Chăm Sóc Và Điều Trị Bỏng Toàn Diện (Total Burn Care – Tập 5)

48  •  Musculoskeletal Changes Secondary to Thermal Burns
511
along the pin track and the formation of cigarette sequestra
are:
■ The introduction or migration of organisms from the
burn wound
■ Thermal necrosis during introduction of the pins
■ Linear pressure of the traction pin
■ Prolonged traction
■ Excessive movement of the extremity leading to loosen­
ing of the pin
■ Sealing of the skin of the pin sites.
For traction or suspension, pins may be inserted through
acutely burned skin, through eschar, through granulation
separately by Choctaw et al.16 and Wang et al.17 We treated
three patients in whom open fractures of the femur compli­
cated thigh burns. Each case required aggressive and
repeated debridement. One fracture was treated in traction,
and the other two were treated with external fixators. In
one of the patients, who was admitted 8 months after acute
burn, there was established osteomyelitis of the femur in
relation to the exposed fracture. Osteomyelitis did not
develop in either of the other patients; in the end, all three
had sound femurs.
When traction pins are directed through burned skin for
the treatment of fractures or for suspension of a burned
extremity, the factors favoring development of infection
D
C
B
A
Fig. 48.2  (A) Advanced osteoporosis in the hands of a 14-year-old boy 9 months after a 100% total body surface area burn. All growth plates are open.
(B) At 24 months after injury, osteoporosis persists, and there is irregular closure of the metacarpal and phalangeal growth plates. (C) At 8 months
after injury, the growth plates of the distal tibiae and fibulae remain open. (D) At 24 months after injury, the distal growth plates of the tibiae and
fibulae are closed. Other major growth plates remain open. Osteoporosis is unchanged.

48  •  Musculoskeletal Changes Secondary to Thermal Burns
512
fixator, or with skeletal traction (Fig. 48.4). Fractures in
extremities with first-degree or superficial second-degree
burns can be managed in the same way. Deep second- and
third-degree burns present a different problem only with
respect to the early bacterial colonization of third-degree
burns and the degradation of deep second-degree burns to
full-thickness burns that will in turn become colonized.
There is a precious window of time when fractures requir­
ing open reduction and internal fixation (ORIF) can be
definitively treated without increased risk for infecting the
bone; however, fracture reduction and stabilization are so
important in the functional management of a severely
burned patient that the risk for bone infection should be
acknowledged and shouldered at any postburn stage.
English and Carmichael15 showed that if fractures were
treated with open reductions within the first 48 hours post­
burn, the risk of infection is minimal. Therefore, early sta­
bilization is encouraged in the first 48 hours before the risk
of infection increases. Skeletal traction is used infrequently
today. The disadvantages of skeletal traction are the con­
finement to bed and the imposed relatively fixed position of
the affected extremity. External fixators make it possible to
align and stabilize fractures in burned extremities without
open operation and provide mobility to the patient. Brook­
er’s extensive favorable experience supports this concept.21
With both skeletal traction and external fixation, there is an
added risk for bone infection because of the path from
surface to bone provided by the pins. Pin tract infections can
be minimized by scrupulous pin site care and by removal
and replacement of any loosening pins. Frye and Luterman
tissue, or later through ischemic burn scar, which may be
colonized with uncommon and antibiotic-resistant organ­
isms. No amount of local cleaning is likely to sterilize the
surface through which the pin must pass, yet it seems that
organisms in sufficient numbers to colonize and infect are
rarely introduced in this manner.
Local low-grade infections usually resolve when pins are
removed if the pin sites are vigorously curetted of granula­
tion tissue. In one case in which a four-pin custom external
fixator was used in the treatment of an open infection of
the elbow, diffuse osteomyelitis of the humerus and radius
resulted. The infection was controlled with antibiotics and
without surgery after the pins were removed. This case was
included in Barret et al.’s report of skeletal pinning in 41
severely burned children.18 In experience with the Ilizarov
system for correction of skeletal deformity in burns, one
patient developed a pin track infection of such severity as
to require removal of the pin, curettage, and intravenous
antibiotics for control of meticillin-resistant Staphylococcus
spp.19 In an ongoing yet unpublished study, we treated nine
patients with open joints in external fixation for an average
of 7.1 weeks, and none of them developed pin tract infec­
tions or osteomyelitis. The open joints were treated in joint-
spanning external fixators. Most patients had multiple
failed skin grafting procedures before fixator placement.
The fixators were thought to have decreased the need for
additional skin grafting.
Hematogenous osteomyelitis and that caused by spread
from an infected joint are rare. There is no report of the
occurrence of either entity in association with burns. If
bone infection of this sort were be recognized, effective
treatment would depend on the identification of the offend­
ing organisms for organism-specific antibiotic regimens.
FRACTURES
Pathological fractures were at one time common in burn
management because of the practice of delayed excision of
eschar and of keeping patients in bed until wounds were
completely covered. During that time, fractures occurred
because of bone collapse when patients first stood or walked
or when stiff joints were manipulated (Fig. 48.3).20 The
bones most commonly affected were the femur at its distal
metaphysis and the tibia at its proximal one. The only treat­
ment required was support of the extremity until the frac­
ture consolidated, usually in 4–6 weeks. Children were
more often affected than adults, and the fractures usually
compressed one cortex, producing an angular deformity
that rapidly corrected with growth. Klein et al.’s study2
strongly suggests that fractures occur more frequently in
burned children than in a matched normal population even
months after the acute burn. Now, however, in acute burn
management, the most frequently seen fractures are those
occurring at the time of, or in association with, the burn
injury. Falls or violent trauma account for many of the frac­
tures, and the sites are those common to the causes, bearing
no relation to the burn itself.
Although fractures complicate burn treatment and occa­
sionally delay mobilization of patients, their management
need not be complex. Fractures in extremities not burned
can be treated by manipulative reduction and cast immobi­
lization, by open reduction and fixation, with an external
Fig. 48.3  Pathological fracture of the osteoporotic femur of a 9-year-
old girl sustained on the first day she stood after 5 weeks of confine­
ment for a 40% total body surface area burn.

48  •  Musculoskeletal Changes Secondary to Thermal Burns
513
burns, and Choctaw et al.16 reported successful use of a cast
for immobilization of an open comminuted fracture after
immediate postburn grafting of the affected extremity.
Common sense should dictate which fractures can be
treated with circular or bivalved casts or with splints. If
casts are used over burn skin, they would need to be remov­
able to allow burn care. If a reduced or moderately dis­
placed but aligned fracture is so stable as to require external
support only for maintenance of alignment, then cast or
splint immobilization should be all that is needed. On the
recognized and discussed the specific and continuous diffi­
culties encountered in the management of fractures and
burns.22
When casts are used for stabilization of fractures in
burned extremities, the wound is made inaccessible, and
there is an abiding fear that the unattended wound will
seriously degrade or at best not improve. Such fear may be
well founded; however, Wang et al.17 showed that a bivalved
circular cast could be used effectively for an open commi­
nuted fracture of a proximal tibia with overlying deep
C
B
A
Fig. 48.4  (A) This 15-year-old boy sustained closed fractures of the right femur, left tibia, and left humerus at the time of a 46% total body surface
area burn involving mainly the trunk and right lower extremity. The femur and humerus fractures were treated in skeletal traction. Suspension of the
right lower extremity aided management of circumferential deep burns of that extremity. Lesser burns of the left leg made it possible to treat the
minimally displaced fracture of the left tibia in a circular cast. All fractures consolidated in 6 weeks in satisfactory alignment. (B) Fracture of the left
humerus as it appeared at the time of admission to the hospital. (C) At 5 weeks after injury, the fracture shows maturing callus. Traction was discon­
tinued at 6 weeks.

48  •  Musculoskeletal Changes Secondary to Thermal Burns
514
tendon calcifications at around 1.25% each in a radiographic
study. Even if HO occurs infrequently in thermal burns, it
remains that after it develops, it often compromises joint
motion and is difficult to treat. In addition, its pathogenesis
is still incompletely understood; thus, protocols for preven­
tion may in fact miss the mark.
PATHOGENESIS OF HETEROTOPIC
OSSIFICATION
The metabolic changes occurring after thermal burn are
increased metabolic rate, protein catabolism, ureagenesis,
fat mobilization, glycogenolysis, gluconeogenesis, elevated
glucose flow, and eventual total body weight loss.36,37 There
is an accompanying suppression of the immune system
that favors wound infection but at the same time favors
survival of skin allografts. Infection, failure of skin graft
take, or anything that delays closure of a burn wound will
extend the altered metabolic state. Although it might be
assumed that there occurs, along with the metabolic
upheaval, an adverse change in connective tissue milieu,
the exact nature of such a change is not known. It is also
not known what the metabolic changes have to do with the
development of HO, but it is apparent that the burn disease
is necessary to its formation. Other factors to be considered
in the genesis of HO are percentage of burn, location of
burn, period of confinement, osteoporosis, superimposed
trauma, and genetic predisposition.
Percentage of Burn Effect on Heterotopic Ossification
Most reported cases of HO have had a 20% or greater
total body surface area (TBSA) burn; however, it has been
found in patients with as little as 10% third-degree burn.20
Peterson et al.,29 Munster et al.,34 and Elledge et al.28 have
reported affected patients with TBSA burns of 8%, 14%,
and 12%, respectively. In addition, with the now extensive
experience with salvage of patients with 80% or greater
burns, it is clear that HO occurs no more frequently among
these patients than in the general burn population. Thus,
the percentage of burn is not a determining factor.
Location of Burn Effect on Heterotopic Ossification
By no means has all of the reported HO occurred in joints
with overlying burn. In their initial report, Evans and Smith
described HO occurring a distance from any third-degree
burn involvement.38 Johnston noted that in one of his three
patients, the skin overlying one affected joint was not even
superficially burned.39 If degradation of connective tissue
milieu in burns is a total-body phenomenon, it follows that
heterotopic bone formation need not be burn site depen­
dent. Thus, the location of the burn cannot alone be a
determining factor.
Period of Confinement Effect on
Heterotopic Ossification
Evans and Smith expressed the belief that length of bed
confinement was an important factor in the development of
HO.38 At the time of that report, patients with even moder­
ate burns might be kept in bed for several weeks. The con­
sequences of prolonged confinement were loss of active
range of joint motion and bone demineralization; it was
other hand, if a fracture, because of instability, requires
maintenance of reduction by three-point pressure or
molding of the cast material, it will be better treated by
other means.
English and Carmichael had 28 fractures that were
treated over a 20-year span. In that study, 22 of 24 frac­
tures available for long-term review healed in appropriate
time. There were five infections noted, including two super­
ficial pin tract infections from external fixation and three
cases of osteomyelitis, all of which were open fractures. In
contrast, there were no infections among Saffle’s 42 frac­
tures, nine of which were treated by ORIF.23 With two frac­
tures of the femur, each of which was exposed at the base
of a deep chronic burn, aggressive debridement of the
wounds and the fracture ends was followed by treatment
with skeletal traction in one and by external fixation with
the Ilizarov system in the other. Both fractures healed
without further complication. Coverage of exposed bone
can be done with skin grafts, local flaps, and free flaps.
Burring of the exposed bone to stimulate bleeding and
induce granulation tissue can be used alone or with other
procedures to help cover exposed bone.14 Newer techniques
using graft substitute have shown promise in coverage of
exposed bones in burn patients.24,25
Among severely burned patients, nondisplaced or mini­
mally displaced fractures may not be detected until unusual
local pain in an affected extremity prompts radiographic
examination. A radiograph obtained for other reasons may
reveal a fracture as an incidental finding. These fractures
are usually of no functional significance. Modest angular
deformity near a joint is more of a problem in adults than
in children who still have remodeling potential. Undetected
transphyseal fractures in children can be a major functional
threat, however.
Changes Involving Pericapsular
Structures
HETEROTOPIC OSSIFICATION
Heterotopic ossification (HO) is a rare but functionally impor­
tant complication of thermal burns. The incidence in a general
burn population is reported to be somewhere between 1%
and 3%.1,26–31 In select populations, the incidence may be
higher, as it will be if patients with periarticular calcifica­
tion are included in the statistics. For example, Tepperman
et al. reported a 35.3% incidence among patients referred
to a tertiary care center for rehabilitation.32 Jackson and
Mac made the observation that the incidence of HO could
be expected to be less in institutions that admit patients with
minor burns.33 Munster et al.’s34 radiographic survey of 88
adult and teenaged patients with 160 burned upper extremi­
ties yielded a 16% incidence of pericapsular calcification; the
23% incidence reported by Schiele et al.1 included both HO
and heterotopic calcification. In the early routine radiographic
study reported by Evans,20 periarticular calcification that
did not progress to HO was excluded from the final calcula­
tion of an incidence of 2%. The 3.3% incidence recorded
by Kolar and Vrabec35 included patients with pericapsular
calcification. Pandit11 noted pericapsular, periarticular, and

48  •  Musculoskeletal Changes Secondary to Thermal Burns
515
attachments to coronoid process and biceps tubercle. And
if there is loss of pronation and supination range, stretch­
ing may cause HO to form in line with the proximal radio­
ulnar ligaments and interosseous membrane. There is an
implication here that both the quality and timing of post­
burn exercise may be important. Gentle passive and active
motion should cause less tissue disruption than abrupt
passive or active or even chronically repeated motion, and
the effect of any mobilization effort must vary with the rela­
tive stiffness of the joint and the intrinsic resistance of soft
tissue. The longer a joint is limited in its motion, the stiffer
it will become and the greater will be the soft tissue damage
with any forced manipulation.
The concept of superimposed trauma as a cause of het­
erotopic bone is supported by the experimental work of
Evans48 and of Michelsson and Rauschning.49 Evans found
that all burned and nonburned rabbits given a single nec­
rotizing injection in one quadriceps muscle readily healed
the lesions, but rabbits burned or nonburned that were
given a second same-site injection 7 days after the first uni­
formly developed well-defined and histologically identifiable
HO. In this experiment, it was clear that in susceptible
animals, it was not the burn that made the difference but
the chronicity of the wound. Michelsson and Rauschning
determined that forceful or regular active remobilization of
rabbit knees that had been immobilized for 1 to 5 weeks
resulted in the development of heterotopic calcification and
ossification in the muscles that were stretched. The response
was more consistent in the quadriceps of the knees immo­
bilized in extension than in the hamstrings of those immo­
bilized in flexion. The longer the period of immobilization
and the more vigorous the remobilization, the greater was
the response. Muscle necrosis was a prominent histologic
finding.50
Superimposed trauma is implicated in the development
of HO in head-injured patients or those with posttraumatic
or infectious transverse myelitis.51–53 In these patients, it is
assumed that tissue media are altered by injury to the
central nervous system. The secondary injury, as in burns,
is periarticular. In posttraumatic myositis ossificans, the
development of HO depends on persistence of the muscle
lesion and local necrosis and thus, at least by inference, on
repeated insults to the affected muscle.
The development of HO in burns has been associated
with the agitation of patients and their resistance to physi­
cal therapy.38,54 Two affected adults and one affected child
in a 10-year study resisted physical therapy programming.48
One adult refused to move, and the other was extremely
apprehensive. The child was likewise apprehensive and
refused to cooperate with the therapist. The development in
all three of posterior HO in both elbows could have been
ascribed both to the difficulty encountered in mobilizing the
elbows and to the continual pressure on the elbows in bed.
Genetic Predisposition to Heterotopic Bone
It is difficult to explain the low incidence of HO among great
numbers of patients similarly burned except on the basis of
some, as yet unidentified, inherited factor. It is known that
persons with proliferative noninflammatory arthritis of the
hip are more likely to develop HO after total hip replacement
than persons who have hips replaced for other reasons. In
this instance, the predisposing inherited abnormality is
thought that each of these adverse changes might contrib­
ute to the formation of HO. Thus, any maloccurrence that
necessitated longer confinement could be a factor in the
pathogenesis. Kolar implicated wound sepsis as an indepen­
dent factor along with the length of confinement.35 Other
investigators have not addressed the period of confinement
as specifically as Kolar, and there have been no comparative
studies of groups of confined and nonconfined patients.
Thus, it may never be determined whether the current
aggressive practice of early mobilization of patients will
have an effect on the incidence of heterotopic bone. We
believe the incidence of HO is lower at our institution after
the advent of early mobilization postoperative protocols.
Osteoporosis and Heterotopic Ossification
Only Schiele et al. have found a relation between HO and
osteoporosis.1 Among their group of 70 adults with burns
confined to the upper extremities, 11 of the 16 who devel­
oped HO had radiographically identifiable osteoporosis. In
their series of patients, there were 24 with osteoporosis.
Thus, fewer than one half of these developed HO, and there
were two in the group who developed HO who did not have
osteoporosis. If the findings in that study are not altogether
persuasive, the matter is further confused by the knowledge
that the survivors of extensive TBSA burns, who may
develop profound osteoporosis, seem to have no greater
liability to the formation of heterotopic bone than the
general burn population.
Superimposed Trauma on Heterotopic Ossification
In one of the patients reported by Evans and Smith, the
elbow of the more often used and minimally burned right
upper extremity developed HO, but the elbow of the less
used but more seriously burned left upper extremity did
not.38 In the same patient, the right hip spontaneously dis­
located. After reduction, that hip developed extensive HO in
the planes of the rectus femoris and iliopsoas. The opposite
hip developed only a small, inoffensive spicule of HO ante­
riorly at the joint line. Experience with this one patient rein­
forced the authors’ belief that there occurs with burns a
general compromise of connective tissue that renders it
particularly susceptible to superimposed trauma and that it
is this liability to injury that accounts for the appearance of
HO at sites of repeated stretching of soft tissue, as at the
minimally burned elbow or at sites of recognized abrupt
excessive stretching as with the dislocated hip. According to
all reports, the elbow is the most common site of HO in
adults and children.28,29,35,40–47 Perhaps it is the regular use
of this joint that accounts for that orientation. Jackson has
pointed out that the elbows are subjected to pressure poste­
riorly and medially when they are used for leverage or are
simply in contact with the bed.33 He suggests with this
observation that external pressure is a factor in the orienta­
tion of HO to the elbow. There may be other factors that
favor the elbow. Commonly, the elbow is splinted in exten­
sion to prevent flexion contracture. If flexion range is lost,
passive stretch and encouragement of active flexion are
part of the rehabilitation effort. The posterior structures
most affected by this effort are those attached to the olecra­
non. HO often develops medially in line with and deep to the
medial fibers of the triceps. If a flexion contracture devel­
ops, the HO is commonly in the line of brachialis or biceps

48  •  Musculoskeletal Changes Secondary to Thermal Burns
516
anterior surface of the elbow develops in the planes of the
brachialis and biceps muscles extending from the humerus
to the coronoid process or the biceps tubercle. Occasionally,
a bridge of HO develops between the radius and ulna just
distal to the joint. More rarely, bone has been found to fill
the olecranon fossa and even to ensheathe the entire joint.
At the shoulder, bone has been found to extend from the
acromion to the humerus in the line of the rotator muscles
or deep to the deltoid (Fig. 48.5C), to lie anteriorly in the
plane of the pectoralis major, and more deeply, to parallel
the subscapularis. Hoffer et al.59 reported that HO at the
shoulder lay anteriorly in the plane of the capsule. At the
hip, HO may extend from pelvis to femur in the planes of
rectus or iliopsoas anteriorly or in the plane of the gluteal
muscles laterally. Jackson has reported HO in the plane of
the quadratus femoris.33 Similar to the shoulder, the hip
may be ensheathed anteriorly with HO that appears to orig­
inate in the capsule.
When HO bridges a joint, it becomes part of the skeleton
and may, if loaded, increase in dimension as a fully devel­
oped ossicle with mature cortex and medullary cavity. In
children, if the bone does not bridge a joint, it will gradually
disappear when the burn wound has healed and the child
is healthy. In recovering adults, nonbridging bone will, in
time, diminish in size, but it may not disappear. The same
tendency for heterotopic bone to regress after resolution of
disease was noted by Lorber, who reported on two patients
with paraplegia secondary to tuberculosis in whom deposits
of heterotopic bone diminished in size after return of motor
function.51 Bottu and Van Noyen60 reported a similar expe­
rience with a patient who had transient viral meningoen­
cephalitis, and Jacobs reported almost complete resorption
of large bilateral deposits of heterotopic bone in a patient
who recovered from paralytic measles encephalomyelitis.52
Serum concentrations of calcium, phosphorus, and alka­
line phosphatase (ALP) have been reported by most authors
to be normal or, at best, insignificantly higher in burned
patients who have developed HO.26,34,38,61,62 In addition,
there is no convincing evidence that calcium intake affects
heterotopic bone formation one way or the other. Evans and
Smith’s limited routine studies of affected and unaffected
patients led the authors to believe that the values of serum
calcium, phosphorus, and ALP were so consistently normal
as to make further investigation unnecessary.38 One inter­
esting observation was that of Koepke, whose studies sug­
gested that those patients who were susceptible had
elevation of serum ALP before development of heterotopic
bone but not afterward.27
PREVENTION AND TREATMENT OF
HETEROTOPIC BONE
The incidence of HO in burns is so low as to make it imprac­
tical to administer indometacin or other nonsteroidal anti­
inflammatory drugs (NSAIDs) that are currently used for
patients at risk for development of heterotopic bone after
major hip surgery. Rather, the thrust in prevention should
be toward reducing the period of bed confinement and the
duration of the postburn hypermetabolic state. The now
prevailing practice of early wound excision and grafting
may, in fact, address both of these problems as nearly as it
is possible to do so. Even patients with extensive TBSA burns
identifiable. Although HO formation may occur more regu­
larly among spinal cord-injured and head-injured patients
than among burned ones, by no means do all persons with
head and spinal cord injuries develop HO. The total burn
experience at the University of Texas Medical Branch has
yielded only two similarly affected siblings. Twin brothers
who had 19% and 20% TBSA burns and who were mobile
throughout much of their treatment and recovery period
developed near-identical HO of both elbows.55 There is,
however, no scientific proof that genetic predisposition has
anything to do with the formation of HO in burns. Nor is
there any literature to support the idea that a person who
develops HO when burned will be liable to develop it if he
or she sustains head or spinal cord injury. Vrbicky,56 in a
comprehensive review of postburn HO formation, suggests
that a key for the genetic predisposition may be in the
human leukocyte antigen (HLA), reporting that an HLA
B27 survey showed a 7% HLA distribution in the normal
population compared with 70% in a population with HO.
CHARACTERISTICS AND BEHAVIOR OF
HETEROTOPIC BONE
Heterotopic ossification associated with burns has been
reported to occur about all major joints. The joints most
commonly affected are elbow, shoulder, and hip, in that
order of frequency. The early manifestations are joint swell­
ing and tenderness not unlike any acute inflammatory
process. The patient may call attention to the process by a
reluctance to move the affected joint. Onset may be as early
as 1 month and as late as 3 months or more after the burn,
but it is more likely to be associated with the acute recovery
phase of treatment than later. Crawford et al. reported that
the clinical diagnosis was made in advance of radiographic
changes in 9 of his 12 patients.40 Tepperman et al.32 and
Peterson et al.29 found that bone scans could help make a
diagnosis before there were radiographic changes. The ear­
liest radiographic alteration is local periarticular increase in
soft tissue density. There follows diffuse, stippled calcifica­
tion in the same distribution in or about the capsule of the
joint. It is at this point that the process may reverse itself,
perhaps because of the improved state of the patient. Owing
to this change in course, there may be patients whose peri­
articular calcification is not detected. If the calcification
persists, it may be assumed that bone will develop by either
the intramembranous or the enchondral route or both, as
it does in animal models.
The flecks of calcification appear radiographically to lie
within the capsule, but HO not only may involve capsular
structures but also may extend into the planes of muscles
and tendons. At each major joint, there is a more or less
characteristic distribution of HO, which is similar to that
associated with patients with head and spinal cord injury.
At the elbow, posteriorly disposed bone extends from the
olecranon to the medial epicondylar ridge of the humerus
in line with the medial border of the triceps muscle (Fig.
48.5A and B). At the joint, it may extend medially to bridge
the ulnar groove.57,58 The medial, rather than lateral, orien­
tation of the heterotopic bone may be related to the medial
position of the olecranon and the greater tension on soft
tissue on that side, and as Jackson points out, the contact
area of the elbow is consistently medial.33 HO on the

B
A
C
Fig. 48.5  (A) At 3 months after a 94% total body surface area burn of a 16-year-old man, resistance to motion, local swelling, and pain of both elbows
prompted obtaining radiographs, each of which showed spotty linear soft tissue calcification and ossification along the distal humerus and between
the radius and ulna at the level of the biceps tubercle. (B) At 6 months after burn, elbow flexion and extension were reduced to 10 degrees on the left
and to less than 5 degrees on the right. Bridges of immature heterotopic bone extended from the medial epicondylar ridges to the olecranon. Forearm
rotation was 0% because of interosseous bridges of heterotopic bone at the level of the bicipital tuberosities. The prognosis for restoring functional
range of motion in the elbows is poor. (C) At 6 months postburn, glenohumeral motion on the right was limited to a few degrees by heterotopic bone
underlying the deltoid. At the same time, a lesser deposit of heterotopic bone at the left hip did not limit motion.

48  •  Musculoskeletal Changes Secondary to Thermal Burns
518
et al.,29 patients suspected of having HO had active ROM
exercises only. Ten regained functional ROM, and eight
developed ankylosis.
Surgical excision of heterotopic bone is indicated when
joint motion is lost or significantly compromised by bridging
bone or exostoses. Evans has suggested that surgery be post­
poned until the burn wound has healed, scars are soft and
associated with no inflammatory response, the patient is
healthy, and the offensive bone is radiographically mature
(i.e., well-defined and not increasing in dimension)
(Fig. 48.6).20 This position makes sense considering the
behavior of heterotopic bone (i.e., proliferation while there
are open burn wounds or active scars and regression with
wound healing and scar softening). For removal of hetero­
topic bone, surgical exposures should be planned with
extensible incisions so as to facilitate total excision. When
there is a bridge of bone, each end of the bridge should be
slightly excavated. When there is attachment at only one
end, the cartilaginous or fibrous extension should be
removed along with the bone. Capsular sheets of bone
should be removed completely. If bridging heterotopic bone
is incompletely excised, the bridge is likely to recur. When a
joint is bridged by bone in only one plane, removal of the
offending bone will usually restore functional motion, and
recurrence of the bridge is unlikely. When a joint is bridged
in more than one plane, recurrence is more likely, and the
chance for restoration of functional ROM is correspond­
ingly diminished. When the local inflammatory process has
may now be out of bed and walking within the first post­
burn week.
If certain patients are predisposed to the development of
HO, the quality and timing of joint mobilization for those
patients may be critical. Stretching edematous pericapsular
structures in the early postburn period may very well be
hazardous if additional tissue damage is the result; however,
maintenance of joint motion and muscle function is part of
the early excision and grafting program, and it is certain
that the longer joint motion is restricted the more likely it is
that pericapsular structures will be damaged by stretching.
We like to think that secondary injury to soft tissue can be
avoided by controlled and assisted active range of motion
(ROM) and terminal resistance.
When a patient is reluctant to move a joint previously
moved with relative ease, and certainly when there is evi­
dence of unusual swelling about the joint, radiographs
should be obtained to determine if there is pericapsular cal­
cification or ossification. After heterotopic bone or calcifica­
tion is recognized, joint exercise should be restricted to
gentle passive and assisted active motion only. Crawford et
al.40 observed that ossification progressed to complete anky­
losis in all patients who persisted in moving an affected joint
beyond the pain-free range. They concluded that active
ROM exercises and stretching were contraindicated if het­
erotopic bone or calcification was suspected, but that active
ROM could be safely resumed within pain-free range after
the diagnosis had been confirmed. In the series of Peterson
A
B
C
Fig. 48.6  (A) A mature sheet of heterotopic bone extends from humerus to olecranon, obliterating the olecranon fossa 11 months after a 53% total
body surface area burn in a 13-year-old girl. Elbow flexion and extension range were less than 10%. Pronation and supination were near normal range.
(B and C) At 3 months after excision of heterotopic bone, the patient had attained 90 degrees of elbow motion, and a continuing increase to functional
(hand to mouth) range was predicted. Now the patient can extend the elbow and can flex it to 90 degrees.

48  •  Musculoskeletal Changes Secondary to Thermal Burns
519
common a subcutaneous dorsal surface, accounting for
their ready exposure. The bone and joint changes are found
mostly in severely burned patients and include contractures
and even ankyloses of smaller joints.11
The elbow, for its trochlear architecture, is more intrinsi­
cally stable than the other joints in this group. It requires
loss of collateral support to render it easily displaceable. The
knee, on the other hand, is immediately in danger of sub­
luxation if there is loss of continuity of its central slip, the
patellar tendon, even if the retinacula remain intact. In this
circumstance, gravity alone will displace the tibia posteri­
orly in relation to the femur if the patient is recumbent. The
hamstring muscles contribute to the displacement force
regardless of the position of the extremity. Loss of collateral
ligaments compounds the problem, but loss of collateral
ligament stability in the presence of an intact patellar
tendon and functioning quadriceps constitutes far less a
threat than loss of patellar tendon. For the lower extremity,
persistent posterior translation of the tibia beneath the
femur with inefficient quadriceps function leads to severe
functional problems.
For both the elbow and the knee, the protecting position
is extension. These two joints are rarely at risk for articular
displacement from contracture alone and, if there is no liga­
ment or tendon loss, extension resting splints will give ade­
quate positional support. When there is soft tissue
disruption, splinting may not adequately protect either
joint. An external fixator with two-pin, four-cortex fixation
above and below the joint will provide stability and will
permit access to the wound. For the elbow, it allows fine
adjustment to the normal carrying angle as well. If the knee
is accurately reducible at the time of application of the
fixator, there is a good possibility that the reduction can be
maintained. If the tibia cannot be brought forward com­
pletely by manual manipulation, it may be necessary to
caused intraarticular synovial proliferation and cartilage
destruction, the joint is most likely destined for ankylosis.
Removal of the heterotopic bone about a joint so affected
may allow more functional positioning of the joint, but it is
not likely to arrest the process. On the other hand, extraar­
ticular arthrodesis by a bridge of heterotopic bone may pre­
serve the joint. This is particularly the case at the elbow
when there is only one posterior bridge of bone from olec­
ranon to the medial epicondylar ridge of the humerus. In
this situation, the olecranon is fixed in the trochlea, but the
radiocapitellar and radioulnar joints remain functional. In
Evans’ experience with removal of single bridges at the
elbow, joint cartilage was found to be healthy as long as 5
years after ankylosis. Preservation of pronation and supi­
nation was credited with maintaining the synovial bath to
provide nutrition for the humeroulnar cartilage. Indeed,
when pronation and supination additionally are blocked by
bridging bone, cartilage degradation is certain. Evans’
further experience with long-term survival of glenohu­
meral cartilage after ankylosis by bridging bone from acro­
mion to humerus is not as easily explained.
Reported experience with excision of heterotopic bone in
burns has not been uniformly favorable. Dias,62 Hoffer
et al.,59 and Peterson et al.29 reported restoration of func­
tional ROM in most of their patients with timely excision of
heterotopic bone. Gaur et al.41 reported good functional
return in seven burned children with nine affected elbows.
Ring and Jupiter42 reported good results in a varied popula­
tion, and Chung et al.43 and Tsionos et al.45 have reported
good results with early excision a mean of 9 months after
the burn. Other surgeons have reported less satisfactory
results.31 In our own experience, results have varied, as
anticipated, with the severity of the condition. We have
learned that if heterotopic bone recurs after excision, it is
worthwhile to excise again if the joint affected remains
structurally identifiable. For the most part, however,
attempts to improve joint function with second operations
have failed. We believe that ultimate failure can be predicted
at the time of initial surgery; we are convinced that the
single most important factor in successful initial excision is
in timing surgery to coincide with the patient’s return to
good health.
Changes Involving the Joints
DISLOCATION
Luxations and subluxations of joints in burned patients
may occur as a result of direct destruction by the burn of
ligaments and capsules, loss of articular cartilage caused
by infection, faulty positioning, and eventually scar con­
tracture. In all phases of management, but particularly
in the acute phase, positioning is of prime importance in
the prevention of joint deformity. The preferred positions,
listed in Table 48.1, serve as a guide for the prevention of
dislocation of joints and of malposition secondary to scar
contracture.
The joints most liable to structural compromise caused
by exposure by the burn and loss of soft tissue support are
knee, elbow, proximal interphalangeal joints of the hand,
and metacarpophalangeal joints. These hinge joints have in
Table 48.1  Preferred Positions for Major Joints
Joint
Preferred Position
Neck
Midline in neutral or slight extension
Shoulders
Scapulothoracic retraction and depression, 85
degrees of glenohumeral elevation with
20–25 degrees of horizontal flexion
Elbows
Extension
Wrists
Slight extension
Metacarpophalangeal
joints 2–5
80–90 degrees of flexion
Fingers
Proximal and distal interphalangeal extension
Thumbs
Carpometacarpal flexion and abduction,
metacarpophalangeal flexion 5–10
degrees, interphalangeal extension
Spine
Extension with no lateral deviation
Hips
Extension and slight external rotation in 15
degrees of symmetric abduction
Knees
Extension
Ankles
Neutral
Feet
Neutral

48  •  Musculoskeletal Changes Secondary to Thermal Burns
520
position, the arms are in at least 15 to 20 degrees of exten­
sion from the more secure neutral position in line with the
scapulae, and the humeral heads are forced forward against
the anterior capsule. Even when the patient is supine, full
abduction and extension of the arms should be avoided. For
short-term management, particularly when the patient
gets out of bed each day, this position probably does not
threaten the joint. But if the patient is to be bed confined
and the position unrelieved for days or weeks, the head of
the humerus may begin to subluxate forward. In the
extreme situation, the head of the humerus will dislocate
to a medial subcoracoid position. In patients with deep
burns extending from the chin to the axillae to the chest,
the common posture of elevation and protraction of the
scapulae may be associated with upward subluxation of the
humeral heads.
The head of the humerus is most secure in the glenoid
fossa when the arm is adducted to neutral and internally
rotated, a position that is incompatible with wound man­
agement of burns of the trunk, neck, and upper extremities.
The protecting position that accommodates the need for
abduction for axillary burns is elevation of the arms in line
with the scapulae. The arm is then approximately 20
degrees forward of the coronal plane or in 20 degrees of
horizontal flexion. When the patient is prone, the protecting
position can be gained only if the chest is supported on a
chest width mattress, folded blankets or towels, or a foam
rubber pad, any of which will allow the arms to drop
forward. When the patient is positioned this way, whether
supine or prone, the forearms will be pronated, and the
arms will be in sufficient internal rotation to favor seating
of the head of the humerus in the glenoid.
The hip will tend to subluxate posteriorly if the thigh is
persistently allowed to remain flexed, adducted, and inter­
nally rotated during the acute burn phase. For the most
part, however, the protecting position of extension to
neutral or 180 degrees and 15 to 20 degrees of symmetric
abduction is easy to attain and maintain and is, in fact, the
most desirable position for wound management.
Infection of a joint may result in its subluxation or dislo­
cation. Hip displacement because of apparent spontaneous
dissolution has been described by Evans and Smith.38 Eszter
and Istvan65 and Cristallo and Dell’Orto66 reported similar
cases. In none of these cases, however, could it be deter­
mined that the joint destruction was attributable to
infection.
SEPTIC ARTHRITIS
A joint exposed by a burn or by removal of burn eschar is
presumed to be infected. The joints most frequently exposed
are the knee, the elbow, the proximal interphalangeal joints
of the hand, and the metacarpophalangeal joints, all on the
subcutaneous dorsal surfaces. The wrist and ankle are less
often affected, and other joints are affected rarely. Treat­
ment requires stable positioning of the joint for maximum
reduction of wound size so as to facilitate soft tissue closure
or grafting and to allow aggressive daily lavage. The posi­
tion for all of the joints listed except the ankle is extension.
The ankle is positioned in neutral. External fixation, intra­
medullary pinning, or skeletal traction may be required
to secure the position. To maintain ankle position, it is
suspend the tibia through a transverse pin at the level of
the tibial tubercle. For static vertical traction, the extremity
must be elevated from the bed. For dynamic traction,
enough weight must be used to accomplish the same eleva­
tion. If the tibia can be brought forward by this means, an
external fixator will hold the reduction. For the knee to
remain stable with the tibia forward, the patellar tendon
must be reattached and quadriceps integrity reestablished;
otherwise, when the fixator is removed, the tibia will again
begin an incremental posterior shift toward its own point of
stability. No amount of external splinting or bracing is likely
to prevent this shift.
The proximal interphalangeal joints of the hands are
more frequently exposed by burn than any others. If the
central extensor slip remains intact, there is less risk for
subluxation of the joint. Even if there is loss of continuity
of the central slip but preservation of the lateral bands,
subluxation is easily prevented if the joint is maintained in
extension while soft tissue cover is being achieved. It is with
loss of the support of lateral bands and collateral ligaments
that the joints become liable to dislocation. With the meta­
carpophalangeal joints, the tendency to displacement or
subluxation may be greater because these joints are func­
tionally multiplanar, but the interphalangeal joints are uni­
planar. Fortunately, the metacarpophalangeal joints are
less often exposed than the interphalangeal ones.
The protecting position for the proximal interphalangeal
joints is full extension. If only the central slip is lost, the
position may be held with an external splint. In states of
greater instability, it may be necessary to use intramedul­
lary transarticular Kirschner wires to hold the position. The
wires, although reasonably efficient, do not control rota­
tion, and they carry with them a risk for posttreatment joint
stiffness. In small children, it is impossible to introduce the
Kirschner wires through the distal phalanx; thus, it is
better, with the proximal phalanx flexed to 90 degrees, to
place the wire through the corresponding metacarpal head
into the proximal and middle phalanges. Short-term trans­
fixation does not harm the joint, and metacarpophalangeal
flexion is the favored position for functional restoration. Pin
traction through the distal phalanges in a skeletally stabi­
lized metal splint is another method for maintaining exten­
sion of threatened digital joints.63,64 It has the advantages
of patient comfort and mobility; secure positioning of hand
and upper extremity; easy maintenance of elevation; and
easy access for dressings, for additional surgery, and for
exercise of lesser affected joints. The system likewise makes
it possible to keep digits separated, thus facilitating local
care. Traction should not be used if collateral ligaments are
not intact. By whatever means attained, the corrected posi­
tion must be maintained until the joint is covered with graft.
Protection should continue with a standard splint or brace
until the joint is sound.
The two joints most likely to dislocate because of faulty
positioning are the shoulder and the hip. These two ball-
and-socket, multiplanar joints sacrifice stability in favor of
mobility. This is particularly true of the shoulder, where the
shallow glenoid contains at any one time only one third of
the head of the humerus. In burns, the head of the humerus
may begin to subluxate forward if, during prone positioning
for management of back and buttock wounds, the arms are
maintained in full abduction in the coronal plane. In this

48  •  Musculoskeletal Changes Secondary to Thermal Burns
521
joints even if motion will be restricted. For example, if a
forearm or leg must be sacrificed, the elbow or knee should
be spared if the more proximal muscles controlling that
joint are intact, if the bone bleeds, and if there is the pos­
sibility that the remaining tissue of the stump has sufficient
blood supply to produce granulations for grafting. Aside
from affording a better functional prospect, sparing the
joint will provide the surgeon opportunity at a later time to
choose an appropriate revision level if the joint does not
function. The patient will at that time be healthier, and
stump closure will be routine. Jackson suggests that it may
be technically feasible to cover even nonviable bone with a
free flap to maintain extremity length.33 In electrical burns,
the level of amputation is most often determined by muscle
viability. Stump care is the same as with thermal injury.
Prostheses can be easily fitted over stumps covered with
split-thickness grafts. Ridges of hypertrophic scar will break
down if there is friction within the socket of the prosthesis,
but scar often softens and flattens with the constant, even
pressure of a well-fitted socket; prostheses fitted early over
grafted stumps may prevent scar thickening. Breakdown
may occur at points where the graft is adherent to bone.
This problem may require surgical freeing of the adherent
graft and reshaping of the bone. Minor hip and knee flexion
contractures complicate the fitting and function of a pros­
thesis; thus, every effort should be made to maintain full
extension of these joints. Late revisions of amputations in
children are required when the bone overgrows in length
and when offensive terminal exostoses develop. The over­
growing bone can be shortened and the exostoses removed.
Klimisch et al.69 studied 259 amputations for burns at our
institution. Stump overgrowth requiring revision surgery
occurred in 10% of patients and 5.8% of amputations.
Lower-extremity amputations had overgrowth in about
16% of stumps and the upper extremity in 2%.
It is important in the early management of upper-
extremity amputations in infants and young children to
supply temporary prosthetic extensions. This provides func­
tional orientation to a prosthesis, maintains muscle bulk
and tone, and encourages continuing bimanual activity at
normal extremity length until a prosthesis with an appro­
priate terminal device can be applied. Children quickly
acquire prehension and transfer skills if they have an oppos­
able stump, and they may reject prostheses if they are not
applied early. It is equally important to restore bipedal func­
tion as soon as possible. If delay of healing or ulceration of
a lower-extremity stump prevents early prosthetic fitting,
an ischial weight-bearing device that suspends the stump
will permit the child to walk in advance of prosthetic fitting.
Inflatable plastic air bags provide both even pressure and
accurate fit for weight bearing in container sockets. Early
prosthetic fitting is desirable in teenagers and adults as well
but is not as critical as it is in children. As in nonburned
persons, an upper-extremity prosthesis may be rejected at
any age if the opposite extremity is fully functional.70
Alterations in Growth
In 1959, Evans and Smith reported that a patient who was
24 years of age when burned had a subsequent 1.5-inch
increase in height. It was suggested that one explanation
sometimes appropriate to insert a large vertical Steinmann
pin through the calcaneus and talus into the tibia. The
position should be maintained until the exposed joint is
covered with epithelialized granulation tissue or skin graft.
Exposed adjacent bone can be shaved or drilled, as previ­
ously described, to encourage surface granulation. Drilling
is particularly useful at the elbow where the olecranon is
regularly exposed. Often, however, granulation tissue will
quickly extend the wound margins and effectively close the
wound so as to allow split-thickness skin grafting. If the
burn is isolated to the joint or if the extremity is not other­
wise seriously burned, a local muscle, skin, or compound
flap may be used to close the joint. Free vascularized flaps
are useful and should always be considered if it is antici­
pated that nerve graft or tendon graft or transfer at the site
will be required in the future. Incremental remobilization
of the joint may proceed when wound closure is sound.
Culture of material from an exposed joint will likely yield
a variety of organisms consistent with those of the general
burn wound, thus requiring broad-spectrum antibiotic
management.
The incidence of hematogenous septic arthritis is
obscured by its frequent association with severe burns and
because there are rarely separable clinical signs such as
local heat and swelling, elevation of temperature, and ele­
vation of sedimentation rate. Local tenderness and greater
than usual pain with motion may focus attention on the
affected joint. Aspiration of the joint will confirm a diagno­
sis. A radiograph is helpful but in the early phases of infec­
tion will show only local cellulitis as increased periarticular
soft tissue density. If a patient has been receiving broad-
spectrum antibiotics, material aspirated from the affected
joint may not grow an organism in culture. Clearly, without
organism identification and sensitivity determinations, spe­
cific antibiotic therapy cannot be initiated.
We are of the opinion that surgical debridement and
exteriorization of the joint and regular vigorous lavage are
as important as antibiotics in the treatment of closed
infected joints. We believe now that arthroscopic debride­
ment and closed irrigation should be considered as an alter­
native method of management whether or not skin over the
affected joint is burned. Rarely in burns, a joint may become
infected from adjacent metaphyseal osteomyelitis. In this
situation, joint preservation is the treatment priority, and
measures are the same as for septic arthritis of strictly
hematogenous origin.55 In children, most infected joints
can be salvaged. Adult joints are less resilient. Persistent
joint infection will destroy cartilage and lead to ankylo­
sis.67,68 All chronically infected joints are liable to disloca­
tion because of surface destruction and capsular laxity.
AMPUTATIONS
In thermal burns, major amputations are most often per­
formed because of nonviability of the extremity or because
a surviving extremity is rendered useless by scar, deformity,
or insensitivity. Occasionally, in an extensive burn, a severely
burned extremity that might be salvaged in part is sacrificed
to reduce the extent of the burn or as a lifesaving measure.
In thermal burns, the level of extremity amputation is
determined by the viability of muscles and tendons. The
more distal the site, the better, and it is important to retain

48  •  Musculoskeletal Changes Secondary to Thermal Burns
522
are developing symmetrically and on schedule. Extremity
and trunk alignment must likewise be part of the assess­
ment because subtle angular deformity can occur because
of partial closure of a growth plate. Jackson’s report
addresses this problem.33
So-called growth arrest lines seen in the radiographs of
nonburned children, who have serious illness or major
trauma other than burns, are commonly observed in
burned children. In burns, as in other conditions, these
transverse markers of relatively increased mineralization
represent normal recovery from an insult to enchondral
bone formation due to serious stress. They are of no clinical
or functional significance. They are more related to total
burn than to involvement of select burned extremities as all
major long bones are affected. There is no evidence that
growth arrest lines per se have any effect on growth.
Complete references available online at

Further Reading
Chen HC, Yang JY, Chuang SS, et al. Heterotopic ossification in burns: our
experience and literature reviews. Burns. 2009;35:857-862.
The most recent comprehensive review of the subject of heterotopic bone.
Evans EB. Heterotopic bone formation in thermal burns. Clin Orthop Relat
Res. 1991;263:94-101.
A detailed discussion of heterotopic bone and a comprehensive cover of the
subject.
Evans EB, Larson DL, Abston S, et al. Prevention and correction of defor­
mity after severe burns. Surg Clin North Am. 1970;50:1361-1375.
Descriptions of burn-related deformity and management, with the impor­
tant inclusion of the concepts of Barbara Willis.
Johnston JT. Atypical myositis ossificans. J Bone Joint Surg Am.
1957;39:189-193.
The earliest description of burns related to heterotopic bone.
Klein GL, Herndon DN, Langman CB, et al. Long-term reduction in bone
mass after severe burn injury in children. J Pediatr. 1995;126:252-256.
A comprehensive discussion of causes and persistence of mineral loss.
Michelsson JE, Rauschning W. Pathogenesis of experimental heterotopic
bone formation following temporary forcible exercising of immobilized
limbs. Clin Orthop Rel Res. 1983;176:265-272.
This includes an introduction of the concept of superimposed trauma in
burns.
Youel L, Evans E, Heare TC, et al. Skeletal suspension in the management
of severe burns in children. A sixteen-year experience. J Bone Joint Surg
Am. 1986;68:1375-1379.
Traction system in the management of wound burns.
for this growth spurt might be local change in hemodynam­
ics with stasis, passive hyperemia, and chronic inflamma­
tion. We have not since documented height changes in
burned adults, but we have observed children whose growth
after burn has seemed to be retarded. If growth plates
remain open, it is difficult to explain overall growth retarda­
tion except on an endocrine or humoral basis. It is easy,
however, to explain extremity length differences on the
basis of premature closure of growth plates caused by direct
involvement of the bone or the severity of an overlying
burn. Frantz reported lower-limb length discrepancy in four
patients with foot and ankle burns.71 Growth plates closed
prematurely in only two of the cases. Jackson described two
patients with digital and lower-extremity deformity, respec­
tively, caused by partial closure of growth plates.33 In Ritsilä
et al.’s case, contracture alone was apparently the cause of
growth retardation in an upper extremity.72 It seems rea­
sonable, although hard to prove, that growth in a severely
burned extremity would be retarded because of functional
impairment.
There is yet another confusing aspect of premature
closure of growth plates in that within an extremity with
total full-thickness burn, only a few of the growth plates
will close prematurely. The explanation for this capricious
selectivity is at best obscure. Evans and Calhoun recorded
an example of spotty closure of growth plates in a 14-year-
old boy with a 90% total TBSA burn.19 There was complete
closure of distal tibial and fibular epiphyses 1 year after
burn together with closure of all digital epiphyses in the feet
and of several digital epiphyses in the hands. Other major
epiphyses were spared (Fig. 48.2).
In early experience, abnormal growth plate closure was
observed in a 6-year-old girl with a 50% TBSA third-degree
burn that did not involve the legs or ankles.73 Rapidly
destructive septic arthritis of one ankle resulted in closure
of the adjacent tibial growth plate.
Only occasionally can growth changes be anticipated
because of obvious affection of the bone. More often the
changes are subtle. It seems clear, thus, that among seri­
ously burned children, regular height and extremity length
measurements must be part of ongoing postburn assess­
ment until it is determined that the extremities and trunk

522.e1
48  •  Musculoskeletal Changes Secondary to Thermal Burns
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32. Tepperman PS, Hilbert L, Peters WJ, et al. Heterotopic ossification in
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34. Munster AM, Bruck HM, Johns LA, et al. Heterotopic calcification
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39. Johnston JT. Atypical myositis ossificans. J Bone Joint Surg Am.
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40. Crawford CM, Varghese G, Mani MM, et al. Heterotopic ossification:
are range of motion exercises contraindicated? J Burn Care Rehabil.
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41. Gaur A, Sinclair M, Caruso E, et al. Heterotopic ossification around
the elbow following burns in children: results after excision. J Bone
Joint Surg Am. 2003;85:1538-1543.
42. Ring D, Jupiter JB. Operative release of complete ankylosis of the
elbow due to heterotopic bone in patients without severe injury
of the central nervous system. J Bone Joint Surg Am. 2003;85:849-
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43. Chung D, Hatfield S, Dougherty ME, et al. Heterotopic ossification of
the elbow in burn patients: results after early surgical treatment. Pro­
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Las Vegas, NV: American Burn Association; 2006:4–7April.
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immobilized limbs. Clin Orthop Rel Res. 1983;176:265-272.
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6. Klein GL, Herndon DN, Rutan TC, et al. Bone disease in burn patients.
J Bone Miner Res. 1993;8:337-345.
7. Van der Wiel HE, Lips P, Nauta J, et al. Loss of bone in the proximal
part of the femur following unstable fractures of the leg. J Bone Joint
Surg Am. 1994;76:230-236.
8. Dowling JA, Omer E, Moncrief JA. Treatment of fractures in burn
patients. J Trauma. 1968;8:465-474.
9. Klein GL, Herndon DN, Goodman WG, et al. Histomorphometric and
biochemical characterization of bone following acute severe burns in
children. Bone. 1995;17(5):455-460.
10. Dolecek R, Tymonova J, Admkova M, et al. Endocrine changes after
burns: the bone involvement. Acta Chir Plast. 2003;45(3):95-103.
11. Pandit SK, Malla CN, Zarger HU, et al. A study of bone and joint
changes secondary to burns. Burns. 1993;19(3):227-228.
12. Klein GK. Disruption of bone and skeletal muscle in severe burns.
Bone Res. 2015;24(3):e15002.
13. Rousseau AF, Foidar-Dessale M, Ledoux D, et al. Effects of cho­
lecalciferol supplementation and optimized calcium intakes on
vitamin D status, muscle strength and bone health: a one-year
pilot randomized controlled trial in adults with severe burns. Burns.
2015;41(2):317-325.
14. Parrett BM, Pomahec B, Demling RH, ORgill DP. Fourth-degree burns
to the lower extremity with exposed tendon and bone: a ten year
experience. J Burn Care Res. 2006;27(1):34-39.
15. English C, Carmichael KD. Management of fractures in children with
thermal injuries. J Peditr Ortho. 2002;22(6):1-4.
16. Choctaw WT, Zawacki BE, Dorr L. Primary excision and grafting of
burns located over an open fracture. Arch Surg. 1979;114:1141-1142.
17. Wang XW, Zhang ZN, Nie QD, et al. The successful treatment of a
patient with extensive deep burns and an open comminuted fracture
of a lower extremity. Burns Incl Therm Inj. 1984;10:339-343.
18. Barret JP, Desai MH, Herndon DN. Osteomyelitis in burn patients
requiring skeletal fixation. Burns. 2000;26:487-489.
19. Evans EB, Calhoun JH. Musculoskeletal changes complicating burns.
In: Epps CH Jr, ed. Complications in orthopaedic surgery. Philadelphia:
JB Lippincott; 1994:1239-1278.
20. Evans EB. Orthopaedic measures in the treatment of severe burns.
J Bone Joint Surg Am. 1966;48:643-669.
21. Brooker AF Jr. The use of external fixation in the treatment of burn
patients with fractures. In: Brooker AF Jr, Edwards CC, eds. External
fixation: the current state of the art. Proceedings of the 6th International
Conference on Hoffmann External Fixation. Baltimore: Williams &
Wilkins; 1979.
22. Frye KE, Luterman A. Burns and fractures. Orthop Nurs. 1999;18:
30-35.
23. Saffle JR, Schnelby A, Hoffmann A, et al. The management of frac­
tures in thermally injured patients. J Trauma. 1983;23:902-910.
24. Verbelen J, Hoeksema H, Pirayesh A, et al. Exposed tibial bone
after burns: flap reconstruction versus dermal substitute. Burns.
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25. Yeong EK, Cehn SH, Tang YB. The treatment of bone exposure in
burns by using artificial dermis. Ann Plast Surg. 2012;69(6):607-610.
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27. Koepke GD. Personal communication, 1964.
28. Elledge ES, Smith AA, McManus WF, et al. Heterotopic bone forma­
tion in burned patients. J Trauma. 1988;28:684-687.
29. Peterson SL, Mani MM, Crawford CM, et al. Postburn heterotopic
ossification: insights for management decision making. J Trauma.
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61. Proulx R, Dupuis M. [Para-articular ossifications and calcifications
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62. Dias DA. Heterotopic para-articular ossification of the elbow with soft
tissue contracture in burns. Burns. 1982;9:128-134.
63. Harnar T, Engrav L, Heimbach D, et al. Experience with skeletal
immobilization after excision and grafting of severely burned hands.
J Trauma. 1985;25:299-302.
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Joint Surg Am. 1986;68:1375-1379.
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serulteken. Orv Hetil. 1972;113:48.
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deformity after severe burns. Surg Clin North Am. 1970;50:1361-1375.
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523
Reconstruction of Bodily
Deformities in Burn Patients:
An Overview
LARS-PETER KAMOLZ, PAUL WURZER, and TED HUANG
49 
must be continued while the surgical treatment plan is
instituted.
Although the true efficacy of a nonsurgical regimen,
such as pressure garments (Fig. 49.5), to control deformi­
ties has not been established, the frequency of secondary
joint release among individuals who endured the morbidi­
ties associated with proper joint splinting for a period of at
least 6 months has been noted.3,4 The use of pressure dress­
ings, especially in areas such as the upper and lower limbs,
with proper splinting of the hand and fingers, is strongly
recommended soon following the injury. The nonsurgical
management of burn deformities must include daily phys­
iotherapy and exercise to maintain joint mobility and to
prevent muscle wasting.
The basic principle of restoring bodily deformities that
impose functional difficulties before directing surgical
efforts to restore appearance should be followed. The sur­
geon’s efforts should be concentrated on restoring the
deformed bodily parts essential for physical functions. For
example, an exposed skull or a calvarial defect, contracted
eyelids, constricted nares, contracted major joints, and a
urethral and/or anal stricture in individuals with severe
perineal burns are prime indications for early surgical inter­
vention. In contrast, restoration of contour deformity can
be delayed until the scars reach their final structure. In fact,
in children reconstruction of the nose and the ear, for
instance, should not be initiated until their growth patterns
have reached the growth peak; ear reconstruction may be
initiated once the child has reached 6–8 years of age, while
nasal reconstruction should be delayed until 16–18 years.
Although the exact scientific basis remains unclear, it has
been advocated that attempts at reconstructing burn defor­
mities should be delayed for at least 2 years after burn—the
time needed for scar maturation. During the interim, the
use of pressure garments and splinting is recommended to
facilitate scar maturation and minimize joint contracture.
The true efficacy of pressure garments in facilitating scar
maturation remains undefined. Lack of a reliable method
to determine various stages of scar maturation and subjec­
tive differences in assessing scar appearance could account
for the controversy. On the other hand, splinting a joint
embedded in burn scars with an external device to main­
tain a proper joint angulation has been found to be effective
in reducing the need for reoperation to achieve joint func­
tion. However, this is possible only if the patient wears the
splint faithfully for a minimum period of 6 months. A phys­
ical exercise regimen providing vigorous movements of
burned joints has been found to be effective in reducing the
need for surgical intervention.
The severity of burn injuries can usually be ascertained if
not by patient survival then by the consequences of the
injury: scar hyperplasia/hypertrophy, scar contracture, and
structural deformities due to loss of bodily components.
Since bodily deformity is closely related to the magnitude of
injury, restorative procedures are seldom indicated if the
depth of injury is superficial and the burned area limited
(Fig. 49.1). However, these procedures are required for deep
burns (Fig. 49.2).
Formation of scar tissues at a wound site and contraction
of those scar tissues are the normal consequences of an
injury. At a microscopic level, thickened and contracted
scar tissues (i.e., changes that are “normal” and “expected”
consequences of the wound-healing processes) appear as
collagens arranged in whorls and nodules. These changes
can be observed as early as 3–4 weeks following the injury,
and they are cosmetically unsightly and disturb function
(Fig. 49.3).
Reconstruction of Burn
Deformities
GENERAL PRINCIPLES
Burn injury is a traumatic condition resulting in aberrant
physiological processes caused by thermal destruction of
the skin. These physiologic alterations affect not only
healing of the original burn wounds, but also healing as
part of secondary surgical procedures. The treatment
should aim to repair the burn wounds first, and attempts to
restore deformities should be delayed until recovery from
the initial phase of injury is complete.1 As initially described
by Knobloch and Vogt,2 each surgical approach and recon­
structive procedure interacts with another. Hence burn
reconstructive surgery can best be viewed as reconstructive
clockwork (Fig. 49.4).
EARLY TREATMENT OF DEFORMITY AND
TIMING OF SURGICAL INTERVENTION
Making a decision of how to operate on a patient with burn
deformities is quite simple. In contrast, deciding when to
operate on a patient with burn deformities can be difficult.
Creating a realistic plan to restore physical function and to
alleviate pain and discomfort in the area of injury requires
an in-depth analysis of the physical deformities and psycho­
logical disturbance sustained by the patient. Psychiatric,
psychosocial, and physiotherapeutic care, in this sense,

49  •  Reconstruction of Bodily Deformities in Burn Patients: An Overview
524
The 2-year moratorium on early burn reconstruction is,
in some ways, justifiable. Operating on an immature scar
characterized by redness and induration is technically more
cumbersome; hemostatic control of the wound is difficult,
and inelasticity and lack of tensile strength of scar tissues
render tissue manipulation more difficult. A high rate of
contracture has been noted in instances where a partial-
thickness skin graft is used to release a wound showing
active inflammatory processes, further supporting the
2-year delay in initiating burn reconstruction.5
We have recently changed our approach to handling
individuals in need of reconstruction based on the finding
that contracted bodily parts can be effectively reconstructed
in the first 2 years postburn if skin flap, fasciocutaneous
(FC) flap, or musculocutaneous (MC) flap techniques are
used. Reconstruction is initiated in individuals as early as
3–6 months following the initial injury. The approach is
well-suited for those encountering functional difficulties
because of scarring and scar contracture.6
A
B
Fig. 49.1  (A) An 8-year-old boy sustained flash flame burns of the face.
The depth of injury was judged to be superficial. (B) The wounds
healed spontaneously. The scar formed was judged to be minimal 5
years later.
A
B
Fig. 49.2  (A) A 4-year-old boy sustained flame burns involving 75% of
his total body surface. (B) The injury was extensive; the wound required
staged debridement and skin grafting, resulting in extensive scarring.
A
B
Fig. 49.3  (A) Scarring around the injured sites became apparent within
3 weeks. (B) Thickening of the scar continued during the subsequent
5–6 months. Contraction of scars caused difficulty in closing and
opening the eyelids and mouth.
Skin
Grafts
Tissue
Engineering
Allo/
Xeno
Grafts
Skin
Substitutes
Expander
Bionic
Prosthesis
Local/
Free
Flaps
Direct
Closure
Laser
Fig. 49.4  Reconstructive clockwork shows the interaction between the
different reconstructive methods.
Fig. 49.5  The use of splints over the mobile joints and pressure gar­
ments is an essential component of patient management.

49  •  Reconstruction of Bodily Deformities in Burn Patients: An Overview
525
made along the marked line and is carried through the full
thickness of the scar down to the subcutaneous fatty layer.
While the outer layer of the scar tissue is excised, 4–5 mm
of collagen layer is left attached to the base. The conven­
tional approach of wedged scar excision will result in a
depression along the scar excision site, an iatrogenic conse­
quence that could be difficult to amend secondarily. To mini­
mize interference to the vascular supply along the wound
edges, the undermining of scar edge should be kept minimal.
Synthetic sutures are preferred for wound closure (Fig.
49.6).
Skin Grafting Technique
Free Skin Graft Without Incorporating a Dermal
Template. Covering an open wound with a piece of skin
graft harvested at an uneven thickness is the conventional
approach to wound closure. While the whole structure of
the skin removed as an intact unit (i.e., epidermis and
dermis) is defined as a full-thickness skin graft, a piece of
skin cut at a thickness varying between 8/1000ths of an
inch (0.196 mm) and 18/1000ths of an inch (0.441 mm)
is considered to be a partial- or a split-thickness skin graft.
The thickness of a full-thickness skin graft is quite variable
depending on the body site. A full-thickness skin graft har­
vested from the back, for instance, will be 16/1000ths of
an inch (4 mm) in thickness, whereas one harvested from
the upper eyelid will be around 35/1000ths of an inch
THE TECHNIQUES OF RECONSTRUCTION
There are several techniques routinely used to reconstruct
bodily deformities common to burn injuries (i.e., unsightly
scars, scar contractures, and joint contractures). Princi­
pally they are as follows: (1) excision of scars with a primary
closure technique; (2) wound closure following scar exci­
sion with grafting of a piece of free skin, with or without
the use of a dermal template; (3) an adjacent skin flap tech­
nique; (4) an adjacent FC flap technique; (5) an adjacent
MC flap technique, and (6) a distant skin, FC flap, or MC flap
via microsurgical technique.
Primary Wound Closure Technique
Excision of an unsightly scar with layered closure of the
resultant wound is the simplest and most direct approach
in burn reconstruction. The margins of the scar requiring
excision are first marked. It is important to determine the
amount of scar tissue that can be removed, yet will allow
the resultant defect to be closed directly. “Pinching” the
edge of scar at three or four different sites along its length
to determine the mobility of the wound edges is the simplest
yet most reliable method to determine the amount of scar
tissue that can be safely removed. Leaving a rim of scar
tissue is generally necessary unless the scar is so small that
removal and direct closure of the resultant wound would
not lead to contour deformity. A circumferential incision is
A
B
C
D
E
Fig. 49.6  (A) The scar formed in the left submental area was pruritic and unsightly. The extent of the excision was marked, and the area was infiltrated
with 0.25% lidocaine containing 1 : 400,000 epinephrine to achieve hemostasis. (B) The epidermal layer was sharply excised, leaving the dermal layer
intact. (C) The wound edges were closed primarily in layers using nylon sutures. (D) The extent and appearance of scarring noted before excision, 10
months following the initial burns. (E) The appearance of the operative site 5 years following partial scar removal.

49  •  Reconstruction of Bodily Deformities in Burn Patients: An Overview
526
Skin Flap Technique
The approach of using a segment of skin with all attached
structural components to restore a destroyed and/or absent
bodily part follows the fundamental principle of reconstruc­
tive surgery. However, this approach will cause not only
skin scarring at the flap donor site, but also a donor site
contour alteration that may be considered cosmetically
unsightly. Loss of a skin flap, more commonly encountered
in burn patients when the vascular supplies to the skin are
altered by injuries and surgical treatment, could render this
technique unsuitable, if not undesirable. Despite the draw­
backs, the approach to restoring a damaged bodily part
with a piece of analogous tissue is technically sound, and
the procedure will restore bodily function and contour. The
technical innovation of incorporating a muscle and/or
Fig. 49.7  A partial-thickness skin graft was used to cover an open
wound resulting from releasing of a contracted lower lip.
A
B
C
D
Fig. 49.8  (A) A 6-year-old girl bothered by recurrent infection caused by scar-embedded inclusion cysts in the left flank area that extended from the
lower axilla to the upper trochanteric region. (B) A piece of Integra was used to cover a wound that was 25–30 cm × 10–15 cm. (C) The vascularized
Integra-covered wound was covered with a partial-thickness skin graft of 8/1000ths of an inch in thickness 3 weeks later. (D) The appearance of the
grafted area a year following the operation. The scar was noted to be soft and pliable.
(0.8 mm). The difference is attributable to the difference in
the thickness of the dermis.
Although a power-driven dermatome is usually used to
harvest a partial- (split-) thickness skin graft, a free hand
knife can be used to cut a piece of full-thickness skin graft.
A paper template may be made to determine the size of skin
graft needed to close a wound. The skin graft is laid onto the
wound, colloquially known as the “wound bed,” and is
anchored into place by suturing the graft to the wound
edge-to-edge at various sites. An apposition of the skin graft
with the wound bed is essential to ensure growth of the
vascular network into the graft within 3–5 days and to
ensure graft survival. Any mechanical barriers, such as
blood clots or pools of serous or purulent fluid, will prevent
the vascularizing process and lead to graft loss. A gauze or
cotton bolster tied over a graft has been the traditional tech­
nique to anchor the graft and to prevent fluid from accu­
mulating underneath it even though no objective evidence
supports the efficacy of this maneuver. A quilting technique
has been found to be more effective than the bolstering
technique in immobilizing skin grafts and is associated with
fewer morbidities (Fig. 49.7).
Free Skin Graft With Prior Incorporation of a Dermal
Regenerative Template. For the past several years, artifi­
cial dermal substitutes have been manufactured from allo­
plastic or xenographic materials (e.g., Alloderm and Integra;
the manufacturing process was initially described by Yannis
and Burke in 1980). These biosynthetic, two-layered mem­
branes are composed of a three-dimensional porous matrix
of fibers and cross-linked bovine tendon and glycosamino­
glycan (chondroitin-6-sulfate). When implanted over an
open wound, this material forms a layer of parenchymal
structures resembling a dermis, enabling wounds to be
covered with an autologous skin graft when immediate
closure is not possible. The need for a staged approach to
wound grafting, however, is considered cumbersome
(Fig. 49.8).

49  •  Reconstruction of Bodily Deformities in Burn Patients: An Overview
527
flap to reconstruct tissue defects in individuals with deep
burn injuries. That is, fabricating a flap in a burned area is
possible if the underlying muscle or the fascia is included in
the design.
Musculocutaneous Z-Plasty Technique. While the skin
pattern in this technique is identical to that in the conven­
tional z-plasty technique, the muscle underneath must be
included in the flap fabrication. Although physical charac­
teristics of normal skin (i.e., the skin pliability and expand­
ability) are absent if scarred skin is included in the flap
design, a scarred-skin MC or FC flap can be safely elevated
and transferred to close an open wound. In practice, the MC
z-plasty technique is useful in neck release and in the eyelid
because of the character of the underlying muscle; the pla­
tysma and orbicularis oculi muscles are thin, pliable, and
easily movable (Fig. 49.12).
Fasciocutaneous Z-Plasty Technique. This is a techni­
cal modification of the MC z-plasty technique in which only
the muscular fascia is included. Separation of skin and its
subcutaneous tissues from the underlying fascia must be
avoided to ensure that the blood supply to the flap is not
impaired. In practice, the technique is useful in reconstruct­
ing contractural deformities around the knee and ankle
areas.
Three-Quarter Fasciocutaneous Z-Plasty Technique.
A 45-degree triangular FC flap that includes the fascial
layer may be fabricated anywhere in the body. The flap is
elevated and then turned 90 degrees to cover a tissue defect
resulting from a released contracted wound. Although
unburned skin is more versatile when used to fabricate a
triangular flap, scarred skin with or without subcutane­
ous tissues may also be used for flap fabrication. Suturing
the fascia to the skin edge is a useful maneuver to avoid
accidental separation of the fascia from the overlying skin
and interrupting vascular supply to dermal structures
(Fig. 49.13).
Paratenon Cutaneous Z-Plasty and Three-Quarter
Paratenon
Cutaneous
Z-Plasty
Techniques.
In
instances where fabrication of a composite skin flap is indi­
cated in the distal section of the upper and lower extremities
(i.e., wrist and ankle), the paratenon, a fascial extension of
the voluntary musculatures, should be included in the flap
design and fabrication (Fig. 49.14).
fascial layer in skin flap design, especially in burned areas,
has further expanded the scope of burn reconstruction
because more burned tissues can now be used for flap
fabrication.
The Axial Skin Flap. The skin in many areas is nourished
directly by known cutaneous arteries. A skin flap, regardless
of its length-to-width ratio requisite, may be fabricated
if the vascular trees are included in the flap pattern
(Fig. 49.9).
The Z-Plasty Technique. Briefly described, this technique
is based on the principle of mobilizing a full segment of skin,
with its vascular supplies undisturbed, from an area adja­
cent to the site needing tissue replacement. This is conven­
tionally achieved by interposing two skin flaps of an
equilateral triangle (i.e., 60 degrees) that has a common
limb drawn along the scarred area. A scarred and con­
tracted area is released as the flaps are interposed in an
opposite direction. Any space defect due to skin and under­
lying tissue movement is made up by mobilizing tissues from
an adjacent area (Fig. 49.10).
The Modified Z-Plasty Technique; Alias Three-
Quarters Z-Plasty Technique. As in the conventional
z-plasty technique, two flaps of a right-angled triangle are
used. That is, one has an internal 90-degree angle, and the
other has a “modified” 45-degree angle; the angle for the
triangular flap has decreased from a conventional 60
degrees to 45 degrees; hence the “three-quarters” z-plasty
technique. The limb of the 90-degree triangle is made in the
scarred area resulting from the tissue loss. The second limb
of the triangle is made perpendicular to the first one. The
angle formed by the second limb of the right-angled triangle
and the hypotenuse of the second right-angled triangle is
45 degrees. A triangular skin flap fabricated in this manner
is rotated to fill a tissue defect formed from surgical release
of a contracted scarred area. The procedure, in this sense,
is a variant of the conventional rotational/interpositional
skin flap technique in which the 45-degree triangular skin
flap is singularly rotated to make up the defect (Fig. 49.11).
Musculocutaneous or Fasciocutaneous
Flap Technique
Inclusion of not only the skin, but also the subcutaneous
tissues, fascia, and muscle is necessary to fabricate a skin
A
B
C
D
E
Fig. 49.9  (A) A triangular skin mark made over the right nasolabial area to mark an axial skin flap fabricated for left lower eyelid ectropion reconstruc­
tion. (B) The size of skin flap was equal to the size of the lower eyelid defect to cover an open wound that had a cartilage graft for tarsal replacement.
(C) The triangular flap was rotated cephalad and laterally to fill the left lower eyelid tissue defect. (D) The left lower eyelid ectropion consequential to
the loss of eyelid skin and the tarsus. (E) Appearance of the left lower eyelid 3 years following the reconstructive procedures.

49  •  Reconstruction of Bodily Deformities in Burn Patients: An Overview
528
A
B
C
D
E
Fig. 49.10  (A) Neck scar. (B) Two equilateral triangles were marked into a “z” and incisions were made to free up two triangular skin flaps. (C) Two
flaps were interposed to achieve the release. (D) Before release, the patient, a 13-year-old boy, complained of tightness over the neck area caused by
a tight scar band. (E) The appearance of the neck 4 years following releasing procedures. The z-plasty procedure alleviated the neck tightness.
A
B
C
Fig. 49.11  (A) A horizontal line was drawn along the site of tightness. A triangular skin marking was also drawn with its cathetus perpendicular to the
line of release. (B) The triangular flap was rotated cephalad and medialward to make up the wound defect that resulted from release. (C) The flap
donor site closure as well as the inset of flap was achieved primarily.

49  •  Reconstruction of Bodily Deformities in Burn Patients: An Overview
529
Free Composite Tissue Transfer via
Microsurgical Technique
With the advent of microsurgical techniques, transplanta­
tion of a composite tissue can now be carried out with
minimal morbidities. However, opportunities for using this
approach may be limited in burn care because of a paucity
of donor materials. It is ironic that burn patients with suit­
able donor sites seldom require such elaborate treatment.
Those who are in need of microsurgical tissue transplanta­
tion are inevitably those with no appropriate donor sites
because of extensive tissue destruction.
Tissue Expansion Technique
An extreme stretching of the integument is quite com­
monly observed in human bodies. The tissue expansion
technique follows the same principle, except it is carried
out intentionally with an inflatable device, known as a
tissue expander. Because excessively active scarring proc­
esses are frequently seen after burns, especially during the
period immediately following the accident, choosing a time
to initiate the procedure is difficult. Use may be limited
because of pain and discomfort associated with expansion
(Fig. 49.15).
A
B
C
E
D
Fig. 49.12  (A) Two equilateral triangles were marked into a “z.” (B) Incisions were made to free up two triangular skin flaps that included the platysmal
musculatures underneath. (C) Two flaps were interposed to achieve the release. (D) Before release, the patient, a 9-year-old boy, complained of tight­
ness over the neck area caused by a tight scar band. (E) The appearance of neck 4 years following releasing procedures. The z-plasty procedure allevi­
ated the neck tightness.

49  •  Reconstruction of Bodily Deformities in Burn Patients: An Overview
530
A
B
C
D
Fig. 49.13  (A) A triangular skin marking was made with its cathetus drawn along the line of contracture and perpendicular to the inferior wound edge
resulting from the release. (B) Incisions were made along the skin marking for flap fabrication. (C) The triangular skin flap was elevated to include the
fascial layer to form a random fasciocutaneous flap. (D) The appearance of flap and the wound 10 days following the release and flap
reconstruction.
A
B
C
D
E
F
Fig. 49.14  (A) Two equilateral triangles were marked over the left heel cord, the area felt to be tight. (B) The skin flap was fabricated to include the
fascial layer underneath. (C) Two fasciocutaneous flaps were interposed to achieve the release. (D) The inset of two flaps completed. (E) The appear­
ance of left heel cord before release. (F) The appearance of left heel cord 4 years following release.
A
B
C
Fig. 49.15  (A) A 4-year-old patient with scalp alopecia resulting from extensive burns involving the scalp and the face area. (B) No attempt was made
to reconstruct the scalp alopecia until she was 8 years of age. The tissue expander technique was used to expand the left side of the scalp for wound
coverage. (C) The appearance of right temporal scalp following two scalp expansion-advancement procedures.

49  •  Reconstruction of Bodily Deformities in Burn Patients: An Overview
531
surviving burns is in need of reconstruction, functional or
otherwise.
Unsightly hypertrophic scars, scar contractures (particu­
larly those affecting the joint structures), and destroyed
body parts are still the most common sequelae of burn inju­
ries. Although the use of skin grafting and skin flaps has
remained a mainstay of burn reconstruction, the outcomes
can still be suboptimal because the techniques cannot
correct the three above-mentioned problems.
The exact time at which to initiate reconstruction of
burn deformities remains unsettled. Difficulty in obtaining
suitable tissues for replacement, morbidities associated with
surgical procedures that involve tissues with active scarring
processes, and outcomes that cannot be assured may
account for the controversy. Novel approaches using
adipose-derived stem cells and other cultured cells may
open new avenues, but the safety of these techniques must
be proved in daily clinical practice. On the other hand, flap
techniques, particularly the three-quarter FC z-plasty and
three-quarter paratenon cutaneous z-plasty, are established
approaches that enable reconstruction of contractural
deformities involving the major joints as well as eyelid defor­
mities as early as 4–6 months following the injury.
Although many questions remain concerning the ideal
approach in managing burn deformities, the science of
regenerative medicine and tissue engineering, which
includes bionic prostheses, could lead to the formation of
body parts that could be used to replace absent or destroyed
body components.
Complete references available online at

Further Reading
Brou J, Robson MC, McCauley RL. Inventory of potential reconstructive
needs in patients with burns. J Burn Care Rehabil. 1989;10:556-560.
Condé-Green A, Marano AA, Lee ES, et al. Fat grafting and adipose-derived
regenerative cells in burn wound healing and scarring: a systematic
review of the literature. Plast Reconstr Surg. 2016;137(1):302-
312.
Huang T, Larson DL, Lewis SR. Burned hands. Plast Reconstr Surg.
1975;56:21.
Lantieri L, Grimbert P, Ortonne N, et al. Face transplant: long-term follow-
up and results of a prospective open study. Lancet. 2016.
Larson DL, Abston S, Willis B, et al. Contracture and scar formation in
burn patients. Clin Plast Surg. 1974;1:653.
Fat Grafting Technique
Recently the use of subcutaneous fat has been gaining pop­
ularity as a tool to increase postburn wound healing and
reduce scarring.7 The fat is usually harvested by lipoaspira­
tion. Current research is focused on several approaches that
can be taken to use fat as a source of stem cells or as an
additional layer between the wound and skin graft. Fat can
be sprayed directly onto the wound site, transferred with
dermal replacements onto the wound, or directly injected
into scars to make them smother. Further prospective clini­
cal trials are warranted to prove the safety and efficacy of
fat grafting in burn patients.
Allotransplantation:
Facial Transplantation
The face may be the most challenging area to reconstruct
after burns. Every face is unique and matches each person­
ality. Moreover, facial expressions are important parts of
daily conversations and interactions between people. Hence
composite tissue transplantation and face transplantation
are more topical than ever. In 2009, Lantieri8 performed the
first face transplant in a burn patient. Unfortunately, the
patient died during the recovery phase from severe infection
and heart failure. The same group recently published long-
term results on patients who received facial transplanta­
tions; not all were burn patients, but they showed that
careful preoperative patient selection and strict local as well
as institutional regulations are needed to improve outcomes
following composite tissue transplantation and face
transplantation.8
Comments
Burn treatment regimens have changed drastically over the
past 60 years, and a more aggressive approach in managing
burned wounds was adopted in the 1980s. Early debride­
ment and wound coverage initially with biological dressing
and later with autologous skin grafts has enhanced the sur­
vival rate. Ironically this improved survival has caused an
upsurge in patients needing reconstruction: everyone now

531.e1
49  •  Reconstruction of Bodily Deformities in Burn Patients: An Overview
References
1. Brou JA, Robson MC, McCauley RL, et al. Inventory of potential
reconstructive needs in the patient with burns. J Burn Care Rehabil.
1989;10(6):555-560.
2. Knobloch K, Vogt PM. The reconstructive sequence in the 21st century.
A reconstructive clockwork. Chirurg. 2010;81(5):441-446.
3. Huang T, Larson DL, Lewis SR. Burned hands. Plast Reconstr Surg.
1975;56:21.
4. Celis MM, Suman OE, Huang T, et al. Effect of a supervised exercise
and physiotherapy program on surgical intervention in children with
thermal injury. J Burn Care Rehabil. 2003;24:57.
5. Robson MC, Barnett RA, Leitch IOW, et al. Prevention and treatment
of postburn scars and contracture. World J Surg. 1992;16:87-96.
6. Huang T, Herndon D. The early burn reconstruction in burned patients.
Presented at the annual meeting, Texas Surgical Society, San Antonio,
Texas, April 1, 2005.
7. Condé-Green A, Marano AA, Lee ES, et al. Fat grafting and adipose-
derived regenerative cells in burn wound healing and scarring: a system­
atic review of the literature. Plast Reconstr Surg. 2016;137(1):302-312.
8. Lantieri L, Grimbert P, Ortonne N, et al. Face transplant: long-term
follow-up and results of a prospective open study. Lancet. 2016.

532
Reconstruction of the Head and
Neck after Burns
MATTHIAS B. DONELAN and BRANKO BOJOVIC
50 
surgery is typically complex and morbid with potentially
severe complications. Scar rehabilitation is minimally
morbid and has few complications. The secrets to success
with scar rehabilitation in the head and neck are accurate
early diagnosis, conservative management, and the effec­
tive use of new technologies and treatments to enable
patients to reap the maximum benefit from their own
amazing wound-healing and scar remodeling capabilities
(Fig. 50.1). This new approach will be discussed in this
chapter along with more traditional methods of recon­
struction in the head and neck.
Burn injuries constrict and deform the face; distorting its
features, proportions, and expression.1 Burns also alter the
surface of the facial mask by causing scars and altering
texture and pigmentation. The changes to the surface of the
skin are deforming but are much less important to facial
appearance than are the changes in proportion, features,
and expression. The removal of scars should not be the
primary goal of facial burn reconstruction. A normal-
looking face with scars is always better looking than an
even slightly grotesque looking face with fewer scars.
Mature scars that result from burn injury will often be less
conspicuous than surgically created scars after excision or
surgically transferred flaps or grafts. The subtle and gradual
transition between unburned skin and burn scar is an
excellent example of nature’s camouflage and can render
scarring remarkably inconspicuous. New techniques of
scar rehabilitation using lasers and carefully crafted, mini­
mally morbid surgery helps scars blend even better. The
principal goal of facial burn reconstruction should be the
restoration of a pleasing and tension-free facial appearance
with appropriate animation and expression.2 If this goal is
kept in mind and is pursued with persistence and determi­
nation, the amount of improvement that can result after
severe facial burn injury can be remarkable. Ignoring this
basic principle can result in iatrogenic catastrophes during
reconstructive surgery of the head and neck following
burns.
Successful reconstruction of burn deformities of the
head and neck requires a well-functioning and extensive
team.3 Major burn deformities in this area can easily be
intimidating and overwhelming. Experience and a spe­
cialized infrastructure are required to take care of these
patients comfortably and successfully. Familiarity with
their unique problems and a firm commitment to cor­
recting their challenging deformities is required from all
members of the reconstructive team. The care of a patient
from the onset of a major burn involving the head and
neck to a successful reconstructive outcome requires skill,
patience, determination, and enthusiasm from all who are
involved.
Introduction
Reconstruction of the head and neck1 following burn inju­
ries presents great challenges and great opportunities. Suc­
cessful treatment requires sound surgical judgment and
technical expertise, as well as a thorough understanding
of the pathophysiology of the burn wound and contrac­
tures. Many disciplines are required to successfully care for
patients with burns of the head and neck. These include
skilled nursing, experienced occupational and physical
therapy, and psychological and social support systems.
The surgeon must also have familiarity and expertise
with nonsurgical treatment modalities such as pressure
therapy, steroids, and laser therapy. Realistic expectations
on the part of both patients and surgeons are essential to
achieve successful treatment outcomes. Burns to the head
and neck of a serious nature result in tissue injury with
scarring, and complete removal of scars is not possible. A
scar can only be modified or exchanged for another scar or
tissue of a different variety. Despite this fundamental limi­
tation, reconstruction of the burned face and neck creates
great opportunities for plastic surgery to significantly
improve functional and aesthetic deformities resulting in
profound improvement for this large group of challenging
patients.
Recent advances in technology and improved under­
standing of wound-healing physiology are transforming
the ways we should look at, and think about, burn scars and
contractures. This change in perspective is particularly
important in the head and neck because normal appear­
ance and normal function in this area are of paramount
importance. The presence of visible scarring and even mini­
mally grotesque deformity is particularly debilitating in the
face and neck. Since the early 20th century and the brilliant
work of Sir Harold Gillies reconstructing facial deformities
with tubed pedicle flaps, scar excision in the head and neck
and replacement with flap tissue, either from regional or
distant donor sites, has dominated facial burn reconstruc­
tion thinking. This was further popularized by the concept
of aesthetic unit scar excision coupled with ever-improving
surgical ability to transplant tissue. It is time to rethink this
paradigm. It is now possible to dramatically rehabilitate
hypertrophic and contracted scars on the face and neck to
the point where the scars are often the patient’s best recon­
structive anatomy. That is because the scars are autologous,
in the right location, and the closest match to normal
because they are the “original equipment.” Excision and
replacement of facial scars creates iatrogenic donor sites
and requires extensive surgery to replace the scars with
uninjured tissue from other areas of the patient’s body. This

50  •  Reconstruction of the Head and Neck after Burns
533
Acute Management
Although the main focus of this chapter is the reconstruc­
tion of established facial burn deformities, an understand­
ing of the acute care of facial burn injuries is necessary in
order for the surgeon to have an accurate perspective. Exci­
sion and grafting of deep second-degree and full-thickness
burns has become the standard of care since it was first pro­
posed in 1947.4–6 It remains controversial whether this is
the optimal treatment for facial burn injuries. Early excision
and grafting of the face is problematic because of difficulty
in diagnosing the depth of the facial burn and accurately
predicting an individual patient’s long-term prognosis both
functionally and aesthetically. Laser Doppler imaging is a
validated way to improve diagnosis in these difficult cases
and can decrease the risk of overly aggressive excision.
Preventing unnecessary early excision is particularly
important with current improved techniques to rehabilitate
hypertrophic scars. The overwhelming majority of facial
burns treated conservatively with a moist regimen of topical
antibiotics will heal within 3 weeks. Burns that are clearly
full-thickness are best treated by early excision and graft­
ing within 7–10 days to promote early wound closure and
minimize contractile forces (Fig. 50.2). The problem cases
are those where healing has not occurred by 3–4 weeks or
longer. Early tangential excision and grafting has been pro­
posed for these patients in order to achieve more favorable
healing with less eventual contracture deformities.7 Pro­
ponents of conservative therapy argue that early excision
and grafting may result in a patient with a grafted face who
would otherwise have healed favorably by successfully epi­
thelializing their partial-thickness burn from skin append­
ages.8 Conservative management has been facilitated by the
D
C
B
A
Fig. 50.1  (A,B) A 9-year-old boy from the Dominican Republic 2.5 years after 30% flame
burns with severe hypertrophic scars and contractures. His chin was attached to his chest,
and he had an axillary contracture that had been open for a year. (C,D) Five years later, after
four Z-plasty procedures, six fractional ablative laser treatments, and one small split-thick­
ness graft to the base of his right neck, his appearance and function are very close to normal.
No scar tissue has been excised.

50  •  Reconstruction of the Head and Neck after Burns
534
done when it is clearly the best alternative. The majority of
acute facial burns are treated conservatively in most burn
centers, with early excision and grafting limited to those
cases where it is clear that a full-thickness burn injury has
occurred.
Pathogenesis
Superficial-thickness, second-degree burns usually heal
without scarring or pigmentary changes. Medium-
thickness, second-degree burns that epithelialize in 10–14
days usually heal without scarring, although there can be
myriad ancillary techniques currently available to favorably
influence the healing of facial burns such as pressure, sili­
cone, silicone-lined computer-generated facemasks, topical
and intralesional steroids, vitamin E, massage, and treat­
ment with pulsed dye lasers (PDLs) and ablative fractional
CO2 lasers. Impressive results have been obtained by advo­
cates for early excision and grafting.9 Very good outcomes,
however, can also be achieved by being more conservative
with this difficult group of patients (Fig. 50.3). The ben­
efits in appearance and function of rehabilitated scars over
early excision and grafting are dramatically demonstrated
by the patients and accompanying videos in Figs. 50.4 and
50.5. Committing a patient to a grafted face should only be
C
B
A
Fig. 50.2  (A) A 5-year-old Native American girl, 3 days after deep second- and third-degree burns to her face. (B) Tangential excision and split-thickness
autografting were performed on the 10th postburn day. (C) Five years after facial excision and grafting. She has had a subsequent nasal
reconstruction.
B
A
Fig. 50.3  (A) Ungrafted facial burn injury 30 days following 85% burn in a 34-year-old electrician. Wound closure was obtained with split-thickness
grafts at 5 weeks. (B) Four years following burn injury. Lower lids and alar lobules have been released and grafted.

50  •  Reconstruction of the Head and Neck after Burns
535
C
B
A
Fig. 50.4  (A) Four-year-old male 2 years after a mixed second- and third-degree scald burn from hot coffee. Parents refused excision and grafting.
Scars are hypertrophic and inelastic with a significant contracture across the deltopectoral groove. (B) Multiple Z-plasties separated the scars into
smaller, discreet areas with focal reductions in tension. Pulsed dye laser therapy was initiated at his first Z-plasty procedure. (C) Seven years later, after
two small Z-plasty procedures and 21 laser treatments using both pulsed dye laser and fractional ablative CO2, his chest scars are flat, soft, thin, incon­
spicuous, and elastic. (D) Video demonstrating the function of the scars after treatment.
C
B
A
Fig. 50.5  (A) Eighteen-month-old female after a hot liquid scald
burn following excision and grafting 2 weeks following the injury. (B)
Appearance of the skin grafts at age 12. (C) Appearance of the grafts
after 8 treatments with the fractional ablative CO2 laser. (D) Video
demonstrating the function of the grafts after treatment.

50  •  Reconstruction of the Head and Neck after Burns
536
patient’s body will be less common in the future. The best
reconstructive plan for the facial scar tissue will be scar
rehabilitation using all available modalities to preserve its
unique advantages as much as possible. Improved outcomes
will be achieved with a judicious combination of contrac­
ture releases by Z-plasty, grafts, and flaps, followed by appro­
priate scar revision and laser therapy. Laser therapy preceding
scar revision improves scar quality and facilitates surgery.
Extensive scar excisions in aesthetic units and replacement
long-term changes in skin texture and pigmentation. Deep-
thickness, second-degree burns that epithelialize after 21
days or longer are unpredictable and must be carefully
managed because they have a propensity to develop severe
late hypertrophic scarring (Fig. 50.6). These patients should
be closely monitored after initial healing and, at the first
sign of hypertrophy, must be managed with all available
ancillary treatment modalities. Pressure garments have
been shown over several decades to be effective in suppress­
ing and reversing hypertrophic scarring. Adding silicone to
pressure therapy seems to increase its efficacy. Computer-
generated clear face masks lined with silicone have improved
the ability to deliver pressure to facial hypertrophic scars
and are better tolerated by patients (Fig. 50.7). The vascular-
specific PDL decreases hyperemia and seems to diminish
hypertrophy. When tension plays a role in the development
of early hypertrophic scarring, relief of the tension with
either focal Z-plasty or judicious release and grafting can be
very helpful. Ablative fractional CO2 laser therapy can be
used to decrease tension and also deliver corticosteroids
into the hypertrophic scars with encouraging results. Defi­
nite full-thickness facial burns should usually be excised
and grafted unless focal and small.
Evaluation of Facial
Burn Deformities
Facial burn reconstruction should be based on an overall
strategy and a clear understanding of the fundamental
problems. Many reconstructive techniques have been
described in the literature and can result in improvement if
the strategic goals are appropriate.10–12 The new era of scar
rehabilitation has changed older strategies, and where this
will eventuate is unclear at this time. It seems likely that
scar excision and replacement with other parts of the
B
A
Fig. 50.6  (A) One month following a flash burn, the right cheek is epithelialized. (B) Ten months later, there is massive hypertrophy despite conserva­
tive therapy with pressure.
Fig. 50.7  Computer-generated clear silicone-lined masks are well tol­
erated and more efficacious than previous devices.

50  •  Reconstruction of the Head and Neck after Burns
537
Fortunately the majority of facial burn injuries are not
severe and do not involve the entire face. A relatively small
number of patients sustain injuries that deeply involve the
entire face, such as shown in Fig. 50.8. It can be helpful to
separate patients with facial burn deformities into two fun­
damentally different categories, as described in Box 50.2.
Type I deformities consist of essentially normal faces that
have focal or diffuse scarring from their burns and may
have associated contractures. Type II deformities make up
a much smaller number of patients who have “pan-facial”
burn deformities with some or even all of the facial burn
stigmata. Although these categories are not rigidly defined,
and there are some patients who do not fit neatly into one
or the other, understanding the fundamental difference
between these two groups of patients can help define treat­
ment goals. It can also aid in selecting the most appropriate
methods for reconstructive surgery.
Patients with type I deformities have an essentially
normal facial appearance despite scars from their burns. In
these patients, one must be certain that surgical interven­
tion does not adversely alter normal facial features or create
distortion from iatrogenically induced tension. Overall
facial appearance should not be sacrificed in an effort to
“excise scars” (Fig. 50.9). The best reconstructive options
today for patients with type I facial burn deformities are
with microvascular free tissue transfer from distant sites
will likely become less frequent. The role of face transplan­
tation in burn reconstruction of the head and neck is
unclear at this time.
Deep second- and third-degree burns heal by contraction
and epithelialization. The more severe the burn injury, the
more contraction takes place during the healing process.
The changes in facial appearance following a deep second-
degree burn injury are dramatically demonstrated in Fig.
50.8. Three weeks following a deep second-degree burn, the
patient’s facial features and proportions remain essentially
normal. Six months later, contractile forces have deformed
the facies in a pattern that is repeated to a variable degree
in virtually all severe facial burns. These changes make up
the stigmata of facial burn injury and are listed in Box 50.1.
The eyelids are distorted with ectropion, the nose is fore­
shortened with ala flaring, the upper lip is shortened and
retruded with loss of philtral contour, the lower lip is everted
and inferiorly displaced, the lower lip is wider than the
upper lip in anterior view. The tissues of the face and neck
are drawn into the same plane with loss of jawline defini­
tion. The severity of these changes is proportional to the
severity of the injury.
B
A
Fig. 50.8  (A) Three weeks following a deep second-degree burn with essentially normal facial features and proportions. (B) Six months later, contrac­
tion and hypertrophy have created facial burn stigmata.
Box 50.1  Stigmata of Facial Burns
■ Lower eyelid ectropion
■ Short nose with ala flaring
■ Short retruded upper lip
■ Lower lip eversion
■ Lower lip inferior displacement
■ Flat facial features
■ Loss of jawline definition
Box 50.2  Facial Burn Categories
Type I
Essentially normal facies with focal or diffuse burn scarring with
or without contractures
Type II
Pan-facial burn deformities with some or all of the stigmata of
facial burns

50  •  Reconstruction of the Head and Neck after Burns
538
the type II category are shown in Fig. 50.11. The surgical
goals for this group of patients should be the restoration of
normal facial proportion and, as much as possible, the res­
toration of the position and shape of normal facial features.
The intrinsic and extrinsic contractures that exist in these
patients require large amounts of skin. The correction of
these contractures should be carried out in a carefully
planned and staged fashion. The best sequence of opera­
tions is usually the following: eyelids, lower lip and chin,
upper lip, cheeks, nose, and then other residual deformities.
As each area is reconstructed, the addition of skin results
in the relief of tension, which benefits other areas of the
face. Excision of normal skin or elastic healed second-
degree burned skin is almost never indicated. After facial
proportion has been achieved and facial features have been
laser therapy combined with scar release and revision with
Z-plasties when indicated or tissue rearrangement with
local flaps. The PDL was the first laser to have demonstrated
efficacy in the treatment of hypertrophic and contracted
facial burn scars13 and can be helpful for decreasing post-
burn erythema and treating persistently erythematous
burn scars. Z-plasties in combination with the PDL can be
a powerful scar-improving combination14 (Fig. 50.10). Full-
thickness skin grafts are excellent for focal contractures.
Excision of scars and resurfacing operations in aesthetic
units and major flap transpositions, with or without tissue
expansion, are rarely indicated.
The much less frequently encountered group of patients
with type II facial burn deformities presents a completely
different clinical situation. Examples of patients falling into
D
C
B
A
Fig. 50.9  (A) Five-year-old male with normal facial appearance and focal hypertrophic scar­
ring without contractures. (B) After serial scar excision, he has a grotesque facial deformity
from an extrinsic contracture. (C) Twelve-year-old female with a normal facial appearance and
mildly erythematous, hypertrophic scarring. There was great pressure from patient and family
to “remove scars.” (D) After scar excision and cervicopectoral flap transposition she has a sad
facial expression and loss of jaw line definition.

50  •  Reconstruction of the Head and Neck after Burns
539
D
C
B
A
Fig. 50.10  (A) Hypertrophic scarring of both cheeks, lips, and chin
6 months following flame burn. (B) Multiple Z-plasties release
tension on facial scars. (C) Pulsed-dye laser therapy can be used to
decrease erythema. (D) Improved appearance 3 years following
burn. No scars have been excised.
B
A
Fig. 50.11  (A,B) Typical examples of patients with “pan-facial” burns resulting in type II facial deformities.

50  •  Reconstruction of the Head and Neck after Burns
540
Fundamental Principles
and Techniques
CONTRACTURES
Burn injuries result in open wounds that either heal by
contraction and epithelialization or are closed by skin graft­
ing. Contractures result from both of these forms of wound
healing. Contractures are either intrinsic or extrinsic. Intrin­
sic contractures result from loss of tissue in the injured area
with subsequent distortion of the involved anatomic part.
Extrinsic contractures are those in which the loss of tissue is
at a distance from the affected area but the distorted struc­
tures, such as eyelids or lips, are not injured themselves.
restored to their normal location and shape without tension,
scar revision can be carried out to smooth and blend the
remaining junctional scars (Fig. 50.12).
Normal faces are a mosaic of colors, textures, wrinkles,
and irregularities. In a face that has undergone major burn
injury, a mosaic appearance of scars, grafts, pigmentary
abnormalities, and other flaws can be attractive as long as
the facial features are restored to a normal location and are
sufficiently loose and mobile for normal and appropriate
facial expression. Laser therapy with vascular and frac­
tional ablative CO2 devices further blends, obscures, thins,
and softens scars, enhancing facial expression and a more
natural appearance (Fig. 50.13). Cosmetics can be useful
for blending and camouflaging areas of pigmentary and
textural abnormality, particularly in females.
D
C
B
A
Fig. 50.12  (A,B) A 29-year-old firefighter with “pan-facial” burn deformity causing facial burn
stigmata. (C,D) Seven years later, following the reconstructive sequence outlined in the text.
Facial features and proportion have been restored. Note philtral reconstruction with compos­
ite graft from ear triangular fossa.

50  •  Reconstruction of the Head and Neck after Burns
541
reconstruction. Tight faces are never attractive. Tight scars
are always hypertrophic and erythematous. Relaxed scars
are happy scars. The fractional ablative laser has created a
new paradigm for the management of tight, hypertrophic,
erythematous, and even ulcerated pan-facial scarring with
contractures. It is a clearly more powerful and efficacious
treatment modality than the PDL. The patient shown in
Fig. 50.13 is a perfect example of this beneficial change in
the management of facial burn scars. Her scars were more
diffuse and severe than those of the patients shown in Fig.
50.9 who were severely deformed by scar excision surgery.
Her face is essentially normal after the rehabilitation of her
“original equipment.”
Corrective measures should be directed at the cause of the
contracture in order to provide optimal benefit and prevent
iatrogenic deformities. It is helpful to minimize the amount
of skin and scar excised when correcting facial contractures.
When tension is released, many scars will mature favorably
and become inconspicuous. Even long-standing scars will
respond to a change in their environment. Healed second-
degree burns under tension may be unattractive but when
restored to a tension-free state can be superior in function
and appearance to any replacement tissue. Minimizing exci­
sion also decreases the amount of new skin that must be
provided in the reconstruction. Every effort should be made
to relieve tension from the face when performing burn
E
D
C
B
A
Fig. 50.13  (A,B) Eleven-year-old female
from Kosovo 18 months after a flash burn
to her face with diffuse, erythematous,
ulcerated, contracted, and hypertrophic
scars. (C) Z-plasties separate broad areas of
scarring, relieving tension, and immedi­
ately flattening and improving the appear­
ance of the scars. (D,E) Six years later, after
three additional small Z-plasty procedures
performed at the same time as laser treat­
ments. She has only had a total of nine
pulsed dye laser treatments and six abla­
tive fractional laser treatments because she
lives in Kosovo. No scars were excised.

50  •  Reconstruction of the Head and Neck after Burns
542
of a flat, epithelialized surface is a superior outcome to sur­
gical excision with its concomitant increase in facial
tension.14 The development of fractional ablative and
nonablative laser therapy using various types of lasers,
including CO2 and erbium-YAG, offers promising new
options for the management of facial burn scars in the
future.31
GRAFTS
Skin grafts are an essential part of facial burn reconstruc­
tion. Surgical decisions regarding donor site selection, the
use of split-thickness versus full-thickness grafts, the timing
of intervention, and the postoperative management of
grafts often determine the success or failure of facial burn
reconstruction. Split-thickness skin grafts contract more
than full-thickness grafts, wrinkle more, and always remain
shiny, with a “glossy finish” look. Split-thickness skin grafts
should be used primarily in the periphery of the face unless
the limited availability of donor sites requires their use in
more prominent areas. Split-thickness skin grafts can be
excellent for upper eyelid releasing and resurfacing. Hyper­
pigmentation of split-thickness grafts on the face is a fre­
quently occurring problem in dark-skinned patients,
particularly those of African descent.
The full-thickness skin graft is a reliable workhorse in
facial burn reconstruction. The broad, central, conspicuous
areas of the face such as the cheeks, upper and lower lips,
and dorsum of the nose are excellent sites for the use of
full-thickness grafts. The missing or damaged parts in the
vast majority of even severe facial thermal burns are the
epidermis and the dermis, and that is what full-thickness
skin grafts provide. After facial burns, the subcutaneous fat
may be compressed or distorted by contractures but it is rare
that it is injured or completely lost. Adequate skin must be
provided when doing definitive resurfacing operations with
full-thickness grafts. Contractures must be overcorrected,
and postoperative management with conformers and pres­
sure is essential. Full-thickness skin grafts are very reliable
when used electively in the face for reconstruction after
burns.32
FLAPS
Flaps can be useful for facial burn reconstruction, but they
must be used judiciously and skillfully, recognizing their
problems and limitations. The thickness of skin flaps from
all distant donor sites is greater than that of the normal
facial skin. The face is tight following burn injury, and
flaps tend to contract when transferred. They can therefore
compress or obscure underlying tissue contours. Transpos­
ing or advancing flaps from the neck and chest up to the
face can easily create extrinsic contractures that adversely
affect facial appearance. When flaps have been enlarged
by tissue expansion, they are even more dangerous in this
regard. Contractures with a downward vector create a
“sad” facial appearance that is distressing to patients (Fig.
50.9). Cervicopectoral flaps provide the best color match
in color and texture to facial skin. Distant flaps, whether
transferred by traditional technique or microsurgery,
share the common flaw of poor match in terms of color
and texture.
AESTHETIC UNITS
The concept of facial aesthetic units has profoundly affected
plastic surgical thinking since its introduction by Gonzalez-
Ulloa.15 Initially conceived as the ideal approach for resur­
facing the face following burn injury, this important
concept has been emphasized in virtually all subsequent
writings about facial burns. It is important to keep facial
aesthetic units in mind during burn reconstruction, but
the desire to adhere to this concept should not supersede
common sense. When small, unburned, and unimport­
ant islands of skin are in an aesthetic unit that is being
resurfaced, they can be sacrificed. Otherwise the excision
of normal facial skin is rarely indicated in burn reconstruc­
tion. All burned faces to some degree are mosaic. Scar revi­
sion with Z-plasties is an excellent technique to camouflage
scars in a burned face. Mosaic faces that are proportional,
tension free, and normally expressive appear much better
in real life than they do in images. Lasers, as noted previ­
ously, also aid in obscuring marginal scars and add to the
camouflage effect.
Z-PLASTY
The Z-plasty operation is a powerful tool in the surgeon’s
armamentarium for facial burn reconstruction. The
Z-plasty has been used for more than 150 years to lengthen
linear scars by recruiting lax adjacent lateral tissue.16
Z-plasty can also cause a profound beneficial influence on
the physiology of scar tissue when it is carried out within
the scarred tissues rather than after excising them.17 The
physiology of this phenomenon is related to the immediate
and continuing breakdown of collagen that occurs in
hypertrophic scars following the relief of tension.18–20
Z-plasty also narrows scars at the same time that it length­
ens them. In addition, the Z-plasty adds to scar camouflage
by making the borders of the scar more irregular. In order
for Z-plasties to lengthen a burn scar and restore elasticity,
the lateral limbs of the Z-plasty must extend beyond the
margins of the scar. The improvement in the appearance of
facial scars following Z-plasty and without any scar excision
can be dramatic, particularly when combined with PDLs
and fractional ablative laser treatments (Figs. 50.1, 50.10,
50.13, 50.19).
LASER THERAPY
Hypertrophic scarring is a frequent complication after
partial-thickness facial burn injuries that take longer than
3 weeks to completely epithelialize.21 Despite conservative
management and close monitoring, hypertrophic scarring
can become severe during the first 2 years after the burn
(Fig. 50.6).22–24 The PDL has emerged as a successful treat­
ment modality during this period of scar proliferation and
is an effective alternative to scar excision in patients with
hypertrophic facial burn scars.14,25 Multiple studies have
demonstrated its beneficial effect on scar erythema and
hypertrophy.26–30 The PDL also rapidly decreases pruritus
and pain26,27 and provides an additional, low-morbidity
therapeutic intervention for patients and their families
during the often prolonged period of scar maturation. Res­
toration of hypertrophic facial scars to their previous state

50  •  Reconstruction of the Head and Neck after Burns
543
important in this group of patients because it can positively
influence further maturation of scars and grafts. Scar reha­
bilitation with lasers has emerged as probably the most
effective treatment modality in this intermediate phase of
facial burn deformity reconstruction. Late-phase recon­
structive patients present to the reconstructive surgeon
with established facial burn deformities many years follow­
ing their acute injury. Careful scar analysis and judicious
use of the right techniques is essential during this period. It
is the responsibility of the treating surgeon to weigh all the
options and select the best combination of treatments to
maximize the patient’s own healing capabilities.
ACUTE-PHASE RECONSTRUCTION
Eyelids
Upper and lower eyelid ectropion can occur from burn inju­
ries to the periorbital region (intrinsic contracture) or may
arise secondarily as a result of the contracture of open
wounds and skin grafts at more distant sites (extrinsic con­
tracture). With severe ectropion, such as shown in Fig.
50.14A, early intervention is mandatory in order to prevent
irreversible injury to the cornea. Conservative measures to
protect the cornea, such as temporary sutures or contact
lenses, are often ineffective. Tarsorrhaphy can cause irre­
versible iatrogenic injury and should not be used unless
absolutely necessary. The best treatment is early interven­
tion with release of contracture and resurfacing with split-
thickness skin grafts (Fig. 50.14B). Release of even extreme
contractures with grafting can be done in the presence of
open wounds and effectively restores protective eyelid
function.
Perioral Deformities
Microstomia occurs from circumferential scarring at the
junction between lips and cheek. Perioral scarring from
either open wounds or contraction of skin graft suture lines
can act as a pursestring, resulting in diminished oral
opening (Fig. 50.15). This can compromise alimentation
and airway access. Microstomia is best addressed by the
TISSUE EXPANSION
Tissue expanders must be used with caution in the recon­
struction of the head and neck. The underlying theme of
almost all burn deformities is tension secondary to tissue
deficiency. Stretching adjacent tissue in order to carry out
scar excision can easily result in an increase in tension and
therefore create iatrogenic contour abnormalities. The
complication rate of tissue expansion following burn injury
is high, especially in the neck area and the extremities.33–35
The scalp is a privileged site, however, that tolerates tissue
expansion quite well, even in the burn patient population.36
As noted earlier, care must be taken when advancing or
transposing expanded flaps from the cervicopectoral area to
the face because this can create extrinsic contractures with
a downward vector.
Timing of Reconstructive Surgery
The timing of reconstructive plastic surgery following facial
burn injury falls into three separate phases: acute, interme­
diate, and late. Specialized burn centers create an ideal
patient care environment where acute care and reconstruc­
tive surgery can be planned and carried out in optimal cir­
cumstances
with
collaboration
among
acute
and
reconstructive physicians and surgeons. The reconstruc­
tion of facial burn injuries to the head and neck should
optimally begin with the acute care.
Acute reconstructive surgery occurs during the first
months following the burn injury and includes urgent pro­
cedures that are required to facilitate patient care or to
prevent acute contractures from causing permanent sec­
ondary damage. Acute reconstructive intervention is most
frequently indicated in the eyelid, perioral, and cervical
areas. Intermediate reconstructive surgery takes place
during the months to years after wounds are closed and the
scar maturation process is proceeding. During this phase of
recovery, some patients will present to the reconstructive
surgeon after having received their acute burn care at
another facility. Timely intervention when indicated is
B
A
Fig. 50.14  (A) Extreme eyelid ectropion during early acute phase. (B) Successful correction of ectropion with release and graft despite operative
wounds.

50  •  Reconstruction of the Head and Neck after Burns
544
the oral mucosa and can result in irreversible damage to the
dentition. Early intervention with release and grafting of
the lower and/or upper lips should be carried out as soon as
possible. Definitive reconstruction is best carried out at a
later period.
Cervical Deformities
Anterior neck contractures in the acute period are best pre­
vented by aggressive splinting and incisional releases and
grafting when indicated.37 When severe anterior neck
flexion contractures occur, early release and grafting are
necessary to allow for adequate airway access and to mini­
mize hypertrophic scarring as a result of excessive and per­
sistent tension (Fig. 50.17). Although secondary releases
and grafts are often necessary, permanent correction of
neck contractures with split-thickness skin grafts is fre­
quently possible when postoperative management includes
proper splinting and pressure (Fig. 50.17).37
INTERMEDIATE-PHASE RECONSTRUCTION
The intermediate phase of plastic surgical intervention con­
sists of scar modification designed to favorably influence the
healing process in the early months to years following acute
wound closure. The treatment options during this period
are multifaceted and are continuing to evolve. Significant
progress is being made with these types of interventions.
It is often recommended that definitive reconstructive
surgery be carried out after facial scars and skin grafts are
mature, soft, and supple. This process takes at least a year
and frequently takes many years to fully occur. The matura­
tion of facial burn scars takes much longer than is generally
appreciated by patients and reconstructive surgeons alike.
If scars are continuing to improve, it is usually best to allow
them to continue to mature. If scars are not maturing favor­
ably or are improving very slowly, well-timed and well-
conceived surgical intervention to favorably influence the
clinical progress can be beneficial. The scar maturation
process after facial burns is influenced by multiple factors.
The most important factor, other than the initial severity of
the injury, is the amount of tension present in the face and
acting on the scars. Surgical procedures to decrease tension
and to favorably alter the direction and contour of scars can
achieve significant improvement in scar maturation for
many years following a burn. Whenever healing burns
cross concave surfaces, there is a tendency for hypertrophic
scarring to develop. Examples in the face are the glabella,
the nasojugal groove, the crus helicis of the ear, and the
infracommissural folds. Relieving tension with Z-plasties
without scar excision is very effective in correcting hyper­
trophy (Figs. 50.10 and 50.13). Steroids, both topically,
intralesionally, and through ablative laser delivery, can be
helpful during this period but must be used sparingly to
avoid atrophy, telangiectasia, and erythema. In more severe
cases, tension can also be relieved by judiciously placed
releases and skin grafts (Fig. 50.18). The skin grafts can be
of either split-thickness or full-thickness variety. Split-
thickness skin grafts are best used where the location of the
graft will be inconspicuous or where large amounts of skin
are required to relieve the contractures. This is frequently
indicated when there are associated neck contractures.
Tension from the neck must be eliminated as much as
acute release of the oral commissures, taking care to avoid
extensive transverse releasing incisions in the aesthetic
units of the cheek. Overcorrection can easily result in mac­
rostomia. As soon as adequate oral opening is achieved for
feeding and airway access, definitive reconstruction is best
left for the postacute period.
Macrostomia is caused by rapid contraction of open
wounds or grafts in the cheek and perioral region, resulting
in eversion of the upper and lower lips and lateral move­
ment of the oral commissures (Fig. 50.16). The loss of an
effective oral sphincter causes drooling and desiccation of
Fig. 50.15  Microstomia during acute phase as a result of circumoral
contracture.
Fig. 50.16  Macrostomia secondary to contracture of open wounds and
grafts with lip eversion and loss of oral competence.

50  •  Reconstruction of the Head and Neck after Burns
545
time of his reconstruction (Fig. 50.13). The result would
also have been achieved more expeditiously, with fewer
operations and less morbidity.
LATE-PHASE RECONSTRUCTION
Late-phase reconstructive surgery takes place when scars
are mature and the patient’s deformities are essentially
stable. In some patients, scars will be soft and supple, but,
in others, even long-standing scars may be hypertrophic
and hyperemic many years following the burn injury
because of persisting tension or unfavorable orientation.
Scars can remain indurated and hyperemic for decades fol­
lowing a facial burn. Reorientation in this late phase with
Z-plasties and treatment with the PDL can result in
possible to allow for favorable maturation of facial burn
scars. The use of full-thickness skin grafts during the inter­
mediate phase of reconstruction should be rare and limited
to circumstances where definitive repair is being carried out
and there is little chance that further skin will be required
in that region. The PDL is a proven adjunctive therapy that
can decrease erythema and speed the rate of scar matura­
tion (Fig. 50.10). Fractional ablative laser treatment is a
paradigm-changing new intervention during this interme­
diate phase of recovery and reconstruction. It is an effective
way to enhance the remarkable ability of scars to regener­
ate and remodel themselves. Every scar has the right to live,
if it can be rehabilitated. The patient shown in Fig. 50.19
would certainly have achieved an even better result if vas­
cular and ablative fractional lasers were available at the
D
C
B
A
Fig. 50.17  (A,B) Extreme anterior cervical contracture secondary to burns of the entire chest
and neck. (C,D) At 23 years post-burn, after release and split-thickness skin grafting. Two
additional releases and grafts were required.

50  •  Reconstruction of the Head and Neck after Burns
546
D
C
B
A
Fig. 50.18  (A,B) Three-year-old male adopted
from an orphanage in China 18 months after a
severe house fire; he has pan-facial hypertro­
phic scars and contractures. (C) Pulsed dye
laser therapy was initiated, and preauricular
releases and split-thickness grafts were placed
bilaterally. (D) Continuous scarring across the
face was released lateral to each oral commis­
sure with full-thickness grafts. (e) Z-plasties
were performed to further release and flatten
the now greatly improved linear scars. (F,G)
Seven years later his rehabilitated scars are now
soft and supple and his facial appearance and
expression are acceptable. Fractionated abla­
tive laser therapy is continuing.
F
E
G

50  •  Reconstruction of the Head and Neck after Burns
547
D
C
B
A
Fig. 50.19  (A,B) Diffuse, hypertrophic scarring of cheeks, chin, and lips 8 months following
flame burn injury. (C,D) At 12 years post-burn after treatment with pressure therapy, steroid
injections, and multiple Z-plasties within the scar tissue. No scar tissue was excised.
remarkable improvement (Fig. 50.20). Fractional ablative
lasers have also been shown to benefit facial burn scars
many years after the injury. Scar excision can often be
avoided, with its concomitant increase in facial skin tension
and distortion of facial features.
Reconstruction of Specific Areas
of the Head and Neck
SCALP
Scalp alopecia is seen in as many as 25% of children who
suffer burn injuries of the head and neck.38 McCauley et al.
devised a system of classification for burn alopecia based
on the pattern and extent of deformity.39 They describe
the pattern of alopecia as uniform, segmental, patchy, or
total (types I–IV, respectively) and the extent of alopecia
as 25% of the scalp, 25–50%, 50–75%, or more than
75% (subtypes A–D, respectively). Their system serves as
both the means of description and an initial step in plan­
ning operative care. Previously described reconstruction
techniques include serial excision, rotational scalp flaps,
free hair follicle transplantation, and staged scalp tissue
expansion.40 Of patients with scalp injuries, associated
adjacent burn deformities were commonly found involv­
ing the ear, nose, and eyebrow.41 These injuries included
ear deformity (46%), nasal deformity (27%), and eyebrow

50  •  Reconstruction of the Head and Neck after Burns
548
C
B
A
Fig. 50.20  (A) A 16-year-old female 11 years following contact burn. Right cheek scar remains erythematous, indurated, and conspicuous. (B) Relax­
ation and reorientation of scar tissue with Z-plasty. (C) Five years later, after six treatments with the pulsed-dye laser.
deformity (46%). Therefore, in planning the surgical
reconstruction for pediatric scalp alopecia, it is helpful to
evaluate each patient for adjacent structure burn inju­
ries requiring reconstruction. Therefore, as one plans the
stages of tissue expansion procedures, one can plan con­
current reconstruction of associated burn injuries, some­
times taking advantage of the region of expected alopecia
excision.
EYEBROWS
Eyebrow reconstruction following complete loss is an
unsolved surgical problem. Composite grafts of hair-bearing
scalp from carefully selected sites in the retroauricular area
can satisfactorily transfer hair.42–44 Unfortunately the hair
is scalp hair that grows rapidly and is more projecting than
the tangential delicate hair of the normal eyebrow. For com­
plete eyebrow replacement, the technique of composite
grafting as described by Brent42 is most useful. For partial
eyebrow loss, micro- and mini-grafting of scalp hair can be
efficacious. Occasionally, borrowing composite grafts from
a contralateral unburned eyebrow is appropriate. Temporal
artery island flaps for eyelid or eyebrow reconstruction have
been used for many years.44–46 When used for eyebrow
reconstruction, they can be bushy and conspicuous and
should be used with caution, particularly when carrying
out unilateral eyebrow reconstruction.
Burn injuries of the scalp and upper face often result in
scars that distort the relative positions of the anterior hair­
line, eyebrows, and upper eyelid. Contour of the brow is
distorted with exaggerated elevation of the central peak.
Furthermore, scar contracture involving the upper eyelid
can result in cicatricial ectropion associated with efface­
ment of the supratarsal fold and corneal exposure. This
stereotypic set of upper facial deformity can be treated with
tissue expansion and antegrade forehead plasty.47 In this
technique, the scalp and forehead areas are tissue expanded.
The tissue expander is removed and the scalp aponeurosis
is advanced antegrade and loaded in redundant fashion
over the brows at the level of the arcus marginalis. Account­
ing for the fourth dimension of time and tissue recoil, the
brows are returned to a natural contour and improved posi­
tion (Figs. 50.21 and 50.22).
EYELIDS
Correction of upper and lower eyelid contractures in the
late reconstructive period can be a daunting and humbling
challenge. The periorbital region is made up of complex
three-dimensional anatomy and requires abundant skin to
appropriately drape the contours of both the upper and
lower eyelids. The slightest amount of excessive tension
from either the eyelid skin itself or contractures in adja­
cent regions such as the forehead or cheek can profoundly
and adversely affect eyelid function and appearance. Recon­
structive goals should be restoration of a normally shaped
palpebral fissure with appropriate orientation of upper and
lower eyelashes at rest and in the open position whenever
possible. This often requires extensive releasing incisions
extending medial to the medial canthus and lateral to the
lateral canthus in order to adequately release all the con­
tracted tissues. When ectropion is the result of a distant con­
tracture, the normal eyelid skin should always be returned
to its normal location. Incisions should not be made at the
eyelid margin, thereby separating the normal eyelid skin
from the ciliary line and replacing it with a graft. When
overlying scar is released, care must be taken to prevent
injury to the underlying orbicularis oculi muscle. This is
often rolled up and contracted and is rarely completely lost.
It must be unfolded to its normal flat broad shape and the

50  •  Reconstruction of the Head and Neck after Burns
549
D
C
B
A
Fig. 50.21  Tissue-expanded antegrade forehead plasty. This patient suffered flame
burn injury to the scalp and forehead. The hyperpigmented skin graft on the scalp
serves as a marker illustrating movement of the expanded scalp and forehead tissue.
Before the forehead plasty, the patient suffered from upper lid ectropion and expo­
sure of the left cornea. Note the overelevated eyebrows and effacement of the supra­
tarsal fold in the left upper eyelid (A). A tissue expander was placed (B). Antegrade
forehead plasty was performed, and forehead tissue was loaded in a redundant
fashion above the brows, with overcorrection to account for tissue recoil (C). At 1
month postoperation, note the extent of antegrade forehead movement, where the
hyperpigmented skin graft is observed to move from the scalp to mid-forehead
region. At 2 years following the operation, the forehead tissue has flattened out and
the eyebrows are restored to an improved position over the orbital rims. Note the
restoration of the supratarsal fold to the left upper eyelid and partial recoil of the
hyperpigmented skin graft (D).
Fig. 50.22  Diagram illustrating tissue movements of antegrade forehead plasty. Scalp tissue is maximally expanded, with consequent further exag­
geration of eyebrow elevation (left). Tissue expander is removed and the expanded scalp and forehead skin are advanced anteriorly, loaded in redun­
dant fashion over the eyebrows (middle). Over time, the redundant skin recoils, restoring the eyebrows to a more natural position (right).

50  •  Reconstruction of the Head and Neck after Burns
550
contractures, or releases in combination with full-thickness
skin grafting. Shortening of the nose with flaring or partial
loss of the alar rims is common in more severe facial burns.
Local release of the alar lobules with full-thickness skin
grafts is a useful technique for minor to moderate contrac­
tures. Complete excision of dorsal scar and graft in an aes­
thetic unit with a full-thickness skin graft is useful for more
severe shortening. When the lower third of the nose has
been amputated by the burn injury, inferiorly based, turn-
down flaps of the dorsal nasal tissues can provide satisfac­
tory lengthening and improved contour to the tip and alar
lobules. More severe cases of nasal deformity can be treated
by either dorsal turn-down flaps or other forms of total
nasal reconstruction. The dorsal turn-down flap usually
requires at least two stages but can be effective in even near
total nasal amputation (Fig. 50.23). Forehead flaps are
usually unavailable in patients who have sustained facial
burns severe enough to result in total nasal amputation.
Distant flaps can be used with either microsurgical transfer
using a radial forearm flap or using the frequently unburned
skin of the upper inner arm for a Tagliacozzi flap. If the face
is otherwise composed of burn scar and graft, these distant
flap nasal reconstructions have the disadvantage of appear­
ing to be “stuck on” and stand out in the midst of the oth­
erwise mosaic appearance of the face. When the face has
required resurfacing with flaps, a nasal reconstruction with
flap tissue is the best option (Fig. 50.26).
EAR DEFORMITIES
Improved care in the acute phase of burn injury has greatly
decreased the incidence of helical chondritis and the result­
ing associated deformities of crumpled or lost cartilage.
Minor ear deformities are often seen in patients with little
or no hair loss and can easily be camouflaged. Larger defects
can be treated by myriad local reconstructive tech­
niques.12,54–56 Subtotal ear amputation (Fig. 50.27) often
lends itself to reconstruction with a conchal transposition
flap and skin graft.57 Complete ear loss can be masked by
the use of a prosthesis. Fixation has been improved by the
use of osteo-integrated implants, but cost and color changes
remain problematic. Selected patients can be appropriate
candidates for total ear reconstruction using autologous
cartilage and soft-tissue coverage from either temporalis
fascia flaps or expanded local tissue.58 Alloplastic materials
should not be used in the reconstruction of post-burn ear
deformities due to an unacceptably high extrusion rate.59
Burn Neck Contractures
PREVENTION
Cervical contractures are a major problem in burns involv­
ing the chest, neck, and face. The anterior neck skin is thin,
and the neck is a highly mobile flexion area easily prone to
contracture. As noted previously, severe neck flexion neck
contractures in the acute phase often require early recon­
struction to aid in airway management. Neck contractures
should usually be dealt with prior to carrying out facial
burn reconstruction because the extrinsic contractile forces
from the neck cause facial deformities and can adversely
resulting defect resurfaced with abundant skin graft. Upper
eyelid resurfacing is best carried out with split-thickness skin
grafts from the best available donor site.44 Full-thickness skin
grafts in the upper eyelid usually transfer a thick dermal
component that compromises the delicate contour of the
supratarsal fold. Lower eyelid resurfacing may be done
with either split-thickness skin grafts or appropriate full-
thickness grafts when indicated. For minor contractures
of either upper or lower eyelids, the perfect reconstructive
material can be obtained from an unburned contralateral
upper eyelid. Medial canthal folds are best corrected with
Z-plasties when there is not a significant tissue deficiency.48
LOWER LIP AND CHIN
Deformities of the lower lip and chin usually occur in com­
bination. Contracting forces result in inferior dislocation
and eversion of the lower lip. In addition, there is compres­
sion of the soft-tissue contours of the chin prominence.
Release should be carried out at the vermillion scar junction
and the lower lip carefully unfurled, taking care to prevent
iatrogenic injury to the underlying orbicularis oris muscle.11
The resulting defect is then resurfaced with split-thickness
skin grafts or full-thickness grafts when indicated. Restora­
tion of chin contour can be improved with chin implants.
UPPER LIP DEFORMITIES
The upper lip is usually shortened and retruded by severe
facial burn injuries. Releasing and grafting should be
carried out, taking care not to overcorrect the deformity
and create a long upper lip.11 Full-thickness grafts from the
best available donor sites are usually the best option for
resurfacing. Reconstruction of the philtrum when indi­
cated is best performed by the technique of Schmid,49 using
a composite graft from the triangular fossa of the ear (Figs.
50.12 and 50.23).
ELECTRICAL BURNS OF THE ORAL COMMISSURE
Electrical burns of the oral commissure constitute a unique
and challenging burn injury to the head and neck. The
injury occurs in small children and usually results from
placing a live extension cord outlet in the mouth. Most of
these injuries are minor and all should be treated conserva­
tively in the acute period. If there has been minimal tissue
loss, reconstructive surgery using local flaps can improve
aesthetics.50–52 When there has been extensive full-thickness
loss of skin, vermillion, mucosa, and muscle, as shown in
Fig. 50.24, reconstruction requires complete release of the
contracture and replacement with adequate tissue of suit­
able quality.53 A ventral tongue flap provides abundant
mucosa and muscle and allows the lips and cheek to return
to their proper location and shape. Normal facial appear­
ance, mobility, and expression can be restored (Fig. 50.25).
NASAL DEFORMITIES
Burn injuries to the nose result in a broad range of deformi­
ties which can be focal and minor or can result in complete
nasal amputation. Minor deformities are best dealt with by
local scar revision, particularly with Z-plasties to relieve

50  •  Reconstruction of the Head and Neck after Burns
551
D
C
B
A
Fig. 50.23  (A) A 3-year-old female 10 months following severe facial burn with subtotal nasal amputation. (B) Intraoperative design of a nasal turn-
down flap. (C) Split-thickness skin grafting to nasal dorsum following turn-down flap and contracture releases. (D) At 16 years following turn-down
flap after second release and graft.
B
A
Fig. 50.24  (A) Severe oral commissure burns destroy vermillion, mucosa, muscle, and the skin of the lip and cheek. (B) Extensive contracture results
with thickening of the leading edge of the commissure.

B
A
Fig. 50.25  (A) A 16-year-old male following
devastating right oral commissure electrical
burn. Some 40% of lip circumference is lost
and the commissure is thick and immobile. (B)
Following tongue flap reconstruction, the com­
missure is thin and mobile and facial expression
is restored.
D
C
B
A
Fig. 50.26  (A,B) Pan-facial burn deformity in a 14-year-old male. Cervicopectoral flap resur­
facing was chosen for reconstruction of the cheeks and chin. (C,D) Nasal appearance follow­
ing reconstruction with a Tagliacozzi flap. A scalp flap was used to reconstruct the upper lip
and create a moustache.

50  •  Reconstruction of the Head and Neck after Burns
553
B
A
Fig. 50.27  (A) Typical post-burn pattern of peripheral helical loss. (B) Reconstructed ear following expansion with conchal transposition flap and skin
grafts.
D
C
B
A
Fig. 50.28  (A,B) Persistent anterior neck contracture following repeated inadequate split-
thickness skin grafting. (C,D) Release and anterior neck resurfacing was carried out with
bilateral shoulder flaps. Secondary midline Z-plasties improved the vertical release and
created an aesthetic neck contour. Chin augmentation improved the patient’s profile.

50  •  Reconstruction of the Head and Neck after Burns
554
has frequently been disfigured to some degree by the burn
injury.
DISTANT FLAP RECONSTRUCTION
Free flaps have been advocated for the treatment of anterior
neck contractures.60 Excellent outcomes can be obtained
but require microsurgical technique and create the possibil­
ity of complete flap loss. Another potential negative of free
flaps to the anterior neck is that they can be thick and bulky,
requiring multiple defattings and secondary revisions. The
free flap can also appear to be an island in the midst of a
broad area of healed graft and burn scar.
Complete references available online at

Further Reading
Davis JS. The relaxation of scar contractures by means of the z-, or reversed
z-type incision: stressing the use of scar infiltrated tissues. Ann Surg.
1931;94:871-884.
Donelan MB. Conchal transposition flap for postburn ear deformities. Plast
Reconstr Surg. 1989;83:641-654.
Janzekovic ZA. New concepts in the early excision and immediate grafting
of burns. J Trauma. 1970;10:1103-1108.
Longacre JJ, Berry HK, Basom CR, et al. The effects of Z plasty on hyper­
trophic scars. Scand J Plast Reconstr Surg. 1976;10:113-128.
Parrett BM, Donelan MB. Pulsed dye laser in burn scars: current concepts
and future directions. Burns. 2010;36:443-449.
Pisarski GP, Mertens D, Warden GD, et al. Tissue expander complications
in the pediatric burn patient. Plast Reconstr Surg. 1998;102:1008-1012.
affect the maturation of scars on the face. Preventive
methods to minimize cervical contractures during the acute
period as burn scars and grafted areas contract include
splinting, physical therapy, neck collars, and the use of a
three-quarter mattress to encourage neck extension.
RELEASE AND GRAFTING
The majority of anterior neck contractures can be satisfac­
torily treated with release and skin grafting. Extensive con­
tractures usually require split-thickness skin grafting. Focal
contractures can be appropriate for full-thickness grafting,
which will result in a superior outcome from both a func­
tional and an aesthetic standpoint. When neck contrac­
tures are extensive, the lower face and chest are usually a
combination of healed skin graft and scar. Split-thickness
skin grafts represent “like tissue” and will blend into the
area (Fig. 50.17).
LOCAL FLAP RECONSTRUCTION
When split-thickness skin grafting is unsuccessful because
of recurrent contracture or does not provide a satisfactory
aesthetic result, local flap reconstruction of the anterior
neck is an excellent technique if there is available tissue.
Flaps can either be unilateral or bilateral. When bilateral
flaps are available, midline Z-plasties secondarily can help
to improve neck contour (Fig. 50.28). Donor site morbidity
is usually minimal because the upper chest in these patients

554.e1
50  •  Reconstruction of the Head and Neck after Burns
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45. Conway H, Stark RB, Kavanaugh JD. Variations of the temporal flap.
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46. Monks GH. The restoration of a lower eyelid by a new method. J Burn
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47. Liao EC, Driscoll DN, Donelan MB. Restoration of brow position and
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48. Converse JM, McCarthy JG, Dobhovsky M, et al. Facial burns. In: Con­
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49. Schmid E. The use of auricular cartilage and composite grafts in
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51. Converse JM. Technique of elongation of the oral fissure and restora­
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52. Kazanjian VH, Roopenian A. The treatment of lip deformities result­
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53. Donelan MB. Reconstruction of electrical burns of the oral commissure
with a ventral tongue flap. Plast Reconstr Surg. 1995;95:1155-1164.
54. Antia NH, Buch VI. Chondrocutaneous advancement flap for the mar­
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56. Davis J. Aesthetic and Reconstructive Otoplasty. New York: Springer-
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57. Donelan MB. Conchal transposition flap for postburn ear deformities.
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555
Management of
Postburn Alopecia
RAJEEV B. AHUJA and PALLAB CHATTERJEE
51 
until a vascular surface is reached, followed by immediate
application of SSG; this may involve chiseling until reaching
the underlying diploë. Alternatively, after soft tissue débride­
ment multiple holes may be drilled in the outer cortex until
reaching bleeding diploë. The wound is dressed for a few
weeks until it is fully covered by healthy granulations and
then split-skin grafted. Alopecia reconstruction is under­
taken at 6–9 months after skin grafting. Immediate cover­
age with local flaps to obviate temporary alopecia is not
warranted except in small wounds with normal surround­
ing scalp. In type IV injuries, because there is loss of cal­
varium, the exposed dura requires coverage with local flaps
(for small defects) or a free flap.6,7 Historically SSG has been
applied directly to dura to cover defects in a strategy that is
risky but may be the only option in a resource-constrained
setting. The goal is to obtain an early wound closure and
restore aesthetics as a secondary procedure. These patients
may have more complex reconstructive needs other than
simple alopecia reconstruction. It is not unusual in develop­
ing countries to see patients requesting coverage of exposed
calvarium several months after the injury.
Surgical Correction of Alopecia
A whole gamut of reconstructive options is available to
correct postburn alopecia. The surgical options include
serial excision,8 scalp reduction, bipedicle flaps, modified
rotation flaps on a template design,9,10 other local flaps
(Juri flaps,11–13 Elliot flaps,14 or Orticochea flaps15,16), tissue
expansion,17 and hair grafting (micro- or minifollicles).18
It is intuitive and expedient to surgically excise the alope­
cia patch (whether from scar, skin graft, or a nonhealing
wound) and to close the defect directly or with a local flap.
In practice, this approach works for small areas of involve­
ment.19,20 Scalp tissue characteristics and underlying galea
make the skin less stretchable and therefore less amenable
to direct closure. Large areas of alopecia need to take into
account the size and location of the defect and the state of
remaining scalp before planning any procedure.
SERIAL EXCISION
Huang et al., in 1977, proposed a classification of the
extent of postburn alopecia to guide reconstruction.8 They
recommended that alopecia defects of less than 15% of
entire hair-bearing scalp were suitable for excision and
direct closure by two or three serial excisions.8 Seemingly
mathematical, it still is an empirical approach because such
calculations are not exact guides to the extent that other
stages of serial excision would be possible. For small to
Introduction
The importance of burn involvement of the scalp is due to
its very visible location on the body. Deformities of the scalp
may not always be easy to hide or camouflage, causing
great distress to the individual. In large surface area burns,
the scalp may be involved in 25–45% of cases.1,2 Superficial
burns of the scalp heal rapidly owing to the abundance of
dermal epithelial structures. However in cases of deep
dermal or full-thickness burns, the loss of dermal adnexa
manifests as alopecia once healing is complete. As with
anywhere else in the body, burns of the scalp that take more
than 2 weeks to heal spontaneously are at a risk of develop­
ing increased scarring with accompanying cicatricial
alopecia.3
Repeated split skin graft (SSG) harvesting from the scalp
may also result in scalp alopecia. Although scalp, because
of its thickness and high density of hair follicles, lends itself
to reharvesting of SSG, Brou et al. reported a 61% inci­
dence of alopecia if scalp was used to harvest skin grafts
and had also sustained burns.1 This is in contrast to only a
2.2% incidence of alopecia in patients without scalp burns
who underwent harvesting of SSG from scalp.4
Spectrum of Postburn Alopecia
Burns of the scalp may purely involve the soft tissue or may
also involve the underlying calvarium. While deeper partial-
thickness burns may cause alopecia, full-thickness burns
will inevitably lead to alopecia. A different dimension is
added to the clinical problem if the calvarium also sustains
burns, as is likely in an electrical injury. Optimal manage­
ment of such an extensive injury has been a topic of discus­
sion for a long time, with an evolving consensus for optimal
management.
CLASSIFICATION OF SCALP BURNS
Harrison offered a classification to guide the treatment
based on the depth of the injury:5
Type I: Total skin loss with intact pericranium
Type II: Total skin loss with involvement of pericranium
Type III: Total skin loss with involvement of outer table
Type IV: Total skin loss with involvement of both plates
of the skull.
Patients with type I injuries typically require SSG for wound
coverage in the acute stage, and later they present for alope­
cia reconstruction. Type II/III injuries require débridement