal swelling, wound contraction, and subsequent con-
tracture following grafting. With more limited wounds
or scars, the unique laxity of penile skin enables up to
one-quarter of the circumference of the penis to be
excised and closed primarily [Fig. 31.4(B)].
Empiric circumcision, discarding nonbumed foreskin,
should never be done because this skin may be important
for acute closure or for subsequent reconstruction. Acute
swelling of the foreskin may require a dorsal (or ventral)
slit for decompression and access to the glans. Deep bums
of the uncircumcised penis usually spare the inner surface
of the prepuce. Even with full thickness bums of the rest of
the penile skin, a flap of this inner prepuce skin may be used
to resurface the debrided penile shaft [Fig. 31.5(A-D)].
Most burns of the scrotum may be treated with debride-
ment of eschar and application of topical antimicrobials.
Relatively large wounds will rapidly contract with
almost imperceptible scars. Occasionally, grafting is
required for full-thickness loss of large areas. In the
event of testicular exposure, the testicles should be
sutured together for stability and covered with split-thick-
ness skin grafts. Alternatively, if the medial thigh skin is
uninjured, the testicles may be temporarily buried under
the thigh skin.
Deforming intrinsic contractures of the penis, scrotum,
or vulva is rare in superficial injuries; yet extrinsic contrac-
tures or webbing across the perineum and groin is a
common result of extensive perineal and groin injuries
(Fig. 31.6). As in other areas of the body, prevention of
contracture is superior to treatment. All patients with
groin and perineal wounds should have their lower extre-
mities maintained in abduction. Compression garments
and night abduction splinting should be considered for 6
months to 2 years as prophylaxis against contracture for-
mation. Custom foam or elastomer forms may be required
under the elastic garments to provide adequate contact
with the skin.
III.
RECONSTRUCTION
Burn scar deformities of the perineum can be categorized
as quantitative or qualitative. Quantitative skin surface
area loss is usually due to wound contraction, since most
contractures represent a net loss of functional tissue. An
example of a more severe quantitative change is loss of
all or part of the external genitalia. However, relatively
few perineal burn injuries result in major quantitative
deformities.
Qualitative skin changes include alterations in texture,
pigmentation, moisture, and pliability. These qualitative
changes should not be minimized, since problems with
sexuality and body image may be produced by these
skin alterations. In addition, surface irregularities and
dryness may cause the patient to be unable to maintain
hygiene and lead to the development of recurrent or per-
sistent skin irritation.
A sympathetic, caring, and understanding burn care
team, family, and sexual partner will do much to help
these patients accept their qualitative bum scar deformities.
Repeated discussion concerning realistic expectations of
sexual function, appearance, and reconstmctive options is
important, beginning early in the acute phase and continu-
ing throughout the reconstruction.
Figure 31.4 (A) Full-thickness burn to dorsum of penis and lateral aspect of scrotum. (B) Distal portion of burn excised and closed
primarily. Proximal portion of burn tangentially excised and grafted. Note healing of scrotal burn by contraction.

420
Functional and Aes thetic Recons truction of Burned Patients
Figure 31.5
(A) Full-thickness scald burn to penis, sparing the inner surface of prepuce. (B and C) After excision of burned shaft and
outer prepuce skin, the unbumed inner layer of prepuce was used to resurface the shaft. (D) Two weeks postoperative of inner prepuce flap.
Figure 31. 6
Severe webbing of perineum in patient who
sustained a 98% burn.
Discussion of surgical intervention of the qualitative
and quantitative deformities should include the nature of
the deformity, the available options, the realistic expec-
tations of both the patient and the surgeon, and an under-
standing of the limitations of reconstructive techniques.
Patients need to understand that scars cannot be erased.
The goal is to exchange an unacceptable scar for a more
acceptable one.
The reconstruction of qualitative deformities is
perhaps the most difficult challenge in reconstructive
surgery. These deformities may not impair function, as
such, but instead damage self-image. For example,
many perineal scald bums in children are the result of
child neglect or abuse. The presence of a “ring sign,”
which is pathognomonic of abuse, brands these patients
for life (Fig. 31.7). The scar is a constant painful reminder
of the initial trauma and its alteration of body image.
Qualitative reconstruction attempts to restore the altered
body image.
Successful intervention for qualitative deformities gen-
erally entails resurfacing the entire bum scar area. The
desired result may be difficult to obtain because of the pre-
sence of limited normal adjacent skin, unacceptable donor

Reconstruction of the Perineum and Genitalia
421
Figure 31. 7 “Ring sign.” Area of buttock not burned due to
the child being forcibly held against the bottom of the tub. This
burn distribution is pathognomonic of child abuse.
deformities from available flap or full-thickness graft sites,
and the inability of split-thickness grafts to accomplish the
desired goals. When the undesirable scar is not extensive
and is adjacent to adequate normal skin, tissue expansion
is a reasonable way to obtain qualitatively normal skin
with little or no donor site deformity. However, expanders
in the perineal region (especially in burn patients) tend to
have an inordinate amount of complications from infection
and erosion (2). In addition, it is mechanically difficult for
a patient to tolerate the “bulge” of an expander in the peri-
neum, which interferes with walking, sitting, and normal
daily activities. Despite these limitations, when expansion
techniques are successful they usually produce satisfactory
results. An alternative to expansion of adjacent flaps is
expansion of distant flaps or donor sites for full-thickness
grafts. This allows for large, good quality full-thickness
skin grafts with minimal donor site morbidity.
Correction of quantitative deformities is frequently
straightforward even when the deformity is severe. The
goals and expectations of both physician and patient are
more easily accomplished. Tightness, webbing, and distor-
tion of the external genitalia are all due to a relative lack of
skin. Vulvar injuries with subsequent webbing may com-
promise normal sexual activity and cause difficulty with
urination. Webbing can be corrected with any one of the
many ways available to lengthen a line. If there is adjacent,
relatively pliable skin, then one of the transposition
(Z-plasty) or advancement (V-Y) techniques may be used
[Fig. 31.8(B)]. This works best if uninjured skin can be
interposed to “break up” the scar contracture. When
normal adjacent skin is not available and the contracture
is totally surrounded by inelastic scarred skin, geometric
flaps alone rarely accomplish the goals of complete
release. Frequently, additional skin grafts are required to
close residual open areas if a full contracture release is
to be obtained. Severe contractures can only be released
by incising (or excising) the contracting scar band
(Fig. 31.9). These large defects require resurfacing with
grafts or flaps. Contractures will invariably recur if the
resultant defect following release is closed with split-
thickness skin grafts. If flaps or full thickness grafts are
not available, use of a dermal substitute (such as Integra)
should be considered.
The ideal time for contracture release is after active
contraction is complete and maximum scar maturation
has occurred. This usually requires at least 6 months and
even up to 2 years after injury. Occasionally, early con-
tracture release may need to be performed because of
severe functional disability.
Intrinsic contractures of the penis may result from
injury and subsequent scarring of Dartos fascia, Buck’s
fascia, the tunica albuginea, or the corpora itself. The
Figure 31.8 (A) Double opposing Z-plasty designed on groin web contracture. (B) Flaps of double opposing Z-plasty transposed to
release contracture.

422
Functional and Aes thetic Recons truction of Burned Patients
Figure 31.9
Large open wound after incisional release of
posterior contracture.
resultant scar bends the penis during erection (3)
(Fig. 31.10). Treatment is similar to that of secondary
hypospadias repairs or Peyronie’s disease (4). The basic
principle is to release the scar tissue by surgical incision
(Fig. 31.11) or, in selected cases, excision. The reconstruc-
tion depends on the layer injured. If it is the superficial
fascia (along with the overlying skin), then transposition
flaps or skin grafts are adequate. If the contracture is due
to an injury or deficiency of Buck’s fascia or the tunica
albuginea, then a dermal graft may be necessary to recon-
struct this layer (5). Dermal grafts need to be covered by
Byars’ flaps or a local flap, depending on the extent of
scarring. A Nesbit tuck procedure of the tunica on the
convex side of a penile bend may be helpful in some
patients with lateral bending (6).
Simple extrinsic contractures of the penis may lend
themselves to Z-plasty or surgical release and grafting.
In more severe cases the entire penis may be buried
Figure 31.10
Intraoperative artificial erection. After applying
Penrose tourniquet to base of penis, saline is injected into corpus
with a 23-gauge butterfly catheter.
Figure 31.11
Scar released by incision allowing penis to
straighten. The resultant defect was closed with a full-thickness
skin graft.
beneath a mass of scar, appearing severely foreshortened
or absent. These cases are usually the result of deep
partial-thickness burns in children that were allowed to
heal secondarily. The penis retracts into the pubic fat
and the skin becomes tethered proximally. The loose
areola layer is usually intact but may need to be released
due to secondary shortening. After aggressive surgical
release there is almost always a large raw surface area of
the penile shaft (Fig. 31.12). This should be grafted and
dressed with a compressive dressing, maintaining its
released length.
When scarring involves the urethral meatus, stricture
occurs. In mild cases, the patient or parents can be
taught to dilate the meatus with an appropriately sized
catheter. In more severe cases, Z-plasty or other interdigi-
tation of adjacent skin into the constricting band is necess-
ary. Distal ventral urethral loss secondary to deep burns
and/or pressure from Foley catheters is corrected using
Figure 31.12
Released penis requiring skin graft to entire
shaft.

Recons truction of the Perineum and Genitalia
423
Figure 31.13
Neurosensory radial forearm free flap marked
on forearm.
the principles of distal hypospadias repairs (7). Modifi-
cations are necessary, depending on the availability of
foreskin and the amount of adjacent scarring.
Complete loss of the penis usually requires the creation
of a perineal urethrostomy. Considerations of penile
reconstruction should await a closed wound and scar
maturation. The first reconstruction of the penis was
reported in 1936 (8). The history of total penile recon-
struction has paralleled the history of flap development
in plastic and reconstructive surgery. The multistaged
tube pedicle flap reconstruction has given way to the
axial pattern skin flaps and muscle flaps (9-11). These
procedures have subsequently yielded to the state-of-
the-art neurosensory fasciocutaneous free flap (16).
Ideally, the reconstructed phallus should fulfill several
criteria to be functionally and psychologically satisfying.
Figure 31.14
Penile reconstruction with its donor sites.
Forearm donor site was closed with a skin graft harvested from
thigh.
It should be aesthetically acceptable with a shaft of ade-
quate length and simulation of a glans. It should have
close to normal tactile and erogenous sensitivity. The
girth should be adequate for placement of a prosthesis
for sexual function, but not too large to preclude intromis-
sion. It should contain a neourethra that has the potential
to be anastomosed to the patient’s residual native urethra.
The patient should be able to stand to void through a
meatus in the glans (12).
The reconstructive technique that best fulfills all these
criteria
is
the
neurosensory
radial
forearm
flap
(Fig. 31.13). By connecting the antebrachial cutaneous
nerves of the flap to the native penile or pudendal
nerves, this flap offers the possibility of both erogenous
and protective sensations. Providing protective sensation
minimizes the chance of pressure necrosis from the pros-
thesis placed for erectile function (13). The main draw-
back of this flap is the skin grafted forearm donor site
(Fig. 31.14). Some bum patients may not be candidates
for radial forearm flap penile reconstruction due to injury
of both forearms. In this situation, although perhaps
less optimal in sensation, girth and quality of urethra,
alternative methods of penile reconstruction should be
considered (14,15).
REFERENCES
1.
Andreason NJ, Norris AS. Long term adjustment and adap-
tation mechanism in severely burned adults. J Nerv Ment
Dis 1972; 154:352-362.
2.
Gottlieb LJ, Parsons RW, Krizek TJ. The use of tissue
expansion techniques in burn reconstruction. J Burn Care
Rehab 1986; 7:234-237.
3.
Gittes RF, McLaughlin AP. Injection technique to induce
penile erection. Urology 1974; 4:473.
4. Horton CE, Devine CJ Jr. Peyronie’s disease. Plast
Reconstr Surg 1973; 52:503-510.
5. Devine CJ Jr, Horton CE. Surgical treatment of Peyronie’s
disease with a dermal graft. J Urol 1974; 111:44.
6. Nesbit RM. Congenital curvature of the phallus: a report of
three cases with description of correction operation. J Urol
1965; 93:230-232.
7. McDougal WS, Peterson HD, Pruitt BA, Persky L.
The
thermally
injured
perineum.
J
Urol
1979;
121:320-324.
8. Bogoras NA. Ueber die volle plastiche wieder Herstellung
eines zum Koitus fähigen Penis. Zentralbl Chir 1936;
63:1271.
9. Gilles H, Harrison RJ. Congenital absence of the penis. Br J
Plast Surg 1948; 1:89.
10. Kaplan L, Wesser D. A rapid method for constructing
a functional sensitive penis. Br J Plast Surg 1971;
24:342-344.
11. Hester JR, Hill HL, Jurkiewicz MJ. One-stage reconstruc-
tion of the penis. Br J Plast Surg 1978; 31:279-285.

424
Functional and Aes thetic Recons truction of Burned Patients
12.
Cherup L, Gottlieb LJ, Zachary LS, Levine LA. The sensate
functional total phallic reconstruction. Plast Surg Forum
1989; 58:25-27.
13.
Levine
LA,
Zachary
LS,
Gottlieb
LJ.
Prosthesis
placement after total phallic reconstruction. J Urol 1993;
149:593-598.
14.
Shenaq SM, Dinh TA. Total penile and urethral reconstruc-
tion with an expanded sensate lateral arm flap: case report.
J Reconstr Microsurg 1989; 5(3):245-248.
15.
Sadove RC, Sengezer M, McRoberts JW, Wells MD.
One-stage total penile reconstruction with a free sensate
osteocutaneous fibula flap. Plast Reconstr Surg 1993;
93:1314-1323.
16.
Chang T, Hwang W. Forearm flap in one stage recon-
struction of the penis. Plast Reconstr Surg
1984;
74:251-258.

Management of the Acutely Burned Hand
32
ROBERT L. SHERIDAN
Shriners Hospital for Children and Massachusetts General Hospital, Boston, Massachusetts, USA
I.
INTRODUCTION
Survival after serious bums has improved dramatically
over the past 20 years (1). However, despite generally
satisfying long-term quality of life, many such patients
will have significant lingering physical disability, much
of which can be traced to compromised hand function
(2). If optimal function is to be recovered after a serious
bum, proper acute care of the injured hand is essential.
Before the modem era, hand burns were managed by
application of various salves or topical medications while
necrotic tissues liquefied (3). With this management,
the outcome was a healed wound if the injury was super-
ficial, a closed but distorted hand if the injury was deep
dermal, and a chronic open wound if the injury was full
thickness. Although early excision of localized deep
hand burns was reported 60 years ago, most hand bums
were managed with topical antibacterial agents awaiting
eschar separation and spontaneous healing until the
1980s, when the improved outcomes with early surgery
were reported (4).
II.
PREOPERATIVE EVALUATION
A thorough initial evaluation is essential to overall man-
agement. Important points of history include the mechan-
ism of injury (particularly to exclude other hand trauma),
the nature of the burning agent (including temperature
and contact time), and prior hand injuries. A careful phys-
ical exam should then be done, even in massively burned
patients. Examination should include assessment of
wound depth, circumferential components, associated
injuries, and soft tissue perfusion. Radiographs are done
if indicated by injury mechanism. Injuries of abuse
should be suspected with sharply demarcated scalds or
deep dorsal contact injuries (Fig. 32.1).
Accurate determination of burn depth can be difficult
early after injury. Several diagnostic tools, such as laser
doppler, ultrasound, intravenous fluorescein, and indocya-
nine green have been proposed as aids in diagnosing burn
depth, but none are more accurate than the eye of an
experienced examiner (5). Differentiation can usually
be made between superficial burns, deep- dermal or
425
I.
Introduction
425
D-
Techniques to Salvage Length with
II.
Preoperative Evaluation
425
Fourth-Degree Injury 428
TTT
0
.
, ^
E.
Palmar Bums
429
III.
Surgical Options
426
V
Pitfalls
429
IV.
Intraoperative Considerations
427
A.
Technique of Escharotomy
427
VL
Nursing Considerations
432
B.
Technique of Fasciotomy
427
VII.
Rehabilitation Issues
433
C.
Techniques of Excision
VIII. Long-Term Outcomes
434
and Grafting
427
References
434

426
Functional and Aes thetic Recons truction of Burned Patients
decompression should be performed to prevent otherwise
avoidable ischemic injury. Soft tissue pressure measure-
ment >30 cmH20 support the decision to perform eschar-
otomy, but are generally not necessary if serial
examinations suggest diminished perfusion.
Figure 32.1
Injuries of abuse should be suspected with
sharply demarcated scalds, as demonstrated here, or deep
dorsal contact injuries.
full-thickness injuries, and injuries involving extensors,
joint capsule, or bone. This determination is important as
it facilitates prompt operation in those with other than
superficial injuries, avoiding the functional problems
associated with nonoperative management of deep
dermal and full-thickness injuries.
Some hand burns can be reasonably managed in the
outpatient setting (6). This management plan should
include a daily dressing change with would cleansing,
inspection, and passive ranging. Adequate monitoring
and follow-up are essential. The costs associated with sub-
optimal outpatient management, including infection and
contractures, make inpatient management cost-effective
if adequate outpatient care seems unlikely.
A critical part of the initial care of hand burn is to
ensure that soft tissues are well perfused. This is an area
in which early surgical intervention can make a tremen-
dous difference to ultimate outcome. Hands at risk for
ischemia include those with circumferential or near-
circumferential bums, those with very deep burns, and any
injuries involving high or intermediate-range voltage. The
hand should be dressed so that it can be examined easily,
and a specific monitoring plan should be ordered and
followed. It is important to look at signs more subtle
than the loss of palpable flow in named arteries at the
wrist. Mean arterial pressure in the central system is
three times higher than capillary pressure, and blood
flow may be maintained in these larger vessels when
flow in distal soft tissues is impaired. If the hand is
warm, soft, and has pulsatile flow detectable by doppler
in the palmar arch and digital vessels and a normal trans-
mission pulse oximetry signal at the distal digit, then flow
is adequate. As flow is progressively impaired, the hand
will become firm, cool, and doppler flow and oximetry
signal will be lost. Voluntary motion will become difficult
and the hand will assume a clawed position. At this point,
III.
SURGICAL OPTIONS
Should the hand be decompressed and how? Should the
wound be grafted? When should the wound be grafted?
With what should the wound be closed? What should be
done if burns involve joint and bone? These are some of
the questions that must be addressed when considering
surgical options.
Prompt recognition and correction of impending ische-
mia secondary to subeschar or intracompartmental edema
is essential to a good outcome. As noted earlier, a clear
monitoring plan for hands at risk should be set up with
the bedside care providers. Once evolving ischemia is
suspected, prompt escharotomy and/or fasciotomy is
indicated.
Should the wound be grafted? Surgery is indicated for
any deep dermal or full-thickness hand burn that will not
promptly heal within 3 weeks. Generally, this need is
apparent to an experienced examiner within 5 days of
injury. The skin of the dorsal hand is much thinner than
that of the palmar hand. It is quite common for circumfer-
ential hand bums to heal very well over their palmar
aspect, yet require grafting on the dorsal surface.
When should the wound be grafted? The patient’s
overall condition and wound size are important consi-
deration in the decision about operation. When caring
for patients with very large burns, priority is given to
maximum initial surface area wound excision and
closure with skin grafts and the hands are autografted
later in the patient’s course. Excision and allografting of
hand burns while awaiting availability of suitable auto-
graft can be useful in selected patients, but is not necessary
if unexcised hands undergo daily ranging and antidefor-
mity positioning. There is general agreement that earlier
surgery is associated with a better functional result and a
decreased need for reconstructive procedures; however,
patients with large injuries in whom the hands are defini-
tively closed later in the hospitalization while awaiting
autografting. Good outcomes in this setting depend on
aggressive daily hand therapy.
Only about 15% of palmar burns require grafting, as the
palmar skin is much thicker than the dorsal skin. When the
palm is deeply burned and loss of the palmar concavity and
range are at risk, the hand is splinted with the palm
extended to minimize contracture.
With what should the wound be closed? Practical
options include split-thickness autograft, full-thickness

Management of Acutely Burned Hand
427
autograft, and groin or abdominal flaps. Split-thickness
sheet autograft, generally thick, is the optimal cover for
most hand burns. Full-thickness grafts are ideally reserved
for palmar surface burns, particularly deep wounds of
limited extent or reconstructive operations during the
acute recovery phase. Groin and abdominal flaps can be
very useful when managing isolated fourth-degree inju-
ries, but are rarely needed in other circumstances.
What should be done if the bums are fourth degree,
involving tendon, joint, and bone? Is digital amputation
indicated? If tissue loss is circumferential, amputation
usually is required. However, a common pattern is viable
volar tissue with very deep dorsal injury including
exposure of burned bone. Many of these digits can be
salvaged.
IV.
INTRAOPERATIVE CONSIDERATIONS
Surgical treatment of hand burns has become more widely
practiced sine the 1970s (3,7). It has become increasingly
clear that allowing such injuries to heal over the course of
may weeks by contraction will result in very poor long-
term results (8). However, the operations need to be per-
formed well and carefully if they are to be effective.
Surgical treatment begins with decompression in the face
of acute ischemia.
A.
Technique of Es charotomy
Escharotomy should be done for decreasing perfusion
suggested by decreasing temperature, increasing firmness,
decreased capillary filling, and decreasing pulsatile per-
fusion in the superficial palmar arch and digital vessels
as detected by dopper and transmission oximetry. With
coagulating electrocautery, longitudinally oriented medial
and lateral incisions are made through eschar on the arm
and forearm (the former being made anterior to the ulnar
styloid to avoid injury to the ulnar nerve), stopping at
the metacarpophalangeal joints of the first and fifth
digits. Unburned skin or second-degree burn should not
be incised as this may result in deformity that will
require later treatment [Fig. 32.2(A) and (B)]. The hand
is then re-examined for perfusion prior to performing
digital escharotomies. Often, blood flow is enhanced ade-
quately by decompression of the arm, making digital
escharotomies unnecessary.
The efficacy and safety of digital escharotomies is
debated. One study demonstrated a reduced incidence of
amputation if digital escharotomies were done on circum-
ferentially burned digits (9). However, particularly in
small children, improperly performed finger escharo-
tomies can cause significant injury and are ideally only
done by those experienced with this procedure. When
digital perfusion remains marginal or inadequate despite
decompression of the arm and forearm, escharotomies of
full-thickness burns of the digits should be performed
[Fig. 32.2(C)]. Incisions are carefully made with pinpoint
electrocautery between the neurovascular bundle and the
extensors, avoiding both structures. A single longitudinal
incision is made on the radial aspect of the thumb and
the ulnar aspect of the digits. This places the incisions
on the side of the digit with the least functional importance
should the digital nerve be exposed by separation of ede-
matous tissue after escharotomy. The central digital
incision can be extended proximally onto the dorsum of
the hand between the metacarpals to enhance decompres-
sion. Meticulous hemostasis is maintained throughout the
procedure and the success of decompression is documen-
ted by Doppler examination. Digital escharotomies do
not result in injury to the extensor mechanism or digital
vessels when properly performed.
Escharotomy can generally de done using aseptic tech-
nique at the bedside or in the emergency department. Intu-
bated patients are managed with a brief intravenous
anesthetic. Others are treated with conscious sedation sup-
plemented with subeschar injections of local anesthetics.
Some patients will require a general anesthetic in the oper-
ating room to have this procedure performed properly and
humanely, especially if digital escharotomy is needed.
B.
Technique of Fas ciotomy
Edema within the fascial compartments of the forearm and
hand are seen following high-voltage electrical injury or
exceptionally deep thermal injury. These procedures
should ideally be done in the operating room. Upper-
extremity fasciotomy may include volar and dorsal
decompression, carpal tunnel release, and dorsal hand fas-
ciotomy. A curvilinear incision is ideal for volar exposure
of the compartments of the forearm [Fig. 32.3(A)]. This
approach allows one to gain access to all individual
muscle bundles in the volar forearm and decompress
the carpal tunnel through a contiguous incision, and
creates a well-vascularized flap of skin that will maintain
coverage over the median nerve at the wrist upon com-
pletion of the fasciotomy [Fig. 32.3(B)]. When needed,
straight linear incisions are adequate for exposure of the
dorsal aspect of the forearm [Fig. 32.3(C)]. Intermeta-
carpal incisions on the hand allow one to decompress
the intrinsic muscles of the hand if this is necessary
[Fig. 32.3(D)].
C.
Techniques of Excis ion and Grafting
Deep partial- and full-thickness hand burns generally
require layered excision and autografting. These procedures
are ideally done after exsanguination of the extremity with

428
Functional and Aes thetic Reconstruction of Burned Patients
Figure 32. 2
(A) When performing escharotomy, unburned skin or second-degree bum should not be incised. (B) This deformity
resulting from escharotomy placed in unbumed skin required correction (using multiple Z-plasties). (C) When digital perfusion
remains marginal or inadequate despite decompression of the arm and forearm, escharotomies of full-thickness bums of the digits
should be then performed. Incisions are carefully made with pinpoint electrocautery between the neurovascular bundle and the extensors,
avoiding both structures. A single axial incision on the radial aspect of the thumb and the ulnar aspect of the digits is done. The central
digital incisions can be extended proximally onto the dorsum of the hand between the metacarpals to enhance decompression.
an elastic wrap and inflation of a pneumatic tourniquet on
the arm to decrease blood loss. The excision is done sequen-
tially until a bed of viable tissue is reached. Viable tissue is
recognized by a pearly white moist dermis or the presence
of bright subcutaneous fat without thrombosed small
vessels or extravascular hemoglobin [Fig.32.4(A)]. Recog-
nition of viable tissue in an exsanguinated extremity with
a proximal pneumatic tourniquet is an acquired skill that
greatly facilitates low blood loss excisions. The hands are
then placed in a snug wrap of epinephrine soaked gauze
prior to deflation of the pneumatic tourniquet. Definitive
hemostasis is secured with judicious use of pinpoint electro-
cautery after some time is allowed to elapse for spontaneous
hemostasis (this is a good time to harvest autograft). Hands
are close with sheet autograft, except in the setting of
massive injuries, and grafts are secured with interrupted
fine absorbable suture. Grafted hands are then covered
with a gently compressive gauze wrap and placed in a
thermoplastic splint in functional position or may be left
open and held in such a splint with hooks glued to the
fingernails which are then pulled into the splint by elastic
bands. A compressive gauze dressing seems to be better tol-
erated by children. The hands are elevated and immobilized
for 7 days prior to reinstituting passive and active hand
therapy. Skeletal immobilization has been advocated, but
thermoplastic splints suffice in most.
D.
Techniques to Salvage Length with
Fourth-Degree Injury
In the presence of fourth-degree injury, involving under-
lying extensor mechanism, joint capsule, and bone, man-
agement can be more complex and less satisfying. The
ultimate outcome is largely dependent on the degree of
initial injury, although most patients can be expected to
have the ability to perform activities of daily living. Patients
with small overall surface area bums are candidates for
early debridement with groin or abdominal flap coverage
(10). In those with larger injuries, in whom flap coverage
is impractical, maintenance of a functional position with
splinting and therapy is critically important to an optimal
long-term outcome. A common patterm is deep dorsal

Management of Acutely Burned Hand
429
Figure 32.3
(A) A curvilinear incision is ideal for volar exposure of the forearm compartments. (B) This approach allows one to gain
access to all individual muscle bundles in the volar forearm, allows one to decompress the carpal tunnel through a contiguous incision,
and creates a well-vascularized flap of skin that will maintain coverage over the median nerve at the wrist upon completion of the
fasciotomy. (C) On the dorsal aspect of the arm, straight linear incisions provide excellent exposure. (D) Intermetacarpal incisions on
the hand allow one to decompress the intrinsic muscles of the hand.
bum with exposure of the proximal interphalangael joints
and dorsal phalanges with viable volar tissue. If these
wounds are kept moist and clean, and proper position main-
tained, often the avascular tissue will cover with granulation
tissue, which can then be autografted with an acceptable
result. Sometimes this process can be facilitated by very
carefully debriding off remnants of burned cortical bone
[Fig. 32.4(B)]. Autografting is done wherever possible,
and exposed joints and bones are allowed to granulate and
subsequently are autografted. When autografting is sub-
sequently done, unstable open joints are maintained in a
position of function with axially placed Kirchner wires. It
is important to prevent desiccation of these wounds with
wet dressings or allograft. Joints which remain unstable
after coverage is achieved are later fused by open arthrod-
esis. High priority is placed on maximizing digital length.
E.
Palmar Burns
Most palmar bums will heal without surgery, given the
thickness of the palmar stratum corneum. Palmar bums
that require grafting are usually covered with thick sheet
autograft if the defect is large and full-thickness grafts if
the defect is small [Fig. 32.5(A)]. Grafts are secured in
place with tie-over dressings crafted such that the size of
the palmar wound is at a maximum. After 7-10 days,
these dressings are removed and passive and active
therapy is started. Especially in young children, contrac-
tures may evolve over the palm and across the volar
metacarpophalangeal and interphalangeal joints. When
recalcitrant to therapy, these are ideally addressed with
early release and grafting [Fig. 32.5(B)]. Instep grafts
have been advocated for aesthetic reasons, but functional
results with full-thickness or thick split-thickness grafts
are generally excellent [Fig. 32.5(C)].
V.
PITFALLS
Common pitfalls in the management of acute hand bums
include: (1) inadequate decompression, (2) inadequate
ranging and splinting, (3) inadequate excision, (4)
inadequate PIP coverage and the burn boutonnière deform-
ity, (5) inadequate early rehabilitation, and (6) inadequate
early reconstruction.

430
Functional and Aesthetic Recons truction of Burned Patients
Figure 32. 4 (A) Layered excision is done under tourniquet until a bed of viable tissue is reached. Viable tissue is recognized by a
pearly white moist dermis or the presence of bright subcutaneous fat without thrombosed small vessels or extravascular hemoglobin.
Wounds are closed with sheet autograft. (B) A common pattern of fourth-degree hand burn is deep dorsal bum with exposure of the
proximal interphalangeal joints and dorsal phalanges with viable volar tissue. If these wounds are kept moist and clean, and proper pos-
ition maintained, often the avascular tissue will cover with granulation tissue which can then be autografted with an acceptable result.
Sometimes this process can be facilitated by very carefully debriding off remnants of burned cortical bone. Autografting is done wherever
possible, and exposed joints and bone are allowed to granulate and subsequently are autografted. When autografting is subsequently done,
unstable open joints are maintained in a position of function with axially placed Kirchner wires.
Inadequate decompression occurs when distal ische-
mia is allowed to progress to the point that irrecover-
able soft tissue injury occurs. It is essential to be
sensitive to the clinical settings in which this will
occur. These include near- or completely circumferential
injury, particularly deep injury, and high-voltage injury.
In these settings, ischemia is a result of subeschar
edema or intracompartmental edema or a combination
of both. It is essential to set up a monitoring regimen
of hands at risk and to perform prompt escharotomy
and/or fasciotomy when distal soft tissue perfusion is
compromised.
Inadequate ranging and splinting will result in the
“clawed hand” or intrinsic minus deformity, even in the
absence of deep hand injury (Fig. 32.6). This deformity,
which is difficult to correct, can be prevented by taking
each joint through a full range of passive motion each
day with resting splinting in the position of function: the
metacarpophalangeal joints at 70°-90° of flexion the
interphalyangeal joints in extension, the wrist at 20° of
extension and the first webspace open. Special attention
should be paid to the firth finger, as it is particularly
prone to contractures that result in fixed interphalangeal
joint flexion and rotation (Fig. 32.7). When established,
this can only be corrected operatively.
Inadequate excision is a pitfall in any acute burn opera-
tion, as it is the most common reason for graft failure and
often results in secondary infection. In the hand, such
failures of early closure may compromise the ability to
participate in early therapy and possibly compromise
long-term outcome or delay full recovery. Inadequate
excision is a particular risk as most of these operations
are done after inflation of a proximal pneumatic tourni-
quet. Substantial experience is required to ensure adequate
excision of nonviable material using this technique.
Inadequate proximal interphalangeal (PIPJ) coverage is
a common problem, particularly in young children, and
can lead to the “bum boutonnière” deformity if not recog-
nized and addressed early. This deformity can be very
difficult to address subsequently (Fig. 32.8). The skin
overlying this joint is thin and there is minimal soft
tissue to protect the underlying extensor mechanism. If
this is compromised by direct injury or subsequent desic-
cation and rupture, the collateral bands will migrate
volar and the PIPJ will be brought into a position of
flexion from which recovery may be impossible. In some
case this unfortunate sequence of events can be prevented
by ensuring prompt coverage of the PIPJ. If the depth of
injury is such that the integrity of the overlying extensor
mechanism is threatened, splinting in extension or