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

51  •  Management of Postburn Alopecia
557
design, if there is undue tension in flap closure it is better
to place a small SSG at the extreme end of the donor area
(Fig. 51.5D). Such small resultant defects generally are
covered by surrounding hair but can also be excised after
9–12 months.
Quite often the alopecia patch is a large area of exposed
calvarium. A dry, uninfected exposed calvarium need not
be chiseled to create a bleeding surface because it will be
well vascularized after a viable flap cover (Figs. 51.4 to
51.6). However if the outer table of calvarium is seques­
tered completely or partially, the complete outer table
should be excised before flap coverage (Fig. 51.2). All flaps
need to be provided suction drains for 3–4 days, even if the
calvarium outer table has not been excised.
Although now of historic interest only for large vertex
defects Orticochea introduced a four-flap technique15 that
was subsequently modified to a three-flap “banana peel”
technique in 1971.16 This was before the era of tissue
expansion and the rotation template design. Although
quite useful in the correction of moderately sized areas of
alopecia, these techniques cause extensive blood loss and
excessive scarring.
Juri et al.11–13 and later Elliot14 described a variety of
innovative monopedicled scalp flaps to cover segmental
areas of alopecia, especially to restore the frontal hairline
and for the occipital region. However only small-sized alo­
pecia segments that were located in favorable locations
base to facilitate movement at the cost of compromising the
blood supply. A paradigm change in geometry was proposed
by Ahuja in 1988,9 wherein a modified rotation flap was
used clinically in scalp defects, and then subsequently a
rotation flap template design was offered to logically explain
the movement.10 It became possible to primarily close mod­
erate to large scalp defects in a single stage without “back
cuts,” thus obviating the requirement for serial excisions or
tissue expansion in such cases. The technique has since
been adopted in an algorithmic approach to scalp defects.21
Rotation flaps planned on the template design can easily
close defects up to 6.5 cm in width, something that was
never possible using the classical rotation flap. Fig.
51.3(A–D) explains the execution of a rotation flap tem­
plate design for triangulated defects. Figs. 51.4 to 51.6 illus­
trate clinical execution of a single template flap, bilateral
template flaps, and two template flaps in an S-shaped design
to cover large alopecia areas in a single stage.
To improve the extensibility of the scalp skin it is often
useful to score the galea on the under surface of the flap
perpendicular to the flap movement. Raposio et al. state
that each galeatomy corresponds to a 40% reduction in
scalp closing tension and a tissue gain of approximately
1.67 mm.22 However this technique should always be a
reserved move to lessen tension and should never be con­
sidered as a means to excise larger areas by making com­
promises in the design. Occasionally, at the limits of the flap
A
B
C
D
E′
E
P
+
P
+
D
A
B
B
D
D
C
E
E
P
+
P
+
C
A
B
D
C
P
F
E
E′
B
A
B
D
C
P
E
+
A
Fig. 51.3  (A,B) Line drawings to show the execution of a rotation flap template design for triangulated defects. An isosceles defect is created, with a
less than 30-degree apical angle (A), and the pivot point (P) is selected so that CP is slightly longer than AB. With AP as the radius, an arc ADE is drawn.
CDE is the rotation flap template. The incision can continue along the arc of rotation beyond E if CP = AB or slightly less due to anatomical constraints.
This extension of incision beyond E is a design reserve and not a back-cut because it does not compromise the blood supply of the flap. The triangle
ABD is geometrically shown to be excised, but only a small piece needs trimming after flap movement, and this helps in accommodating tension in
large defects. (B) To design the arc ADE, strategic points can be marked using a thread, and these are joined in free hand. (C,D) Large defects may be
excised maximally as an equilateral triangle that can be bisected to have a template flap on either side of the defect or as an appropriate rhomboid
with flaps designed diagonally. Flap planning takes into account the available tissue, anatomic limitations, and minimal excision of normal tissue to
fit a suitable geometry.

51  •  Management of Postburn Alopecia
558
C
B
A
Fig. 51.4  (A) A 35-year-old patient with a 6 × 9.5-cm defect in the scalp following electrical injury. There is an alopecia patch with exposed calvarium.
(B) Showing triangulation of the defect and markings for a rotation flap template. Note the area ABD has been marked in the defect that will be excised
and not as a part of the triangulation. (C) Intraoperative picture showing primary closure of the large defect and complete correction of alopecia.
E
D
C
B
A
Fig. 51.5  (A) A 65-year-old patient with a long-standing defect on the scalp measuring 7 × 6 cm. Bilateral rotation flaps have been marked after pro­
posed triangulation of the defect. (B) Left lateral view to show the extent of flap marking. (C) Left lateral view at the 10th postoperative day. The flaps
were rotated over the exposed bone without chiseling of the outer cortex (bone was dry and noninfected). (D) Right lateral view at 6 weeks showing
well-healed incisions. A small skin graft was placed to ease some tension because the defect was extremely large and closure was leading to some
tension. (E) Showing primary healing of the flaps at midline with complete resurfacing and correction of alopecia.

51  •  Management of Postburn Alopecia
559
a wait of several months, the second expander can be placed
strategically to complete the reconstruction.
Tissue expansion generates a source of local skin that
may be used as an advancement or a rotation template flap,
and it permits direct closure of the donor site.32 After proper
planning of the desired flap movement following expansion,
a suitably sized and shaped expander is chosen by measur­
ing the dimensions of the recipient area. Although the lit­
erature is replete with several mathematical models in
deciding the most appropriate size and shape of the
expander,33 the selection can be easily made clinically by
recipient site requirements and the donor flap available for
expansion. As a rule of thumb, the available donor skin
before expansion should never be less than the recipient
could be corrected. Feldman increased coverage of patients
with significant burn alopecia by combining horizontal
scalp reduction with the Juri flap.23
TISSUE EXPANSION
Although the concept of soft tissue expansion using inflat­
able subcutaneous balloons was introduced in 1956 by
Neuman,24 Radovan is credited with its rediscovery and
making it popular for clinical use in the 1980s.25
Briefly tissue expansion is the result of a constant
mechanical stress load that leads to tissue regeneration.26
The epidermis becomes thicker, with most of the mitotic
activity occurring in the stratum spongiosum. The dermis
thins out, with the greatest amount of thinning occurring
in the papillary dermis.27,28 The activation of a number of
growth factors for epithelial and connective tissue growth
may be responsible for this true tissue regeneration and not
merely stretching of overlying tissue.26
McCauley et al. described the effective use of tissue
expansion in the treatment of post-burn alopecia of the
scalp in 1990.17 This was at a time when the rotation flap
template design was just introduced, so their classification
of post-burn alopecia based on both pattern and extent of
scalp involvement to guide treatment strategy included the
option of tissue expansion only.17 With our current
approach, we propose a simplified treatment strategy to
manage scalp alopecia by modifying the recommendation
of McCauley et al. (Table 51.1). Despite the fact that tissue
expansion has complication rates ranging from 15% to
20%29–31 in scalp defects, it remains the best option and is
the only option for defects of between 20% and 75% of hair-
bearing scalp area. For defects larger than 75%, the only
possibility is camouflage with a hairpiece.
Use of tissue expanders massively improved the outcomes
for reconstruction of large alopecia patches. Losses between
50% and 75% will require placement of two expanders
simultaneously or sequentially. Sequential expansion aims
to achieve partial reconstruction from one expander; after
B
A
Fig. 51.6  (A) A 5.5 × 6.5-cm circular defect on the vertex of the scalp following electrical injury. Large rotation template flaps have been designed
diagonally with proposed freshening of the defect as a rhomboid. (B) Immediate postoperative result showing complete closure of the scalp defect
(as well as correction of alopecia).
Table 51.1  Treatment Strategy Recommended for
Alopecia Management
Alopecia Segment
Treatment Strategy
SINGLE
<20% of the hair-
bearing scalp
Rotation flap template
20–50% of the
hair-bearing scalp
Single tissue expander
50–75% of the
hair-bearing scalp
Two expanders placed simultaneously
or sequential expansions
>75% of the hair-
bearing scalp
Use hair piece (wig)
TWO OR MORE
If amendable to tissue
expansion
One/two expanders placed
simultaneously or sequentially
Not amendable to tissue
expansion
Use hair piece (wig)
Modified from McCauley RL, Oliphant JR, Robson MC. Tissue expansion in the
correction of burn alopecia: classification and methods of correction. Ann Plast
Surg. 1990;25:103–115.)

51  •  Management of Postburn Alopecia
560
patient discomfort or blanching of the overlying skin, after
which a few milliliters of fluid are withdrawn. The width of
the expanded skin over the dome should at least equal two
times the recipient area plus 30% (to allow for skin retrac­
tion). Hallock described the utility and safety of expander
overexpansion very early in the evolving concept,34 and
nowadays overexpansion beyond the manufacturer’s
volume recommendations are routine. After complete
expansion, the expander is removed through an incision
that traces the proposed flap. Optimal mobilization of the
flaps is accomplished by releasing the periphery of the
capsule under the expanded tissue. Capsular scoring inci­
sions should include galea, and they are made perpendicu­
lar to the direction of flap movement.32
Tissue expansion is painful and socially incapacitating for
the patient during the expansion phase. In addition, it has
a substantial complication rate from infection, exposure, or
extrusion, ranging from 15% to 20%, which may require
premature removal of the expander and abandonment of
area for one-stage expansion. The minimum expander base
should be a little more than the recipient area, although the
largest expander possible should be selected. Expander
volume is less of a clinical guide because overexpansion is
always possible. Figs. 51.7 and 51.8 are illustrative clinical
examples of tissue expansion for alopecia correction.
The inextensible skin of the scalp makes it a bit tougher
to place the implant, and it is essential that an adequate
pocket is created below the galea. It is hazardous to place
tissue expanders above the galea in the subcutaneous tissue.
A short incision parallel to the defect and about a centime­
ter into healthy skin is used for implant placement. The port
of the expander is located at a short distance through
another narrow pocket. Magnasite expanders are conve­
nient but more expensive. They have an in-built port that
can be detected under the skin with a magnet. The expan­
sion is initiated 10–14 days after the insertion. Full expan­
sion is achieved over 3–4 months, by weekly injections, as
an outpatient procedure. The end point of injection is slight
C
B
A
Fig. 51.7  A 21-year-old girl with a 10 × 10 cm alopecia patch on the vertex following thermal burns. A 500-mL crescent tissue expander was inserted
through an incision just parallel to the edge of the defect. (A) Showing full expansion achieved in 3 months. (B) Lateral view to show the posterior
extent of expansion. (C) The alopecia patch was excised and the expanded flap advanced into the defect. Postoperative view at 10 days.
B
A
Fig. 51.8  (A) A laterally situated, extremely large alopecia patch on a 12-year-old boy following thermal burns. A single 800-mL, crescent-shaped
expander was inserted and inflated over a 4-month period. The incision line gave way slightly after 3.5 months, but the expansion continued with an
exposed implant for the next 10 days. (B) Five-year postoperative picture showing complete restoration of hair on the scalp by tissue expansion.

51  •  Management of Postburn Alopecia
561
it is hypothesized that the metabolic demand is very low,
thus allowing them to survive in scar tissue. This affords an
important technique to provide coverage to irregular
patches or to provide refinements to misaligned hairlines
following various flap coverage techniques.
Conflict of Interest
None of the authors has any conflict of interest to report.
Complete references available online at

the procedure.30,31 Occasionally it may be possible to con­
tinue expansion with an exposed implant but only for a
few days because each injection to inflate the implant also
causes the skin gap to widen.
HAIR FOLLICLE GRAFTING
More recently Barrera has shown successful use of micro-
and minigrafts in the correction of large alopecia segments
in 32 burn patients.18 Because of the small size of micro­
grafts (1–2 hair follicles) and minigrafts (3–4 hair follicles),

561.e1
51  •  Management of Postburn Alopecia
References
1. Brou JA, Vu T, McCauley RL, et al. The scalp as a donor site: revisited.
J Trauma. 1990;30(5):579-581.
2. Burns BF, McCauley RL, Murphy FL, et al. Reconstructive manage­
ment of patients with 80% TBSA burns. Burns. 1993;19(5):429-433.
3. Deitch EA, Wheelahan TM, Rose MP, et al. Hypertrophic burn scars:
analysis of variables. J Trauma. 1983;23(10):895-898.
4. Barret JP, Dziewulski P, Wolf SE, et al. Outcome of scalp donor sites in
450 consecutive pediatric burn patients. Plast Reconstr Surg. 1999;103:
1139-1142.
5. Harrison SH. Exposure of the skull from burns. Br J Plast Surg.
1952;4:279-292.
6. Spies M, McCauley RL, Mudge BP, et al. Management of acute cal­
varial burns in children. J Trauma. 2003;54(4):765-769.
7. Worthen EF. Regenerations of the skull following a deep electrical
burn. Plast Reconstr Surg. 1971;48:1-4.
8. Huang TT, Larson DL, Lewis SR. Burn alopecia. Plast Reconstr Surg.
1977;60:763-767.
9. Ahuja RB. Geometric considerations in the design of rotation flaps in the
scalp and forehead region. Plast Reconstr Surg. 1988;81(6):900-906.
10. Ahuja RB. Mechanics of movement for rotation flaps and a local flap
template. Plast Reconstr Surg. 1989;83(4):733-737.
11. Juri J. Use of parieto-occipital flaps in the surgical treatment of bald­
ness. Plast Reconstr Surg. 1975;55:456.
12. Juri J, Juri C, Arufe HN. Use of rotation scalp flaps for the treatment
of occipital baldness. Br J Plast Surg. 1978;61:23.
13. Juri J, Juri C. Aesthetic aspects of reconstructive scalp surgery. Clin
Plast Surg. 1981;8:243-254.
14. Elliott RA Jr. Lateral scalp flaps for instant results in male pattern
baldness. Plast Reconstr Surg. 1977;60(5):699-703.
15. Orticochea M. Four flap scalp reconstruction technique. Br J Plast
Surg. 1967;20:159-171.
16. Orticochea M. New three flap scalp reconstruction technique. Br J
Plast Surg. 1971;24:184-188.
17. McCauley RL, Oliphant JR, Robson MC. Tissue expansion in the cor­
rection of burn alopecia: classification and methods of correction.
Ann Plast Surg. 1990;25:103-115.
18. Barrera A. The use of micrografts and minigrafts for the treatment of
burn alopecia. Plast Reconstr Surg. 1999;103:581-589.
19. Paletta C. Surgical management of the burned scalp. Clin Plast Surg.
1982;9:167.
20. Vallis CP. Surgical management of cicatricial alopecia of the scalp.
Clin Plast Surg. 1982;9:179.
21. Leedy JE, Janis JE, Rohrich RJ. Reconstruction of acquired scalp defects:
an algorithmic approach. Plast Reconstr Surg. 2005;116(4):54e-e72.
22. Raposio E, Santi P, Nordström RE. Effects of galeotomies on scalp flaps.
Ann Plast Surg. 1998;41(1):17-21.
23. Feldman G. Post-thermal burn alopecia and its treatment using exten­
sive horizontal reduction in combination with a Juri flap. Plast Recon­
str Surg. 1994;93:1268-1273.
24. Neumann CG. The expansion of an area of skin by progressive disten­
tion of a subcutaneous balloon. Plast Reconstr Surg. 1957;19:124.
25. Radovan C. Tissue expansion in soft tissue reconstruction. Plast Recon­
str Surg. 1984;74:491.
26. Takei T, Mills I, Arai K, et al. Molecular basis for tissue expansion: clini­
cal implications for surgeons. Plast Reconstr Surg. 1998;102:247-258.
27. Pasyk KA, Argenta LC, Hasseh C. Quantitative analysis of the thick­
ness of human skin and subcutaneous tissue following controlled
expansion with a silicone implant. Plast Reconstr Surg. 1988;81:516.
28. Pasyk KA, Argenta LC, Austed ED. Histopathology of human expanded
tissue. Clin Plast Surg. 1987;14:435-445.
29. Garavito E, McCauley RL, Verbitzky J. Reconstruction of the burned
scalp. In: McCauley RL, ed. Functional and Aesthetic Reconstruction of
Burned Patients. Boca Raton, FL: Taylor and Francis; 2005:217-226.
30. Neale HW, High RM, Billmire DA, et al. Complications of controlled
tissue expansion in the pediatric burn patient. Plast Reconstr Surg.
1988;82:840-845.
31. LoGiudice J, Gosain AK. Pediatric tissue expansion: indications and
complications. J Craniofac Surg. 2003;14(6):866-872.
32. Zide BM, Karp NS. Maximizing gain from rectangular tissue expand­
ers. Plast Reconstr Surg. 1992;90(3):500-504.
33. Agrawal K, Agrawal S. Tissue regeneration during tissue expansion
and choosing an expander. Indian J Plast Surg. 2012;45(1):7-15.
34. Hallock GG. Safety of clinical overinflation of tissue expanders. Plast
Reconstr Surg. 1995;96(1):153-157.

562
Trunk Deformity Reconstruction
PETER DZIEWULSKI and JORGE LEON VILLAPALOS
52 
Any deep damage to the tissues of the trunk at those
levels may cause simultaneously deep soft tissue loss,
damage that affects body parts such as the breast, or a burn
scar contracture either primarily or secondarily by involve­
ment of those important joint mobile areas.
Recently published International Society for Burn Inju­
ries (ISBI) practice guidelines for burn care1 supported by
best evidence and research established recommendations
for optimum acute management of the burn wound.
Those most relevant to successful reconstruction of the
trunk are:
■ Thermally injured patients should be evaluated using
a systematic approach that first seeks to identify the
greatest threat to life.
■ Evaluation of burns should estimate TBSA utilizing a
standardized method and delineate characteristics that
require immediate attention from a designated burn
center.
■ Appropriate resuscitation should be initiated promptly
and tailored based on patient parameters to avoid over-
and underresuscitation.
■ Adult patients with burns greater than 20% TBSA and
pediatric patients with burns greater than 10% TBSA
should be formally resuscitated with salt-containing
fluids; requirements should be based on body weight
and percentage burn.
■ Abdominal escharotomy should be performed when
circumferential or near circumferential eschar is asso­
ciated with evidence of intraabdominal hypertension
(IAH) or signs of abdominal compartment syndrome
(ACS).
■ Early surgery for small to moderate-sized deep burns
(less than approximately 20% TBSA) speeds recovery,
might improve outcome, and is cost-effective.
■ Tangential excision is the standard method of burn
wound excision. Fascial excision may be indicated in
very deep burns and high-voltage electrical conduc­
tion injuries.
■ Burn wound excision and grafting can be undertaken
without undue blood loss by using some or all the fol­
lowing: subcutaneous infiltration of burn wound and
donor site or topical application of epinephrine solu­
tions, or both; tourniquets for limb surgery; fascial-
type excision using electrocautery; other topical
hemostatic agents such as thrombin and fibrinogen;
prevention of hypothermia; compression dressings;
limb elevation; and staged burn excision.
■ After excision or débridement of the deep burn wound,
it is essential that the wound is covered with autograft
skin or an appropriate skin substitute.
■ Deep dermal burns (wounds that heal in >3 weeks)
require aggressive and monitored scar prevention
Introduction
Burn injuries to the trunk may have functional and cos­
metic consequences.
The torso, abdomen, and back connect anatomically
with the shoulder girdle and the axilla laterally, with the
neck superiorly, and with the groin tissue and the lower
limbs inferiorly. This means that burn injuries to the trunk
may cause damage primarily to three areas:
a. Damage to soft tissue layers including skin, subcuta­
neous tissue, fascia, muscle, and internal organs
b. Damage to the trunk boundaries, causing potential
contracture and functional deficit to the neck, axillae,
and groin areas
c. Damage to specialized body parts within the trunk,
specifically the breast.
Even though the initial acute management of any extensive
burn injury is relatively universal and subjected to well-
recognized protocols of trauma resuscitation, the exten­
sive total body surface area (TBSA) that can potentially be
involved when the whole of the trunk is injured—up to 36%
TBSA—may have devastating consequences: skin, muscle
and visceral damage, breast and nipple-areolar destruc­
tion, and potential development of life-changing burn scar
contractures in the vicinity of the neck, axillae, and groin
areas.
It is then easy to understand the potential complexity of
the reconstructive challenges that trunk tissue damage may
require. Superficial damage may leave minimal functional
deficit and barely noticeable cosmetic embarrassment that
may not need difficult or lengthy reconstruction, but deeper
damage may require the use of multiple reconstructive pro­
cedures of ascending order of complexity in several sub­
zones of the trunk: excision of scars, use of split-skin grafts
(SSG) with or without the support of dermal matrices, full-
thickness grafts, tissue rearrangement procedures based on
the z-plasty principle, tissue expansion surgery, and local,
regional, distant, or free flaps.
Complex reconstruction will require maximum complic­
ity and collaboration of the burn patient with the multidis­
ciplinary team, specifically with the scar management and
physical rehabilitation teams to ensure restoration of
anatomy and return of the patient to his normal life and
society environment.
The impact of appropriate acute management in sub­
sequent reconstruction cannot be understated. The
principles of prompt trauma management, judicious resus­
citation, early débridement with a dermal preservation
approach and soft tissue cover, and a strong rehabilitation
approach impact greatly on the subsequent approach to
reconstruction.

52  •  Trunk Deformity Reconstruction
563
therapies augmented with appropriate pain relief and
combined with early positioning regimens and physio­
therapy for joint mobilization to prevent hypertrophic
scarring and joint contractures.
■ All extensive hypertrophic burn scars should receive
pressure therapy with silicone therapy as the first line
of treatment. Restraint should be applied in opting for
the surgical modality before scar maturation unless
the scar is functionally limiting because of a develop­
ing contracture.
Therefore, four clear burn care phases are ultimately
considered:
■ Initial evaluation and resuscitation
■ Wound excision and initial skin cover
■ Definitive skin closure and rehabilitation
■ Reconstruction and reintegration to society.
Appropriate implementation of these recommendations in
a staged fashion ensures the survivability of the burned
patient, but also of the quality of the reconstruction.2
Reconstruction of the Trunk Soft
Tissue Layers
Even though the late effects of burn injury in the tissue
layers of the abdomen, torso, and back may be less prob­
lematic than in other anatomical areas, the consequences
of abnormal scarring and tissue derangement may still
cause functional problems such as pain, itching, limitations
in activities of daily living, and cosmetic embarrassment.
The torso protects the thoracic cavity and upper abdomen
and assists in the process of respiration. The abdominal
wall, with its multilayered structure, protects the abdomi­
nal viscera and assists in position, breathing, and visceral
function.3 The clinical consequences of the burn injury to
this part of the trunk in an acute setting may be relatively
mild or utterly devastating if full-thickness soft tissue loss
occurs.
ACUTE RECONSTRUCTIVE MANAGEMENT OF
THE TRUNK SOFT TISSUE LAYERS
In the acute setting, superficial skin loss may be treated in
a relatively conservative fashion with standard dressings or
with the application of dermo-protective matrices such as
Biobrane or Suprathel. A recent Cochrane review4 aiming
to assess the effects of burn wound dressings on partial-
thickness burns suggested that dressing selection should be
based on their effects on healing but that other parameters
such as ease of application and removal, dressing change
requirements, cost, and patient comfort should also be con­
sidered. Their conclusion was that, following analysis of a
total of 30 randomized controlled trials (RCTs), traditional
dressings containing silver sulfadiazine (SSD) were consis­
tently associated with poorer healing outcomes than were
biosynthetic (skin substitute) dressings, silver-containing
dressings, and silicon-coated dressings.
Dermo-protective skin substitutes are characteristically
used to aid reepithelialization in the acute management of
partial-thickness burns until full healing occurs.5 Biobrane
is a bi-layered semi-permeable biosynthetic wound dressing
with an outer silicone layer, a nylon-net in the middle layer,
and an inner porcine collagen type I layer. Suprathel is a
synthetic wound dressing consisting of a copolymer-foil of
D,L-laktidtrimethylencarbonate and e-caprolakton.
A study comparing both dressings showed satisfying
comparable clinical results in the use of both types of pros­
thetic material.6
In the acute setting, extensive burns and injudicious fluid
resuscitation may lead to ACS, defined by the presence of
organ dysfunction because of increased abdominal pres­
sure or IAH.
Patients with severe burns are at risk for developing ACS
due to the large volume of resuscitation fluid that is infused,
abdominal wall compliance, and capillary leakage due to
increased permeability.7 This subsequently reduces blood
flow to the abdominal viscera and may lead to bowel ische­
mia, multiorgan failure, and death if not properly addressed.8
When decompressive laparotomy is necessary, the com­
plications due to an open abdomen add to those due to the
extent of the burn.9
Decompressive laparotomy may help in the survival of
burn patients, but the mortality can still be up to 50% and
introduce a serious physiological and reconstructive
challenge.10
Recently updated consensus definitions and clinical prac­
tice guidelines from the World Society of the Abdominal
Compartment Syndrome state that decompressive laparot­
omy is the standard surgical method to treat severe IAH/
ACS despite considerable potential mortality even after
decompression.11 Taking into consideration that the longer
the abdomen remains open, the greater the potential com­
plications, this forum of experts established several recom­
mendations significant for the reconstructive strategies of
the open abdomen following decompressive laparotomy for
IAH:
■ Prevent visceral adhesions, loss of soft tissue coverage,
lateralization of the abdominal musculature and its
fascia, malnutrition, and enteric fistulae.
■ Aim to achieve same-hospital-stay closure of the open
abdomen.
■ Consider the use of negative pressure wound therapy
(NPWT) for temporary abdominal closure after decom­
pressive laparotomy.
■ Consider component separation to facilitate early
fascial closure of the open abdomen.
■ Bioprosthetic meshes should not be routinely used in
the early closure of the open abdomen compared to
alternative strategies.
Several temporizing options using external devices have
been suggested to aid the closure of the abdomen following
decompressive laparotomy.12,13
The use of techniques that apply to the closure of large
hernia defects can be used to close large decompressive
laparotomy defects as well. The technique of component
separation is not contraindicated in the burn patient, even
in large burns with a deep pattern of injury.14
In this series, fascial access was obtained by raising
burned skin flaps at the level of the costal margin from the
anterior superior iliac spine inferiorly to the ribs superiorly.
These skin flaps were then excised to facilitate grafting of

52  •  Trunk Deformity Reconstruction
564
Tissue engineering options have expanded the pos­
sibilities of reconstruction for the burned trunk. The
ideal tissue engineering device needs to be rapidly avail­
able, autologous, site-matched, possess reliable wound
adherence and express minimal donor site morbidity, be
clinically manageable, improve the quality of scar, and be
affordable.18
Some of the techniques currently available involve the
use of dermal scaffolds such as Integra (Integra Life Sci­
ences Corporation, Plainsboro, NJ), Matriderm (MedSkin
Solutions, Dr. Suwelack, Germany), or Pelnac (Gunze Ltd.,
Japan) and the use of confluent and nonconfluent keratino­
cyte culture techniques such as Recell (Avita Medical, UK).
A deeper pattern of injury may require the use of more
complex steps of the reconstructive ladder. The chest and
abdomen, due to their anatomic proximity, are injured
together frequently in flame, scald, or electrical injuries. In
these situations, in which deep visceral structures may
become exposed, the use of large flaps such as the omentum,
latissimus dorsi, rectus abdominis, or deltopectoral may be
indicated.19–22
Fig. 52.1  Allograft cover of the back of an 80% total body surface area
(TBSA) burn.
Fig. 52.2  Acute Meek autografting covering back skin following 80%
total body surface area (TBSA) burn.
Fig.
52.3  Healing
of
trunk
burn
wounds
following
Meek
autografting.
the abdominal wall. The fascial release that facilitated
abdominal closure was made, in standard fashion, lateral to
the rectus sheath through the aponeurosis of the external
oblique muscle.
The acute reconstruction of trunk soft tissue loss related
to the direct effects of the burn injury follows the steps
applied to other parts of the body. Following stabilization,
resuscitation, and débridement, acute soft tissue cover
methods are decided based on the depth and extent of the
burn, the availability of suitable donor sites, and the micro­
biology and nutritional status of the patient.
Extensive burns may destroy the skin layers and their
blood supply to the extreme of making impossible self-
healing and regeneration following a conservative approach.
There are occasions in which the paucity of autologous skin
or concerns regarding the infection control status of the
recipient site recommends the use of temporizing tech­
niques such as xenografts or allografts (Fig. 52.1) until
definitive skin cover is achieved. Characteristically split-
thickness autografting has been the standard method to
address soft tissue loss during this period. A recent expert
panel white paper on the surgical management of the burn
wound and use of skin substitutes15 clearly establishes the
differences between skin substitute—a commercial bioma­
terial, engineered tissue, or combination of materials and
cells or tissues that can be substituted for skin autograft or
allograft in a clinical procedure—from a skin replacement,
which is a tissue or graft that permanently replaces lost skin
with healthy skin.
Skin grafts are usually meshed to a desired level of expan­
sion; split-thickness grafts are frequently used if the wound
bed exhibits appropriate vascularity and the donor skin is
available in appropriate quantities. As every burns surgeon
is aware, expansion of the SSG is associated with small
areas of the wound healing by secondary intention and a
poorer scar outcome.
In cases of extreme paucity of donor sites, the use of
micrografting (Meek) techniques with or without dermal
regeneration templates may represent a suitable form
of reconstruction in the acute period16,17 (Figs. 52.2
and 52.3).

52  •  Trunk Deformity Reconstruction
565
Fig. 52.4  Hyperpigmented scar on the left side of the chest following
electrical injury.
Fig. 52.5  Hypertrophic scar on the abdomen following flame burn.
Fig. 52.6  Extensive mesh pattern on the back following grafting.
Fig. 52.7  Unstable scar in the center of the chest after flame burns
treated conservatively.
LATE RECONSTRUCTIVE MANAGEMENT OF THE
TRUNK SOFT TISSUE LAYERS
The late reconstruction of the soft tissue layers addresses
the impact of abnormal scarring on the cosmetic and func­
tional integrity of the trunk. Reconstruction due to scars in
the boundaries of the trunk that alter the functionality of
the neck, axillae, and groin area and reconstruction of spe­
cific body parts such as the breast will be addressed later in
the chapter.
The reconstruction of the soft tissue layers of the trunk
is simultaneous with recognized protocols of scar manage­
ment such as massaging, moisturizing, and sun-protecting
the scar; application of compression garments; and physical
therapy. These are beyond the scope of this chapter and will
not be addressed here.
The wise use of recognized surgical techniques in the
acute phase of scar maturation diminishes the complexity
of reconstructive needs. These include the use of darts in
escharotomies when crossing joints, placing the seams of
the skin grafts following skin tension lines, using sheet
grafts when possible, placing grafts transversely over joints,
applying early pressure therapy, and implementing an early
ambulation and exercise regimen.23
The skin layers of the trunk may be affected by abnormal
pigmentation, hypervascularity, hypertrophic and keloid
scars, texture abnormalities in both the reconstructed and
the donor site (Figs. 52.4 to 52.6), by the presence of con­
tractures that can be well defined or diffuse, and by the
presence of unstable tissue (Figs. 52.7 and 52.8) with a
tendency to breaking down.24 The approach to the manage­
ment of these abnormalities is to always prioritize function
over cosmesis, have a realistic approach to reconstruction,
and appropriately time any surgical procedure to avoid
interfering with the maturation of scars.
Selective scar resection and direct closure of the subse­
quent defect may be used in the trunk providing that suffi­
cient skin laxity and tension-free closure exists.25
The skin of the abdomen, with its natural laxity and the
possibility of redundant tissue, allows the use of recognized
techniques of reconstruction such as abdominoplasty and
liposuction to become valid options of soft tissue cover after
scar excision.26,27

52  •  Trunk Deformity Reconstruction
566
Fig. 52.8  Unstable scar on the center of the chest after flame burns
treated conservatively. Close-up.
The use of full-thickness grafts or dermal regeneration
templates constitutes the next stage in the resurfacing and
reconstruction of elective scar revision surgery. They
provide the patient with a reconstruction of improved pli­
ability28,29 that has been proved to withstand even the
natural skin tension resulting from a pregnancy.30
In cases of cosmetically disfiguring scars that exhibit lack
of pliability, the use of tissue expansion techniques either
on their own or combined with flap techniques31 in the
trunk offers the possibility of providing reconstruction with
autologous skin following a two-stage procedure. The first
stage introduces the expanders in a pocket near the scar.
Once appropriate expansion has been achieved, including
overexpansion,32 the scar is excised and the subsequent
defect covered with a flap of expanded skin usually using a
technique of advancement, transposition, or rotation. It
has been postulated that the insertion of the largest possible
expander, a rectangular shape, and the method of advance­
ment provides the largest amount of expanded tissue avail­
able.33 Traditional tissue expanders are connected to a
tubing system and a port that is placed usually over a bony
prominence distant to the implant itself. Recently the use of
osmotic tissue expanders has introduced a new option for
reconstruction and resurfacing of defects after scar excision
by avoiding the need for repeated injections. This is espe­
cially useful when dealing with pediatric patients.34
The insertion of osmotic tissue expanders requires careful
dissection of an appropriately sized pocket to place the pros­
thesis. This is an important issue in the learning curve of
the early user of this technique because the osmotic tissue
expander tends to grow relatively quickly during the first 2
weeks of insertion.
Insertion of the expander too close to the scar to be
reconstructed will increase the potential for implant extru­
sion. A sequence for the insertion of osmotic tissue expand­
ers can be seen in Figs. 52.9 to 52.14. Following insertion,
our protocol is to review the patient weekly for the first
month post insertion to review the wound and assess for
breakdown or dehiscence. We then follow the patient
monthly until the second stage of reconstruction. This
stage includes expander removal, scar excision, and recon­
struction of the defect usually by advancement (Figs. 52.15
to 52.18).
Fig. 52.9  Insertion of osmotic tissue expanders for reconstruction of
chest burn scarring: skin markings.
Fig. 52.10  Insertion of osmotic tissue expanders for reconstruction of
chest burn scarring: pocket dissection.
Fig. 52.11  Insertion of osmotic tissue expanders for reconstruction of
chest burn scarring: pocket dissection.
Reconstruction of the
Trunk Boundaries
Primary reconstruction of the neck, axillae, and groin areas
will be described in a different chapter. Scarring in the trunk

52  •  Trunk Deformity Reconstruction
567
Fig. 52.12  Insertion of osmotic tissue expanders for reconstruction of
chest burn scarring: insertion of expander into pocket.
Fig. 52.13  Insertion of osmotic tissue expanders for reconstruction of
chest burn scarring: insertion of expander into pocket.
Fig. 52.14  Insertion of osmotic tissue expanders for reconstruction of
chest burn scarring: insertion of expander into pocket.
Fig. 52.15  Expanders after 2 months and prior to removal and
reconstruction.
Fig. 52.16  Removal of expanders.
Fig. 52.17  Scar excision.
bordering these areas may cause contractures requiring
reconstruction. The management of these involve the use
of known principles of reconstruction, such as tissue rear­
rangement techniques like z-plasties or the introduction of
additional tissue with skin grafts, dermal templates, or flaps.
The following clinical case illustrates these techniques.
A 21-year-old who suffered 40% TBSA burns 4 years ago
presented to our office complaining of tightness in the
right flank, right axilla, and neck due to burns in the torso
(Fig. 52.19).

52  •  Trunk Deformity Reconstruction
568
Fig. 52.18  Expanded skin flap advancement, reconstruction and
closure.
Fig. 52.19  Extensive chest scarring in a 40% total body surface area
(TBSA) burned patient.
Fig. 52.20  Z-plasty designed along right flank linear burn scar
contracture.
Fig. 52.21  Z-plasty designed in right axillary linear burn scar
contracture.
The scar contracture in the neck was addressed with the
use of a dermal substitute (Matriderm) and a thin skin graft.
An area of tightness in the right flank was treated with a
long releasing z-plasty (Fig. 52.20). The tightness in the
right axilla was addressed with a standard z-plasty for the
anterior axillary fold and a five-flap plasty for the posterior
shoulder area (Figs. 52.21 and 52.22).
The symptoms, once healing of the wounds was com­
pleted, were largely resolved by these procedures.
Reconstruction of the Breast
The management of the burned breast is a special and
unique part of trunk reconstruction. The specific stages of
the surgical techniques used to reconstruct the breast cor­
respond to the distinct developmental stages it goes through.
Due to this, reconstruction is particularly important in the
prepubescent young girl because absence of a nipple is a
noticeable concern.
Once disfigurement and deformity are established, accu­
rate assessment, characterization, and planning are crucial
to timely and successful reconstruction.35,36
Abnormal burn scarring during puberty results in com­
promised breast growth and displacement of the nipple-
areolar complex (NAC), the breast mound, and the
inframammary fold.37
It is important to avoid excision of the breast bud in order
to preserve the development of the breast in prepubescent
girls.38
Burns during pregnancy and lactation are usually
addressed with tangential excision and split-thickness skin
grafts to facilitate healing of the wounds, allow breast-
feeding, and reduce potential compromise to mother and
fetus. The use of bromocriptine in the lactating woman
ceases lactation and induces breast involution, allowing
tissue cover as soon as possible.39

52  •  Trunk Deformity Reconstruction
569
(intrinsic or extrinsic), the NAC position, the sternal notch
to nipple distance, the breast base size, and any differences
between the breasts in terms of symmetry, shape, and size.
In addition it is important to note what tissues are left and
what parts are missing.
It is also important to document what sort of donor sites
are available: areas for harvesting both full- and split-
thickness skin grafts, the back to examine the latissimus
dorsi donor site, and all areas where potential flaps can be
harvested for free tissue transfer such as the lower abdomen
(deep inferior epigastric perforators [DIEP] flap), inner thigh
(transverse upper gracilis [TUG] flap), and the buttock
(superior gluteal artery perforator [SGAP] flap). In addition
areas of fat deposition on flanks, buttocks, and upper
abdomen must also be examined as potential sites of fat
harvest for autologous fat transfer.
The reconstructive techniques to improve the burned
breast appearance include the principles outlined earlier
for reconstruction of the trunk such as skin grafts and
tissue rearrangement techniques through z-plasties.
Specific breast procedures include nipple reconstruc­
tion, implant-based breast augmentation, autologous fat
transfer to improve breast volume, free tissue transfer,
and reduction of the contralateral unburned breast to
match the underdeveloped burned breast. The principles
used to reconstruct the burned breast are described in
Box 52.1.
RELEASE AND SCAR RESURFACING
This is addressed by contracture release to expand breast
skin surface and split-thickness skin grafting combined or
not with dermal regeneration templates, specifically at the
inframammary fold, periareolar area, sternal area, and
anterior axillary line. This helps to improve shape and
volume (Fig. 52.23).
Expansion of breast skin may be achieved by standard
tissue expansion or the use of distal or free flap tissue
options.40
Reconstruction of the inframammary fold can also be
performed by a release and advancement flap through
expanded reverse abdominoplasty techniques.41
REPLACEMENT OF MISSING PARTS: BREAST
MOUND RECONSTRUCTION
Volume replacement can be achieved by prosthetic implant-
based reconstruction and autologous tissue reconstruction.
The burn scar can be stretched to obtain volume, using
tissue expanders inserted either in an open or endoscopic
fashion (Fig. 52.24).42
Postburn breast sequelae can be classified according to
the descriptions in Table 52.1.
The burned breast can suffer scar contractures that can
be intrinsic or extrinsic. Burn scars crossing the inframam­
mary fold show both loss of definition and flattening of this
area. When the breast mound is involved, breast growth
can be compromised, and hypoplasia or aplasia ensues. The
resulting asymmetry will cause distress and a perceived loss
of femininity.
PRINCIPLES OF BREAST RECONSTRUCTION
Reconstruction of the burned prepubescent breast is best
achieved once breast maturity is attained. Generally scar
maturation is awaited, and reconstruction is performed
during early adulthood. Appropriate timing of the contrac­
ture release is fundamental to avoid a hypoplastic-looking
breast during postpubertal development. Staged recon­
struction throughout puberty may be required to optimize
the aesthetic result.
It is fundamental to document on examination the
quality of the skin and scar, the type of scar contracture
Fig. 52.22  Five-flap plasty designed in right posterior shoulder area.
Table 52.1  Classification of Postburn Breast Deformity
Location
Unilateral
Bilateral
Extent
Total
Subtotal
Anatomical
Breast mound
NAC
Inframammary fold
Deformity
Contracture: Intrinsic/extrinsic
Hypoplasia
Aplasia
Symmetry
Box 52.1  Principles of Postburn Breast
Reconstruction
Release scar contracture
Resurface unsightly or painful scar
Replace missing parts including breast mound and NAC
Reestablish symmetry

52  •  Trunk Deformity Reconstruction
570
Ai
Aii
Aiii
Aiv
Av
Avi
Fig. 52.23  Breast contracture release. (Ai) Planned release of symmastia and inframammary fold contractures to release breast mound. (Aii) Following
incisional release; note skin deficit. (Aiii) Resurfacing with dermal template. (Aiv) Use of topical negative pressure to secure dermal template and prevent
shearing. (Av) Dermal template ready for autografting. (Avi) Second-stage resurfacing of dermal template with sheet autograft. (Bi–Biii) Preoperative
views. (Biv–Bvi) Postoperative views following nipple-areolar complex reconstruction showing improvement in projection, cleavage, inframammary
fold.
Bi
Bii
Biii
Biv
Bv
Bvi

52  •  Trunk Deformity Reconstruction
571
To prevent exposure and extrusion of the implant, sub­
muscular placement and potential flap cover with a pedicle
latissimus dorsi flap may be necessary.
Staged use of dermal templates (Integra) followed by
tissue expansion appears to be a reliable technique to
correct breast hypoplasia:43
■ First stage: Scar release, expander submuscular inser­
tion, and coverage of the anterior chest wall with
Integra
■ Second stage, 1 month later: Grafting of Integra, gradual
expander overinflation
■ Third stage: Expander removal and replacement with a
permanent silicone implant.
Total breast reconstruction will be required in cases of
breast aplasia. This is addressed with submuscular implants
if the skin envelope is appropriate or with an array of flaps
in cases of breast bud destruction. This will usually involve
replacement of both skin and breast volume through sub­
muscular tissue expansion, pedicle (latissimus dorsi) or free
flap (DIEP, SGAP, TUG),44,45 or a combination of both (Fig.
52.25).46 Fat transfer provides options both for reconstruc­
tion and for scar modulation.47,48
NIPPLE-AREOLA COMPLEX RECONSTRUCTION
Reconstruction of the NAC is usually performed at a second
stage once breast mound volume and shape have been
addressed. The process can be divided into subtotal or total
depending on how much of the NAC is preserved following
burn injury. Subtotal reconstruction is usually addressed
with release and skin grafting.
Total NAC reconstruction characteristically uses local
flaps such as the skate or C-V flap but may be limited by the
lack of pliability of scarred skin and by lack of projection of
the reconstruction.
The areola can be reconstructed by using full-thickness
skin grafts or tattooing techniques (Fig. 52.23 Bi–Bvi).
ASYMMETRY
Symmetrization procedures performed on the contralateral
breast include breast augmentation or reduction and
shaping using mastopexy/reduction techniques. Even
though caution is warranted, concerns with reduction
mammoplasty due to potential devascularization of the
skin graft or NAC have proved warrantless because
A
B
C
D
E
F
Fig. 52.24  Postburn breast mound reconstruction using tissue expanders. (A–C) Preoperative views showing characteristic flattening of breast, ptosis,
and poor definition of cleavage. (D–F) Five-year postoperative insertion of bilateral tissue expanders showing improved projection, cleavage, and
volume.

52  •  Trunk Deformity Reconstruction
572
A
B
C
D
E
Fig. 52.25  Reconstruction of breast with DIEP flap. (A) Isolated burn scar on left breast in woman requiring mastectomy for breast cancer. (B) Markings
for DIEP, including perforators. (C) Following mastectomy, subpectoral implant placement. (D) DIEP flap in place for skin cover. (E) Postoperative
appearance following nipple-areolar complex reconstruction and contralateral mastopexy for symmetrization. (Case courtesy of Mr V Ramakrishnan
FRCS [Plast] Consultant Plastic and Reconstructive Surgeon, St. Andrews Centre for Plastic Surgery, Chelmsford, Essex, UK.)
reduction mammoplasty in this group of patients is safe and
carries minimal risk.
Conclusion
Initial care of the burned breast follows the general prin­
ciples of burn management for the rest of the trunk, includ­
ing resuscitation and judicious wound débridement with
dermal and NAC preservation. This minimizes postburn
deformity and maximizes reconstructive potential. Breast
reconstruction principles include preservation and restora­
tion of shape, volume symmetry, inframammary fold, NAC,
and breast symmetry. Soft tissue cover applies reconstruc­
tive ladder principles of ascending complexity including
symmetrization procedures.
Complete references available online at

572.e1
52  •  Trunk Deformity Reconstruction
23. Barret JP. Burns reconstruction. BMJ. 2004;329(7460):274-276.
24. Cartotto R, Cicuto BJ, Kiwanuka HN, et al. Common postburn deformi­
ties and their management. Surg Clin North Am. 2014;94(4):817-837.
25. Leon-Villapalos J, Kaniorou-Larai M, Dziewulski P. Full thickness
abdominal burn following magnetic resonance guided focused ultra­
sound therapy. Burns. 2005;31(8):1054-1055.
26. Maguina P, Busse B, Emelin J. Mini-abdominoplasty in burn recon­
struction. J Burn Care Res. 2012;33(2):e39-e42.
27. Ma G, Lei H, Chen J, et al. Reconstruction of large hypertrophic
scar on trunk and thigh by means of liposuction technique. Burns.
2010;36(2):256-260.
28. Leffler M, Horch RE, Dragu A, et al. The use of the artificial dermis
(Integra) in combination with vacuum assisted closure for recon­
struction of an extensive burn scar–a case report. J Plast Reconstr
Aesthet Surg. 2010;63(1):e32-e35.
29. Shelley OP, Van Niekerk W, Cuccia G, et al. Dual benefit procedures:
combining aesthetic surgery with burn reconstruction. Burns. 2006;
32(8):1022-1027.
30. Kakagia D, Kyriopoulos E, Zapandioti P, et al. Natural expansion of
artificial dermal template by successful full-term pregnancy. J Burn
Care Res. 2012;33(3):e166-e168.
31. Lykoudis EG, Seretis K, Ziogas DE. Tissue expansion and latissimus
dorsi transfer for arm-thorax synechia reconstruction. J Burn Care
Res. 2011;32(2):e15-e20.
32. Di Mascio D, Castagnetti F, Mazzeo F, et al. Overexpansion technique
in burn scar management. Burns. 2006;32(4):490-498.
33. Hudson D, Grob M. Optimising results with tissue expansion: 10 simple
rules for successful tissue expander insertion. Burns. 2005;31(1):1-4.
34. Chummun S, Addison P, Stewart KJ. The osmotic tissue expander: a
5-year experience. J Plast Reconstr Aesthet Surg. 2010;63:2128-2132.
35. Maxwell GP, Gabriel A. Breast reconstruction. In: Aston SJ, Steinbrech
DS, Walden JL, eds. Aesthetic Plastic Surgery. Philadelphia: Elsevier;
2009.
36. Muller M, Gahankari D, Herndon DN. Operative wound management.
In: Herndon DN, ed. Total Burn Care. 3rd ed. London: Saunders Else­
vier; 2007:193.
37. Ogilvie MP, Panthaki ZJ. Burns of the developing breast. J Craniofac
Surg. 2008;19:1030.
38. Armour AD, Billmire DA. Pediatric thermal injury: acute care and
reconstruction update. Plast Reconstr Surg. 2009;124:117.
39. Giele HP, Nguyen H, Wood F, et al. Management of full thickness
burns to lactating breasts. Burns. 1994;20:278.
40. Grishkevich VM. Restoration of the shape, location and skin of the
severe burn-damaged breast. Burns. 2009;35:1026.
41. Haik J, Grabov-Nardini G, Goldan O, et al. Expanded reverse
abdominoplasty for reconstruction of burns in the epigastric region
and the inframammary fold in female patients. J Burn Care Res. 2007;
28:849.
42. Levi B, Brown DL, Cederna PS. A comparative analysis of tissue
expander reconstruction of burned and unburned chest and breasts
using endoscopic and open techniques. Plast Reconstr Surg. 2010;
125:547.
43. Shariff Z, Rawlins JM, Austin O. Burned breast reconstruction by
expanded artificial dermal substitute. J Burn Care Res. 2007;28:929.
44. Granzow JW, Levine JL, Chiu ES, et al. Breast reconstruction
with gluteal artery perforator flaps. J Plast Reconstr Aesthet Surg.
2006;59(6):614-621.
45. Arnez ZM, Pogorelec D, Planinsek F, et al. Breast reconstruction by the
free transverse gracilis (TUG) flap. Br J Plast Surg. 2004;57(1):20-26.
46. Figus A, Canu V, Iwuagwu FC, et al. DIEP flap with implant: a further
option in optimising breast reconstruction. J Plast Reconstr Aesthet
Surg. 2009;62(9):1118-1126.
47. Elfadl D, Garimella V, Mahapatra TK, et al. Lipomodelling of the
breast: a review. Breast. 2010;19(3):202-209.
48. Locke M, Feisst V, Dunbar PR. Concise review: human adipose-
derived stem cells: separating promise from clinical need. Stem Cells.
2011;29(3):404-411.
References
1. ISBI Practice Guidelines Committee. ISBI practice guidelines for burn
care. Burns. 2016;42:953-1021.
2. Sheridan RL. Burns. In: Vincent JL, Abraham E, Moore FA, et al, eds.
Textbook of Critical Care. New York: Saunders; 2011.
3. Townley WA, Hofer S. Abdominal wall reconstruction. In: Cugno S,
Bultrode N, Ross D, eds. Plastic and Reconstructive Surgery: Approaches
and Techniques. New York: Wiley-Blackwell; 2015.
4. Wasiak J, Cleland H, Campbell F, et al. Dressings for superficial
and partial thickness burns. Cochrane Database Syst Rev. 2013;(3):
CD002106.
5. Hubik DA, Wasiak J, Paul E, et al. A retrospective analysis of outcomes
at a specialist adult burns centre. Burns. 2011;37:594-600.
6. Rahmanian-Schwarz A, Beiderwieden A, Willkomm LM, et al. A clini­
cal evaluation of Biobrane W and Suprathel in acute burns and recon­
structive surgery. Burns. 2011;37:1343-1348.
7. Oda J, Yamashita K, Inoue T, et al. Resuscitation fluid volume and
abdominal compartment syndrome in patients with major burns.
Burns. 2006;32:151-154.
8. Markell K, Renz E, White C, et al. Abdominal complications after
severe burns. J Am Coll Surg. 2009;208(5).
9. Hershberger RC, Hunt JL, Arnoldo BD, et al. Abdominal compart­
ment syndrome in the severely burned patient. J Burn Care Res.
2007;28(5):708-714.
10. Hobson KG, Young KM, Ciraulo A, et al. Release of abdominal com­
partment syndrome improves survival in patients with burn injury.
J Trauma Acute Care Surg. 2002;53(6):1129-1134.
11. Kirkpatrick AW, Roberts DJ, De Waele J, et al. Intra-abdominal hyper­
tension and the abdominal compartment syndrome: updated con­
sensus definitions and clinical practice guidelines from the World
Society of the Abdominal Compartment Syndrome. Intensive Care
Med. 2013;39(7):1190-1206.
12. Heimes J, Carlton E, McDonnell J, et al. Use of an abdominal reap­
proximation anchor (ABRA) system in a patient with abdominal
compartment syndrome after severe burns: a case report. Burns.
2013;39(4):e29-e33.
13. Keramati M, Srivastava A, Sakabu S, et al. The Wittmann patch as
a temporary abdominal closure device after decompressive celiot­
omy for abdominal compartment syndrome following burn. Burns.
2008;34:493-497.
14. Poulakidas S, Kowal-Vern A. Component separation technique for
abdominal wall reconstruction in burn patients with decompressive
laparotomies. J Trauma. 2009;67(6):1435-1438.
15. Kagan R, Peck M, Ahrenholz D, et al. Surgical management of the
burn wound and use of skin substitutes: an expert panel white paper.
J Burn Care Res. 2013;34(2):e60-e79.
16. Papp A, Harma M. A collagen based dermal substitute and the modi­
fied Meek technique in extensive burns: report of three cases. Burns.
2009;29:167.
17. Medina A, Riegel T, Nystad D, et al. Modified Meek micrografting tech­
nique for wound coverage in extensive burn injuries. J Burn Care Res.
2016;37(5):305-313.
18. Wood F. Tissue engineering of skin. Clin Plast Surg. 2012;39(1):21-32.
19. Bhatia Y, Menon P, Bhavsar M. Coverage of chest wall defect in a case
of electric burns by pedicled omental flap. J Burn Care Res. 2014;35(4):
e262-e264.
20. Honda T, Yamamoto Y, Mizuno M, et al. Successful treatment of a case
of electrical burn with visceral injury and full-thickness loss of the
abdominal wall. Burns. 2000;26(6):587-592.
21. Nnabuko N, Anyanwu C, Ezinwa C, et al. Reconstructive challenges in
full thickness left anterior chest wall defect following electrical burn:
a case report demonstrating the use of extended reverse double turn­
over deltopectoral flap. Burns. 2011;37(5):e37-e40.
22. Li Y, Min L, Huang J, et al. Successful treatment of a case of severe elec­
trical burns with heart and lung injuries. J Burn Care Res. 2007;28:
762-766.

573
Management of Contractural
Deformities Involving the
Shoulder (Axilla), Elbow, Hip,
and Knee Joints in Burned
Patients
KAREL D. CAPEK, RAMON ZAPATA-SIRVENT, and TED T. HUANG
53 
INCIDENCE OF BURN CONTRACTURE
INVOLVING THE SHOULDER (AXILLA), ELBOW,
AND KNEE JOINTS
Burn treatment that requires a long period of bed confine­
ment and physical inactivity as well as restriction of joint
movement will lead to joint dysfunction. Consequently
every bodily joint (i.e., the vertebral, mandibular, shoulder,
elbow, wrist, finger, hip, knee, ankle, and toe) is susceptible
to changes. Of various bodily joints involved, the contrac­
tural deformities of the shoulder (axilla), elbow, hip, and
knee are relatively common. Factors such as a wide range
of joint movement and asynchronous muscular control are
characteristic features of these joints, and, when combined
with a high vulnerability to burn injuries, are the probable
reasons accounting for the high incidence encountered.
A review of the records of 1005 patients treated at the
Shriners Burns Hospital in Galveston, Texas, over 25 years,
indicated that the elbow was the joint most commonly
affected. There were 397 patients with elbow joint defor­
mity followed by 283 knee contractures. There were 248
axillary deformities. Hip joint contracture was the defor­
mity least encountered and was noted in only 77 patients
(Table 53.1).
EFFICACY OF SPLINTING IN CONTROLLING
BURN CONTRACTURES OF SHOULDER (AXILLA),
ELBOW, AND KNEE JOINTS
Although Cronin in 1955 demonstrated that the neck
splint was effective in preventing recurrence of neck con­
tracture following surgical release,4 the routine use of
splinting for burn patients did not become a part of the
regimen of burn wound care in Galveston until 1968,
when Larson, the former Surgeon-in-Chief and Willis, the
former Chief Occupational Therapist at the Shriners Burns
Institute, began to fabricate splints with thermoplastic
materials to brace the neck and extremities.5–8
For more than three decades, a neck brace, a three-point
extension splint, and a molded brace fabricated from ther­
moplastic materials—prototypes of devices used to splint
the neck, elbow, and knee joints—were used in the manage­
ment of burn patients at the Shriners Burns Hospital and
Introduction
Burn injuries, regardless of the etiology, rarely involve a
joint itself. However the joint function is often impaired
because of burns. The joint problems and joint deformities
noted in burn patients are mostly due to physical inactivity
combined with limitation of joint movement because of
scar contracture. The consequences of joint dysfunction are
usually left for reconstruction later in the course of burn
convalescence.
Contractural Deformities of
the Shoulder (Axilla), Elbow,
Hip, and Knee Observed in a
Burned Patient
THE FACTORS LEADING TO FORMATION OF
CONTRACTURAL DEFORMITIES
Folding bodily joints in flexion, a so-called posture of
comfort, is a characteristic body posture seen commonly in
a distressed individual. Although the exact reasons are not
entirely clear, contraction of muscle fibers at rest and con­
tractile force difference between the flexor muscle and the
extensor muscle play an important role in the genesis of this
body posture. The magnitude of joint flexion, furthermore,
increases as an individual loses voluntary control of muscle
movement, as frequently occurs in a burn victim (Fig. 53.1).
A prolonged period of physical inactivity associated with
burn treatment and scar tissue contraction around the joint
structures as the recovery ensues further impedes joint
mobility.
A subtype of joint problem seen with major burn injuries
is heterotopic ossification. This may affect any joint,
although the elbow is by far the most frequently affected.
Its initial symptoms are markedly increased pain with
motion and hyperemia/swelling. A high index of suspicion
is needed to differentiate this problem from background
post-burn pain.1–3 The splinting and exercise/range-of-
motion (ROM) care of patients with heterotopic ossification
differ from standard burn rehabilitation, as noted later.

53  •  Management of Contractural Deformities Involving the Shoulder (Axilla), Elbow, Hip, and Knee Joints in Burned Patients
574
decreasing to 3% with splinting, and further decreasing to
1% if splint usage was maintained for more than 6 months
(Table 53.2). Although splinting and bracing were shown
to be effective in minimizing joint contracture, it was not
entirely clear if restriction of joint movement would affect
the quality of scar tissues formed across the joint surface.
The effects were assessed by determining the frequency of
secondary surgery performed in this group of patients.
More than 90% of 219 individuals who did not use
splinting/bracing required reconstructive surgery. In con­
trast, the need for surgical reconstruction in individuals
who wore splints was 25%.9
Management During the Acute
Phase of Recovery
It is believed that inadequate physical exercise and lack of
joint splinting and bracing, although allowing a patient to
assume the posture of comfort, are the main factors respon­
sible for the genesis of contractural deformities seen in
patients during the acute phase of recovery from burn inju­
ries. The deformities, furthermore, are made worse because
of skin involvement and burn scar contracture. To mini­
mize this undesirable consequence of burn injuries, proper
body positioning and splinting of the joint structures must
be incorporated into the regimen of burn treatment. The
treatment should be implemented as soon as the patient’s
condition allows.
BODY POSITIONING AND JOINT SPLINTING
Body Position
Although a supine position is preferred, the patient may be
placed in a lateral decubitus position while confined in bed.
The head should be placed in a neutral position with the
neck slightly extended. For a patient placed in a supine posi­
tion, neck extension is achieved by placing a small pad
between the scapulae to facilitate scapular traction. A neck
brace may be used if a patient is placed in other body
positions.
Fig. 53.1  The posture of comfort characterized by flexion of shoulder
(axilla) and elbow joints, plus hip and knee joints, is assumed by
patients under distress, as in burn patients.
Table 53.1  The Distribution of Joint Deformities
Joint Involved
n
Shoulder (axilla)
248
Elbow
397
Hip
77
Knee
283
Total
1005
Table 53.2  The Incidence of Contractures Across the
Shoulder (Axilla), Elbow, and Knee Joints
Without Splint
WITH SPLINT
<6 months
>6 months
Shoulder
  Severe/moderate
137
24
23
  Mild/none
37
6
129
Elbow
  Severe/moderate
75
17
10
  Mild/none
61
33
161
Knee
  Severe/moderate
26
4
2
  Mild/none
45
16
155
the University of Texas Medical Branch Hospitals in Galves­
ton, Texas. An “airplane splint” similarly made of thermo­
plastic materials was also used to splint the axilla when the
use of other splinting and bracing techniques, such as a
“figure-of-eight” bandage, were not feasible.
A study was conducted in 1977 to determine the efficacy
of splinting across large joint structures such as the elbow,
axilla, and knee by reviewing the records of 625 patients.
There were 961 burns over these joints in this group of
patients. Of these, 356 had involved the axillae, while 357
and 248 involved the elbow and knee joints, respectively.
The incidence of axillary contractural deformities without
splinting was 79%; with splinting this decreased to 26%.
The subgroup able to wear splints for longer than 6 months
had the lowest incidence of contracture at 15%, whereas
discontinuation of splinting before 6 months identified a
subgroup at high risk for splint failure, with 80% incidence
(similar to a no-splint group). At the elbow, the incidence
of contracture was 55% without splinting, decreasing to
12% with splinting, and further decreasing to 6% if splint
usage was maintained for more than 6 months. At the knee,
the incidence of contracture was 37% without splinting,

53  •  Management of Contractural Deformities Involving the Shoulder (Axilla), Elbow, Hip, and Knee Joints in Burned Patients
575
of the joint structure, especially in instances where the inju­
ries involved the patella surface. Maintenance of the knee
in full extension is, in this sense, an essential component of
therapeutic regimen. This is accomplished by means of a
knee brace or a three-point extension splint to assure a full
extension of the knee joint (Fig. 53.5).
EXERCISE
Although exercising a burned victim is an integral part of
burn therapy, it is seldom implemented until the resuscita­
tive measures are completed and the condition of the patient
is considered stable. The primary goal of exercise is to main­
tain the functional integrity of joint structures and muscle
strength. This is attained by, in most instances, moving the
joint manually and the muscles passively. Frequency and
intensity of an exercise regimen, however, may vary depend­
ing on the magnitude of injury and the extent of joint
involvement. The treatment, if possible, should be intensive
and rendered as frequently as possible.
Fig. 53.2  A splint made of thermoplastic material is used to limit joint
flexion.
Fig. 53.3  A three-point extension splint manufactured similarly to an
orthotic device is used either to extend a contracted elbow joint or
immobilize the joint in full extension.
Fig. 53.4  A hand splint that will maintain the DIP-PIP joints at full
extension and MCP joints at 70 degrees while keeping the wrist joint
at 30 degrees extension (i.e., the hand in a position of “safety”).
Shoulder (Axillary) Joint.  The shoulder joint is kept at
90–120 degrees of abduction and 15–20 degrees of flexion.
The position is not only useful in protecting the brachial
plexus from traction injury but also effective in maintaining
the stability of the glenohumeral joint. The position is best
kept with the use of foam wedge, trough, and/or airplane
splints. A figure-of-eight wrapping over a pad around the
axilla, more frequently used for patients during the inter­
mediate phase of recovery from injury, is effective in main­
taining shoulder abduction. It is also useful in preventing
excess shoulder flexion.
Elbow Joint.  Elbow flexion is commonly seen in a dis­
tressed patient. Rigid flexion contracture of the elbow is a
common sequela if the elbow is left unattended. With burns
of the skin around the olecranon, exposure of the elbow
joint is a common sequela if the elbow is allowed to contract
freely. Maintaining the elbow in full extension therefore is
essential. An extension brace (Fig. 53.2) or a three-point
extension splint across the elbow joint is effective for this
purpose (Fig. 53.3). If concern for heterotopic ossification
develops, the elbow splint should be expediently changed to
a functional position (around 90 degrees flexion) to avoid
fusion of this joint in extension.
Wrist Joint.  A contractural deformity involving a wrist
joint is relatively common in individuals with hand burns
that were not splinted properly. A cock-up hand splint
should be applied to maintain a 30-degree wrist extension
(Fig. 53.4).
Hip Joint.  A contractural deformity of the hip is relatively
uncommon unless the hip joint is allowed to remain flexed
for a long period of time. Hip extension can be achieved by
placing the patient in a prone position. In a supine position,
15–20 degrees of abduction is maintained with the use of
a brace or anklet.
Knee Joint.  Flexion of the knee is another posture com­
monly assumed by a burned victim. Similar to the elbow,
uncontrolled flexion of the knee joint will lead to exposure

53  •  Management of Contractural Deformities Involving the Shoulder (Axilla), Elbow, Hip, and Knee Joints in Burned Patients
576
Management During the
Intermediate Phase of Recovery
A period starting from the second month following injury
through the fourth month is considered the intermediate
phase of recovery from burn injuries. The burn victims typi­
cally will have full recovery of physiologic functions with
integument integrity restored. The cicatricial processes at
the injured sites, on the other hand, are physiologically
active, even though healing of the burned wound is consid­
ered satisfactory. This process is characterized by, in addi­
tion to a maximal rate of collagen synthesis, a steady
increase in the myofibroblast fraction of the fibroblast popu­
lation in the wound,10,11 a cellular change believed to
account for contraction of the scar tissues. Continuous use
of splinting and pressure to support joints and burned sites
is, in this sense, essential to control changes caused by
ensuing scar tissue formation and scar contracture.
BODY POSITIONING AND JOINT SPLINTING
Joint splinting and body positioning are similar to the
regimen used during the acute phase of burn recovery. That
is, the shoulder is kept at 15–20 degrees of flexion and
80–120 degrees of abduction. A figure-of-eight wrapping
over an axillary pad is used to maintain this shoulder joint
position (Fig. 53.6). The elbow and knee joints are main­
tained in full extension by means of a three-point extension
splint or brace. A pressure dressing or garment is incorpo­
rated into the splint. In instances where the use of figure-
of-eight bandages or pressure dressings and/or garments is
not feasible because of recent surgery, devices such as an
airplane splint (Fig. 53.7) or a three-point extension splint
may be used to splint the axilla, elbow, and knee joints.
PRESSURE DRESSING
A compression dressing, originally incorporated in the
treatment of burned wounds of the upper and lower
extremities at the Shriners Burns Hospital in 1968 as a
means to provide mechanical support to healing wounds,
Fig. 53.5  A three-point extension splint can be also used to manage
the flexion contractures of a knee joint.
Fig. 53.6  An elasticized bandage is used to wrap around the shoulder
(axilla) joints in a figure-of-eight fashion to extend and abduct the
shoulder joints. An axillary pad is included in the wrapping to increase
pressure upon the axillary fold.
Fig. 53.7  An airplane splint made of thermoplastic materials is used to
maintain shoulder abduction. The angle of separation may be increased
as the joint becomes more mobile.

53  •  Management of Contractural Deformities Involving the Shoulder (Axilla), Elbow, Hip, and Knee Joints in Burned Patients
577
Shoulder (Axillary) Contracture
Tight scars formed across the shoulder joint, usually in the
area along the axillary folds, often limit joint movement.
The joint stiffness caused by scar contracture may be further
aggravated by physical inactivity, especially if the patient is
allowed to remain in the posture of comfort.
Two nonsurgical methods are commonly used to mobi­
lize a contracted shoulder (axilla) joint. One is the figure-of-
eight compression dressing technique and the other an
airplane splinting technique.
Figure-of-Eight Compression Dressing.  An elasticized
bandage is wrapped over a pad placed in the axillary fold
and around the shoulder joint in a figure-of-eight fashion
to extend and abduct the shoulder. The dressing must be
worn continuously, and it is removed only for cleansing.
Continuous wearing of the dressing for a period of 3–6
months is necessary to obtain release. The mobility of the
joint increases as the scar tissues across the axilla soften.
The extent of release may be limited if the scar is thick and
unyielding to pressure (Fig. 53.8).
Airplane Splint.  This splint is fabricated with a thermo­
plastic material. The spreading angle of the splint is con­
formed to the extent of the shoulder (axilla) joint held at
maximum abduction plus 10–15 degrees of extension.
Abduction and extension of the joint (i.e., elevation of the
arm) will be maintained by pushing the arm away from the
upper thorax. Care is needed to protect the skin over the
inner aspect of the arm and the side of the chest. The splint
is changed regularly as the angle of joint abduction
increases. To achieve the needed release, in most instances
1–3 months of continuous use of this device is usually nec­
essary (Fig. 53.7).
Elbow and Knee Contracture
Flexion contracture is the most common deformity encoun­
tered in these two joints. The scar formed across the ante­
cubital and the popliteal fossae frequently aggravates the
magnitude of contractural problems in these joints. The
following techniques are frequently utilized before surgery
to obtain joint movement and joint extension.
Three-Point Extension Splint.  The three-point exten­
sion splint is assembled similarly to a prosthetic/orthotic
device. Two sidebars hinged at the middle are connected
with a bracing trough at the end. A cap pad is attached at
the mid-section of the sidebar to fit over the elbow or
kneecap. The splint is placed across the antecubital fossa or
popliteal fossa. Fitting of the splint is adjusted with Velcro
straps (Figs. 53.2 and 53.3).
The amount of extension achieved by the joint is deter­
mined by the extent of preexisting joint stiffness. The angle
of extension is initially determined by the angle of joint
contracture. The magnitude of extension is controlled by
tightening the olecranon or patellar pad. Extension is
increased gradually as the joint gains its mobility. Problems
encountered with the use of a three-point extension splint
are uncommon; however breakdown of the skin can occur.
Leverage attainable from three-point pressure application
may be limited in a young individual because of short limb
is effective in reducing tissue swelling and in promot­
ing softening of a burned scar. Compression of a burn
wound even while healing is still in progress is most easily
achieved by wrapping the extremity with an elasticized
bandage. Wrapping of the extremity should begin at the
hand or foot. The bandage is moved cephalad in a criss-
cross fashion. The splint is reapplied over the bandage. It
is important to rewrap the extremity three to four times
daily. Wrapping an extremity with an elasticized bandage
can produce a pressure gradient of 10–25 mm Hg.6,12 The
use of a pressure dressing should be continued for 12–18
months.
Management of Established
Contractural Deformities
Contraction of the shoulder, elbow, hip, and knee joints
can occur despite proper splinting and intensive physical
therapy. Surgical reconstruction of contractural defor­
mities, in this sense, remains an essential component of
patient care and patient rehabilitation. The task of decid­
ing the timing of surgical intervention, however, can be
difficult and requires detailed evaluation of the patient
and the deformity. The following are ascertained before
surgery:
a. The causes of joint immobility
b. The extent and availability of nearby tissues that
could be used for reconstruction
c. The extent of maturation of scar tissues that sur­
round the joint.
PATIENT EVALUATION
Numerous factors will affect joint movements in burn
patients. Although hypertrophy and contraction of scar
tissues and/or contracted skin graft around a joint are the
most common causes of joint impairment, changes in the
ligamentous structures or the joint itself due to burn inju­
ries could also limit joint mobility. Detailed examination
that may include radiographic assessment of the joint
structures is essential in order to formulate a definitive
treatment plan.
NONOPERATIVE OR MINIMALLY INVASIVE
APPROACH TO CORRECT A CONTRACTED AND/
OR STIFF JOINT
Restoration of movements in a contracted and/or stiff joint
may be attained by minimally invasive or nonsurgical
means.5–9,13 “Pushing” and “pulling” of an extremity that,
in turn, stretches contracted scars and tissues around an
affected joint is the principle behind this modality of man­
aging a contracted and/or stiff joint. The treatment is found
to be especially effective in mobilizing a contracted joint
caused by a long period of physical inactivity and, in some
instances, by scar contracture.
Although the morbidities associated with this modality
of treatment are minimal, breakdown of the skin due to
pressure and/or friction resulting from pushing and pulling
can occur.

53  •  Management of Contractural Deformities Involving the Shoulder (Axilla), Elbow, Hip, and Knee Joints in Burned Patients
578
For a flexion deformity of the elbow, the patient is
placed in supine position. The pulley traction device will
provide a horizontal and then a vertically downward pull
(Fig. 53.9).
Instead of a skeletal traction device, a weight placed
around the ankle, with the patient placed in prone position,
may be used to pull the foreleg to loosen a contracted knee.
This technique is especially useful in treating individuals
with a limited knee flexion contracture. Traction is contin­
ued for a period of time and is repeated several times a day
(Fig. 53.10).
Although morbidities due to infection are uncommon,
the continuous and constant force of pull can cause
length. In such instances, the skeletal traction technique
may be used.
Skeletal Traction Technique.  Utilizing a skeletal trac­
tion technique to restore movements in a contracted joint
typically requires percutaneous insertion of a Steinmann’s
pin through the radius for the elbow joint and the tibia for
the knee joint. The pin is inserted through both cortices at
the junction of the proximal two-thirds and the distal third
of the radius or tibia. A contracted joint can be mobilized
by continuous and constant “pull” on the long bone utiliz­
ing the gravitational force generated by 10–15 pounds of
weight hung with a pulley device.
D
C
B
A
Fig. 53.8  (A) A 6-year-old boy sustained burns to the right side of his body extending from the lower neck to the upper thorax that included the axil­
lary crease. (B) He experienced difficulty in extending both the neck and the right arm because of ensuing contraction of scar tissues around the neck
and the axilla. (C) A figure-of-eight dressing was used to maintain the shoulder extension and abduction. The dressing was used for 12 months. (D)
He regained shoulder extension and mobility with the use of pressure dressing.

53  •  Management of Contractural Deformities Involving the Shoulder (Axilla), Elbow, Hip, and Knee Joints in Burned Patients
579
ineffective and where functional integrity of a joint is at
jeopardy.
Presurgical Evaluation
The patient is seen and the involved joint is examined before
surgery. The following features are assessed:
■ The extent of joint contracture is determined and the
passive and active range of joint motion is assessed.
Radiographic evaluation may be obtained to delineate
the structural integrity of the joint.
breakdown of the skin, typically located in the area across
the joint surface. The wound can be temporarily covered
with a surgical or biological dressing. Closure of the wound
is contemplated once the joint contracture is fully
corrected.
SURGICAL TREATMENT OF A
CONTRACTED JOINT
Surgical treatment of a contracted joint is contemplated in
individuals in whom the use of nonsurgical treatment is
D
C
B
A
Fig. 53.9  A contractural deformity had developed involving the left elbow joint, even though there were no direct injuries involving the joint. A
Steinmann’s pin was inserted through the distal third of the radius for traction. A 500-g weight was used. A full extension of the contracted elbow
joint was completed in 3–4 days.
B
A
Fig. 53.10  A knee contracture developed in an 8-year-old boy due to improper positioning and immobilization of the knee joint. There were no direct
injuries involving the knee area. With the patient being placed in a prone position, the ankle was strapped with a 10- to 15-pound weight. The flexion
contracture was relieved in 3 days.

53  •  Management of Contractural Deformities Involving the Shoulder (Axilla), Elbow, Hip, and Knee Joints in Burned Patients
580
Primary Closure of the Wound.  Wound closure per
primum following burn scar excision is difficult if not entirely
impossible. Inelasticity of the skin surrounding the wound
and an inadequate amount of uninjured skin available for
mobilization and closure preclude the use of this method of
wound closure. Closure of a resultant wound following
release, in practice, would defeat the original objective of
contractural reconstruction.
Skin Grafting Technique.  The use of a skin graft, full or
partial thickness, to cover a wound is the most fundamental
technique of wound coverage; it is technically simple and
has minimal morbidities.
OPERATIVE TECHNIQUE.  A partial-thickness skin graft of
15/1000th to 20/1000th inch in thickness is harvested
from an unburned area using a dermatome. The scalp,
lower abdomen, and the anterior surface of the upper thigh
are common donor sites.
A full-thickness skin graft can be harvested from
the lower abdomen, above the suprapubic or ingui­
nal area, without leaving unsightly donor site defects.
The subdermal fatty tissues are removed but attempts
should be made to preserve the subdermal capillary
plexus (Fig. 53.11). The donor defect is usually closed
primarily.
The graft is cut to fit the defect and the edges are anchored
with 3-0 silk sutures. The ends are left sufficiently long to
tie over a bolster to immobilize the graft. Several anchoring
mattress stitches using 4-0 or 5-0 chromic catgut sutures
may be placed in the center of the graft to immobilize the
skin graft against the base. Hemostasis around the recipient
site is essential. Hematoma formed underneath the graft
will hinder the “take” of the graft.
AFTER-CARE.  The bolster is usually removed 4–5 days after
the procedure. Bodily fluid or blood elements accumulated
underneath the graft (i.e., seroma and/or hematoma) are
evacuated. This is achieved by making a small nick in the
graft with a pair of surgical scissors. The fluid is “rolled” out
with a cotton tip applicator. The joint is immobilized imme­
diately, and a pressure dressing is used to minimize the con­
sequence of contracture. Physical exercise is resumed 3
weeks after the surgery.
Interposition Flap Technique.  This technique, known
by various names such as the three-quarter z-plasty tech­
nique or the banner flap interposition technique, is the
most useful method of wound coverage following a releas­
ing procedure for a contracted joint. The technique is based
on the principle that an open wound consequential to sur­
gical release may be covered with a skin flap mobilized
from an adjacent area. While the flap design is technically
simple, it requires an area of movable tissue containing
as little scar as possible adjacent to the released wound.
Smaller defects can be treated with flaps of skin and sub­
cutaneous tissue, although most functionally significant
contractures require adjunctive measures to provide effec­
tive and durable release. We have found that an inter­
position flap, with its width tapering at its distal extent,
can be fabricated with a length-to-width ratio as high as
5 : 1 by carrying the subjacent fascia with the rotation
flap; this flap is the mainstay of our treatment of axillary
contractures.14,15
■ The magnitude of scarring and scar thickness is assessed.
The scar is usually thickest across the joint surface.
■ The location and size of uninjured skin are delineated. The
availability of uninjured skin frequently determines
the technique of reconstruction. Skin graft and skin
flap donor sites are also ascertained.
■ The point and axis of joint rotation are located. The line
of incisional release is in alignment with the axis of
joint movement.
Techniques of Joint Contracture Release
Despite detailed examination before surgery, the exact cause
of joint stiffness can only be delineated with surgery. In
practice, contraction of the scar tissues across the joint
structure is the most common cause of contractural joint
deformities.
Release of Joint Contracture by Incising the Scarred
Tissue.  A contracted joint is freed by making an incision
in the scar across the joint surface. The incision is placed
in line with the axis of joint rotation. The incision is con­
fined within the width of the scar initially and is lengthened
as necessary to achieve the intended release. Prior infiltra­
tion of the area with lidocaine containing epinephrine in
1 : 400 000 concentration is useful in obtaining hemostasis
and later pain control. The incision must be made with
caution to avoid injuring major vessels and nerves. This
is achieved by using a pushing instead of a slicing motion
with a surgical blade to free the scarred tissues. The extent
of release is assessed by the improvement of joint motion
gained as the scarred tissue is severed.
In rare instances, cicatricial changes could involve the
joint capsule. Then, reconstruction of the capsular struc­
ture will be necessary.
Z-Plasty Technique.  A contracted area can be length­
ened by use of the z-plasty technique.9 The technique uti­
lizes the principle that a contracted wound is lengthened
by interposing two triangular skin flaps mobilized from an
unburned area immediately adjacent to the area of release.
The lengthening of the wound is maximally attained by
interposing two triangular flaps of 60-degree angles. While
the z-plasty technique is an excellent means to amelio­
rate the problem of wound contracture, it is not feasible
if the amount of uninjured skin adjacent to the wound
is limited.
Wound Coverage
There are six basic techniques of wound coverage. Namely:
a. Primary closure of the wound
b. A full-thickness or partial-thickness skin graft
c. An interposition skin flap mobilized from the area
adjacent
d. Combination of an interposition skin flap and skin
grafting
e. A muscle or skin-muscle flap mobilized from the adja­
cent area
f. A free skin or skin-muscle flap harvested from a
distant site and transferred via a microsurgical
technique.

53  •  Management of Contractural Deformities Involving the Shoulder (Axilla), Elbow, Hip, and Knee Joints in Burned Patients
581
Splinting of the joint may be resumed within 4–5 days and
joint exercise in 10–14 days.
Muscle Flap or Skin-Muscle Flap Technique.  The
technique is utilized in instances where the resultant defect
following release is so extensive that coverage of the wound
with a skin flap or a skin graft is not feasible.
While the latissimus dorsi muscle harvested either as a
muscle flap or as a musculocutaneous flap may be used to
cover the axillary defect, the soleus muscle flap or the gas­
trocnemius muscle-skin flap may be used to cover the
wound around the knee joint (Fig. 53.14). A fasciocutane­
ous flap may similarly be fabricated to cover a tissue defect
consequential to surgical release of a contracted joint (Fig.
53.15).
Use of a Free Flap or Muscle Flap.  Although most of
the major joint deformities could be reconstructed with the
techniques described, the use of microsurgical technique
may be occasionally necessary to transfer a segment of soft
tissue from a distant donor site.
Of the varieties of flap available, we prefer the use of
an anterior lateral thigh (ALT) perforator flap.16,17 The vas­
cular supplies to the skin around the anterior section of
the upper thigh are consistent, so preparation of a flap is
therefore technically simple. While the morbidities attribut­
able to flap harvest are generally minimal, the flap can be
bulky; secondary procedures to thin down a flap are often
necessary (Fig. 53.16). Instead, a muscle flap may be used.
The tissue bulkiness may be curtailed by using a skin graft
(Fig. 53.17).
OPERATIVE TECHNIQUE.  A triangular skin flap is designed in
an unburned area adjacent to the wound following release.
A vertical limb of the flap begun at the end of released
wound edge is set at a 90-degree angle to the end of the
wound. The limb length is equal to the wound length. A
triangular flap is formed by making the width of flaps at
mid-section the same as the wound width. The flap can be
based either proximally or distally depending on the direc­
tion of the triangular flap designed. The flap is dissected out
and rotated 90 degrees to cover the defect. The flap donor
defect is closed primarily. Healing of the wound is usually
uneventful (Fig. 53.12).
The width of flap may be narrow in instances where the
size of unburned skin is not enough to fabricate a trian­
gular skin flap sufficiently wide to cover the wound. The
flap, in such an instance, is anchored in the middle of the
wound. The two sides not covered by the flap are closed
with a skin graft (Fig. 53.13). For larger or wider defects
requiring longer flaps, a fasciocutaneous flap is employed.
This flap is designed as above, but the tissue to be mobilized
is sharply dissected free “straight-down” to incorporate the
outer leaf of the subjacent fascia. It is important to pre­
serve the microcirculatory connections between the fascia
and the skin. Occasionally we place a temporary suture
between the edge of the fascia and its skin edge above while
the flap is mobilized. A 5 : 1 or greater length-to-width ratio
is possible using this technique. Superficial epidermolysis
of the most distal aspect of the flap may occur but rarely is
of clinical significance and resolves with local wound care
over the course of 1–3 weeks.
AFTER-CARE.  The wound edges are kept clean with antibi­
otic ointment. Sutures may be removed in 10 days.
C
B
A
Fig. 53.11  (A) A piece of skin with subcutaneous tissues is removed from the abdomen and will be used as a full-thickness skin graft. (B) The subcu­
taneous fatty tissues were sharply removed with a pair of fine scissors. The capillaries were left undisturbed. (C) A close-up view to show the capillaries
that are left in the graft.
Text continued on p. 586.

53  •  Management of Contractural Deformities Involving the Shoulder (Axilla), Elbow, Hip, and Knee Joints in Burned Patients
582
C
B
A
E
D
Fig. 53.12  (A) An interpositional skin flap technique (i.e., a modified z-plasty technique) is useful in reconstructing a flexion/adduction deformity
around the joint, as seen in this 12-year-old individual who had sustained burn injuries around the right axilla. (B) An incision made across the area
with maximal contraction resulted in a large tissue gap of 12 × 5–6 cm. (C) A triangular skin + fascia flap was mobilized from the lateral upper chest
area and was rotated 90 degrees posteriorly to cover the wound. (D) The donor site was closed primarily. (E) The appearance of the wound 2 years
following reconstruction.

53  •  Management of Contractural Deformities Involving the Shoulder (Axilla), Elbow, Hip, and Knee Joints in Burned Patients
583
E
D
C
B
A
Fig. 53.13  (A) An interpositional skin flap technique of wound closure may be modified, as in this 5-year-old girl who had sustained burns around the
right axilla that caused contracture of the axillary joint. (B) The skin defect was so extensive that it could not be covered completely with a single flap.
(C) The uninjured skin raised as a flap was transferred to the middle of the wound, leaving the areas proximal and distal to the flap to be covered with
skin grafts. (D) The appearance of the wound 10 days following the surgery. (E) The appearance of the wound 10 years after surgery. The flap placed
in the middle of the wound had increased in size because of body growth and stretching of the scar tissues.

53  •  Management of Contractural Deformities Involving the Shoulder (Axilla), Elbow, Hip, and Knee Joints in Burned Patients
584
D
B
A
C
Fig. 53.14  (A) Flexion of the knee was limited because of tight scars around the patella. (B) An incisional release of the tight area across the patella
provided relief of knee contracture. However, it resulted in an open wound of 4–5 cm in size. (C) A medial segment of the soleus muscle was used to
cover the defect. (D) The appearance of the knee area 3 months following the procedure.
B
A
Fig. 53.15  (A) A moderate degree of dorsiflexion contracture involving the right ankle of a 6-year-old boy required release. A triangularly shaped skin
+ fascia flap was marked over the medial side of the lower leg. (B) A fasciocutaneous flap was fabricated and rotated 90 degrees anteriorly to cover a
tissue defect consequential to contractural release.

53  •  Management of Contractural Deformities Involving the Shoulder (Axilla), Elbow, Hip, and Knee Joints in Burned Patients
585
C
D
(C) The closure of the flap donor site required the use of a skin graft. Healing was uneventful. (D) The appearance of the right ankle
area 18 months following surgery.
Fig. 53.15, con’d 
B
A
Fig. 53.16  (A) An anterior lateral thigh (ALT) perforator flap was used to reconstruct an ankle contracture deformity. (B) While wound coverage was
achieved, the tissue was noted to be bulky, requiring secondary debulking procedures.

53  •  Management of Contractural Deformities Involving the Shoulder (Axilla), Elbow, Hip, and Knee Joints in Burned Patients
586
B
A
C
Fig. 53.17  (A) The patient had sustained electrical burns resulting in tissue loss over the right heel area. (B) Wound débridement resulted in a large
soft tissue deficit exposing the Achilles tendon. A muscle flap was transferred via microsurgical means to cover the wound. The muscle was covered
with a skin graft. (C) Healing was uneventful.
Conclusion
Contractural deformities of the shoulder (axilla), elbow, hip,
and knee joints are commonly encountered after burn inju­
ries. Although the injury involving limbs and joint struc­
tures could alone account for the deformities encountered,
lack of proper positioning and inadequate physical exercise
while recovering from injuries exacerbates these problems.
The use of braces, splinting, and pressure dressing is
important in minimizing such an undesirable consequence
of burn injuries. The treatment for an established joint
deformity, on the other hand, requires surgical release of
the contracted skin and scars. In this chapter, various
methods of reconstruction have been described to manage
the problems encountered and to outline the approach of
managing contractural deformities involving the shoulder
(axilla), elbow, hip, and knee joints. The interposition of an
intact “integumentary functional unit” comprising epider­
mal, dermal, adipose, and fascial tissues with native
nervous, vascular, and lymphatic connections allows
release of the intrinsic tissue tension driving scar hypertro­
phy and contraction. Accumulating cellular evidence indi­
cates that this mechanically transduced signal may lead to
myofibroblast apoptosis and more rapid resolution of scar
hypertrophy (Figs. 53.18 and 53.19).18,19
Complete references available online at

53  •  Management of Contractural Deformities Involving the Shoulder (Axilla), Elbow, Hip, and Knee Joints in Burned Patients
587
E
C
B
A
D
Fig. 53.18  (A) Preoperative contracture appearance. (B–D) Operative technique of contracture release and three-quarters random fasciocutaneous
Z-plasty flap interposition. (E) Appearance 2 years after release.

53  •  Management of Contractural Deformities Involving the Shoulder (Axilla), Elbow, Hip, and Knee Joints in Burned Patients
588
C
B
A
D
Fig. 53.19  (A) Preoperative contracture appearance. (B and C) Operative technique of contracture release and three-quarter random fasciocutaneous
Z-plasty flap interposition. (D) Appearance 3 years after release.
Further Reading
Huang TT, Blackwell SJ, Lewis SR. Ten years of experience in managing
patients with burn contractures of axilla, elbow, wrist, and knee joints.
Plast Reconstr Surg. 1978;61:70-76.
Kuo YJ. Experience of ALT flap. Ann Plast Surg. 2002;48:161-166.
Larson DL, Abston S, Evans EB, et al. Contractures and scar formation in
the burn patient. Clin Plast Surg. 1974;1:653-666.
Larson DL, Evans EB, Abston S, et al. Techniques for decreasing scar for­
mation and scar contractures in the burn patient. J Trauma.
1971;11:807-823.
Linaris HA, Larson DL, Willis-Galstaum BA. Historical notes on the use of
pressure in the treatment of hypertrophic scars or keloids. Burns.
1993;19:17-21.

588.e1
53  •  Management of Contractural Deformities Involving the Shoulder (Axilla), Elbow, Hip, and Knee Joints in Burned Patients
10. Baur PS, Larson DL, Stacey TR. The observation of myofibroblasts in
hypertrophic scars. Surg Gynecol Obstet. 1975;141(1):22-26.
11. Linares HA, Kischer CW, Dobrkovsky M, Larson DL. On the origin of
the hypertrophic scar. J Trauma. 1973;13(1):70-75.
12. Linares HA, Larson DL, Willis-Galstaun BA. Historical notes on the
use of pressure in the treatment of hypertrophic scars or keloids.
Burns. 1993;19(1):17-21.
13. Neugebauer CT, Serghiou M, Herndon DN, Suman OE. Effects of a
12-week rehabilitation program with music & exercise groups on
range of motion in young children with severe burns. J Burn Care
Res. 2008;29(6):939-948.
14. Ponten B. The fasciocutaneous flap: its use in soft tissue defects of the
lower leg. Br J Plast Surg. 1981;34(2):215-220.
15. Chen B, Song H, Gao Q, Xu M. Pedicled fasciocutaneous flaps for cor­
recting scar contracture in pediatric patients-a retrospective study of
22 cases. J Pediatr Surg. 2016;51(7):1207-1215.
16. Kuo YR, Seng-Feng J, Kuo FM, Liu YT, Lai PW. Versatility of the
free anterolateral thigh flap for reconstruction of soft-tissue defects:
review of 140 cases. Ann Plast Surg. 2002;48(2):161-166.
17. Mardini S, Tsai FC, Yang JY. Double free flaps harvested from one or
two donor sites for one or two-staged burn reconstruction: models
of sequential-link and independent-link microanastomoses. Burns.
2004;30(7):729-738.
18. Junker JP, Kratz C, Tollback A, Kratz G. Mechanical tension stimulates
the transdifferentiation of fibroblasts into myofibroblasts in human
burn scars. Burns. 2008;34(7):942-946.
19. Hinz B, Mastrangelo D, Iselin CE, Chaponnier C, Gabbiani G.
Mechanical tension controls granulation tissue contractile activity
and myofibroblast differentiation. Am J Pathol. 2001;159(3):1009-
1020.
References
1. Agarwal S, Loder S, Brownley C, et al. Inhibition of Hif1alpha pre­
vents both trauma-induced and genetic heterotopic ossification. Proc
Natl Acad Sci USA. 2016;113(3):E338-E347.
2. Levi B, Jayakumar P, Giladi A, et al. Risk factors for the development
of heterotopic ossification in seriously burned adults: a National Insti­
tute on Disability, Independent Living and Rehabilitation Research
burn model system database analysis. J Trauma Acute Care Surg.
2015;79(5):870-876.
3. Schneider JC, Simko LC, Goldstein R, et al. Predicting heterotopic
ossification early after burn injuries: a risk scoring system. Ann Surg.
2016 Jun 24;[Epub ahead of print].
4. Cronin TD. Successful corrections of extensive scar contractures of
the neck using split thickness skin grafts. Trans First International
Congress on Plastic Surgery. 1957;123.
5. Willis B. A follow-up. The use of orthoplast isoprene splints in the
treatment of the acutely burned child. Am J Occup Ther. 1970;24(3):
187-191.
6. Larson DHT, Linaris H, et al. Prevention and treatment of scar con­
tracture. In: Artz CPMJ, Pruitt BA, eds. Burns A Team Approach. Phila­
delphia: WB Saunders; 1979.
7. Larson DL, Abston S, Evans EB, Dobrkovsky M, Linares HA. Tech­
niques for decreasing scar formation and contractures in the burned
patient. J Trauma. 1971;11(10):807-823.
8. Larson DL, Abston S, Willis B, et al. Contracture and scar formation
in the burn patient. Clin Plast Surg. 1974;1(4):653-656.
9. Huang TT, Blackwell SJ, Lewis SR. Ten years of experience in manag­
ing patients with burn contractures of axilla, elbow, wrist, and knee
joints. Plast Reconstr Surg. 1978;61(1):70-76.

589
Acute and Reconstructive Care
of the Burned Hand
DEREK M. CULNAN, KAREL D. CAPEK, TED HUANG, and WILLIAM LINEAWEAVER
54 
injury and burn resuscitation can cause a delayed appear­
ance of compartment syndrome and eschar compression.
Wound edema control is best accomplished with elevation.
As discussed in Chapter 8, lymph pressures are typically in
the 1–2 cm H2O range, and this gradient can often be over­
come with elevation by suspending the hand 50–100 cm
above the phlebostatic axis, thereby creating a sufficient
pressure gradient driving lymphatic drainage. Wounds
should be dressed in a manner such that the burned hands
can be monitored for neurovascular embarrassment and
progression of the burned wounds (see Box 54.1).
Acute Care of the Burned Hand
The goals of acute management of hand burns include
maintaining perfusion with resuscitation, neurovascular
protection through the release of eschar compression and
compartment syndromes, removal of necrotic burned
tissue, early grafting, and early ROM. Resuscitation and
hemodynamic support are critical because the heart is the
organ that perfuses the hands. Should eschar compression
or compartment syndrome develop, prompt decompression
is critical for limb salvage. Clinical examination is usually
sufficient to diagnose eschar compressions and compart­
ment syndromes, including paresthesias, pain, passive
resistance to extension, and loss of capillary refill in the nail
beds.
Escharotomies are the mainstay of decompression in
burn care. Incisions are made over the medial and lateral
midaxial lines through the skin down to the fascia. The
line of release extends both caudad and cephalad beyond
the margin of tissue swelling to ensure complete release.
Incisions on fingers are made along the midlateral line just
dorsal to the digital neurovascular bundle between Gray­
son’s and Cleland’s ligaments.3 Releasing incisions may be
extended into the web spaces and to the dorsal surface of
the hand to ensure the integrity of vascular supplies to the
intrinsic musculatures of the hand. Many centers promote
routine performance of escharotomies on both sides of
fingers, and we advocate this approach. In a randomized
control trial (RCT), a threefold increase in finger salvage was
found with extended digital escharotomies.4 Escharotomies
should be carried out liberally because all full-thickness
burns will eventually require excision and grafting, includ­
ing resection of the escharotomy incisions, as seen in
Fig. 54.2D, E.
Deep hand and arm burns may be insufficiently decom­
pressed with escharotomies alone; release of fascial com­
partments will be required. Incisional releases may be
carried out involving the forearm muscle compartment and
Introduction
The hand is a primary means of communication, aesthet­
ics, emotion, and sexuality. It exists at the core of our
humanity. Particularly in the modern age of digital com­
munication, the inability to interface with the digital world
via hands is socially and intellectually isolating. Hands are
injured in 80% of severe burns and are a primary American
Burn Association referral criterion. Loss of hand function
from burn injury frequently limits the patient’s ability to
work and requires evaluation for long-term disability, as
discussed in Chapter 63. Functional recovery of the burned
hand relies on quick and effective intervention by an expe­
rienced burn center.
Initial Assessment and First Aid
Successful restoration of hand function after burn injury
begins with first aid, continues through acute care and
occupational therapy (OT), and is augmented with recon­
structive surgery. A careful history should be taken includ­
ing the nature of the injury, but also of the patient’s hand
dominance, occupation, and special hand uses, such as
playing a musical instrument.
Initial treatment is directed to prevent both further injury
and conversion of the burn penumbra. First, the burning
process must be stopped by removing the patient from the
heat source and irrigating away any inciting chemicals.
Historically, icing the burn had been advocated;1 however,
in modern burn care, maintaining the wound warm is now
standard, and ice should be avoided. Blisters should be
débrided both to allow assessment of the underlying burned
dermis as well as to remove the cytotoxic mediators elabo­
rated in the blister fluid, which can deepen the burn injury.2
The burn should be staged for depth at physical examina­
tion, and the patient should have an initial assessment of
sensation, motor function, skeletal stability, and circulation
(Fig. 54.1). The thin dorsal skin can easily suffer a third- or
fourth-degree injury, whereas the thick glabrous palmar
skin can often heal from even an apparently deep injury.
Initial assessment is aimed at gross and limb-threatening
injuries. Distracting injuries, pain, and fear can prevent an
effective assessment of less obvious injuries, so patients
should be followed up and reassessed.
Careful and repeated assessments must be made for com­
promised perfusion due to compartment syndromes and
circumferential eschar constriction. These processes are
limb threatening, and a high index of suspicion and prompt
response must be maintained. Edema resulting from burn

54  •  Acute and Reconstructive Care of the Burned Hand
590
interosseous compartments dorsally, the thenar and hypo­
thenar compartments, and the palmar spaces as shown in
Fig. 54.2C. The carpal tunnel and Guyon’s canal should
routinely be released as part of treatment of compartment
syndromes of the hand.
The next goal of therapy is management of the skin
injury. Partial-thickness burns to the dorsum of the hand
are effectively treated with local care, skin substitutes, and
immediate motion. If minimal superficial eschar is present,
débridement can be achieved either operatively or with an
enzymatic agent such as collagenase. Standard skin substi­
tutes include homograft, xenograft, and ammonic mem­
brane, which provide a durable covering, a wound matrix,
growth factors to stimulate wound healing, and minimize
chronic wound granulation tissue formation. In recent
decades engineered skin substitutes (Integra, TransCyte,
Hyalomatrix) provide a similar skin substitution covering
and matrix in an acellular manner further discussed in
the carpal tunnel, as well as Guyon’s canal (Fig. 54.2). The
intrinsic muscles of the hand are particularly susceptible to
elevated compartment pressures. These muscles infarct and
contract, leading to an intrinsic-minus (claw) hand, dis­
cussed later. As such, care should be taken to release the
D
C
B
A
Fig. 54.1  Examples of burned hands. (A) A hand
that has sustained a first- and second-degree,
superficial partial-thickness burn with intact
blisters. (B) Second-degree burn that is deep
partial-thickness, typified by pallor mixed with
erythematous changes (e.g., mottling). (C) Find­
ings of skin anesthesia and vessel thrombosis
suggest full-thickness, third-degree skin burn.
(D) Carbonization suggests a complete destruc­
tion of the structures consistent with a deep,
fourth-degree burn.
Box 54.1  Management Priorities of the
Burned Hands
1. Evaluate burn and débride blisters
2. Decompression of compartment syndromes and eschar
constrictions
3. Early therapy and splinting
4. Early excision and grafting
5. Early and aggressive range of motion (ROM) with
occupational therapy
6. Secondary reconstruction of deformities

54  •  Acute and Reconstructive Care of the Burned Hand
591
F
E
D
B
A
I
II
III
IV
V
Thenar
muscles
Hypothenar
muscles
Ad. pollicis
Vol. interossei
Dor. interossei
Dor. interosseous
fascia
B
C
C
D
B
C
A
Fig. 54.2  Upper extremity escharotomies and fasciotomies. (A) A patient having completion of dorsal escharotomy incisions. (B) Drawing of dorsal
fasciotomy locations. (C) Drawing of dorsal hand fasciotomy locations and a cross-section demonstrating the access to decompress all the compart­
ments of the hand. Note the dorsal incisions decompressing the four dorsal interosseous compartments (incisions B and C), as well as accessing the
adductor pollicis compartment via the second dorsal interosseous. The thenar muscles are decompressed via incision “A” volarly and radially, and the
hypothenars are decompressed via incision “D” volarly and ulnarly. (D) Example of digital escharotomy incisions. (E) Subsequent escharotomy dem­
onstrating that escharotomy incisions should be made liberally because all eschar will be subsequently resected. (F) Placement of homograft on
escharotomized fingers, secured with sutures. (A, D, E, and F are courtesy of Dr. Lineaweaver; B and C are used with permission from Rowland S. Fasciotomy:
the treatment of compartment syndrome. In: Green DP, ed. Operative hand surgery. vol. 1, 2 edn. New York: Churchill Livingstone; 1988: 678-679.)

54  •  Acute and Reconstructive Care of the Burned Hand
592
to argue for grafting the dorsum in the fist position because
this increases the total skin length by 20% and mitigates
some of the risk of extension contracture because split-
thickness skin grafts (STSG) are known to contract up to
30–50% of the total graft area.11,12 While there are data
to support all of these grafting and splinting protocols, the
primary goal is to begin hand therapy as soon as possible.
In our experience, fibrin glues help achieve this goal effec­
tively with initiation of motion on the first postoperative day
(Fig. 54.4).
In cases where the paratenon of the extensor mechanism
is compromised, skin grafts may not take well. In these cases
the options are to allow granulation tissue to form on the
tendons and cover with a skin graft, cover the tendons with
an artificial dermal template and delayed skin grafting, or
to use immediate flap coverage. Permitting the extensor
mechanism to granulate with delayed skin grafting can
compromise long-term hand function as the tendon
becomes entrapped in scar. Such delayed treatments,
however, become the treatment of choice in the setting
where large burns and their threat to life are more pressing
treatment priorities. Artificial dermal regeneration tem­
plate materials can be effective in primary burn treatment,
but these adjuncts are susceptible to infection in large or
colonized burn wounds. In a well-selected patient these
adjuncts have minimal complications, high engraftment,
good cosmetic and functional outcomes similar to native
skin,5 and they demonstrate improved Vancouver scar scale,
fingertip-to-palm score, and prehensile score.13
Early flap coverage of dorsal hand burns is an effective
technique to cover and protect the extensor mechanism.
Flap choice is often limited by the overall physiological
state of the patient. The groin flap remains an option for
expedience and reliability, although the bulky nature, pro­
longed inset, limited ROM, and obstruction to OT make it a
flap to be used only when other regional or microvascular
flaps are contraindicated. The merits of various flap tech­
niques are discussed later in this chapter but are equally
relevant to primary coverage. Both the posterior interosse­
ous artery flap and the reversal radial artery flap can cover
the majority of the hand. These flaps are reliable, techni­
cally straightforward, thin, and do not limit OT, making
them practical options for coverage of the burned hand
(Fig. 54.5).
Management of burns to the palm is most often expect­
ant. The thick glabrous skin of the palm has deep reticular
structures and appendages allowing skin regeneration with
minimal sequelae in most burns. In the event that grafting
is required, there is continuing controversy over the best
graft source: STSG, full-thickness skin graft (FTSG), or
medium-thickness glabrous skin graft (MTGSG). Herndon
et al. reported that STSG functions as well as FTSG for palm
burns.14 Conversely Pham et al. have demonstrated that
FTSG performed better for palm burns in children.15 MTGSG
is the best tissue match, with good graft take and low donor
site morbidity.16 In a 12-year experience with MTGSG, good
sensation, color, and donor healing were reported.17 Plantar
glabrous skin also transfers Meissner’s corpuscles and sweat
glands, structures that may be important to the fine sensa­
tion and grip needed on the palms. We tend to use STSG but
the appropriate patient can find good utility in all of these
techniques.
Chapter 15.5 Other synthetic dressing materials such as
nylon mesh with collagen matrix (Biobrane), polylactic acid
(Suprathel), and silver ion-containing nonadherent long-
term coverings (Mepilex or Acticoat) are used functionally
as skin substitutes.6 Collectively these materials function as
skin substitutes, remaining in place, protecting the wound,
providing a wound matrix, and allowing reepithelialization.
However aggressive care and use of skin substitutes is
advised to minimize scarring and fibrosis and maximize
long-term hand function. Thermoplastic custom hand
splints applied immediately play an important role in main­
taining hand position while at rest (Fig. 54.3). Immediate
ROM, however, is the most important intervention to main­
tain hand function. In cases where the wound is not super­
ficial, delayed, or “conservative: burn wound treatment
inevitably leads to delays, which can result in a poor
outcome for the patient. Early removal of all eschar is at the
core of modern burn care. In the setting of large burn
wounds, definitive grafting of the hands may need to be
delayed due to limitations of available grafts; hand wounds
then need to be temporized with cadaveric skin. However
grafting of the hands should be a high-priority limb-saving
treatment, even in extensive burn injuries.
Deep burns to the dorsum of the hand are common
because the skin is thin and the dorsum is exposed to injury
in the protective reflex. Additionally, there is very little sub­
cutaneous tissue so the extensor mechanism is susceptible
to fourth-degree injury, particularly at the proximal inter­
phalangeal (PIP) joint. The use of a split-thickness sheet
skin graft is the preferred covering for the dorsum of the
hand, providing the best scars and color match, although
1 : 1 meshing has similar outcomes.3 The means of secur­
ing the graft, splinting, and the timing of therapy are areas
of continuing controversy. Many groups now secure grafts
with fibrin sealant or sutures and begin gentle active ROM
in the first postoperative day.7,8 Other groups continue
to immobilize fingers in the intrinsic-plus position with
K-wires for up to 6 weeks while reporting no permanent loss
of ROM or articular surface damage.9,10 Still other groups
advocate immobilization of the hand during engraftment
with splints for short periods of time. Finally some continue
Fig. 54.3  Example of thermoplastic hand splinting. A hand splinted in
intrinsic-plus position, also known as the “safe position.” The distal
interphalangeal–proximal interphalangeal (DIP-PIP) joints are main­
tained at full extension, metacarpophalangeal (MCP) joints at 70
degrees flexion, and the wrist at 30 degrees extension.

54  •  Acute and Reconstructive Care of the Burned Hand
593
splinting maximizes ligament and skin stretch in the posi­
tion of function. The implication that the hand is safe in this
position ignores the fact that the best position for the hand
is in motion. No splinting should be considered as a resting
substitute for active ROM.
OT can perform full ROM of all hand joints in the operat­
ing room prior to grafting to establish maximal mobility
without pain and allowing the OT to be far more aggressive
and expedient. This intervention can occur in parallel with
other aspects of an operation thereby not increasing opera­
tive time. When fibrin glue or sutures are used to secure a
sheet graft, therapists can take down the dressing on post­
operative day 1, evaluate the graft, and evacuate any hema­
toma or seromas. If the graft is adherent to the wound bed,
composite fist therapy should be initiated. Grafts are then
dressed with functional compressive dressing and intrinsic-
plus thermoplastic splints worn at night. Full range of hand
motion can be achieved in 5 days with this protocol. Finally
compression gloves should be manufactured to limit edema,
hypertrophic scarring, and shearing of grafts.
Mobilization of the elbow is critical, and this joint should
be kept extended to maintain maximal ligament length.
Extension, however, is not a position of function, and, as
such, elbow contractures in extension are debilitating
because the patient is unable to reach hand to mouth.
Therefore elbow ROM exercises are critical. The shoulder is
Occupational Therapy of the
Burned Hand
Active motion is the means by which the hand maintains
plasticity. The burned hand is predisposed to fibrosis because
skin grafts and scars contract and deform the hand, while
pain, edema, dressings, and splints limit hand mobility. As
such, daily OT and a close working relationship between the
surgeon and the therapist are critical to functional out­
comes, reducing the need for secondary reconstruction to
as low as 3.7% at 9 years according to Kreamer and Deitch.18
A sufficient number of therapists should be available to
treat each patient 1–2 times per day. A ratio of one therapist
to seven patients is a good rule of thumb to allow for suffi­
cient care. However the practicalities of early and aggres­
sive OT are often limited by the particular practice scenario
such as available personnel and other life-saving interven­
tions, such as critical care or large burn wounds. Caring for
hand burns requires extensive OT intervention and exper­
tise in terms of physiotherapy and wound care usually only
available at specialized centers.
The overall goals of OT are to maintain maximal hand
movement, protect grafts, provide effective and well-fitting
splints to maintain ligament length, and guide the patient’s
recovery toward maximum hand function. Intrinsic-plus
C
B
A
Fig. 54.4  Example of excised and grafted dorsal hand burn. Hand having
undergone primary dorsal split-thickness skin grafts (STSG) sheet graft­
ing, secured with sutures in intrinsic-plus splinting with early motion
protocol. (A) Dorsally STSG sheet grafted hand in full active extension,
and (B) in active composite fist volar view and (C) dorsal view. (Courtesy
of Dr. Lineaweaver)

54  •  Acute and Reconstructive Care of the Burned Hand
594
A
B
D
E
C
Fig. 54.5  Examples of regional pedicle flaps for hand coverage. (A) Dorsal hand and wrist defect, (B) markings for posterior interosseous nerve flap,
(C) elevated in a fasciocutaneous manner, (D) rotated and inset to close a dorsal hand defect. (E) Follow-up image of healed posterior interosseous
nerve flap.

54  •  Acute and Reconstructive Care of the Burned Hand
595
tissue coverage is critical to preventive and secondary treat­
ment of these deformities. Chronic wounds also occur com­
monly and require operative excision and closure. The loss
of structures such as digits or extensor tendons is also
common, and a reconstructive balance needs to be struck
between the desire for definitive reconstruction and the
patient’s tolerance for additional surgery.
RECONSTRUCTIVE METHODS
It is important when reconstructing the hand to use the
“reconstructive elevator” to determine the best solution for
the patient and not move in a stepwise fashion through
inadequate treatments. First, the contracture is incised or
resected, the joints maximally stretched, and the entire
extent of the tissue deficit made manifest (Fig. 54.6).
a. Primary closure of the wound: This technique is used
to close a wound resulting from the excision of hyper­
trophic scar tissues. Primary closure should only be
considered when adjacent skin permits tension-free,
nondeforming repair.
b. Grafting of a wound: In situations where a skin con­
tracture has occurred, if the contracture can be
released leaving an adequate bed for additional skin
grafts, then either STSG or FTSG can be considered a
sufficient skin envelope.
c. Skin flaps: Often an adequate bed cannot be established
for a skin graft because critical structures need to be
covered or the recurrence of skin graft contracture is
a major concern. In these cases a random pattern skin
flap can be designed to close the wound. Classic flap
designs, including z-plasty, modified three-quarters
z-plasty transposition flap technique, rhomboids, rota­
tions, and advancements, are all reasonable choices in
the circumstances when adjacent tissue can be used
for a flap (Fig. 54.7). The operating surgeon should
not feel constrained to one type of tissue rearrange­
ment and should choose the best surgery based on the
defect and available adjacent tissue.
d. Muscle flaps, musculocutaneous (MC) flaps, and fascio­
cutaneous (FC) flaps: The vascular supplies to skin flap
skin are enhanced by incorporating the muscle,
fascia, or paratenon. The flap is mobilized to fill a
defect resulting from scar release as a local, regional,
or distant microsurgical flap (Fig. 57.16). In many
cases early microsurgical reconstruction allows the
best and most efficacious coverage of the wound and
should be part of the armamentarium of surgeons
treating these injuries. Muscle flaps bring a viable
muscle to cover a wound, and the flaps themselves
are covered with STSG (e.g., rectus flap). Musculocu­
taneous flaps bring a vascularized muscle with its
overlying skin to cover a wound (e.g., latissimus dorsi
flap). Fasciocutaneous flaps bring vascularized fascia
with overlying skin to cover a defect (e.g., radial
artery flap). Fascial flaps bring viable fascia and are
subsequently covered with STSG (e.g., temporopari­
etal fascia flap). The best reconstruction technique
depends on the patient’s available donor tissue areas
and overall health and tolerance for reconstruction
and should not be constrained by the surgeon’s
similarly best splinted in abduction to prevent axillary con­
tractures. However abduction is not a position of function,
and ROM therapy is again critical.
Management of Established
Burned Hand Deformities
Long-term hand deformities can develop and cause pro­
gressive deformities and disabilities despite aggressive acute
care. As discussed earlier, the best option to avoid recon­
struction is assiduous acute care. Early excision and graft­
ing of hand burns within 4–6 days of injury gives a fivefold
reduction in the need for secondary correction of scars or
of being debilitated.19 When deformities occur refractory
to OT, early reconstruction is advocated.3 It is critical that
both the surgeon and the patient have realistic expecta­
tions of the reconstruction and acknowledge that full pre­
morbid restoration of hand function can rarely, if ever, be
accomplished.
The most common pathophysiology of burn deformity is
insufficient skin coverage from scar contracture. This
primary skin contracture limits or deforms hand movement
and leads to a fibrosis of the tendinous and ligamentous
structures of the hand with progressive loss of function.
Early establishment of durable, flexible, and sufficient soft
F
G
H
(F) Line drawing of a distally based radial forearm
flap, (G) raised and (H) inset to cover a dorsal hand injury. (A–E are used
with permission from Baylan JM, Chambers JA, McMullin N, et al. Reverse
posterior interosseous flap for defects of the dorsal ulnar wrist using previ­
ously burned and recently grafted skin. Burns. 2016;42(2):e24–30. F–H are
used with permission from Lineaweaver WC, Buncke HJ. Flap reconstruc­
tion of the hand. In: Jupiter JB, ed. Flynn’s hand surgery. 4 edn. Philadelphia:
Williams & Wilkins; 1991: 607–625.)
Fig. 54.5, cont’d

54  •  Acute and Reconstructive Care of the Burned Hand
596
the deformity and immobilization of the primary skin
contracture. The contracted skin is released and a skin
defect created by extending the contracted hand, as in
Fig. 54.6. The resulting skin defect can then be closed by
utilizing a transpositional skin flap technique (e.g., three-
quarters z-plasty), pedicled flap, or skin graft, as in Fig.
54.6. Skin grafting is a viable option for closure of defects
where no critical structures are exposed. As discussed in
the acute burn section, there are controversies over the
use of a dermal matrix, FTSG, STSG, or MTGSG should
a volar graft be needed. If release of the contracture is
inadequate, a capsular release of the affected joint may
be needed.
In the setting of exposed critical structures (neurovascu­
lar bundles, tendons or bones), upon release of a volar con­
tracture the best reconstruction depends on the available
technical ability or knowledge. Regardless of the
tissue donor chosen, care must be taken to limit bulk
and allow the patient to move the intricate joints of
the hand freely.
Reconstruction of Phalangeal
Deformities
FLEXION CONTRACTURE DEFORMITIES
Flexion contractures usually occur from deep or full-
thickness burns to the volar skin causing inadequate
skin length. Joint and tendon sheath contractures can
be contributing elements developing secondarily from
D
C
B
A
Fig. 54.6  Release of palmar flexion contracture
with split-thickness skin grafts (STSG). (A)
Palmar contracture in a 7-year-old child. (B) The
tissue deficit created after releasing the contrac­
ture and extending the fingers manifests the
true skin deficiency. (C) STSG inset into the
defect. The digits held in extension with intra­
medullary K-wires. (D) The release of the digits
achieved by palmar release.

54  •  Acute and Reconstructive Care of the Burned Hand
597
A
B
C
D
A
A'
a
a
b
b
B'
B
A
B
E
F
Fig. 54.7  Examples of local flaps for wound coverage in the hand. (A–D) Elevation and inset of dorsal interosseous artery flap. These exist in each web
space and can be used to cover the finger out to the distal interphalangeal (DIP) joint with sensate tissue. (E) Line drawing of a z-plasty transposition
flap. An incision is made along the contracture scar then flaps raised perpendicular at angles of 60 degrees. The flaps are then transposed, increasing
the length of the scar. Typically flaps with tip angles of 60 degrees will increase in length of a contracture by 60% (75% by calculation). (F) Line draw­
ings, elevation, and inset of neurovascular-island flap which can effectively cover the fingers, including the pad, with sensate glabrous tissue.

54  •  Acute and Reconstructive Care of the Burned Hand
598
a
a
a
a'
a'
a'
b'
b'
b
b
K
L
G
H
J
I
(G–J) Line drawings, elevation, and inset of cross-finger flap which can effectively cover any part of the finger. (K) Line drawing of a
hand with a flexion contracture of the small finger and an unstable thumb amputation wound marked with a Limberg (rhomboid) flap closure that
will deepen the first web space and close the defect. The internal angles of the Limberg flap are 60 and 120 degrees, the width equals a to a’ and the
donor defect of b to b’ must close primarily. (L) Line drawing showing the Limberg flap rotated into position as well as the flexion contracture of the
small finger released by transposition of multiple z-plasty flaps. (A–D are used with permission from Agir H, Sen C, Alagoz S, Onyedi M, Isil E. Distally based
posterior interosseous flap: primary role in soft-tissue reconstruction of the hand. Ann Plast Surg. 2007;59(3):291–296. E–K are used with permission from
Lineaweaver WC, Buncke HJ. Flap reconstruction of the hand. In: Jupiter JB, ed. Flynn’s hand surgery. 4 edn. Philadelphia: Williams & Wilkins; 1991: 607–625.)
Fig. 54.7, cont’d
donor tissue. The use of an axial lateral digital flap, a neu­
rovascular island flap (Littler flap), a dorsal metacarpal
artery flap, or a cross-finger flap may be necessary for a
finger that has lost sensory supply to restore not only the
soft tissue deficit but also the sensory supply (Fig. 54.7).
When local flaps are inadequate, a dermal matrix may
allow a staged reconstruction. The reconstructed finger is
maintained at full extension by splinting. Alternatively a
Kirschner wire placed intramedullary or underneath the
flexor tendon sheath to maintain finger position for a period
of 10–14 days can be effective.
EXTENSION CONTRACTURE DEFORMITIES
Burns to the dorsum of the hands are common, and these
burns are often significant due to the thin skin and finely
tuned extensor mechanism. Deformities here occur from
insufficient skin envelope, exposed or compromised tendons
and joints, tendon adhesion, and tendon disruptions (e.g.,
Boutonnières deformities). Surgical intervention is often
needed to correct an established deformity refractory to OT
interventions.
When there is insufficient skin on the dorsum of the
hand, contractures can be released, constricting scar tissue
resected, and the defect regrafted with STSG. STSG recon­
struction can compromise tendon glide if the paratenon is
compromised, although early motion protocols help main­
tain motion. For small defects, a three-quarters z-plasty
transposition flap can be beneficial over the metacarpopha­
langeal (MCP) joint (Fig. 54.8). Often, for large deficits over
the dorsum, a distant flap is needed, such as a distally based
posterior interosseous flap, which can provide large-area
durable coverage with good tendon glide.20 This flap can be
used when the donor area is burned and even in the acute
burn setting when the donor area is recently skin grafted21
(Fig. 54.5). Similarly propeller flaps can be constructed
with reliability in the upper extremity.22 Temporoparietal
fascia free flaps can also provide excellent tendon glide, and
microvascular flap coverage should be available to hand
burn patients. Classically, large defects of the dorsum of
the hand are covered with groin flaps, which are described
later in the electrical burn section (Fig. 54.9). It is far pref­
erable to use a flap that allows one-stage coverage and
early motion, so groin flaps should only be employed in the
rare circumstance where local, regional, and free flaps are
contraindicated.
Extension contractures to the fingers are also common.
They are released by incising the scar over the deformed
finger joint(s) (i.e., the deformed distal interphalangeal
[DIP], PIP, and MCP joints). If needed, the joint capsule is
released. The resultant defect can be closed with the three-
quarters z-plasty technique (Fig. 54.8). STSG can be used

54  •  Acute and Reconstructive Care of the Burned Hand
599
F
E
D
C
B
A
Fig. 54.8  Examples of contractures treated with local transpositional three-quarters z-plasty. (A) Metacarpophalangeal (MCP) joint extension con­
tracture with three-quarters z-plasty transposition flap marked. (B) MCP contracture released with transverse incision and transposition flap raised.
(C) Three-quarters z-plasty flap rotated into position and flap donor area closed directly, (D) with follow-up at 3 years. (E) Release of flexion contracture
of wrist with three-quarters z-plasty transposition flap marked. (F) Skin defect is manifest when the flexion contracture is released with a transverse
incision.

54  •  Acute and Reconstructive Care of the Burned Hand
600
(G) Transposition flap raised
in a fasciocutaneous manner and (H) rotated
into the skin defect on the volar wrist. (I) Flap
donor area closed with split-thickness skin graft,
and (J) contracture release persists at 4-year
follow-up.
Fig. 54.8, cont’d
J
I
H
G
for defects over the MCP joint. Dorsal metacarpal artery
flaps allow coverage of the extensor hood out to the DIP
joint. These flaps are elastic, durable, and sensate coverage
for digits.23 FTSG and cross-finger flaps also provide effective
coverage options (Fig. 54.7).
The thin covering of the dorsum of the finger results in
many central slip injuries and resultant Boutonniere
deformities. PIP fusion or amputation is common because
tenoplasty often fails in this setting of poor soft tissue cover­
age. Finally fat grafting can be used to repair contour defor­
mities from severe contracture and burns to the hand.24 Fat
grafts may also improve tendon glide by elevating prior skin
grafts off the extensors (Fig. 54.10). In a recently published
series fat grafting was shown to significantly improve scar,

54  •  Acute and Reconstructive Care of the Burned Hand
601
Z-plasty, advancement flaps, and V-Y advancements are
also viable means of reconstruction. No additional phys­
iotherapy is necessary. Unrestricted use of the hand daily
will restore the web space and the movements of the fingers
(Fig. 54.11).
First Web Space Contracture
First web space contracture is functionally significant
because of limitations of thumb extension, abduction, and
opposition. While conventional techniques, such as z-plasty
and skin grafting, may be used to reconstruct the deformity,
the technique combining two z-plasties with one central
contour, and Michigan Hand Outcome Assessment com­
pared to the unaffected hand.25
WEB SPACE CONTRACTURE
Narrowing of the web space is a common sequela of hand
burns. Placement of unburned tissues in the dorsal aspect
of the web space is the key to reconstruction. Reconstruc­
tion can be achieved through the use of a triangular skin
flap mobilized from either the radial or ulnar side of the
fingers and then rotated into a contracted web space, espe­
cially to the second, third, and fourth, to achieve the release.
D
E
F
C
B
A
Fig. 54.9  Abdominal flap. (A) Extensive volar burn covered with inferior superficial epigastric artery-based abdominal flap (B). (C) Abdominal flap
following division. (D–F) Line drawings demonstrating the anatomy and inset of a superficial epigastric artery-based abdominal flap. (D–F used with
permission from Lineaweaver WC, Buncke HJ. Flap Reconstruction of the hand. In: Jupiter JB, ed. Flynn’s hand surgery. 4 edn. Philadelphia: Williams & Wilkins;
1991: 607–625.)

54  •  Acute and Reconstructive Care of the Burned Hand
602
A
B
Fig. 54.10  Fat grafting dorsal hand under split-thickness skin graft (STSG). Hand with dorsum extension contracture and contour defect treated with
fat grafting. (A) Dorsally STSG hand with extension contracture. Note the sharp demarcation of the STSG’s skin color and contour from the native skin
at the level of the metacarpophalangeal (MCP) joint and wrist. (B) Six-month follow-up after a single fat grafting with a modest but significant increase
in range of motion, scar quality, and hand outcome score in this preliminary study. Note the clear line demarcating the previously placed STSG at the
level of the MCP and wrist, which now has improved contour and color. The authors postulate multiple graftings might have cumulative effects by
releasing tethered skin and remodeling the subcutaneous layer in the hand. (From Byrne M, O’Donnell M, Fitzgerald L, Shelley OP. Early experience with
fat grafting as an adjunct for secondary burn reconstruction in the hand: technique, hand function assessment and aesthetic outcomes. Burns.
2016;42(2):356–365.).
C
B
A
Fig. 54.11  Release of web space contracture. (A) Contracture of the right second web space with markings for three-quarters z-plasty transposition
flap release. (B) The flap was rotated dorsally and the wound was closed primarily. (C) The appearance of the operative site 3 years following the
release.