Operative Technique in Plastic Surgery – Kevin C.Chung

Video p8-c021
■ Vascular anomalies involving the lip often cause overgrowth and a
deformity.
■ Unlike malignant labial lesions, subtotal resection of benign vascular
anomalies can be performed to improve the patient’s appearance.
■ This technique avoids the placement of a scar on the cutaneous lip (TECH
FIG 3).
■ An elliptical excision is designed along the keratinized and nonkeratinized
vermillion; the markings are tattooed prior to injection of local anesthetic.
■ Diseased vermillion, mucosa, submucosa, and a portion of orbicularis
muscle are removed.
■ The incision is closed with interrupted Vicryl and chromic suture.
■ The patient is maintained on a full-liquid diet for 2 weeks.
■ If the lesion regrows, it can be debulked again using the same incision.
TECH FIG 3 • Transverse mucosal resection of an
involuted infantile hemangioma of the lip. A.

Appearance of the lesion at 3 years of age. B.
Markings for excision. C. Suture line following
resection. D. Postoperative appearance.
■ Suction-Assisted Lipectomy
■ Several types of vascular anomalies are amenable to suction-assisted
removal when they are located primarily in the subcutaneous plane: infantile
hemangioma, capillary malformation, lymphatic malformation, and other
lesions that have a significant adipose component (TECH FIG 4).10
■ This technique allows the removal of diseased tissue without long incisions,
raising skin flaps, and “open” excision, which has increased morbidity and
recovery compared to liposuction.
■ Stab incisions are placed in nonconspicuous areas and tumescent solution is
infused (1 mL of epinephrine 1:1000, 1000 mL normal saline, 50 cc 1%
lidocaine) not to exceed 35 mg/kg of lidocaine.
■ Cannulas of 3 mm typically are used for the face, 4 mm for the upper
extremity, and 5 mm for the trunk or lower extremity.
■ The aspirate is one-half to equal the amount of tumescent that was infused.
■ I usually do not use a tourniquet for extremity lesions.
■ A pressure dressing is applied, and the incisions are closed loosely to allow
drainage.
TECH FIG 4 • A 10-year-old female with a capillary
malformation and overgrowth of her left lower

extremity managed with suction-assisted lipectomy. A.
Preoperative appearance. B. Intraoperative view. C.
Lipoaspirate. D. Reduced circumference of her leg
postoperatively.
PEARLS AND PITFALLS
Diagnosis
■ Vascular anomalies are commonly misdiagnosed.
■ Ensure accurate diagnosis prior to operative intervention to
prevent erroneous treatment.
Nonoperative
management
■ First-line treatment of vascular anomalies often is not operative
intervention.
Operative
indications
■ Resection of vascular anomalies is indicated for small lesions or
those that have failed or are not candidates for other treatments.
Hemostasis
■ Despite being vascular, significant intraoperative hemorrhage
rarely occurs.
■ Blood loss can be reduced using epinephrine, elevation, cold
saline gauze, cutaneous clips, and careful hemostasis with cautery.
Operative
technique
■ Complete excision is not required.
■ Subtotal resection to improve symptoms typically is the goal of
operative intervention.
■ Most lesions outside of the face are excised using lenticular
excision and linear closure.
■ Round lesions on the face often are best removed using circular
excision and purse-string closure.
POSTOPERATIVE CARE
■ Individuals who have had significant resections of the head/neck spend 24 to
48 hours in the hospital and are given Decadron to reduce swelling.
■ Generally, patients may shower 2 days postoperatively and the occlusive
dressing and underlying Steri-Strips are allowed to “fall off.”
■ Children are managed with dissolvable sutures whenever possible.
■ Individuals are examined 2 to 3 weeks postoperatively and 6 to 12 months

later if a second stage is being considered.
■ Incisions are reinforced with Steri-Strips and are protected from the sun for 1
year.
OUTCOMES
■ Patients and their families are counseled that the area involving the vascular
anomaly cannot be made to look exactly like the anatomy without the lesion.
■ The best outcomes typically are obtained by improving the area of deformity
with the simplest approach rather than radical resection and reconstruction.
■ The most favorable results are by surgeons who have experience managing
vascular anomalies.
COMPLICATIONS
■ Operative management of vascular anomalies has a higher risk of
perioperative hemorrhage compared to resection of other types of lesions.
■ Because the tissues usually are ischemic, suture line dehiscence is more likely
than removal of nonvascular lesions; interrupted sutures that are not removed
too early can reduce this risk.
■ Intraoperative blood loss can predispose the patient to iatrogenic injury of
important structures.
■ Circular excision and purse-string closure is more likely to have dehiscence
than lenticular resection and linear closure.
REFERENCES
1. Wassef M, Blei F, Adams D, et al.; ISSVA Board and Scientific Committee.
Vascular anomalies classification: recommendations from the International
Society for the Study of Vascular Anomalies. Pediatrics. 2015;136:e203-e214.
2. Greene AK. Management of hemangiomas and other vascular tumors. Clin
Plast Surg. 2011;38:45-63.
3. Hassanein A, Mulliken JB, Fishman SJ, Greene AK. Evaluation of
terminology for vascular anomalies in current literature. Plast Reconstr Surg.
2011;127:347-351.
4. Greene AK, Perlyn C, Alomari AI. Management of lymphatic malformations.
Clin Plast Surg. 2011;38:75-82.
5. Greene AK, Alomari AI. Management of venous malformations. Clin Plast
Surg. 2011;38:83-93.
6. Greene AK, Orbach DB. Management of arteriovenous malformations. Clin

Plast Surg. 2011;38:95-106.
7. Maguiness SM, Liang MG. Management of capillary malformations. Clin
Plast Surg. 2011;38:65-73.
8. Hassanein A, Couto J, Greene AK. Circular excision and purse-string closure
for pediatric facial skin lesions. J Craniofac Surg. 2015;26:
1611-1612.
9. Mulliken JB, Rogers GF, Marler JJ. Circular excision of hemangioma and
purse-string closure: the smallest possible scar. Plast Reconstr Surg.
2002;109:1544-1554.
10. Couto JA, Maclellan RA, Greene AK. Management of vascular anomalies
and related conditions using suction-assisted tissue removal. Plast Reconstr
Surg. 2015;136:511e-514e.

22
CHAPTER
Section VII: Pediatric Burns
and Wounds
Functional Burn
Reconstruction
David A. Billmire and Kim A. Bjorklund
DEFINITION
■ The hallmark of burn injury in children is burn scar and burn scar contracture.
■ The tendency toward hypertrophic scarring in children is a major challenge.
■ Hypertrophic scars tend to develop in wounds that require greater than 3
weeks to close.
■ These scars are raised, red, tight, hard, and often itchy.
■ Hypertrophic scarring after burns is common and creates a wide range of
cosmetic and functional problems.1
■ Contractures (inability to perform full range of motion) result from factors
such as limb positioning, duration of immobilization, and muscle, soft tissue,
and bony pathology.2
■ Scars result in restriction in movement, particularly when they cross a joint,
and increase the likelihood of contracture development.
■ A similar burn injury in an adult that requires only initial resurfacing of the
wound may require repeated releases and other procedures during subsequent
growth and development of a child.
■ Growth can be affected with restriction, distortion, and, in some cases,
elongation.
■ Heterotopic ossification (HO) resulting from ectopic bone formation in the soft
tissue around joints can significantly affect extremity motion and function.

■ Functional issues are frequently coupled with aesthetic concerns regarding loss
of structures, obliteration, and distortion of normal anatomy.
ANATOMY
■ Major problems tend to occur across joints and sites of active movement.
■ The shoulder, elbow, and hand are most commonly affected by contractures.2
PATHOGENESIS
■ In normal acute wound healing, myofibroblasts provide collagen and
fibronectin deposition and aid in wound contraction over approximately 7 to 10
days.3
■ However, the presence of myofibroblasts following a burn injury can result in
excessive extracellular matrix deposition leading to a pathologic contracture
and hypertrophic scarring.3
■ Although in adults scars typically mature within 12 months, in children, the
scarring diathesis may take years to resolve.
NATURAL HISTORY
■ The natural history of a burn wound is to heal with re-epithelialization in
superficial partial-thickness burns within 10 to 14 days.
■ Deep partial-thickness or full-thickness burns heal by combination of
contracture and re-epithelialization and are unlikely to heal within 14 days.
■ Accordingly, burn wounds that are unlikely to re-epithelialize by 2 weeks
should be treated with early operative intervention for excision and split-
thickness skin grafting (STSG).
■ Sheet grafts should be used in critical areas such as the face and hands.
■ Less cosmetically sensitive areas can be covered by mesh graft techniques.
■ We have found early sheet grafting of burn wounds (where adequate donor
sites allow) to dramatically reduce the need and extent of subsequent
reconstruction.
■ Wound coverage is followed by an aggressive rehabilitation program with
appropriate splinting and positioning in the immediate postoperative period,
followed by ongoing physiotherapy, splinting, and the use of pressure
garments.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Examination should focus special attention on critical areas, beginning with

the airway (neck) and eyes.
■ A history of previous airway problems such as inhalation injury and need for
tracheostomy should be noted.
■ The presence of dry eye symptoms can be subtle in children, and coverage of
the globe needs to be ascertained.
■ Major joints and hands should be examined closely for restriction of growth
and movement.
■ Range of motion and functional limitations from scar contractures or HO
should be carefully documented.
■ In females, the breast buds and/or breasts should be examined to evaluate need
for release or reconstruction.
■ A systematic anatomic approach to catalogue affected structures is important.
Complete or partial loss of limbs, digits, eyes, ears, nose, breast buds/breasts,
genitalia, skull, and hair-bearing scalp should be noted.
■ Previous donor sites and uninjured skin should be evaluated for future
reconstructive efforts.
■ Putting all of this together allows one to plan and sequence the reconstructive
effort.
IMAGING AND DIAGNOSTIC TESTS
■ X-rays should be obtained for significant hand burns.
■ Most major joints usually do not require imaging unless the burn wound
extended into the joint.
■ Joints with functional limitations may benefit from x-rays to look for HO.
■ Facial burns (especially those requiring face masks in a growing child) may
benefit from monitoring with serial cephalograms to track facial growth and
change.
NONOPERATIVE MANAGEMENT
■ Nonoperative management begins in the acute phase of the burn injury.
■ Many of the secondary problems in pediatric burn injuries can be avoided or
lessened by the initial wound management.
■ The use of sheet grafting in sensitive areas such as the head and neck and
hands can dramatically reduce the need for subsequent reconstruction.
■ A rehabilitation program using splinting, stretching exercises, and pressure
garments can be effective in modifying the maturing burn wound and scar.

SURGICAL MANAGEMENT
■ Secondary burn reconstruction ideally begins when the burn wound matures.
■ Burn maturation is a lengthy process that is unpredictable and may take years
in children.
■ Immature burn scars are hyperemic, red, and raised and should become softer,
pale, and flatter as they mature.
■ While the scar is maturing, nonoperative methods previously described above
should be employed.
■ Certain problem areas require early intervention with the knowledge that they
may need to be treated multiple times.
T E C H N I Q U E S
■ Contracture Release
■ Contractures that may interfere with growth in a child should be addressed
surgically.
■ Airway, Eyes, and Lips
■ The airway (neck contracture), eyes (ectropion/lagophthalmos), and
contractures of the lips result in significant functional deficits including
exposure keratitis, blindness, and oral dysfunction that limits eating and
mouth care.4
■ These critical areas should be treated first and early in secondary burn
reconstruction (TECH FIG 1).

TECH FIG 1 • A. Planned release dart into adjacent
unit. B. Appearance following release prior to excision
of scar. C. Creating a template pattern for skin graft;
the mouth is packed to expand the site. D. Full-
thickness harvest site based upon template. E. Graft
sewn in place. F. Stented with bolster tie over
dressing.
■ Burn scar contractures
■ In approaching burn scar contractures, one should start centrally and work
peripherally.
■ The neck, axilla, and elbow should be addressed first to allow access to the
hand and provide a safe airway (TECH FIG 2).
■ Depending on donor-site availability, numerous releases can be performed
with a variety of techniques from thick-split grafts to free flaps.
■ The most common reconstructive techniques include split- or full-thickness
skin grafts and local flaps.

TECH FIG 2 • A. Planned incision for tight axillary
region release. B. Appearance of axilla following
release and skin grafting.
PEARLS AND PITFALLS
Contractures
■ Burns unlikely to re-epithelialize by 2 weeks should be treated
with early excision and split-thickness skin grafting to reduce the
likelihood of hypertrophic scarring and contractures.
■ Early initiation of splinting, stretching, and pressure garments
can help prevent contractures and improve functional motion,
especially in burn injuries across joints.
Reconstructive
planning
■ A systematic approach that examines all affected areas and
potential donor sites should always be employed when
undertaking burn reconstruction.
■ Critical areas (neck, eyes, lips, and hands) are a priority and
should be treated early in secondary burn reconstruction.
REFERENCES
1. Bombaro KM, et al. What is the prevalence of hypertrophic scarring following
burns? Burns. 2003;29(4):299-302.

2. Schneider JC, et al. Contractures in burn injury: defining the problem. J Burn
Care Res. 2006;27(4):508-514.
3. Van De Water L, Varney S, Tomasek JJ. Mechanoregulation of the
myofibroblast in wound contraction, scarring, and fibrosis: opportunities for
new therapeutic intervention. Adv Wound Care. 2013;2(4):122-141.
4. Egeland B, et al. Management of difficult pediatric facial burns:
reconstruction of burn-related lower eyelid ectropion and perioral contractures.
J Craniofac Surg. 2008;19(4):960-969.

23
CHAPTERHarvesting a Skin Graft
David A. Billmire and Kim A. Bjorklund
DEFINITION
■ Skin grafts are an integral part of burn reconstruction.
■ Various graft options include full thickness, split thickness, allografts, cultured
(engineered) skin, dermal substitutes Integra, and Alloderm.
■ Full-thickness grafts consist of the entire dermal layer with the overlying
epidermis.
■ Split-thickness grafts include a portion of the dermis and the overlying
epidermis.
■ Allografts or skin substitutes are used for temporary coverage and may be
biologic or synthetic.
■ Human cadaver allograft, porcine xenograft, and amniotic membrane are
biologic temporary skin substitutes.1
■ Biobrane double-layer dressing (silicone with nylon-containing collagen)
and TransCyte double-layer dressing (silicone with nylon-containing
neonatal fibroblasts) are examples of synthetic skin substitutes.1
■ Cultured skin such as cultured epithelial autograft (CEA) is typically grown
from the patient’s own cultured keratinocytes and may be coupled with an
engineered dermal substrate.
■ Dermal substitutes provide an engineered dermis (Integra) or allograft dermis
(Alloderm) in preparation for eventual grafting with split-thickness grafts.
Advantages
■ Virtually all reconstructive grafting needs can be met by either autogenous
full-thickness or split-thickness grafts.

■ Allografts may be used temporarily to stabilize burn wounds and create an
acceptable bed.2
■ Dermal substrates may allow the use of thinner split-thickness grafts in donor-
limited patients.
NATURAL HISTORY
Split-Thickness Skin Grafts
■ Scarring of the donor site is dependent on the site and depth of harvest, patient
age, and genetic makeup.
■ Once healed, the graft may exhibit dyschromia, increased scar contracture, and
decreased durability.
Full-Thickness Skin Grafts
■ Typically closed primarily, but in large grafts may require closure with a split-
thickness graft
■ Less color change and scar contracture and greater elasticity and durability
Prognosis
■ Highly dependent on the quality of the wound bed and influenced by factors
including vascularity, bacterial contamination, fluid collection under the graft,
and shearing
ANATOMY
■ Skin grafts can be harvested from virtually any part of the body.
■ Physical, functional, and aesthetic characteristics of the recipient site may
dictate the preferable donor site location.
■ Glabrous or hairless skin can typically be harvested from areas including the
sole of the foot, hypothenar eminence, retroauricular, inner upper arm, and
potentially the lateral flank areas, depending on the patient.
■ Full-thickness grafts can be harvested in areas with redundant skin such as the
abdomen, groin, upper arms, and supraclavicular regions.
SURGICAL MANAGEMENT
Preoperative Planning
■ Wound bed preparation is critical and must be debrided to healthy well-
vascularized tissue. If uncertain of the readiness of the wound bed, it may be

prudent to temporize with a skin substitute following debridement.
■ Donor-site choice should be matched to the recipient site for characteristics
such as color, hair bearing, thickness, and texture.
■ Type of graft (split or full) is chosen based upon donor availability and
recipient needs.
T E C H N I Q U E S
■ Split-Thickness Graft Harvest
■ Tumescence of donor site is frequently performed to facilitate harvest, as
well as reduce pain and blood loss. A Pitkin solution (1 L of Normosol with 2
mg of epinephrine [1/500 000]) and ropivacaine 0.5% (maximum dose 3
mg/kg or 10 mL spread out over the entire volume of solution needed) or
other tumescent solution of choice may be used (TECH FIG 1A,B).
■ Split grafts are typically harvested using a dermatome, which is electric,
drum, or air powered (TECH FIG 1C).
■ For average depth split-thickness grafts, the appropriate depth of the
dermatome is 12 to 15 thousands of an inch (TECH FIG 1D–F).
■ For thick split-thickness grafts, the depth is set to 20 thousands of an inch,
whereas for thinner grafts, it is set around 10 thousands of an inch.
■ Manual harvesting knives such as the Humby, Watson, or Braithwaite may
be used as an alternative to a dermatome. These typically require experience
to ensure grafts are harvested at a uniform thickness.
■ The graft may be meshed depending upon recipient site goals and
availability of donor sites for harvest.
■ Meshing will increase the graft surface area and allow for egress of fluid but
is not cosmetically desirable.
■ Grafts are typically meshed 1:1.5; however, the ratio may be increased to
cover a recipient greater area.

TECH FIG 1 • A. Infiltrating Pitkin solution. B.
Postinjection. C. Harvesting with powered dermatome.
D. Stopping to check thickness. E. Harvested site. F.
Dilute lidocaine with epinephrine soak.
Fixation
■ Absorbable sutures, tissue glue, and staples may be used to tack the graft in
place.
■ The recipient bed should be healthy, well-vascularized tissue with no
evidence of infection. The site should be dry to avoid a hematoma.
■ Donor site can be covered with bulky dressing (TECH FIG 2).

TECH FIG 2 • A. Applying Kaltostat alginate dressing.
B. Bulky occlusive dressing.
■ Full-Thickness Graft Harvest
■ A template or specific measurements of the recipient site defect should be
used to avoid harvesting unnecessary graft.
■ The full-thickness graft is typically harvested in an elliptical fashion to allow
for primary closure without dog ears.
■ Depth of harvest should include the epidermis and complete dermis.
■ Subcutaneous tissue should be removed completely prior to insetting the
graft.
■ The donor site should be closed primarily in layers.
■ Sutures are typically used to secure the graft to the recipient site.
Graft Dressing
■ Nonadherent gauze, antibiotic ointment (Bacitracin), bulky dressing, tie over
bolster, Reston Foam, and splint should be applied with either a split- or full-
thickness graft.
PEARLS AND PITFALLS
Dermatomes
■ Always stop and check dermatome thickness prior to beginning
split-thickness harvest.
Tumescent
solution
■ Use of tumescent solution facilitates harvest by stabilizing and
smoothing the surface, and reducing pain and bleeding.

Boluses
■ Reston foam boluses sewn with absorbable sutures allow excellent
fixation, protection, and mobility and may aid in splinting the site.
POSTOPERATIVE CARE
■ The graft should remain immobilized until an initial dressing change at 5 to 7
days for split-thickness grafts and 7 to 10 days for full-thickness grafts.
■ Erythema, drainage, or foul odor at the graft site should prompt a concern for
graft infection and necessitate an earlier graft takedown.
REFERENCES
1. Calota DR, et al. Surgical management of extensive burns treatment using
allografts. J Med Life. 2012;5(4):486.
2. Shores JT, Gabriel A, Gupta S. Skin substitutes and alternatives: a review. Adv
Skin Wound Care. 2007;20(9):493-508.

24
CHAPTER
Burned Hand
Reconstruction
David A. Billmire and Kim A. Bjorklund
DEFINITION
■ More than 80% of all severe burns involve the hand.1
■ These injuries may be devastating with long-term functional consequences and
significant morbidity.
■ Burns of the pediatric hand are common and are most frequently thermal type
injuries (scald, contact, or flame burns).2
■ Injuries tend to occur accidently as children explore their environment with
their hands.
■ However, a glove or stocking appearance to a burn, or an injury not consistent
with the history, should prompt concerns for abuse.
■ Hand function may be affected through tissue loss, burn scar contractures,
impaired growth, and abnormal sensation.
ANATOMY
■ Pediatric skin is thinner and has not yet developed the thickened palmar
epidermis of an adult.3
■ Dorsal skin is thin and pliable and provides less protection for underlying
extensor tendons and bone.
PATHOGENESIS
■ Thin dorsal skin places underlying structures at particular risk for exposure
and stiffness.
■ Extensor tendons are particularly at risk at the PIP joints where the central slip
may attenuate or rupture with exposure, resulting in a boutonniere deformity.
■ Burned hands tend to assume a position of wrist flexion, MCP hyperextension,

PIP flexion, thumb adduction, and interphalangeal hyperextension.4
■ Early elevation, splinting, and escharotomies when indicated affect postburn
edema and help prevent the development of burn contractures.
■ Altered sensation and motor and nerve function may occur secondary to the
burn.
NATURAL HISTORY
■ Untreated or inadequately treated hand burns frequently result in contractures
and long-term functional impairment.
■ Early involvement of a multidisciplinary team with aggressive elevation,
splinting, hand therapy, and early excision and grafting for deep burns is
essential.
■ Hand burns that are unlikely to heal within 2 weeks of injury should undergo
tangential excision and skin grafting.5
■ Palmar burns are more likely than dorsal burns to heal spontaneously from
glabrous skin appendages and may be less likely to require grafting.
■ Approximately 78% of pediatric palm burns heal without the need for grafting;
however, flexion contractures of the fingers and/or shortening of the thenar-
hypothenar distance may occur when burns take greater than 2 to 3 weeks to
heal.6,7
■ Secondary burn deformities may occur as a child grows because burn scars do
not grow at the same rate as the rest of the child’s hand and may impede
overall bone and soft tissue growth.3
■ Secondary burn deformities include intrinsic minus deformities (“claw hand”);
palmar cupping deformity; web space deformities; hypertrophic scars and/or
scar bands; finger deformities including boutonniere, swan neck and mallet
deformities; and deformities of the nail.8
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Evaluation of the location, size, depth, and previous treatment of the burn
■ Mechanism of injury (thermal, contact, chemical, electrical)
■ Previous splinting and hand therapy
■ Nature of the contracture (extension, flexion)
■ Skin and soft tissue adequacy and contracture
■ Tendon function—flexor and extensor
■ Assessment of sensation and vascular status of the hand and digits

■ Joint contractures—passive and active range of motion
■ Bony deformities and inadequate growth
■ Assessment of the entire upper extremity
■ Wrist or elbow contractures may need to be addressed to adequately position
the hand in space.
IMAGING AND DIAGNOSTIC TESTS
■ Plain radiographs of the hands and digits should be assessed for bony
deformities, joint contractures, or destruction.
SURGICAL MANAGEMENT
■ Surgical intervention is warranted for functionally significant contractures not
improving with stretching and splinting.3
■ Multiple surgeries may be required as a child grows for recurrent contractures.
■ Thumb reconstruction
■ The thumb contributes up to 50% of function of the hand, and secondary
reconstruction is critical in restoration of hand function.
■ When thumb loss remains distal to the interphalangeal joint, function is
reasonably well preserved.9
■ Web space deepening in these cases can help maximize function with
techniques such as the 4 or 5 flap Z-plasty and release with full-thickness skin
graft (FTSG) as described above.
■ As the thumb loss extends proximal to the interphalangeal joint, function
becomes increasingly more impaired.
■ Procedures to lengthen the thumb in these cases include pollicization of the
index finger, osteoplastic reconstruction, distraction lengthening, and toe-to-
thumb transfer.
■ Soft tissue is frequently limited and groin flaps or free tissue transfers are
often necessary as a first stage to provide a sufficient soft tissue envelope for
the transplanted toe.9
Preoperative Planning
■ An operative plan should be developed based upon the structures affected:
skin, tendon, joint, and bony structures should be addressed based upon their
involvement in the contracture.
■ Advanced joint destruction may warrant arthroplasty or arthrodesis.
■ Hand mobility, strength, and sensation are important to overall function and

should be carefully assessed in conjunction with an experienced hand therapist.
■ It is important to consider how the burn has previously been treated and if
previous surgery has been performed, as it may change the operative approach.
Positioning
■ The patient is positioned supine on the operating table. A hand board is
attached to the table and centered on the patient’s axilla. The affected extremity
is then extended with the hand positioned either dorsal or volar on the table.
■ A malleable lead hand may be used to secure the hand and fingers.
■ A nonsterile tourniquet may be used on the upper arm.
T E C H N I Q U E S
■ Z-Plasty (Standard, 4- or 5-Flap, Multiple Z-
Plasties in Series) for Thumb Reconstruction
■ Z-plasties are used to break up a tight linear scar when there is unscarred soft
tissue that can be transposed and is particularly useful for the web spaces of
the hand (TECH FIG 1A).9
■ In circumstances where flaps to be transposed are significantly scarred,
consider an alternative procedure such as release and grafting.

TECH FIG 1 • A. Scar band across axilla. B. Z-plasty
in series. C. Final appearance of Z-plasty in series
following closure.
■ 4-Flap or 5-flap “jumping man” Z-plasties are typically used for web space
contracture release and are designed with the transverse limb parallel to the
web space and all limbs being equal in length.
■ With the 4-flap Z-plasty, 90-degree flaps are drawn at the end of each central
limb and bisected to give 45-degree flaps.
■ Multiple Z-plasties in series should be used to break up a long vertical scar
band (TECH FIG 1B,C).
■ Incisions are made down through subcutaneous tissue and flaps are elevated
as thick as possible, allowing for preservation of blood supply (TECH FIG
2A).
■ Flaps should be dissected until they transpose easily without any tension

(TECH FIG 2B,C).
■ In the 1st web space, care should be taken in the dissection to avoid injury to
the index radial neurovascular bundle, which lies beneath the flap.
■ The tourniquet should be released and flaps checked for viability.
Hemostasis should be achieved with pressure and cautery.
■ Flaps should be transposed into position and secured with 4-0 or 5-0 suture
(TECH FIG 2D).
TECH FIG 2 • A. Flaps elevated. B,C. Transposition of
flaps. D. Closure.
■ Contracture Release With Full-Thickness Skin
Grafting
■ Indicated for flexion contractures of the digits, contractures of the dorsal or
volar of the hand, and web space contractures or syndactylies

Incision and Release
■ Scar contracture is assessed for area of maximal tightness and transverse
incision marked at this location (TECH FIG 3A,B).
■ Incision must extend into unscarred tissue on either side of the contracture
band to provide complete release (TECH FIG 3C).
■ Release is performed by pushing into the scar contracture with the blade
while counter tension is applied to the digit by stretching it into extension.
The tight thick scar will give way in the release using pushing movement
with a fresh blade, whereas the underlying neurovascular bundle will be
unharmed, under the appropriate pushing tension.
■ Continue to use pushing technique against scar until complete release is
achieved.
■ Identify underlying flexor tendons and neurovascular bundles and avoid
injury.
■ Slow passive stretch on a digit can help further stretch soft tissue.
■ Following soft tissue release, the contracture is reassessed to determine if
any release of checkrein, collateral ligaments, or volar plate is required.
■ The tourniquet is released and digits assessed for capillary refill and color. If
the digit appears pale with slow capillary refill, it may not tolerate the extent
of the contracture release due to the stretch on the neurovascular bundles. In
this case, the digit should be extended only to the point where it retains
normal color and capillary refill.
■ Meticulous hemostasis of the defect site is achieved.
■ If there is significant memory of the digit following contracture release, a K-
wire can be placed across the joint to maintain its position in extension
(TECH FIG 3D).
■ Color and capillary refill should be checked again after K-wire placement to
ensure the digit can tolerate the extended position.

TECH FIG 3 • A,B. Dorsal hand burn. C. Following
release. D. Following release and pinning of MCPs.
Graft Placement
■ The defect from the soft tissue release outlined using a template from suture
packet or Esmarch bandage.
■ The template is transposed to desired site of full-thickness skin graft (FTSG)
harvest (upper arm if available) and outlined in ellipse.
■ FTSG is harvested and defatted. Donor site is closed in layers.
■ FTSG is secured at the defect site with 5-0 chromic or plain gut suture.
■ A thick split-thickness graft may also be used (TECH FIG 4A).
■ Saline irrigation with a syringe and catheter tip beneath the graft to flush any
clots is performed.
■ A compression dressing with wet cotton and gauze is applied to the graft
site, followed by a splint to maximally protect position of release and graft
(TECH FIG 4B).

TECH FIG 4 • A. Resurfaced with thick split graft. B.
Dressed with dorsal block splint.
PEARLS AND PITFALLS
Neurovascular
limitations
■ It is critical to recognize signs of digital neurovascular
compromise intraoperatively and ensure the digit is returned to a
position where the neurovascular structures are under less tension,
in particular with the PIP joint release when the neurovascular
structure may be under tension with full stretching of the joint
after release.
Incomplete
contracture
release
■ Soft tissue contractures must be completely released and joint and
ligamentous structures examined in sequence if the contracture
remains.
Immobilization
of the graft
site
■ An inadequate compression dressing or failure of extremity
immobilization may result in suboptimal skin graft take.
Therapy
■ Postoperative splinting is critical to preventing recurrence of
contractures.
POSTOPERATIVE CARE
■ To avoid any mobility at the graft site, a cast is applied (long arm in young
child).
■ Healing and graft take is assessed at 7 to 10 days, and daily dressings are
performed if healing is incomplete.
■ If a K-wire is present, it is removed at 4 to 6 weeks. The patient should remain

in a cast to protect the K-wire for the duration.
■ Activities may be resumed once grafts are completely healed and K-wires
removed.
■ Night splinting in maximal extension to prevent recurrence of the deformity
should continue for 3 to 6 months.
COMPLICATIONS
■ Infection
■ Wound healing problems
■ Limited mobility from recurrent contractures
■ Hypertrophic or keloid scarring
■ Pain
REFERENCES
1. Pruitt BA Jr, Dowling JA, Moncrief JA. Escharotomy in early burn care. Arch
Surg. 1968;96:502-507.
2. Choi M, Armstrong MB, Panthaki ZJ. Pediatric hand burns: thermal,
electrical, chemical. J Craniofac Surg. 2009;20(4):1045-1048.
3. Birchenough SA, Gampper TJ, Morgan RF. Special considerations in the
management of pediatric upper extremity and hand burns. J Craniofac Surg.
2008;19(4):933-941.
4. Hentz VR. Burns of the hand: thermal, chemical, and electrical. Emerg Med
Clin North Am. 1985;3:391-403.
5. Pham TN, et al. Results of early excision and full-thickness grafting of deep
palm burns in children. J Burn Care Rehabil. 2001;22(1):54-57.
6. Sheridan RL, et al. Acute hand burns in children: management and long-term
outcome based on a 10-year experience with 698 injured hands. Ann Surg.
1999;229(4):558.
7. Barret JP, Desai MH, Herndon DN. The isolated burned palm in children:
epidemiology and long-term sequelae. Plast Reconstr Surg. 2000;105(3):949-
952.
8. Achauer BM. Reconstruction of the burned hand. Eur J Plast Surg.
1995;18(4):166-170.
9. Gulgonen A, Ozer K. The correction of postburn contractures of the second
through fourth web spaces. J Hand Surg Am. 2007;32(4):556-564.

25
CHAPTER
Reconstruction of Burned
Eyelids
David A. Billmire and Kim A. Bjorklund
DEFINITION
■ The majority of ocular sequelae following facial burns occur as a result of
secondary eyelid deformities.1
■ Burn scar contracture can lead to cicatricial ectropion and lagophthalmos,
which may in turn produce exposure keratopathy and in severe cases result in
corneal scarring.
ANATOMY
■ The eyelids are complex structures providing protection and lubrication for the
surface of the globe.
■ They contain an anterior and posterior lamella, which are separated by the
orbital septum.
■ In children, the levator muscle is rarely involved.
■ Eyelid skin is naturally thin and may result in a deeper burn than a similar heat
exposure elsewhere in the body.
■ Contractures most often affect the lower lids.
■ Reduction of motion and coverage may be the result of direct scar contracture
to the lid itself (intrinsic) or burn scar contracture in sites remote to the lids
such as the cheeks, mouth, neck, and forehead.
PATHOGENESIS
■ Burn scar contracture affects the motion and excursion of the lids and
consequently the coverage of the cornea.
■ With deeper burns, lagophthalmos of the lids develops and places the eye at
risk.

■ Bell phenomenon reflex helps prevent corneal epithelial defects and may be
problematic if absent such as in heavily sedated or paralyzed patients.1
NATURAL HISTORY AND PHYSICAL FINDINGS
■ Patients frequently present with an inability to fully close their eyes and may
complain of irritation and discomfort.
■ The eyes should be carefully examined to determine the etiology of the
dysfunction, noting if the anterior or posterior lamellae are affected and
whether there are additional extrinsic burn scars contributing to the contracture.
■ These symptoms tend to be better tolerated in children than adults.
■ The depth and extent of the eyelid burns should be noted, as well as presence
of eyebrows and eyelashes.1
■ The eyelids tend to demonstrate stiffness and fail to completely cover the eyes,
which may be most noticeable when the patient is asleep. Parents should be
queried about the status of the lids when the child sleeps. It is also easily
noticed when the child is under anesthesia.
■ The conjunctiva of the lower lids may be everted and pulled down onto the
cheeks.
■ The upper lids may demonstrate “clotheslining” where a band of scar runs
from the lateral canthus to medial canthus and functions as a fixed point
holding the lid up and preventing closure.
■ Reconstructive planning should include examination of both upper and lower
eyelids, extent of surrounding scar, including cheek and forehead, and donor
sites for potential FTSG.
NONOPERATIVE MANAGEMENT
■ In mild to moderate cases, eye drops and lubricants and taping can be used
temporarily until definitive release is performed.
■ In the acute burn phase, corneal exposure may be managed by a temporary
tarsorrhaphy, which is replaced as soon as the patient is stable with a formal
eyelid release-resurfacing.
■ The eyelids are delicate structures and tarsorrhaphies routinely pull out and
fail and should not be relied upon for an extended period of time.
SURGICAL MANAGEMENT
■ Operative intervention to protect the cornea and counteract lid retraction
should be considered a priority in burn reconstruction.

■ The timing of surgery is dictated by evidence of lagophthalmos with signs and
symptoms of corneal exposure.1
■ If both lids will require release, it is best to stage them by addressing the more
involved lid first for appropriate overcorrection.
■ Lower lid
■ Both extrinsic and intrinsic sites of the contracture should be released, but
even in a minimally involved lower lid attention should first be directed to the
lid itself.
■ As with all burn scar contractures, it should be overcorrected.
■ Although an extrinsic contracture with an unaffected lower lid may be
released, often the lower lid will still not achieve a normal position. In these
cases, the lower lid will need to be released and overcorrected, even though
there is no scar.
■ Upper lid
■ The surgical approach is similar to the lower lid.
■ Again the levator muscle is rarely involved and when involved actually
results in ptosis. This could be the result of dehiscence or destruction.
■ The lid should be resurfaced and released prior to addressing the ptosis.
■ Depending on the state of the levator, it can be repaired or a suspension
technique utilized.
Preoperative Planning
■ Review photographs and carefully examine the patient to determine etiology
of the problem.
■ Choose an appropriate donor site, preferably glabrous and thin. Acceptable
sites are an unburned opposite lid, retroauricular or preauricular,
supraclavicular, or the inner upper arm for full-thickness skin grafts.
Positioning
■ Supine, with shoulders elevated by a shoulder roll.
■ Ensure the donor site is accessible.
T E C H N I Q U E S

■ Lower Lid Reconstruction
■ The approach is the similar to a blepharoplasty approach for both the upper
and lower lids.
■ Local anesthetic with epinephrine should be injected.
■ In the lower lid, a subciliary incision is performed with a 15 blade and
dissected down to the orbicularis oculi muscle.
■ The incision should be continued from canthus to canthus, extending beyond
the medial and lateral canthi to ensure a complete release.1
■ Hooks or a Frost suture is used to apply steady traction to the lid margin
pulling superiorly as you release the scar.
■ The release should continue until the lid margin easily approximates the
globe.
■ Orbicularis muscle may require dissection if scarred, but typically, the
orbital septum is not involved and should not be violated.
■ A lateral canthotomy and cantholysis with subsequent canthoplasty may
need to be performed.
■ Upper Lid Reconstruction
■ Approach is similar to a blepharoplasty with an incision along the likely
tarsal crease, approximately 1 cm along the lash line (TECH FIG 1A).
■ The incision should be extended more medially and laterally than in a
standard blepharoplasty (TECH FIG 1B).
■ Apply gentle traction and continue to divide the scar until the lid comes
down.
■ As with the lower lid, the release should be overcorrected.
■ Do not violate the orbital septum.
■ The conjunctival surface should easily redrape over the globe.
■ A pattern of the defect is made and transferred to the donor site (TECH FIG
1C).
■ Harvest a full-thickness graft and defat as necessary.
■ In extensive burn cases, a split-thickness graft may be necessary.
■ Sew the graft in place with an absorbable suture, such as 6-0 chromic.
■ A bolster should be applied such as a thin Reston foam tailored stent over a
nonadherent gauze (Adaptic) impregnated with an ophthalmic ointment. The

bolster should be sewn in place again with an absorbable suture and left for 7
to 10 days (TECH FIG 1D).
■ A tarsorrhaphy is unnecessary with this technique as the bolster holds the
eyelid in position and allows the child to have some vision in the affected
eye.
■ Using this method, release and reconstruction of both eyes may be
performed at the same time.
TECH FIG 1 • A. Planned incision. B. Lid released
with medial and lateral extensions. C. Post auricular
donor site. D. Graft placed and stented.
REFERENCE
1. Malhotra R, Sheikh I, Dheansa B. The management of eyelid burns. Surv

Ophthalmol. 2009;54(3):356-371.

26
CHAPTER
Burn Neck Contracture
Release
David A. Billmire and Kim A. Bjorklund
DEFINITION
■ Burn scar contractures of the neck are relatively common and should be a
priority in surgical reconstruction when indicated.
■ Burn contractures of the neck may result in deformities that impair functions
such as eating and speaking.
■ If severe, the contracture can compromise the airway, make intubation
difficult, and distort growth of the facial skeleton.1
ANATOMY
■ Anterior neck contractures have been classified based upon the location of the
band and the degree of flexion and extension away from the anatomical
position of the neck and jaw.2
■ The width of the contracting segments and availability of supple surrounding
skin is also considered in the classification of the deformity.2
■ The key anatomical considerations are the burn scar crossing the mobile
cervical-mental angle or the manubrium.
■ Burn scarring above the cervical-mental angle will primarily affect the chin,
lower lip, and mandible.
■ When the burn crosses the angle, the mandible and head are pulled into
flexion.
PATHOGENESIS
■ Neck burn scar contractures in the pediatric patient can be severe secondary to
the propensity to hypertrophic scarring, which may develop rapidly in the
initial weeks following the injury.

■ Significant neck burn scarring creates a persistent downward force on the
lower lip, chin, and eyelids resulting in ectropion and AP growth restriction of
the mandible.3
■ Contractures may be severely disfiguring and functionally impair neck motion,
making eating and communication problematic.
■ The airway may become compromised and intubation difficult.
■ In extreme cases, scarring pulls the chin down to the chest wall, elongating the
mandible and severely affecting the airway.
NATURAL HISTORY
■ The natural history and progression is dependent on the depth of the burn
wound, the inherent tendency toward scarring, the age of the child, and the
initial treatment and management.
■ Neck burn scar can exert considerable pressure on the growing mandible and
adversely affect growth.
■ Depending on the vector of pull, the AP growth of the mandible can be
negatively affected and require later genioplasty or even a BSSO with
advancement.1
■ In the most severe cases where the mandible is drawn down to the chest,
mandibular lengthening and eventual setback may be required.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ A detailed assessment of the patient’s functional limitations is documented.
■ Previous treatment of the neck burn injury should be noted as well as
compliance with stretching and splinting.
■ Note the specific anatomic location of the neck burn contracture, width of scar
bands, and whether supple nonburned soft tissue is present.
■ Deformities such as lower lip and eyelid ectropion affected by the neck
contracture should be noted.
■ Occlusion is assessed—loss of chin projection and class II occlusion may
develop over time.
■ Range of motion and ability to extend the head and neck should be measured.
■ The patient should be assessed for potential intubation difficulty.
■ Availability of potential donor sites for surgical planning should be assessed.
IMAGING
■ Imaging is rarely required unless growth disturbances are suspected.

■ A standard lateral cephalogram is useful to follow the patient.
NONOPERATIVE MANAGEMENT
■ In the scar maturation phase of the burn wound, splinting and stretching are
recommended to reduce the contracture.
SURGICAL MANAGEMENT
■ Depending on the severity and extent, contracture releases may be
accomplished by a variety of techniques including split-thickness or full-
thickness skin grafting, local flaps, tissue expansion, and local flaps or a free
flap.
■ Operative intervention is warranted for functional deformities that are not
amenable to stretching and splinting.
■ The majority of neck contractures can be managed with a thick split-thickness
skin graft and may also be staged by initial release with a skin graft to assure a
safe airway and at a later date resurfaced with tissue expansion or flap.
■ In a growing child, releases may need to be repeated.
■ Recurrence is also significantly affected by the use of long-term postoperative
splinting:
■ In a study of 143 neck release procedures with Z-plasties or STSG, the
postoperative use of a neck hyperextension brace for over 1 year following
skin grafting decreased the recurrence rate by 40% to 50%.4
Preoperative Planning
■ Consultation preoperatively with anesthesia is critical for any potential for a
compromised airway and difficult intubation.
■ Although fiberoptic intubation has facilitated the process, in severe cases, it is
appropriate that the surgeon be at the bedside to do an emergent release if the
anesthesiologist is unable to establish a safe airway.
Positioning
■ The patient is positioned supine on the operating table.
■ A transverse shoulder roll is placed to allow maximum extension of the neck.
T E C H N I Q U E S

■ Incision and Release
■ Local anesthesia with epinephrine may be injected to help with hemostasis
and developing a dissection plane.
■ The neck is typically incised along the cervicomental angle and extends from
mid axis to mid axis or further if necessary to obtain complete release
(TECH FIG 1A,B).
■ The incision is carried down to a scar-free plane, which usually includes
division of the platysma with the lateral extension into the unburned skin on
either end.
■ The wound is then spread using digital traction or retractors to achieve
release of the scar.
■ This is aided by extending the neck as much as possible and using
continuous slow traction to release the contracture as much as possible.
■ It is important to overcorrect the contracture release as there will be
subsequent secondary contracture with healing.
■ Care should be taken to avoid injury to neurovascular structures deep to
platysma.
TECH FIG 1 • Incision for neck flexion contracture
release, anterior view (A) and lateral view (B). C.
Appearance of neck following release and grafting.
■ Reconstruction

■ When the wound is spread to its fullest extent, meticulous hemostasis is
achieved.
■ A thick split-thickness graft (14 to 16 thousands of an inch) sheet graft is
harvested, pie crusted, and sewn into place (TECH FIG 1C).
■ The graft is then stabilized with a tailored Reston foam stent sewn over a
nonadherent gauze (Adaptic) coated with Bacitracin ointment.
■ Alternatives to Reston foam include a bolster dressing.
■ In difficult recurrent cases, it may be necessary to consider the use of a flap
as opposed to a graft. Options include trapezius fascial or myocutaneous
flaps,5 supraclavicular flaps,6,7 or a free flap of choice.
■ Integra dermal substitute has also been described as a reconstructive option.8
PEARLS AND PITFALLS
Contractures
■ Burn contractures of the neck require early treatment to prevent
compromise of the airway and impairment of functions such as
eating, speaking, and growth of the facial skeleton.
■ Anatomically, it is critical to note burn scars crossing the cervical-
mental angle, which result in a flexion deformity as the mandible
is drawn to the chest.
Airway
■ Preoperative anesthesia assessment is critical for potential
compromised airway and difficult intubation.
Surgical
technique
■ Ensure complete contracture release in plane deep to platysma
with incision along the cervical-mental angle.
Postoperative
splinting
■ Postoperative management with neck splinting to prevent
recurrence of the contracture until the scar is fully mature is
essential.
POSTOPERATIVE CARE
■ The foam bolster is left in place for 10 to 14 days.
■ Following removal, a neck brace is crafted to hold the neck in an extended
position.
■ It will be worn ideally 24 hours a day until the scar matures and may be
beneficial for up to a year.

■ For small releases one can also consider a soft collar.
OUTCOMES
■ Despite a successful release, it may have to be repeated due to subsequent
contracture secondary to growth in children.
■ Factors include the age of the patient, the degree of scar response and the
adherence to the postoperative regimen.9
■ Failure due to significant hypertrophic scarring may require the use of a flap;
however, even flaps can fail as surrounding scar may create tension and result
in vascular compromise to the flap.
■ Once a stable neck release is obtained, it is often possible to replace the
grafted area at a later date by using tissue expansion to expand the unburned
skin on the lateral neck and supraclavicular area if available.
COMPLICATIONS
■ The major complications are graft loss and recurrence of the contracture.
REFERENCES
1. Katsaros J, et al. Facial dysmorphology in the neglected paediatric head and
neck burn. Br J Plast Surg. 1990;43(2):232-235.
2. Onah II. A classification system for postburn mentosternal contractures. Arch
Surg. 2005;140(7):671-675.
3. Upadhyaya DN, et al. Our experience in reconstructing the burn neck
contracture with free flaps: are free flaps an optimum approach? Indian J
Burns. 2013;21(1):42.
4. Waymack JP. Release of burn scar contractures of the neck in paediatric
patients. Burns. 1986;12(6):422-426.
5. Zheng XY, et al. Extended lower trapezius myocutaneous flap in burn scar
reconstruction of the face and neck of children. Pediatr Surg Int.
2011;27(12):1295-1300.
6. Margulis A, et al. The expanded supraclavicular flap, prefabricated with
thoracoacromial vessels, for reconstruction of postburn anterior cervical
contractures. Plast Reconstr Surg. 2007;119(7):2072-2077.
7. Pallua N, Demir E. Postburn head and neck reconstruction in children with the
fasciocutaneous supraclavicular artery island flap. Ann Plast Surg.
2008;60(3):276-282.
8. Lorenz C, et al. Early wound closure and early reconstruction. Experience
with a dermal substitute in a child with 60 per cent surface area burn. Burns.

1997;23(6):505-508.
9. Germann G, Cedidi C, Hartmann B. Post-burn reconstruction during growth
and development. Pediatr Surg Int. 1997;12(5-6):321-326.

27
CHAPTER
Adolescent Burned Breast
Reconstruction
David A. Billmire and Kim A. Bjorklund
DEFINITION
■ Burned breast contractures and loss are a common occurrence in females who
sustain major burns injuries prior to adolescence.
■ Knowledge of the importance of preserving the breast bud in preadolescent
females has lessened the need for complete reconstruction.1,4
■ In the acute burn phase, debridement should be kept to a minimum in the area
of the nipple areolar area.2
PATHOGENESIS
■ With the onset of puberty, the breast bud will begin to grow and expand the
overlying skin acting much like a tissue expander.4
■ Any overlying scar can cause restriction and/or distortion of the maturing
breast mound.
■ Additionally, full-thickness tissue loss from the burn injury surrounding the
breast bud will cause additional loss in the eventual volume of the breast.
■ Complete loss of the breast bud itself will result in a smaller or absent breast.
■ Burn wounds may also result in the loss of the nipple areolar complex, despite
the development of an acceptable breast mound.
NATURAL HISTORY
■ Full-thickness and deep second-degree burn injuries to the female chest
warrant special care in the acute burn wound and careful management in the
subsequent time period prior to development of the breast.3–5
■ Care should be taken with axillary releases, especially when considering the
use of Z-plasties. An inappropriately designed Z-plasty can unknowingly

transpose the breast bud into the axilla.
■ As the breast develops, the amount of constriction and distortion will become
apparent.
■ It is advisable to delay release/reconstruction until the breast has reached its
full size.
■ Rarely, the release may be warranted prior to growth completion and will most
likely need to be repeated.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Long-term follow-up for young females with significant chest burns is critical
to identify any problems during adolescence.4
■ Once the breast has begun developing, the patient should be evaluated about
every 6 months to assess potential problems.
■ The soft tissue envelope of the breast, breast tissue, and nipple areolar
complex should be assessed, noting location and degree of scar contracture.
■ Age and stage of breast development should be determined at each visit.
■ Restriction can be complicated by inherent underlying congenital deformations
such as constricted breast, tubular breast deformity, or Poland syndrome. These
should be considered in addition to the burn injury deformity.
SURGICAL MANAGEMENT
Preoperative planning
■ All areas of constriction and distortion should be noted.
■ Breasts are treated with almost entire release and grafting and/or
resurfacing.4,5
■ Typical areas of release are the inframammary, intermammary, and the
periareolar sites.
■ Reconstruction is typically performed with split-thickness sheet grafts,
although dermal templates such as Integra have been described.6
Positioning
■ The patient is placed supine on the operating table with a shoulder roll and the
arms abducted at 60 degrees.
■ Graft donor site should be exposed, typically the thighs or legs. The back is
also a good choice but requires turning the patient.

Approach
■ Both inframammary and intermammary releases are frequently performed at
the same time.
■ The inframammary release should be at the level of the inframammary fold
(which is frequently obliterated by burn scar) and will curve up at the midline,
joining the incision from the opposite side (FIG 1).
FIG 1 • Incision design for breast release along
inframammary fold.
T E C H N I Q U E S
■ The incision is made as indicated.
■ The underlying breast mound is pulled superiorly to open the release and
define the inframammary fold.
■ At the midline, the breasts are retracted laterally to separate the breasts into

two distinct mounds and define the cleavage (TECH FIG 1).
■ A periareolar release may be performed following the curve of the areolar,
although it may be delayed to a second operation if necessary.
■ Sheet grafts (approximately 15/1000ths thick) are harvested with a
dermatome from the chosen donor site.
■ Grafts are sewn in place and tacking sutures are placed along the
inframammary crease. The graft may be piecrusted to allow escape of
underlying fluid.
■ The grafts are dressed with nonadherent gauze and antibiotic ointment.
Moist fluffed gauze is molded along the inframammary fold followed by a
tailored Reston foam bolus, which can be sewn or stapled into place.
TECH FIG 1 • Appearance of breasts following release
and grafting—inframammary and intermammary
definition apparent, anterior view (A) and lateral view
(B).
PEARLS AND PITFALLS
Burned

breast
deformity
■ In the burned breast with inherent congenital deformities (such as
constricted or tuberous breast), release and correct the burn deformity
first and approach the congenital deformity secondarily.
■ Address the nipple areolar deformity at a later date once scars have
matured and edema has settled.
■ Volume loss can be treated with fat grafting at a later date.
Loss of
the
breast
■ Complete loss of the breast can be approached by any of the techniques
used in breast cancer reconstruction ranging from tissue expansion,7
pedicled flaps such as latissimus dorsi8 or TRAM flaps, to free tissue
transfer.
■ The reconstruction should consider the state of the breast site, the
quality of the tissue, and available donor sites.
■ Nipple areolar reconstruction likewise can be addressed by the standard
techniques used for breast cancer patients.
■ Contralateral breast procedures to address asymmetry may be required
if only one breast is affected.
POSTOPERATIVE CARE
■ Bed rest is not required, and early ambulation should be encouraged.
■ The dressings are left on for 10 to 14 days.
■ After the initial dressings are removed, the patient is dressed in a light padded
gauze dressing and a longline or surgical bra until the grafts are stable.
■ The patient is then switched to silicone inserts molded for the inframammary
fold to apply pressure the maturing graft.
REFERENCES
1. 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(6):718-724.
2. Armour AD, Billmire DA. Pediatric thermal injury: acute care and
reconstruction update. Plast Reconstr Surg. 2009;124(1):117e-127e.
3. McCauley RL, et al. Longitudinal assessment of breast development in
adolescent female patients with burns involving the nipple-areolar complex.
Plast Reconstr Surg. 1989;83(4):676-680.
4. Foley P, et al. Breast burns are not benign: long-term outcomes of burns to the
breast in pre-pubertal girls. Burns. 2008;34(3):412-417.
5. MacLennan SE, Wells MD, Neale HW. Reconstruction of the burned breast.
Clin Plast Surg. 2000;27(1):113-119.

6. Palao R, Gomez P, Huguet P. Burned breast reconstructive surgery with
Integra dermal regeneration template. Br J Plast Surg. 2003;56(3):252-259.
7. Versaci AD, Balkovich ME, Goldstein SA. Breast reconstruction by tissue
expansion for congenital and burn deformities. Ann Plast Surg. 1986;16(1):20-
31.
8. Bishop JB, Fisher J, Bostwick J III. The burned female breast. Ann Plast Surg.
1980;4(1):25.

28
CHAPTER
Pressure Injuries (Sacral
and Pelvic Region,
Columella—From CPAP)
David A. Billmire and Kim A. Bjorklund
DEFINITION
■ A pressure injury is a localized injury of skin and underlying tissue secondary
to prolonged pressure, frequently in combination with shear forces.
■ Severity ranges from nonblanchable erythema to full-
thickness tissue loss.
■ Common locations are over bony prominences such as the sacrum, coccyx,
ischium, and heels.
■ In the pediatric population, children with special needs and those who are
critically ill are at particularly high risk for pressure injuries.1
PATHOGENESIS
■ Pressure injury formation is a complex process that involves numerous
factors.2
■ Extrinsic contributing factors include pressure, friction, and shear.
■ Intrinsic factors include local tissue ischemia, decreased autonomic control,
infection, loss of sensation, decreased mental status, fecal or urinary
incontinence, anemia, and hypoproteinemia.3,4
■ As muscle is more sensitive to pressure than is skin, areas with a significant
amount of muscle may be susceptible to an inverted cone pattern of injury, in
which most of the necrosis is deep to the skin.5
■ Particular risk factors in the pediatric population have been identified1,6:
■ Paraplegia, sensory impairment
■ Cognitive impairment
■ Kyphoscoliosis or kyphosis

■ Chronic fecal or urinary soiling
■ Trauma
■ Immobility
■ Poor nutrition
NATURAL HISTORY7
■ Nonblanchable erythema may be observed within 30 minutes of unrelieved
pressure and typically disappears within 1 hour after pressure is eliminated.
■ Ischemia develops after pressure is present for 2 to 6 hours.
■ Necrosis may occur if pressure is not relieved within 6 hours.
■ Ulceration tends to occur over bony prominences within 2 weeks after
development of necrosis.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Determine factors contributing to the pressure injury (extrinsic and intrinsic)
and whether they can be eliminated postoperatively.
■ Note any chronic medical conditions contributing to the pressure injury, such
as myelodysplasia, cerebral palsy, paraplegia, and scoliosis.
■ Note any temporary conditions contributing to the pressure injury (prolonged
immobility, repetitive trauma) that require resolution.
■ Ambulatory status
■ Previous pressure injuries
■ Compliance and motivation with treatment
■ Assess risk factors using Braden Scale, including mobility, activity, sensation,
moisture, friction/shear, and nutrition.
■ Assess sensation and lower extremity motor function, including spasticity.
■ Palpate for any fluctuance or bony prominences.
■ Note any signs of infection such as warmth, erythema, tenderness, purulent
drainage, and systemic signs of infection.
■ Assess ongoing factors that may be contributing to wound breakdown, such as
items causing pressure, spasticity, and fecal or urinary incontinence.
■ Staging of pressure injuries based on the updated guidelines of National
Pressure Ulcer Advisory Panel8:
■ Stage 1: Nonblanchable erythema of intact skin
■ Stage 2: Partial-thickness skin loss with exposed dermis
■ Stage 3: Full-thickness skin loss