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

54  •  Acute and Reconstructive Care of the Burned Hand
604
F
E
D
C
B
A
Fig. 54.13  Index finger pollicization. (A,B) The skin drawing
marked the skin edges of the index finger remnant. (C,D) The index
finger remnant was fabricated as a composite island flap containing
bony skeleton and the neurovascular bundles. The island flap was
transferred to the remnant of the thumb. K-wires were used to
anchor the flap. (E) The thumb remnant was lengthened by stack­
ing the index finger remnant. The web space was deepened by
removing the second metacarpal. (F) X-ray of a different hand fol­
lowing pollicization that demonstrates the bony changes associ­
ated with the procedure (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.)
digital post. In many patients deepening the first web space
provides an adequate post for grip and pinch.
The technique of stacking a remnant of the index finger
to the thumb ray to elongate the thumb remnant and
deepen the first web space has been used in Galveston for
the past 30 years. Functionally this is a form of pollicization
of the index finger. The remnant of the index finger is
transected at the metacarpal or proximal phalanx level. The
index finger is mobilized as a flap with its neurovascular
bundle intact. The proximal bone margin of the index finger
is fixed to the distal end of the thumb remnant. Resection
of the index metacarpal deepens the first web space. The
procedure carries low morbidities and could be performed
in an outpatient surgical facility (Fig. 54.13).

54  •  Acute and Reconstructive Care of the Burned Hand
605
Microvascular toe-to-thumb transfer has been demon­
strated to lead to good functional outcomes.27 The tech­
nique is beyond the scope of this chapter,28 but it can provide
very high satisfaction and result in a functional and sensate
thumb.29 Furthermore, multiple toes can be transferred to
reconstruct function in the fingerless “metacarpal only”
hand (Fig. 54.14).30
RECONSTRUCTION OF A CLAW HAND
The burned hand can develop a claw deformity from mul­
tiple etiologies. The classic claw hand, the intrinsic-minus
hand familiar to all hand surgeons, can develop from ulnar
nerve injuries either in the primary burn injury, compres­
sion at Guyon’s canal, or compression at the cubital tunnel.
A
B
C
E
D
Fig. 54.14  Toe-to-hand transfer. (A) Metacarpal hand after closure with pedicled groin flap. (B) Thenar muscle function maintained. (C) Design of skin
incision with recipient vessels marked. (D) Donor toes marked with right great toe and left combined second and third toes. (E) Tripod pinch present
at 3-year follow-up. (From Vivek Jain F-CW. The metacarpal hand. In: Norman Weinzweig JW, ed. The mutilated hand. Lansing: University of Michigan/Elsevier
Mosby; 2005: 280.)

54  •  Acute and Reconstructive Care of the Burned Hand
606
repose with MCP hyperextension and PIP contracture. This
claw-like hand is treated by total scar excision and coverage
with skin grafts or flaps. Early and aggressive OT is essential
to regain intrinsic function.31
Electrical Injuries Involving the
Upper Limb
Electrical injuries are discussed in detail in Chapter 38 on
electrical burns, but they are important to consider here
because the upper extremity is a common contact point for
electrical injury. Injuries often include the entire extremity
(i.e., the shoulder to the hand). The damaged structures
noted are mostly the muscles in the arm, neurovascular
bundles, and the skin over contact points in the forearm and
in the hand. The bones typically generate heat due to their
high resistance and burn the tissue from the inside out.
Thus a fourth-degree injury is common, and aggressive
treatment is needed.
Various classification schemes have been described for
electrical burns of the upper extremity but are clinically
cumbersome and do not guide treatment. Treatment and
diagnostic priorities are the same as all burn injuries: rees­
tablishment of blood flow, débridement of necrotic tissue,
decompression, early graft coverage, and early ROM. The
incidence of extremity amputation in cases with deep, cir­
cumferential electrical burns can be in the range of
25–80%, attributable to vascular injuries. Assessment of
vascular injuries and vascular compression in patients with
electrical burns is, therefore, extremely important at the
time of initial evaluation. The structural and functional
integrity of the arteries is assessed with clinical exam,
Doppler flow, magnetic resonance imaging (MRI), and angi­
ography. Surgical exploration remains the definitive strat­
egy for diagnosis and treatment. Patients sustaining
electrical burns of the upper limb are frequently found to
suffer other life-threatening injuries. Surgical débridement
of burn wounds and wound exploration are planned as part
of their overall stabilization.
Decompressive Escharotomy and Fasciotomy
Decompression to reestablish blood flow is particularly criti­
cal in electrical injuries. Tissue destruction particularly
involving deep structures inevitably leads to interstitial
extravasation of tissue fluid and tissue swelling. The release
of muscle compartments is necessary in instances where
the muscle compartments are swollen. Without releasing
procedures, ischemia can cause muscle necrosis and nerve
injury (Fig. 54.2). Deep muscles in contact with the bones,
such as the pronator quadratus and rotator cuff muscles,
are particularly at risk of necrosis and should be evaluated
during decompressive surgery. Necrotic muscles should be
removed as soon as possible to prevent systemic toxicity
such as renal failure.
Early Débridement
In patients with obvious, deep burns to the arm and with
life-threatening injuries, early proximal amputation should
be considered. A proximal amputation can quickly remove
extensive necrotic muscle, particularly when the rotator
cuff muscles are infarcted. Prompt amputation of an
In these cases ulnar nerve decompression can improve
hand function.
A claw hand deformity can occur from necrosis of
intrinsic hand musculature thereby creating an intrinsic-
minus repose. In these cases ulnar nerve tendon transfers
used to treat the intrinsic-minus hand from ulnar nerve
injuries are not typically successful in the burned hand
due to the overall soft tissue damage to the hand. Joint
fusions in a position of function can improve overall hand
function.
A claw-like deformity can also occur in burned hands
with intact ulnar innervation and intrinsic musculature
(Fig. 54.15). Scar contracture can create intrinsic-minus
A
B
C
Fig. 54.15  Claw-like hand. (A) Classic presentation of the “claw-like
hand” with metacarpophalangeal (MCP) joint hyperextension, inter­
phalangeal (IP), proximal and interphalangeal (PIP) flexion, and thumb
adduction. This intrinsic-minus repose appears identical to a claw hand
from an ulnar nerve palsy but in this case is from a severe dorsal con­
tracture. (B) Treatment consists of a transverse releasing incision proxi­
mal to the MCP (arrows) allowing MCP capsulotomy and flexion, then
closure with a split-thickness skin graft (STSG). (C) Follow-up demon­
strates composite grip and intrinsic function of the hand. (From Sabapa­
thy SR, Bajantri B, Bharathi RR. Management of post burn hand deformities.
Ind J Plast Surg. 2010;43(Suppl):S72–79.)

54  •  Acute and Reconstructive Care of the Burned Hand
607
unsalvageable upper extremity can be a life-saving proce­
dure that avoids hemorrhage and sepsis as well as the meta­
bolic complications of multisystem organ failure from
myonecrosis. This can be life-saving due to the risk of renal
failure from rhabdomyolysis and the susceptibility of
necrotic muscle to mold infection.
Complete débridement is advisable in the 1–2 days fol­
lowing injury. The procedures should include removal of all
devitalized tissues, ascertaining the viability of intrinsic
muscles and pronator and supinator muscles. Every effort
should be made to preserve all forearm nerve structures
unless nerve viability is clearly lost. Vascular continuity, in
instances where the patency of both radial and ulnar arter­
ies is compromised, may be restored by means of vein grafts,
although often arterial thrombosis is a marker of severe
necrosis and nonreconstructable disease.
Wound Management
The magnitude of tissue damage in high-voltage electrical
burns is often so extensive that it involves muscles and blood
vessels. Limb removal, in such instances, is the sole treat­
ment option left to minimize lethal consequences of the
injuries. The conventional regimen of a split-thickness skin
graft for wound coverage is often not feasible because
wound beds are devoid of vascular supplies and/or tissue
loss is extensive (Fig. 54.16). Instead, local or distant flaps
are used for wound coverage and protection of nerves,
vessels, joints, and tendons. The pedicled abdominal flap
has utility in this setting because the arm is within the zone
of injury and local or regional flaps may have been compro­
mised (Fig. 54.9).32,33 However, even in the setting of electri­
cal injuries, distant pedicled flaps should only be used in the
rare instances where local, regional, and microvascular
flaps are contraindicated or unavailable. An angiogram can
clarify which regional flaps and microvascular recipient
vessels are available.
FUNCTIONAL RECONSTRUCTION OF
LIMB DEFORMITIES
Loss of limb function is not uncommon following electrical
injuries. Insufficient vascular supply, extensive nerve and
musculotendinous damage, and loss of muscle functions
involving the shoulder girdle and the forearm, as well as loss
of intrinsic musculatures of the hand are factors responsi­
ble for the difficulties encountered. Maintaining joint mobil­
ity and replacement of lost soft tissue in the forearm and
hand are two key features necessary for functional recon­
struction. Patients are encouraged to follow an OT regimen
to maintain joint mobility, particularly of the finger joints.
C
B
A
Fig. 54.16  Microvascular flap reconstruction. Anterolateral thigh fas­
ciocutaneous flap transferred with microsurgical technique to cover
extensive wound to volar arm and hand with exposed tendons and
median nerve.

54  •  Acute and Reconstructive Care of the Burned Hand
608
Complete references available online at

Further Reading
Agir H, Sen C, Alagoz S, Onyedi M, Isil E. Distally based posterior interos­
seous flap: primary role in soft-tissue reconstruction of the hand. Ann
Plast Surg. 2007;59(3):291-296.
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.
Greenbalgh DG. Management of acute burn injuries of the upper
extremity in the pediatric populations. Hand Clin. 2000;16(2):175-
186.
Luce EA. The acute and subacute management of the burned hand. Clin
Plast Surg. 2000;27(1):49-63.
McKee DM. Acute management of burn injuries to the hand and upper
extremity. J Hand Surg. 2010;35(9):1542-1544.
Moore ML, Dewey WS, Richard RL. Rehabilitation of the burned hand.
Hand Clin. 2009;25(4):529-541.
Sabapathy SR, Bajantri B, Bharathi RR. Management of post burn hand
deformities. Indian J Plast Surg. 2010;43(suppl):S72-S79.
Tredget EE. Management of the acutely burned upper extremity. Hand Clin.
2000;16(2):187-203.
Vivek Jain F-CW. The metacarpal hand. In: Norman Weinzweig JW, ed. The
Mutilated Hand. Lansing: University of Michigan/Elsevier Mosby;
2005:280.
Successful nerve grafting for sensory restoration and/or
tendon transfer procedures for digital movements require
prior skin flap procedures mobilized from an adjacent area
or a free flap transferred via microsurgical means to restore
the soft tissue coverage of the injured site. Restoration of
the tendon activities is contemplated once these procedures
are completed. At a minimum, the rehabilitative regimen
in general takes 2–3 years to complete. Centers unable to
offer the full range of reconstruction should refer patients to
those more versed in limb salvage and hand surgery.
Conclusion
Effective hand reconstructive procedures rely not only on
the surgeon’s surgical judgment and skill but also on effec­
tive OT and the patient’s compliance with rehabilitative
treatment. As such it should only be attempted at centers
with specialized surgical and therapeutic expertise. An
experienced burn reconstructive hand surgeon can help
move a patient toward even greater maximal medical
improvement. A well-planned regimen is essential to restore
these individuals to their former lives. This must be carried
out in a multidisciplinary manner with an experienced
surgeon and therapist.

608.e1
54  •  Acute and Reconstructive Care of the Burned Hand
18. Kraemer MD, Jones T, Deitch EA. Burn contractures: incidence, pre­
disposing factors, and results of surgical therapy. J Burn Care Rehabil.
1988;9(3):261-265.
19. Tambuscio A, Governa M, Caputo G, et al. Deep burn of the hands:
early surgical treatment avoids the need for late revisions? Burns.
2006;32(8):1000-1004.
20. Agir H, Sen C, Alagoz S, et al. Distally based posterior interosseous
flap: primary role in soft-tissue reconstruction of the hand. Ann Plast
Surg. 2007;59(3):291-296.
21. Baylan JM, Chambers JA, McMullin N, et al. Reverse posterior interos­
seous flap for defects of the dorsal ulnar wrist using previously burned
and recently grafted skin. Burns. 2016;42(2):e24-e30.
22. Vitse J, Bekara F, Bertheuil N, et al. Perforator-based propeller flaps
reliability in upper extremity soft tissue reconstruction: a systematic
review. J Hand Surg Eur Vol. 2016;42(2):157-164.
23. Eski M, Nisanci M, Sengezer M. Correction of thumb deformities
after burn: versatility of first dorsal metacarpal artery flap. Burns.
2007;33(1):65-71.
24. Lisa A, Maione L, Vinci V, et al. Early experience with fat grafting
as an adjunct for secondary burn reconstruction in the hand: Tech­
nique, hand function assessment and aesthetic outcomes. Burns.
2016;42(7):1617-1618.
25. Byrne M, O’Donnell M, Fitzgerald L, et al. 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.
26. Kurtzman LC, Stern PJ, Yakuboff KP. Reconstruction of the burned
thumb. Hand Clin. 1992;8(1):107-119.
27. Raveendran SS, Syed M, Shibu M. Toe-to-hand transfer in a severely
burned upper limb: a surgical dilemma. J Plast Reconstr Aesthet Surg.
2009;62(11):e463-e465.
28. Valauri FA, Buncke HJ. Thumb reconstruction – great toe transfer. Clin
Plast Surg. 1989;16(3):475-489.
29. Williamson JS, Manktelow RT, Kelly L, et al. Toe-to-finger transfer
for post-traumatic reconstruction of the fingerless hand. Can J Surg.
2001;44(4):275-283.
30. Vivek Jain F-CW. The metacarpal hand. In: Norman Weinzweig JW,
ed. The Mutilated Hand. Lansing: University of Michigan Press/Elsevier
Mosby; 2005:280.
31. Fufa DT, Chuang SS, Yang JY. Postburn contractures of the hand. J
Hand Surg Am. 2014;39(9):1869-1876.
32. Al-Qattan MM, Al-Qattan AM. Defining the indications of pedicled
groin and abdominal flaps in hand reconstruction in the current
microsurgery era. J Hand Surg. 2016;41(9):917-927.
33. Chow JA, Bilos ZJ, Hui P, et al. The groin flap in reparative surgery of
the hand. Plast Reconstr Surg. 1986;77(3):421-426.
References
1. Raine TJ, Heggers JP, Robson MC, et al. Cooling the burn wound to
maintain microcirculation. J Trauma. 1981;21(5):394-397.
2. Nissen NN, Gamelli RL, Polverini PJ, et al. Differential angiogenic and
proliferative activity of surgical and burn wound fluids. J Trauma.
2003;54(6):1205-1210, discussion 1211.
3. Smith MA, Munster AM, Spence RJ. Burns of the hand and upper
limb – a review. Burns. 1998;24(6):493-505.
4. Salisbury RE. Reconstruction of the burned hand. Clin Plast Surg.
2000;27(1):65-69.
5. Danin A, Georgesco G, Touze AL, et al. Assessment of burned hands
reconstructed with Integra((R)) by ultrasonography and elastometry.
Burns. 2012;38(7):998-1004.
6. Kok K, Georgeu GA, Wilson VY. The Acticoat glove-an effec­
tive dressing for the completely burnt hand: how we do it. Burns.
2006;32(4):487-489.
7. Branski LK, Mittermayr R, Herndon DN, et al. Fibrin sealant improves
graft adherence in a porcine full-thickness burn wound model. Burns.
2011;37(8):1360-1366.
8. Butts CC, Sahawneh J, Duffy A, et al. Cost-benefit analysis of out­
comes from the use of fibrin sealant for fixation of skin grafts in small-
size burns compared to staples as historical controls: a retrospective
review. Ann Plast Surg. 2015;74(2):173-175.
9. Harrison DH, Parkhouse N. Experience with upper extremity burns.
The Mount Vernon experience. Hand Clin. 1990;6(2):191-209.
10. Sungur N, Ulusoy MG, Boyacgil S, et al. Kirschner-wire fixation for
postburn flexion contracture deformity and consequences on articu­
lar surface. Ann Plast Surg. 2006;56(2):128-132.
11. Burm JS, Chung CH, Oh SJ. Fist position for skin grafting on the dorsal
hand: I. Analysis of length of the dorsal hand surgery in hand posi­
tions. Plast Reconstr Surg. 1999;104(5):1350-1355.
12. Burm JS, Oh SJ. Fist position for skin grafting on the dorsal hand: II.
Clinical use in deep burns and burn scar contractures. Plast Reconstr
Surg. 2000;105(2):581-588.
13. Dantzer E, Queruel P, Salinier L, et al. Dermal regeneration template
for deep hand burns: clinical utility for both early grafting and recon­
structive surgery. Br J Plast Surg. 2003;56(8):764-774.
14. Pensler JM, Steward R, Lewis SR, et al. Reconstruction of the burned
palm: full-thickness versus split-thickness skin grafts–long-term fol­
low-up. Plast Reconstr Surg. 1988;81(1):46-49.
15. Pham TN, Hanley C, Palmieri T, et al. Results of early excision and
full-thickness grafting of deep palm burns in children. J Burn Care
Rehabil. 2001;22(1):54-57.
16. Bunyan AR, Mathur BS. Medium thickness plantar skin graft for
the management of digital and palmar flexion contractures. Burns.
2000;26(6):575-580.
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skin defects. Plast Reconstr Surg. 2005;116(6):1679-1685.

609
Management of Burn Injuries of
the Perineum
MOHAMED E. ISMAIL ALY and TED HUANG
55 
BURNS OF THE PENIS
Burn injuries limited to the penis, although possible, are
quite rare (Fig. 55.1). Concomitant involvement of the
penis with burn injuries of the lower trunk and the perineal
area, on the other hand, is quite common. Initial patient
management, in addition to resuscitative measures, con­
sists of wound care and urethral stenting. As mentioned
earlier, an indwelling Foley catheter of appropriate size
is inserted to stent the urethral tract and monitor urine
output.
The catheter is removed once the swelling around the
penile shaft has subsided and the wound status is delineated.
No attempt is made to débride the burn wound early; the
wound is left to demarcate and heal by secondary intention.
SKIN LOSS OVER THE PENILE SHAFT
AND SCROTUM
Spontaneous healing is expected in most instances of burn
injuries to the penis and scrotum since full-thickness injury
of the penile and scrotal skin is relatively uncommon. Skin
grafting, with a partial-thickness or full-thickness graft,
could be used to cover the wound when healing is delayed
(Fig. 55.2).
In rare instances, a skin flap is required to reconstruct
structures such as the urethral tract and/or scrotal sac
because of full-thickness skin loss. An inguino-pudendal
skin flap mobilized from the inguinal crease area may be
used if the use of a skin graft is judged not to be feasible.3
The use of musculocutaneous flaps, such as a gracilis flap,
is not recommended. The subsequent high tissue tempera­
ture developing in the skin paddle of the flap can potentially
interfere with spermatogenesis.
BURNS OF LABIA MAJORA
Isolated burns of the labial area are rare, and such burns
are often associated with injuries of surrounding areas
such as the abdomen and inguinal folds. As in the manage­
ment of burns of male genitalia, the injured areas are left
to heal by secondary intention (Fig. 55.3).
Distortion of the labial structures mostly due to scar con­
traction in the pubic and inguinal areas is addressed by
reconstruction at a later stage.
PERINEAL WOUND COVERAGE
An isolated burn injury of the perineal area is, as men­
tioned earlier, extremely rare; nevertheless the perineum
Introduction
Burns of the perineal area are relatively uncommon despite
the common involvement of the lower trunk and the lower
extremities in burn injuries. The incidence of perineal burns
was reported at around 12/1000 admissions more than 25
years ago.1 While the occurrence of perineal burns has
remained at around 1.0–1.5% at our institution, 35 chil­
dren underwent genito-perineal reconstruction out of
1133 presenting with perineal burns between 2002 and
2009.
The continuous improvement in the survival rate follow­
ing extensive burns of total body surface area (TBSA) more
than 40% could account for the increase in the number of
patients requiring secondary reconstruction.
Management During the Acute
Phase of Injury
A conservative approach is usually the first line of manage­
ment of perineal burns during the acute phase of admis­
sion.1,2 The perineal area is cleansed daily with appropriate
antiseptic and the wound is covered with antibiotic topical
dressing. To avoid urine contamination of the burn area
and the development of urethral strictures, the urethral
tract is stented using an indwelling Foley catheter. The cath­
eter is also used to decompress the urinary bladder and
monitor urine output during the acute admission. The peri­
neal area is neither splinted nor braced, the thighs are
maintained at 15 degrees of abduction using a wedge splint
to minimize hip contractures.
Other complications of perineal burns presenting during
the acute injury phase include penile shaft necrosis, tes­
ticular necrosis, urethral stricture, and rectal prolapse.
Although the Shriners Children Burns Hospital and the
University of Texas Medical Branch Hospitals in Galveston,
Texas, have adopted conservative management of perineal
burns, the approach to wound care is, in practice, quite
variable. The management plan is often modified depend­
ing on the anatomical structures involved in individual
patients.
The burn is left to demarcate over time with the
wound left to heal by secondary intention. Non healing
wounds are reconstructed using partial-thickness or full-
thickness skin grafts. On rare occasions, a local skin flap
may be utilized from the adjacent normal skin to recon­
struct full-thickness skin defects of the penile and scrotal
areas.

55  •  Management of Burn Injuries of the Perineum
610
group. A sudden increase in intraabdominal pressure, mal­
nutrition, and constipation could conceivably aggravate the
magnitude of the rectal mucosa descending through the
anal opening.4 Clinically, in addition to eversion of rectal
mucosa, the presence of edematous swelling involving the
buttocks and perianal area is quite common, despite the
lack of burn injuries. The onset can be quite sudden without
any obvious precipitating event; however, straining or the
Valsalva maneuver can produce an eversion of the rectal
canal through the anal opening.
Fig. 55.1  An isolated burn injury of the penis is relatively uncommon.
This was a 27-year-old man who sustained scald burns of the penis
from accidentally spilling hot coffee onto his lap.
B
A
Fig. 55.2  (A) Burns of the penis are more commonly associated with
injuries of the lower trunk and lower extremities. (B) Although skin
grafts were used to achieve wound closure around the perineum, the
major bulk of the penile wounds healed by secondary intention.
will be involved in extensive lower trunk/buttock burn inju­
ries. The extent of scar contraction following wound healing
will vary per the depth of burns. While the wound may heal
spontaneously with residual minimal scarring, perineal
contractures are a common sequela regardless of the
methods used for wound care (Fig. 55.4).
The natural inclination of patients to adduct the thighs
and hips while lying supine in bed during the recovery
phase of acute burn injuries seems to aggravate scar
contraction.
ANAL BURNS
Burns involving the anus are rare, although the area could
be involved in extensive perineal burns. In the case of full-
thickness skin loss around the anal opening, the use of a
skin flap may be necessary to reduce the risk of stricture
development. A skin flap mobilized from the adjacent area
is required to reconstruct the perianal area. Wound cover­
age with a skin graft is technically difficult and will lead
to the development of an anal stricture following graft
contracture.
RECTAL PROLAPSE
Rectal prolapse can occur occasionally in young children
with extensive burn injuries with or without perineal
involvement. The pathophysiology of the development of
rectal prolapse in infants with extensive burns remains
unclear.
Redundant rectal mucosa; the structural relationship of
the rectum to other pelvic organs such as the sacrum and
coccyx, urinary bladder and uterus; and lack of muscular
support provided by the pelvic musculature are anatomical
features unique to infants 1–3 years old. All this could
account for the development of rectal prolapse in this age

55  •  Management of Burn Injuries of the Perineum
611
practice, the technique used to reconstruct perineal and
genital deformities varies depending on the magnitude of
scarring around the perineum and the extent of functional
impediment encountered.
RECONSTRUCTION OF PENILE DEFORMITY
The task of assessing the exact extent of penile deformi­
ties can be difficult. Distortion of the penile anatomy
The treatment consists of rectal padding, daily cleans­
ing of the perineal and perianal area, and a stool softener
added to the dietary regimen to facilitate bowel movement.
Spontaneous resolution of the rectal mucosa prolapse is
likely as the nutritional status of the patient improves and
tissue swelling subsides (Fig. 55.5). Surgical intervention,
although in most instances unnecessary, is indicated if the
prolapse is not readily reducible due to the development of
anal sphincter dysfunction and/or intussusception.4,5
Reconstruction of Established
Deformities of the Perineum and
Perineal Structures
Cicatricial contractures around the perineum are the most
common sequela of perineal burns.1,6 The magnitude of the
contracture is exaggerated as a result of burn scar contrac­
tion in the inguinal crease and inferior-medial gluteal folds.
Other complications, although relatively uncommon,
included complete loss of the penis, anal stenosis, and
intractable rectal prolapse.
There are numerous reconstructive techniques available
such as z-plasty scar release, interpositional skin flap tech­
nique, incisional release of scars and closure with local skin
flaps, or skin grafts to reconstruct the deformities. In
B
A
Fig. 55.3  (A) Burn injuries that involved the lower trunk and thighs,
including the labia. While the lower abdomen and thighs required skin
grafting, the labial injury was left to heal by secondary intention. (B)
The appearance of the genitalia 5 years following the injury.
C
B
A
Fig. 55.4  (A) The patient was an 8-year-old child who sustained third-
degree burn injuries of the trunk and lower extremities also involving
the penis and the scrotum. (B) The wound including the scrotum was
débrided, and skin was grafted using a meshed partial-thickness skin
graft. (C) Scar hypertrophy and burn scar contractures developed at a
later stage; tight scars across the perineum interfered with thigh
movement.

55  •  Management of Burn Injuries of the Perineum
612
shaft deformity whether attributable to skin loss and/or
fascial loss will be delineated once the artificial erection is
achieved.
The skin defect produced following incisional release of
the scar is covered with a full-thickness skin graft if Buck’s
fascia is not involved in the burn injury. In rare instances,
if Buck’s fascia is involved, surgical release of the fascial
deformity is required. A dermal graft harvested from the
lower abdomen can be used to reconstruct the fascial defect.
A skin flap mobilized from the area along the groin crease
as an island pedicled skin flap could provide an alternative
cover to reconstruct the skin defect.
attributable to scar contracture could be due to skin loss
or a combination of skin and Buck’s fascia involvement.
In addition, scarring in the pubic area and/or the inguinal
fold can further exaggerate the extent of penile deformity,
as mentioned earlier.
Engorging the penile shaft is required to assess the extent
of penile deformity because the gross appearance of a
flaccid penis can be misleading. Artificial penile erection is
created under anesthesia by placing a tourniquet at the
base of the penis using a piece of quarter-inch Penrose
drain and normal saline solution is injected into the corpus
cavernosum sufficiently to induce congestion. The cause of
C
B
A
Fig. 55.5  (A) This patient was a 2-year-old girl who had sustained 65–70% total body surface burns.
(B) Prolapse of the rectum appeared 12 days following the injury and was managed conservatively.
(C) The prolapse receded spontaneously 2 months later as she recovered from the burn injury.

55  •  Management of Burn Injuries of the Perineum
613
due to high tissue temperature within the flap. Even though
contracture deformity is likely to occur in the long term, a
skin graft can be used to cover the defect following scar
release.
RECONSTRUCTION OF LABIAL DEFORMITY
An isolated contour deformity of the labia majora is rela­
tively uncommon; nevertheless scar contraction occurring
in the suprapubic and pubic area, as well as the inguinal
fold, could distort the normal configuration of the labia.
Primary surgical release of the contracted scar tissues
around the pubic and inguinal fold areas is an essential step
to determine the extent of labial deformity and the recon­
structive technique for the deformed labia.
To restore a contour deformity caused by skin and sub­
cutaneous tissue loss, a skin flap may have to be mobilized
from the adjacent area. To reconstruct a contour deformity
due to parenchymal tissue loss, lipo-modeling (i.e., transfer
of freshly harvested fat cells) could be useful. To inject free
fat cells to augment the labial contour, the cells are aspi­
rated from the lower abdomen using the inner cannula of
a no. 14 Intracath needle attached to a 3-mL syringe. The
fat is prepared and injected in the desired area as per the
“Coleman” technique.8
RECONSTRUCTION OF BAND DEFORMITY
AROUND THE PERINEUM
Scarring and scar contracture of the perineum is a common
sequela of perineal burns, especially if they are left to heal
by secondary intention. Although it seldom causes difficul­
ties to the young patient, perineal scars could potentially
Complete loss of the penis, although devastating, is
extremely rare (Fig. 55.6). If present, penile reconstruction
is delayed until puberty. The delay is often necessary due to
limited soft tissues that can be harvested for genital recon­
struction soon after the burn injury.
There are several methods currently available to recon­
struct a neo-phallus: a segment of rectus abdominis mus­
culocutaneous flap, for instance, may be mobilized from the
lower abdomen to form a neo-phallus. Although the appear­
ance of a reconstructed phallus may be cosmetically accept­
able, the structure usually lacks sensation; it serves as a
urinary conduit at best.
The microsurgical tissue transfer of a combination of
an innervated radial forearm osteocutaneous flap and big
toe pulp has been described for penile reconstruction.7
While the urethral tract was reconstructed utilizing a full-
thickness skin graft or a tube-within-a-tube technique at
the time of penile reconstruction using a radial forearm
osteocutaneous flap, the pulp of the big toe was used to
reconstruct a glans penis. The big toe pulp provided a struc­
tural contour resembling the glans, and cooptation of the
digital nerve to the penile nerve restored sensory nerve
functions (Fig. 55.7).
RECONSTRUCTION OF SCROTAL DEFORMITIES
Full-thickness burn injuries of the scrotum often result in
scar encasement of testicular structures; reconstruction
requires surgical release of the scarred areas. A thin skin
flap such as the inguino-pudendal flap or a flap mobilized
from the adjacent area is required to cover the resultant
defect. A musculocutaneous flap such as a gracilis flap is
not suitable for scrotal reconstruction because of the thick­
ness of the flap and possible reduction in spermatogenesis
C
B
A
Fig. 55.6  (A) A full-thickness burn of the penis, although uncommon, can occur, and the outcome is devastating, as seen in this 10-year-old boy. No
attempt was made to remove the penile tissue, even though it appeared grossly necrotic. Instead, the wound was left to demarcate, and an indwelling
Foley catheter was used to stent the urethra. (B) The patient lost the phallus entirely. (C) The patient can urinate through a short remnant of the penis.
Reconstruction of the penile shaft was planned for a later stage.

55  •  Management of Burn Injuries of the Perineum
614
tuberosities. The scars result in inadequate spreading of the
buttocks and discomfort while sitting, eventually producing
significant functional impairment.
Although a contracted perineal band can be incised to
achieve release, the task of reconstructing the resultant
defect can be difficult. Recurrence of contractures is a
common sequela following the use of a skin graft. Instead,
interfere with function and physical mobility because of
tightness or contractures. In addition, the patient may
encounter difficulties with bowel movement because of
gluteal contractures and cicatricial changes involving the
anal opening.
The deformity developing in the perineal area is usually
a tight band in the suprapubic area or between the ischial
E
D
C
B
A
Fig. 55.7  (A) There are various techniques available for penile reconstruction; a radial forearm composite flap, one of the methods currently in use,
was chosen to reconstruct a phallus structure for a 51-year-old man who lost his penis following tumor excision. (B) As shown in a schematic drawing,
a section of the skin with radial artery attached is harvested from the volar surface of the forearm and utilized for penile reconstruction. A tube-inside-
a-tube was used to reconstruct the urethral tract. In addition, the pulp from the big toe was also used to reconstruct the glans penis. (C) The tissues
were assembled with vessels and nerve structures set for anastomosis. (D) The appearance of genitalia before reconstruction. (E) The appearance of
the reconstructed penis. (A,B,E from Sasaki K. Penile reconstruction: combined use of an innervated forearm osteocutaneous flap and big toe pulp. Plast
Reconstr Surg. 1998;104:1054–1058.)

55  •  Management of Burn Injuries of the Perineum
615
flaps, the z-plasty technique produces a change in the direc­
tion of scar tissue pull, thus diminishing the tightness
around the perineal area.
RECONSTRUCTION OF ANAL STRICTURES
While burn injuries rarely involve the entire anorectal
canal, it is not unusual for the perianal skin and the exter­
nal sphincter ani muscle to be involved in extensive peri­
neal burns. Anal strictures due to scar contraction and
the cicatricial involvement of the external sphincter ani
muscle are common sequelae. Cicatricial changes around
the anal opening can and will usually interfere with bowel
movement.
The treatment requires surgical release of constricted
scar bands around the anal opening. An interpositional
skin flap fashioned as an island flap or a modified z-plasty
with skin flaps mobilized from the adjacent area is used to
make up the tissue defect (Fig. 55.9).
The use of skin grafts to reconstruct the defect is not
useful because, usually, graft application is difficult and
stricture recurrence is common.
RECONSTRUCTION OF RECTAL PROLAPSE
Although the problem of rectal prolapse is, in most instances,
self-limiting and the prolapse will recede spontaneously as
multiple z-plasties are the preferred reconstruction tech­
nique to release scar bands around the perineum.
The Technique of Multiple Z-Plasties
With the patient placed in lithotomy position, tightness and
scar bands can be delineated with abduction of the hip joint
(Fig. 55.8A). A line is drawn across the scar band along the
horizontal direction of the band. The length of the horizon­
tal line may extend from one side of the scarred area to the
other. A triangular flap with its apex at the end of the hori­
zontal line is marked. The angle may vary between 30 and
60 degrees depending on the uninjured tissues available at
both ends of the horizontal line. The length of the limb of
each triangle will be the same as the incision made perpen­
dicular to the horizontal line to release the tight band
(Fig. 55.8B).
Two z-plasties (i.e., two triangular flaps with a 30- to
60-degree angle and a 90-degree angle, respectively) are
formed as the flaps are raised along the skin markings made.
Release of a contracted scar band is achieved by rotating
these two flaps at each end (Fig. 55.8C). The release of a
tight band across the perineal area is maintained by inter­
posing a segment of the soft tissues mobilized. Fig. 55.8D
shows the appearance of the perineum 4 years following
the releasing procedure.
Although the extent of perineal release may be limited
because of the scarred tissues surrounding the triangular
D
C
B
A
Fig. 55.8  (A) A tight scar band in the perineal area following burn injuries involving the perineum and the lower extremities. (B) Releasing incisions
were placed in the areas distal to the anal opening to avoid injuring the anal sphincter. A triangular flap was designed within the uninjured area at
each end of the scar band. A releasing incision was set perpendicularly to the direction of the scar band. (C) Each triangular flap was rotated 90 degrees
to close the open wound resulting from incisional release. (D) Tight bands develop in the perineal area.

55  •  Management of Burn Injuries of the Perineum
616
E
D
C
B
A
Fig. 55.9  (A) A 4-year-old boy developed, in addition to a tight scar band across the perineum, anal incontinence because of cicatricial contractures
involving the entire perineal area. (B) A modified multiple z-plasties technique was utilized to reconstruct the perineal contracture and anal stenosis.
(C) Skin flaps were rotated into the areas to reconstruct the deformity following the surgical release. (D) The appearance of the anal area before release.
(E) The appearance of the anal area 9 months following release.

55  •  Management of Burn Injuries of the Perineum
617
bands around the perineal structures. Incisional release
and reconstruction utilizing z-plasty techniques or an
interpositional skin flap is effective in correcting the
deformities.
Complete references available online at

Further Reading
Alghanem AA, McCauley RL, Robson RC, et al. Management of pediatric
perineal and genital burns: twenty-year review. J Burn Care Rehabil.
1990;11:308-311.
Ashcraft KW, Garred JL, Holder TM, et al. Rectal prolapse: 17-year experi­
ence with the posterior repair and suspension. J Pediatr Surg.
1990;25(9):992-995.
Huang T. Twenty years of experience in managing gender dysphoric
patients: I. Surgical management of male transsexuals. Plast Reconstr
Surg. 1995;96:921-930.
Sasaki K, Nozaki M, Morioka K, et al. Penile reconstruction: combined use
of an innervated forearm osteocutaneous flap and big toe pulp. Plast
Reconstr Surg. 1998;104:1054-1058.
the nutritional status of the patient and wound healing
improves, surgical intervention is required if the rectal pro­
lapse becomes intractable (Fig. 55.10).5
Conclusion
Burn injuries of the perineum are relatively uncommon,
and management during the acute phase of injury is con­
servative. The urethral tract is stented with an indwelling
Foley catheter and the wound is cleansed daily. Neither a
splint nor a brace is used to immobilize the perineal area,
and the wound is usually left to heal by secondary inten­
tion. The resultant deformity, with the rare exception of
total loss of the penis, is limited.
Instead disfigurement of the scrotal/labial contour and/
or scar bands around the genital area are the common pre­
sentation in most patients. The reconstructive approach
to these deformities centers around scar release of tight
C
B
A
Fig. 55.10  (A) A 2-year-old boy who had sustained a third-degree scald
burn that involved the lower extremities; he developed rectal prolapse
10 days following the injury. (B) He underwent a rectopexy procedure
due to the persistent eversion of the rectal mucosa. (C) The patient
regained anal continence 6 months after the surgery.

617.e1
55  •  Management of Burn Injuries of the Perineum
References
1. Alghanem AA, McCauley RL, Robson MC, et al. Management of
pediatric perineal and genital burns: twenty-year review. J Burn Care
Rehabil. 1990;11(4):308-311.
2. Rutan RL. Management of perineal and genital burns. J ET Nurs.
1993;20(4):169-176.
3. Huang TT. Twenty years of experience in managing gender dysphoric
patients: I. Surgical management of male transsexuals. Plast Reconstr
Surg. 1995;96(4):921-930; discussion 931-934.
4. Rowe MI, O’Neil JA, Grosfeld JL, eds. Other Disorders of Anus and Rectum,
Anorectal Function, Essentials of Paediatric Surgery. Chicago, III: Mosby
Year Book; 1995:451-462.
5. Ashcraft KW, Garred JL, Holder TM, et al. Rectal prolapse: 17-year
experience with the posterior repair and suspension. J Pediatr Surg.
1990;25(9):992-994; discussion 994-995.
6. Pisarski GP, Greenhalgh DG, Warden GD. The management of
perineal contractures in children with burns. J Burn Care Rehabil.
1994;15(3):256-259.
7. Sasaki K, Nozaki M, Morioka K, et al. Penile reconstruction: combined
use of an innervated forearm osteocutaneous flap and big toe pulp.
Plast Reconstr Surg. 1999;104(4):1054-1058.
8. Coleman SR. Structural fat grafting: more than a permanent filler. Plast
Reconstr Surg. 2006;118(3 suppl):108s-120s.

618
Reconstruction of Burn
Deformities of the Lower
Extremity
WILLIAM LINEAWEAVER and DEREK M. CULNAN
56 
or a microsurgical flap for adequate treatment of the defect
(Fig. 56.2). Clear definition of the problem should result in
an appropriate selection of a reconstruction strategy.
Finally the status of the second lower-extremity provides
a context for assessment of the burned lower extremity. A
patient with one intact lower extremity may be less inter­
ested in complex reconstructive salvage of a functionally
impaired extremity. Elective amputation with prosthetic
may be a less complicated path to ambulation supported by
the uninjured extremity. Two injured lower extremities,
however, may make reconstruction a higher priority in
either or both since loss of both lower extremities is a sub­
stantially greater disability than single lower-extremity
loss.4
Amputations
Assessment of burn injuries to a lower extremity can lead
to the conclusion that there is insufficient salvage potential
to justify attempts at reconstruction. Lack of sensation,
extensive muscle or joint damage, and a functioning second
lower extremity may add up to a decision to amputate the
impaired portion of a lower extremity.
Dislocated, dorsally contracted toes can be removed with
simple amputations at the metatarsophalangeal joints.
More extensive damage to the forefoot can be treated with
amputations at the tarso-metatarsal level or through the
ankle joint (Lisfranc and Symes procedures, respectively).
Such amputations require sufficient sensation and circula­
tion to obtain a stable result.5
Unreconstructable injury involving the foot and ankle
can proceed to below-the-knee amputation. The priorities
of that procedure include stable coverage of the tibia and
fibula as well as preservation of sufficient skeletal length to
support a prosthesis. The amputation closure is best
achieved with tissue from the posterior calf. A refinement
of amputation closure consists of using the proximal gas­
trocnemius muscle and its overlying skin to create a durable,
myocutaneous pad.6 This technique can be further modified
to use gastrocnemius muscle covered with skin grafts from
initial burn care (Fig. 56.3).
Severe damage extending proximal to the knee may lead
to above-knee amputation. In this procedure, maximum
secure length is useful. Anterior and posterior thigh muscles
are mobilized and stabilized to each other to form the basis
of closure of the overlying skin. Here also muscle covered
with skin grafts can be satisfactory for stable stump closure.
Assessment of Salvage Potential
Acute care of a burned lower extremity prioritizes circula­
tion and coverage. These goals are achieved through escha­
rotomies and fasciotomies as necessary and excision and
coverage of the burn wounds. Reconstruction of lower-
extremity burn sequelae, however, requires a more complex
and detailed definition of defects, deformities, and func­
tional goals. Assessment of a lower limb for secondary post­
burn reconstruction is therefore directed toward a useful
outcome.1
Sensation is an important element in lower-extremity
salvage potential. A desensate foot can be a source of
chronic wounds and may be a less functional outcome
than a below-knee prosthesis. Treatable sites of sensory
nerve compression are increasingly recognized in burned
lower extremities, and nerve decompression at the tarsal
tunnel (for plantar sensation) and the popliteal fossa (for
dorsal sensation) can be initially considered to restore foot
sensation.2
Muscle function must be sufficient to provide useful active
motion at the ankle, knee, and hip. If direct muscle damage
is incompatible with function, limb salvage may be aban­
doned. Some muscle deficits, such as peroneal nerve palsy
with foot drop, may be associated with nerve compression,
and decompression may be an effective reconstruction to
restore muscle function.
Satisfactory lower-extremity salvage potential requires
functional skeletal components. Associated fractures must
be stably healed. Major joints must have sufficient carti­
lage surfaces and capsule integrity to contribute to limb
function.
When evaluating a lower-extremity soft tissue burn com­
plication, the surgeon should consider whether the problem
is a deformity or a defect.3
A deformity implies a distortion of parts correctible by
rearrangements of local tissue. For example, a single verti­
cal scar band across a popliteal fossa, causing a flexion con­
tracture of the knee, may be incised and lengthened by local
Z-plasties that transpose adjacent supple tissue into the scar
site and permit knee extension. A defect is an absence of
parts and requires replacement by distant tissue. Dorsal toe
contractures, when released, may be secondary to soft
tissue deficiency which, when revealed by contracture
release, will require skin grafts to cover the defect (Fig.
56.1). Full-thickness soft tissue loss around a knee joint
may require a local muscle flap (e.g., a gastrocnemius belly)

56  •  Reconstruction of Burn Deformities of the Lower Extremity
619
Hip disarticulation can be life-saving in burn wounds of
the groin and perineum exposing major vessels. In late
reconstruction of contractures of the hip, a hip disarticula­
tion can replace a nonfunctional lower extremity with a
stable wound that can support a prosthesis.
Early Reconstruction
Some specific maneuvers can contribute to the prevention
of later complications.
For deep burns of the dorsum of the foot involving the
toes, K-wire fixation of the toes across the metatarsopha­
langeal joints can effectively splint the toes to prevent
hyperextension contractures while soft tissue coverage is
established. Early splinting and physical therapy can be
applied to ankle and knee burns to maximize range of
motion and minimize contractions.
Flap reconstruction is a rare element in acute burn man­
agement, but such procedures can be considered to treat
specific sites.7
Deep wounds around the ankle can be covered with local
flaps to prevent unstable wounds, especially over the mal­
leoli (Fig. 56.4). Full-thickness burns around the knee are
within the range of local flaps that can provide stable cover­
age to protect the joint and avoid flexion contractures (Fig.
56.2).
Deep burns of the groin can lead to consideration of uni­
lateral or contralateral inferiorly based rectus flaps that can
securely cover the femoral canal structures and allow early
motion at the hip (Fig. 56.5).
Late Reconstruction
By dorsal release of the metatarsophalangeal joints, hyper­
extension contractures of the toes are relieved. If scar inci­
sion reveals a defect, skin grafts can provide stable tissue
replacement.8 If the dorsal skin is sufficiently supple, the
problem may be considered a deformity treatable by creat­
ing a V-shaped flap over the metatarsophalangeal joints,
advancing the flap to allow reduction of the toes to at least
A
B
C
D
Fig. 56.1  In children with recent onset of toe extension contracture, surgical manipulation of the volar plate of the MTP joint capsule is usually unnec­
essary. (A) Cicatrical dorsal toe contracture creating a hammer toe like deformity. (B) A Kirschner’s wire of 0.020–0.035 inch size is inserted through
the proximal phalanx to keep the digit in full extension while maintaining the MTPJ in 45–60° plantar flexion. (C) Split-thickness skin graft is placed to
fill the skin defect. (D) The wires are removed 10–14 days later, once the take of skin graft or flap is established.

D
C
B
A
Fig. 56.2  (A) A full-thickness injury has exposed the lateral surface of the knee capsule. (B) The lateral gastrocnemius muscle is mobilized; the peroneal
nerve is protected with vessel loop. (C) The muscle is set into the defect. (D) The muscle and overlying skin graft at 4 months.
Soleus m.
Gastrocnemius m.
Popliteal a.
B
A
C
D
Fig. 56.3  Below knee amputation. (A) Gastrocnemius and soleus
demonstrated in anatomic position with popliteal artery supply.
(B) Demonstration of medial incision raising myocutaneous flap for
amputation closure. (C) Gastrocnemius raised and Tibia/Fibula
resected with amputated leg. (D) Flap inset with BRA closure.

56  •  Reconstruction of Burn Deformities of the Lower Extremity
621
marginal insets.10 Muscles also can be harvested through
overlying skin grafts, therefore increasing their potential
availability in burn reconstruction.
Posterior ankle contracture frequently includes shorten­
ing of the Achilles tendon. This structure must be mobilized
from adjacent and proximal scar. If this tenolysis does not
provide enough ankle mobility, the tendon itself must be
lengthened with a step cut procedure.1 Soft tissue coverage
of the resulting defect and tendon exposure requires a flap.
Local flap options include perforator flaps, including, most
simply, a lateral calcaneal flap if it is available9,11,12 (Fig.
56.8). Microsurgical flaps are otherwise an option, and
either cutaneous or muscle flaps can be used.10
A contracture of the knee can be as simple as a deformity
caused by a vertical scar band that can be incised and
restored to length with local Z-plasties. If resection of scar
tissue results in a defect, a lateral or medial gastrocnemius
muscle flap can resurface an entire popliteal fossa, with
restoration of extension. If local muscle cannot be utilized,
microsurgical flaps can be effective, and a large unit such
neutral, and closing the donor site with mobilized marginal
skin (or well-healed skin-graft) to complete a V-Y advance­
ment (Fig. 56.6).
Anterior contractures of the ankle result in dorsiflexion,
whereas posterior contractures cause plantar flexion. Ante­
rior contractures are treated by incision and/or excision of
scarred soft tissue to restore ankle range of motion. Such a
release creates a defect with exposure of the tibialis anterior
tendon. Coverage here is best achieved by a flap, and con­
sideration can be given to local perforator flaps or microsur­
gical flaps (Fig. 56.7). Perforator flaps should be carefully
chosen to be certain that the critical vessels have not been
obliterated by burn injury. Microsurgical flaps should also
be considered within the possibilities of tissue not compro­
mised by the burn injury.9 Cutaneous flaps, including
anterolateral thigh flaps, radial forearm flaps, and scapular
flaps, may be critically damaged in a burn patient. In such
cases, muscle flaps (including rectus, latissimus, and graci­
lis flaps) can be reliable reconstructive options. These
muscles are covered with skin grafts after their vascular and
D
C
B
A
Fig. 56.4  (A) A full-thickness injury exposes the medial malleolus. (B) Potential rhomboid flaps are outlined. (C) Flap 1 captures supple tissue.
(D) The margin of the donor site permits primary closure of the donor site after flap transposition.

56  •  Reconstruction of Burn Deformities of the Lower Extremity
622
D
C
B
A
Fig. 56.5  (A) The stumps of the femoral vessels are exposed in scar tissue on the surface of the amputation stump. (B) The right rectus muscle with
a superior skin paddle is elevated to the deep inferior epigastric vessels. (C) Transposition of the myocutaneous flap covers the vessels. (D) Primary
closure is performed over the repaired rectus sheath while split-thickness skin grafts are applied to the rest of the stump.
C
B
A
Fig. 56.6  (A) Dorsal skin grafts have contributed to contractures that have fixed the toes in extension. (B) The “V” component has been elevated and
advanced while the toes are pinned in metatarsophalangeal flexion. (C) Primary closure of the donor defect completes the “V-Y” flap advancement.

56  •  Reconstruction of Burn Deformities of the Lower Extremity
623
Fig. 56.7  Late result of anterior ankle coverage with a microvascular
rectus flap and a split-thickness skin graft.
C
B
A
Fig. 56.8  (A) Contracted scar is excised and a lateral calcaneal flap is outlined. (B) The flap is rotated into the defect. (C) Late results include stable
coverage and functional range of motion; the donor defect was covered with a full-thickness skin graft.
as a rectus or latissimus can be considered. The vessels in
Hunter’s canal are reliable, deep recipient sites for vascular
insets using the long pedicle vessels harvested with latissi­
mus or rectus flaps.13
Hip flexion contractures occur most commonly in chil­
dren. Treatment consists of resection of superficial and
deep scar to allow extension while protecting the femoral
vessels and nerves. The resulting defect can usually be
managed with a skin graft, while extensive wounds with
wide neurovascular exposure may require an inferiorly
based rectus flap or a sartorius turnover flap.14
Grafts and Flaps
Clear understanding of these reconstructive units allows
coherent planning. Both grafts and flaps are applied to the
treatment of defects. Both also must be selected from areas
not compromised by burn injuries. The elemental difference
between grafts and flaps consists of the difference between
their blood supplies.
Grafts have no intrinsic circulation and must survive on
the bed on which they are placed by the processes of serum
imbibition, inosculation, and neovascularization. Grafts
therefore require beds of vascular tissue and cannot be
applied reliably to bone or tendon. Split-thickness skin
grafts, usually harvested by a dermatome, revascularize
more promptly, and their donor sites, which heal by epider­
mal regeneration from the dermis, allow large grafts to be
utilized. Split-thickness grafts, however, tend to contract
with their underlying beds and can be relatively fragile to
external trauma. Full-thickness skin grafts include epider­
mis and dermis. Their donor sites must be closed as wounds,
so the available area for these grafts is very limited. They
also take longer to revascularize and require optimal beds
and extended immobilization. These grafts have the

56  •  Reconstruction of Burn Deformities of the Lower Extremity
624
microsurgical anastomoses to vessels at the site of the
defect. Such procedures are reliable in acute and delayed
burn surgery. There has long been a reluctance to employ
microsurgical flaps in the acute settings due to prior reports
demonstrating increased flap loss in the 5- to 21-day
period following injury. Those data have been refuted in
more recent series and microsurgical procedures can
serve as reliable, versatile reconstructive units in critical
defects.16–18
Conclusion
In approaching a burn complication in a lower extremity,
the reconstructive surgeon proceeds from a careful analysis
of salvage potential to specific definition of deformity and
defect. This sequence leads to identification of an optimum
reconstructive technique selected from the wide range of
procedures available for modern reconstructive surgery.
Complete references available online at

advantages of decreased contracture, greater durability,
and some potential for sensory reinnervation based on
dermal end organs in the graft and nerve regeneration from
the underlying defect.14
Flaps contain intrinsic blood supplies and therefore can
be reliably used to cover bone, tendon, and poorly vascular­
ized defect surfaces. Flaps also generally contain more tissue
and can fill deep, irregular defects. Flaps have limited poten­
tial for contracture.
Cutaneous flaps include local pattern flaps that have no
defined vascular pedicle. These flaps are based on empiri­
cal designs that include advancement flaps (e.g., V-Y pat­
terns), rotation flaps, and transposition flaps (e.g., Z-plasties
and rhomboid patterns). These flaps require supple tissue,
although they interestingly can often succeed using well-
healed skin grafts, especially if the grafts were placed over
muscle. Pedicled flaps include defined arteries and veins
critical to the flap’s survival (Fig. 56.9). Perforator propeller
flaps are increasingly utilized as versatile options in lower-
extremity reconstructions.15
Microsurgical flaps can be harvested remote from the
defect. Utilizing pedicle vessels, the flap insets will include
G
F
E
D
C
B
A
Fig. 56.9  (A) Resection of an unstable wound exposes an underlying vascular graft. (B) A rotation flap is outlined. (C) Elevation of the flap exposes
the sartorius muscle. (D) The origin of the muscle is transected. (E) Using the muscle as a turnover rotation flap preserves the segmented medical
vascular pedicles. (F) Flap inset covers the vascular graft. (G) Inset of the rotation flap completes the reconstruction. (From Dr. Lineaweaver)

624.e1
56  •  Reconstruction of Burn Deformities of the Lower Extremity
References
1. Maquina P. Reconstruction of lower extremity burns. In: Pu L,
Levine J, Wei F, eds. Reconstructive Surgery of the Lower Extremity. St.
Louis: Quality Medical Publishing; 2013:1175-1190.
2. Wu C, Calvert C, Cairn B, et al. Lower extremity nerve decompression
in burn patients. Ann Plast Surg. 2013;70:563-567.
3. Lineaweaver W. Problem analysis in reconstructive surgery. In: Wei
F, Mardini S, eds. Flaps and Reconstructive Surgery. New York: Elsevier;
2009:3-6.
4. Huang C, Jackson JR, Moore N, et al. Amputation: energy cost of
ambulation. Arch Phys Med Rehabil. 1979;6:18-24.
5. Burgess EM. Major amputations. In: Nora P, ed. Operative Surgery.
Philadelphia: Lea & Febiger; 1980:1052-1069.
6. Dellon AL, Morgan R. Myodermal flap closure of below the knee
amputation. Surg Gynecol Obstet. 1981;153:383-386.
7. Lineaweaver W, Craft-Coffman B, Oswald T. Incidence of flap proce­
dures in the management of burn patients. J Miss State Med Assoc.
2015;56:60-64.
8. Chang J, Kung T, Levi B, et al. Surgical management of burn
flexion and extension contractures of the toes. J Burn Care Res.
2014;35:93-101.
9. Uygar F, Duman H, Ulkar E, et al. Are reverse flow cutaneous flaps an
appropriate option for the reconstruction of severe post burn lower
extremity contractures? Ann Plast Surg. 2008;61:319-324.
10. Parrett B, Pribaz J. Lower extremity reconstruction. Rev Med Clin
Condes. 2010;21:66-75.
11. Parrett B, Talbot S, Pribaz J, et al. A review of local and regional flaps
for distal leg reconstruction. J Reconstr Microsurg. 2009;25:445-456.
12. Grishkevich V. Proximally based sural adipose- cutaneous/scar flap in
elimination of ulcerous scar soft-tissue defect over the Achilles tendon
and posterior heel region. J Burn Care Res. 2014;35:e143-e150.
13. Cartotto R, Cicuto B, Kiwanuka H, et al. Common post burn deformi­
ties and their management. Surg Clin North Am. 2014;96:817-837.
14. Barbour JR, Schweppe M, O SJ. Lower extremity burn reconstruction
in the child. J Craniofac Surg. 2008;19:970-988.
15. Teven CM, Mhlaba J, O’Connor A, et al. The utility and versatility
of perforator-based propeller flaps in burn care. J Burn Care Res.
2017;38(1):20-27.
16. Ibrahim AE, Skoracki R, Goverman JG, et al. Microsurgery in the
burn population: a review of the literature. Ann Burns Fire Disasters.
2015;28(1):39-45.
17. Jabir S, Frew Q, El-Muttardi N, et al. A systematic review of the applica­
tions of free tissue transfer in burns. Burns. 2014;40(6):1059-1070.
18. Jabir S, Frew Q, Magdum A, et al. Microvascular free tissue
transfer in acute and secondary burn reconstruction. Injury.
2015;46(9):1821-1827.

625
Electrical Injury: Reconstructive
Problems
PETER M. VOGT, ANDREAS D. NIEDERBICHLER, and ANDREAS JOKUSZIES
In high-voltage injuries, the internal milieu acts as a
single uniform resistance.7 Instead of conduction through
specific preferential tissues, the body conducts the current
with a composite resistance of all tissue components.8 The
crucial factor in determining the resistance and hence the
magnitude of tissue damage is the cross-sectional diameter
of the affected body part. Devastating injuries to the extrem­
ities occur with a significantly higher frequency than tissue
damage to the thorax and abdomen9 (Fig. 57.1). Because
muscle tissue occupies the largest cross-sectional area in
the limb it also carries the predominant electric current.
Because joint areas are regions where the cross-sectional
tissue composition changes from low-resistance muscle to
high-resistance bone, tendon, and skin, a proportionally
higher current and heat are produced in these areas accord­
ing to Ohm’s Law.9
Arcing describes the energy transmitted by a hot electri­
cally conducting gas. However, this requires a voltage of
more than 20,000 V to bridge even a short distance of
1 cm.10 Effects on tissue vary from minimal skin wounds to
charring and tissue vaporization.
The different trauma mechanisms of the burns induced
by the arcing phenomenon are often referred to as “flush
burns,” heat burns that are induced by the massive heat
generation. “Electrothermal burns” are caused by current
passage through the body and the concomitant heat
production.
Electrical damage to a large artery represents a grave
prognostic sign for limb survival.11 The reported risk of
amputation is high, at between 37% and 65%.12–14
Further nonthermal mechanisms of cellular injury have
been defined. This includes a voltage-induced loss of cell
membrane semipermeability.15–17 When the integrity of the
cell membrane is lost, the impedance is markedly reduced,
leading to a simultaneous increase in the area exposed to
current flow.18 In addition to breakdown in cellular integ­
rity, electrical fields also induce denaturation of membrane
proteins by altering their structural conformation and ren­
dering them nonfunctional.19 Both mechanisms are respon­
sible for rhabdomyolysis and secondary myoglobin release,
which depends directly on the imposed electric current and
is not a thermal effect.20
The human body consists of about 60% water. The intra-
and extracellular water content and their highly resistive
plasma membrane separate these two compartments from
each other.21 Change in the current transporters from
electrons to ions at the skin surface appears as metallic
condensations of dark-grayish skin lesions that resemble
eschar.22
Another central factor of the cellular effect of electrical
current is its frequency, which can arbitrarily be divided
Introduction
Severe cases [of electrical injury] coming for reconstruction
present a formidable problem of flexion contracture and loss of
many tendons and nerves, new pedicled skin and grafted-in
tendons and nerves usually being necessary. One encounters
inside the limb the same type of destruction and cicatrix as is
found after any severe infection.
STERLING BUNNELL, 1948
This chapter will focus on the multitude of surgical and
reconstructive problems that result from electrical injury.
The injury severity is complex due to various factors deter­
mining manifestation and the distribution of the resulting
tissue damage. In common with other types of trauma,
especially burn injuries, the consequences of electrical
injury may affect a wide range of physiological functions.
Its distinct features warrant a differentiated approach
to this unique kind of trauma. The resulting tissue loss
and the damage to essential structures of the involved
body areas often require extensive plastic-reconstructive
procedures.
Although the incidence of low-voltage burns has declined
steadily over recent decades, most probably due to progress
made in the field of home and occupational safety educa­
tion and equipment, electrical injuries still account for
3–5% of all admissions to major burn centers.1,2 Electrical
fatalities are relatively uncommon, and most of them occur
accidentally. Earlier reported limb amputation rates of up
to 71% decreased over recent decades with the increasing
ability to reconstruct anatomic parts and restore function,
but limb salvage remains a surgical challenge.3,4
Physiological Basis of
Tissue Destruction
The traditional pathophysiological understanding of elec­
tric injury was based on the assumption that the passage of
electric current produces heat and triggers tissue damage.5
Thus tissue-specific susceptibility (and vulnerability) is con­
sidered to increase progressively from nerve to blood vessels,
muscle, skin, tendon, and fat to bone. As osseous tissue
shows the highest electrical resistance, it will generate the
most heat. Electric current will preferentially take the path
of least resistance through the body so that the current will
pass particularly along the neurovascular bundles. This
theory further postulated that the lesions produced by the
current would result in delayed vascular occlusion and pro­
gressive tissue necrosis.6
57

57  •  Electrical Injury: Reconstructive Problems
626
into low (<10 kHz) and high (>10 kHz, e.g., radio frequency,
microwave, and ionizing frequencies).
Diagnosis and Acute Treatment
Diagnosis and acute treatment of electrical injury are
described in Chapter 38.
Assessment of Tissue Damage
Accurate assessment of the extent of tissue damage is dif­
ficult. The percentage of burned body surface area grossly
underestimates the injury to underlying tissue. Electrical
burns may appear as mere pinpoint marks. In contrast,
fatal electrocution may even take place without visible skin
burns in the case of a large contact area (Table 57.1).
In contrast to thermal burns, deposition of metallic iron
and copper is found on the epidermis after electrical injuries
as electrolysis occurs in the extracellular fluid of the
skin.24–26
Clinical determination of tissue viability is based on
inspection and the demonstration of muscle contractility.
As yet, there are no other diagnostic tools available to accu­
rately assess the extent of tissue damage in the early phase
following electrical injuries. The value of magnetic reso­
nance imaging (MRI) for the detection of nonperfused
nonedematous muscle is debated.24–26 Angiography,
although not providing information on tissue viability, dem­
onstrates the absence of tissue perfusion and may lead to
an early indication for limb amputation.27
Rhabdomyolysis and
Myoglobinuria
Destroyed muscle cells release myoglobin, resulting in myo­
globinemia. Hemolysis also often occurs with electrical
injury. Serum levels of creatinine and creatinine phospho­
kinase (CPK) are used as indicators of rhabdomyolysis.
After muscle injury CPK levels will peak by 24 h and return
to baseline within 48–72 h.28 This diminishes the diagnos­
tic value of serum and urine chemistry testing.29,30
Renal Failure
Myoglobinuria has traditionally been considered a major
risk factor for the development of acute renal failure.
Recently patients with electrical injuries have been shown
to have a surprisingly low risk for renal failure.31 In 162
cC
B
A
Fig. 57.1  Electrical burn from a domestic water heater (220 V). The 13-year-old girl manipulated the device while being immersed in the bathtub. She
sustained third- and fourth-degree burns to the digits (A). Debridement revealed full-thickness injuries involving tendons, nerves, and phalangeal
bones (B), which necessitated primary amputation (C).
Table 57.1  Dependence of Cutaneous Resistance on
Skin Moisture
Resistance
Dry skin
100,000 Ω
Wet skin
2500 Ω
Skin immersion
1500 Ω
Rubber soles
70,000 Ω
Reproduced from Ohashi M, Koizumi J, Hosoda Y, et al. Correlation between
magnetic resonance imaging and histopathology of an amputated
forearm after an electrical injury. Burns 1998;24:362–368.

57  •  Electrical Injury: Reconstructive Problems
627
delayed wound closure.41 The observed changes may likely
be explained by vascular changes similar to ischemia-
reperfusion injury with immediate cessation of capillary
blood flow in response to current passage. This event is fol­
lowed by vascular spasms lasting for an extended period,
with subsequent vasodilatation and restoration of flow.43–45
Although still controversial, these findings may alter the
acute treatment paradigm.
Although there is little discussion about the early time
point of debridement, several recent studies question the
need for extensive and total necrectomy and advocate the
approach of delayed soft tissue coverage. Conservative
debridement consisting of removal of charred and obviously
necrotic tissue was promoted in a study on 40 patients.46 In
this study partially damaged tendons, muscles, and nerves
were preserved, and wound closure was achieved by imme­
diate flap coverage. Patients treated in this manner with
immediate soft tissue coverage had a significantly better
outcome than a control group who underwent serial
debridement procedures. Similar results were found in a
study using early free-flap coverage for electrical injuries,
suggesting that careful limited initial debridement is an
adequate measure.47,48 According to this study overly exten­
sive and repeated debridement to ensure viability of all
remaining tissue appears not only unnecessary but quite
likely harmful. It appears safe to abandon these strategies
and to perform an early, extensive but selective debridement
in order to preserve continuity of functionally important
structures (Fig. 57.2). Limb salvage with functional preser­
vation of vital structures should be attempted and may
require revascularization using segmental vein grafts or
segmental cable grafting of nerves. Pedicled flaps should be
considered in cases of suspected arterial compromise.
Despite the encouraging results of the studies recom­
mending early soft tissue reconstruction, by all means
it should be noted that for the extent of electrical injury
no scoring system has so far been established. Alterna­
tive approaches to salvage upper-extremity function, such
as the temporary ectopic implantation of an undamaged
hand, have been reported but cannot be considered standard
of care.49
Compartment Syndrome
Muscle compartment pressure should be monitored clini­
cally and by invasive pressure measurements. In contrast to
blunt trauma, pain is not a reliable indicator of increased
compartment pressure owing to the high incidence of elec­
trical nerve injury. When compartment pressures exceed
30 mm Hg surgical decompression by open fasciotomy
becomes necessary to prevent ischemic muscle injury. In
the case of lower compartment pressure, progression may
be prevented by administration of nonsteroidal antiinflam­
matory drugs (NSAIDs) and antioxidants, protective splint­
ing, and rest without elevation of the affected extremities.
However general operative decompression in high-voltage
injuries to extremities appears not to be warranted. In a
cohort study, Mann et al. found an increased amputation
rate of 45% with immediate operative decompression
compared to patients undergoing selective fasciotomy, and
they recommend fasciotomy only in cases of progressive
patients, only 14% had myoglobinuria and none developed
renal failure. Suggested criteria to evaluate the risk of acute
renal failure after electrical injury include prehospital
cardiac arrest, full-thickness burns, compartment syn­
drome, and high-voltage injury. The presence of at least two
of these criteria should instigate immediate treatment
because the timeframe to prevent progression to acute renal
failure is limited to a few hours post injury.
Cardiac Monitoring
Among the estimated 1300 deaths that occur annually in
the United States from electrical injury (including lightning
strike), 30% of patients present with cardiac complica­
tions. The majority of electrocardiographic (ECG) abnor­
malities are sinus tachycardia and nonspecific changes in
the ST-segment and T-wave.32 Death from electric injury
most commonly results from current-induced cardiac
arrest.
However if an initial ECG shows no abnormalities, the
delayed development of cardiac problems is very unlikely
irrespective of whether the patient sustained high- or low-
voltage injuries.33–35
Conversely, the presence of dysrhythmias or conduction
abnormalities on initial presentation, electrical injury in
children, or the projected path of the current flow crossing
the thorax on initial presentation warrant prolonged
cardiac monitoring.36–39 Depending on the nature of the
current-induced arrhythmia, pharmacotherapeutic and/or
invasive interventions may be necessary. Table 57.2 out­
lines recommendations for cardiac monitoring of electri­
cally injured patients based on central clinical findings and
specific features of the trauma mechanism.42
Apart from specific therapeutic measures for cardiac
complications, acute treatment of patients with electri­
cal injuries adheres to guidelines of advanced burn life
support (ABLS), advanced trauma life support (ATLS),
and the current practice of intensive care medicine. The
patient must be continuously monitored for signs of neu­
rovascular compromise and deranged tissue perfusion and
oxygenation.
Surgical Debridement
In recent decades the concept of progressive tissue necro­
sis has led to the treatment strategy of early debride­
ment and fasciotomy, followed by serial debridement and
Table 57.2  Recommendation for Cardiac Monitoring in
the Absence of Other Injuries
Admission and Cardiac Monitoring
Discharge
Loss of consciousness59
Asymptomatic patient60
Extensive burns50
Normal initial ECG61
Current passing through the thorax52
Uneventful 4-h observation62
Cardiac dysrhythmias59
Voltage less than 240/260 in
adults60,61
Voltage less than 120/240 in
children48,62

57  •  Electrical Injury: Reconstructive Problems
628
of the skull theoretically requires complete excision of the
necrotic bone to prevent infectious complications.69 Another
approach suggested is partial debridement followed by
definitive flap coverage of the exposed bone. This, however,
requires early debridement and the prevention of localized
bacterial colonization and infection.52,53
In a series of 10 male patients with nonviable cranial
bone after class IV electrical burns, 3 weeks after initial soft-
tissue debridement multiple burr holes in the nonviable and
preserved bone were made and scalp flap coverage was per­
formed.54 Leaving the necrotic osseous structures in situ
serves as a scaffold of substitution for bone regeneration.55–57
Skull contour was maintained in all 10 patients, making
a secondary cranioplasty unnecessary. During a follow-up
period of at least 1 year no postoperative infection, osteo­
myelitis, or cranial bone sequestration occurred.54
Another option is the use of glycerol-preserved allografts
(GPAs).58 The growth of spontaneous sufficient granulation
tissue is promoted by its angiogenetic capacity, and
split-skin autografts can be performed at a later stage.
Further beneficial properties of GPA appear to be related to
their permeable epidermal barrier, the subjacent network of
dermal collagen, and protection of the bone by restoration
peripheral nerve dysfunction, manifested compartment
syndrome, or other major injuries40 (Figs. 57.2 and. 57.3).
With a fixed neurological deficit, however, surgical decom­
pression shows no influence on outcome.50 If the clinical
situation remains doubtful, however, the performance of
open fasciotomy with early debridement may be preferred.
Head: Scalp, Skull, and Mouth
Exposure and necrosis of osseous structures may lead to
osteomyelitis and epidural abscess formation. Treatment
strategies depend on the extent of the injury to the bone. In
the case of only a partial necrosis of the bone, the outer
table of the skull can be tangentially removed and the viable
diploic cavity exposed. In cases of sufficient vascularization,
the exposed bone can be grafted immediately or, when blood
supply is questionable, grafted when suitable granulation
tissue has developed.51 Vacuum sealing of the wound can
be of significant efficacy in growing adequate amounts of
granulation tissue. When the initial wound debridement is
delayed, necrotic and infected bone potentially becomes the
source of a full-thickness skull defect. Full-thickness injury
C
B
A
Fig. 57.2  High-voltage injury from an overhead power line (30,000 V). The teenager climbed a train and was struck by an arc without touching the
power line. The spectrum of injury included third- and fourth-degree burns and deep tissue necrosis of the forearm (A). After fasciotomy because of
impending compartment syndrome (B). Coverage with free latissimus dorsi flap after conservative debridement. Significant functional deficits after 4
years (C).

57  •  Electrical Injury: Reconstructive Problems
629
hospital stay, and fewer surgical procedures.61,62 However,
in this sensitive age group early excision and reconstruction
may also result in a tightened lower lip and consequent
inhibition of normal mandible growth.63,64
The conservative management approach, which we
prefer, performs the reconstructive procedure after matura­
tion of the burn wound scar. Thus the extent of the damage
is more apparent and the reconstruction can be performed
electively.65 Oral splinting has been advocated during the
initial healing period to reduce the need for reconstructive
surgery. However this more likely reduces scar contrac­
tures, so the planned reconstructive procedure can be per­
formed after scar maturation.66–68
Thorax and Abdomen
Electrical injury to the trunk is generally a minor concern.
However high-tension injuries can cause damage to under­
lying parenchymatous organs such as the lung. Clinically
of a physical barrier that prevents drying out and reduces
the risk of infection. With these allografts, the average
healing time could be shortened to 6 weeks.
Fortunately, involvement of the dura occurs rarely. This
usually requires an extensive free flap procedure.59 We
prefer to use the latissimus flap connected to cervical vessels,
occasionally using interpositional vein grafts. This reduces
the risk of perfusion problems considerably. When these
options are not available, the use of acellular human dermis
to reconstruct the dural defect followed by split-thickness
skin grafting after vascularization may be an option.60
In children, especially toddlers, common sites of low-
tension injury include the mouth, usually in the area of the
oral commissure, affecting the commissure, the lips, and
the tongue. The injury usually results in a localized partial
necrosis of the lips and the commissure, and the subsequent
contracture results in microstomia. The treatment strate­
gies, conservative versus early surgical intervention, are
debated. The more aggressive early approach of excision
and reconstruction results in faster healing, a shorter
dD
cC
bB
aA
Fig. 57.3  High-voltage injury from a power line (50,000 V). Presentation with primary loss of perfusion, loss of function, and compartment syndrome.
Initial operation with fasciotomy, revascularization of the radial artery, and necrectomies. On the following days, adequate perfusion with a patent
radial artery without coexisting veins. Coverage with groin flap on day 6. Venous congestion and subsequent malperfusion was temporarily treated
with leeches. Secondary amputation on day 10 due to late occlusion of the radial artery.

57  •  Electrical Injury: Reconstructive Problems
630
The main area of reconstruction is the forearm, and limb
salvage is the sole cause of free flap coverage.77
Fascial flaps provide thin, pliable coverage for reconstruc­
tion of the dorsum of the hand.
The serratus fascia flap is the flap of choice for larger
defects; for smaller defects the temporoparietal fascial flap
is preferred.78
Other regions of selective destruction in the upper
extremity are the elbow and axilla. Debridement often
leaves a vast tissue defect, which may be covered by rotation
flaps from the anterior or posterior chest wall in the axilla.
Microvascular free flaps at the level of the elbow are rarely
used. For extensive defects on the hand and forearm pedi­
cled groin flaps provide good coverage and an independent
blood supply. The groin flap also avoids a vascular “steal
phenomenon” as can be seen after microvascular free flaps
in such severely injured extremities.
Newer approaches comprising early wound excision, cov­
erage, and revascularization of damaged vasculature with
flow-through free flaps and aggressive endovascular inter­
ventions will offer an opportunity to improve outcomes for
these devastating injuries.79–82
Saint-Cyr and Daigle compared the use of free flaps with
conventional multistage procedures and found a statisti­
cally significantly reduction in the number of operations,
the time required to achieve wound closure, and the dura­
tion of hospitalization in the microsurgical group.83
The flap survival rate as described in the current lit­
erature is lower in the high-voltage injury group than
in the burn injury group. It ranges from 62% to 100%
and is lowest when performed early, within 5–21 days of
trauma.83–85
In conclusion, free flaps play a key role in treating high-
voltage electrical injuries to the extremities by reducing
morbidity and functional impairment, which are character­
istically high after these injuries.83
Amputations
Although distressing to the patient, amputation often
remains the only option. As already mentioned, the ampu­
tation rates for electrical injuries affecting the upper extrem­
ities range from 24% to 49% in the current literature.73,74
Despite an increased awareness of the potential danger of
electrical burns, devastating outcomes with four-limb and
penis amputations are still presented in the literature.86–88
Although very rare, Haik and colleagues presented a case
of a 5-week-old girl undergoing MRI for evaluation of spina
bifida. She sustained a full-thickness burn encompassing
her right forearm and wrist in the area where a non-MR-
compatible pulse oximeter was attached. A possible cause
for this incident could have been an electrical injury due to
an exposed wire segment in direct skin contact. Despite
immediate escharotomy, this injury led to amputation of
the forearm and hand.89
The optimal level of amputation is determined by the
extent of remaining viable tissue and the intention to create
sufficient stump length for function and cosmetic appear­
ance of a prosthesis. In electrical injury involving the lower
extremity, this often requires higher amputation than ini­
tially anticipated in order to achieve sufficient stability of
this may lead to atelectasis and edema requiring aggressive
ventilator support. Intra-abdominal injuries are uncom­
mon but may require treatment as for penetrating injury.
When exploration during escharectomy and debridement
reveals necrotic underlying muscle and fascia, exploratory
laparotomy may be indicated. Reconstructive options for
the closure of chest or abdominal wall defects include
direct closure or placement of a synthetic mesh covered by
local fasciocutaneous or musculocutaneous flaps. However
the potential negative effects of direct closure on intra­
abdominal pressure and the subsequent development of
an abdominal compartment syndrome or compromise of
respiratory function must be considered.
Extremities
Electrical injuries to the extremities, especially to the arms
and hand, are more common in adult members of the work­
force. Electrical burns account for 3–5% of all admissions
to burn units and approximately 1000 deaths per year
in the United States.70 There are three patterns of injury:
direct, arc, and flash-type injuries. Direct injuries are associ­
ated with entry and exit wounds, and nearly 90% of these
injuries involve the upper extremity.71 Because the resis­
tance and hence the local energy production are depen­
dent on the tissue mass and the cross-sectional diameter
of the injured body part, high-tension injuries often lead to
extensive tissue damage and loss of the involved extremity.
Despite aggressive treatment strategies with early debride­
ment and decompression of neurovascular structures, the
likelihood of amputation is high.22–24,72 In the current lit­
erature the amputation rates for electrical injuries affecting
the upper extremities range from 24% to 49%.73,74 Even
if amputation can be avoided the resulting outcome may
be a nonfunctioning extremity. With the phenomenon of
“kissing” lesions, extensive tissue damage may occur, with
resulting thermal necrosis of muscle, tendon, nerves, and
blood vessel. The superficial injury may appear innocu­
ous, but debridement shows deep tissue destruction often
mandating limb amputation. The importance of initial
debridement cannot be overstated, as remaining nonviable
tissue leads to infection and tissue loss. In our view the
early debridement of nonviable tissue prevents this fatal
development. When distal limb ischemia becomes obvious
one can assume that the involved vessels have been severely
injured. In these cases early vascular grafting of upper-
extremity arteries may be indicated to salvage an ischemic
upper limb.75 Imminent or suspected compartment syn­
drome should always trigger open fasciotomy to prevent
further compromise to the involved extremity. Sometimes
it appears wise to perform a simple skin grafting procedure
followed by elective secondary flap coverage and nerve cable
grafting.
In high-voltage injuries (>1000 V) the point of entrance
of the electrical current is usually located on the distal
extremity. Tissue destruction decreases from distal to proxi­
mal. Zelt et al. described specific regions or so-called choke
points, such as the wrist and elbow. These are characterized
by smaller cross-sectional areas and highly resistant tissue
components (tendinous and bony configuration) that result
in increased heat production and more severe damage.76

57  •  Electrical Injury: Reconstructive Problems
631
delayed inadequate escharotomy or fasciotomy. Owing to
the accompanying severe muscle loss and scarring, the
extent of pure nerve damage is sometimes difficult to
determine.
Direct damage to peripheral nerves occurs following the
above-mentioned mechanisms of local heat production,
depending on cross-sectional resistance and the proximity
of peripheral nerves to underlying bone. The local thermal
effect affects vascularity and perfusion of perineural tissue
by producing thrombosis, necrosis, or hemorrhage of epi­
neural vessels. Delayed development of fibrosis and there­
fore a delayed onset of symptoms are not uncommon.
Especially in areas of minimal cross-sectional area, the
peripheral nerve is in close proximity to bone and fibrous
tissue, which results in perineural fibrosis and symptoms of
a compressive peripheral neuropathy. The treatment of
choice to gain nerve recovery is decompressive corrective
surgery.93 Other mechanisms of nerve injury are the devel­
opment of focal axonal degeneration following axonal exci­
tation,94 or electroporation, which more likely affects
myelinated axons, and collagen type I deposition.95–98
Complications
CENTRAL NERVOUS SYSTEM
Approximately 60% of all patients with high-voltage injury
present with immediate neurological complications, pre­
dominantly loss of consciousness.99 Involvement of the
spinal cord has been described in 2–27% of patients with
an entry point of the current located in the head region.100–102
The incidence of a delayed paralysis progressing to tetraple­
gia followed by partial remission has been described.103
Although mortality in patients with neurological complica­
tions from electrical burns is not high, these patients are at
great risk of permanent disability. The neurological sequelae
were classified in 1964 by Silverside into immediate, sec­
ondary, and late effects.104
Immediate spinal cord injury is transient, and symptoms
usually clear within 24 h after the accident. The late effects
are characterized by progressive traits where complete
recovery is not the rule. The ischemic injury in the distal
area of the sulcal branch, the longest branch originating
from the anterior spinal artery, is due to the susceptibility
of the anterior horn cell and the spinal cord at T4–T8 to
ischemic injury. Early administration of prostaglandin E1 or
steroid treatment is recommended to reduce ischemic spinal
cord injury in cases of electrical burns.105 The neuropsy­
chological effects of electric injury have been described,
mainly in case reports and retrospective studies. Typical
consequences and complaints are related to physical, cogni­
tive, and emotional changes.106,107 In a study of 481 profes­
sional electricians, 97% reported having experienced an
electrical shock at some point in their career.108 The low
incidence of neuropsychological dysfunction in this study
differed from other findings about the nature and progres­
sion of a characteristic neuropsychological syndrome of
electrical injury.107,109 Although the development of tran­
sient and progressive neuropsychiatric complications is pos­
sible and undisputed, the actual specific effects of electrical
injury are difficult to determine.
the stump and thus allow early prosthetic fitting and ambu­
lation. However, open (guillotine) amputation should be
avoided whenever possible. Split-thickness skin grafting
onto open stumps is an additional but less preferable
approach because skin breakdown occurs more often in
grafted areas, especially at graft borders or at points where
grafts adhere to underlying bone, and further surgical
interventions will be required. However, if valuable stump
length can be maintained by skin grafting it should be
attempted because secondary plastic surgical correction
and specific prosthetic fitting are available.
In the upper extremity, more length should be preserved
because the resulting weightbearing load on the stump is
less than in the lower extremity. This allows for better
control of the prosthesis by the patient and thus enhanced
functionality. In the forearm, the muscle length of the
flexor–extensor system should be preserved to improve
function. In long forearm stumps, atraumatic handling of
tendons and muscles is necessary to preserve pronation and
supination. Upper-arm amputations should preserve as
much length as possible as this eases subsequent kineplastic
procedures for a functional prosthesis. As in the forearm,
muscular length of the flexor–extensor system is main­
tained by joining them over the bone end. Although it is
technically feasible to maintain extremity length by cover­
age with a free flap, this appears only useful in upper-
extremity amputation where the functional implications
warrant such large-scale surgery and the load on the stump
is reduced.
Despite the availability of sophisticated modern myoelec­
tric prostheses, the old techniques of surgical rehabilitation
should be kept in mind. This includes the Sauerbruch
kinemato-myoplasty of the biceps humeri muscle and the
Krukenberg plasty of the forearm, which provides sensible
chopstick-like stumps. Especially for upper-arm amputa­
tions, distraction osteogenesis procedures (Ilizarov tech­
nique) provide a valuable option to lengthen a short
amputation stump.
Peripheral Nerve Injury
Peripheral nerves are very sensitive to electric alterations,
and even minor injury may cause transient dysfunction.
Clinical findings may be anesthesia, paresthesia, or dyses­
thesia of usually short-term duration. In rare cases minor
electrical injury may cause temporary autonomic dysfunc­
tion and trigger a complex regional pain syndrome (sympa­
thetic reflex dystrophy). Treatment for reflex sympathetic
dystrophy should be initiated early and include elevation of
the extremity to reduce edema formation, active exercise,
NSAIDs, and adequate pain relief. The autonomic dysfunc­
tion may be influenced by α-adrenergic antagonists,
calcium-channel blockers, and low-dose diazepam or may
require intravenous regional blocks and sympathetic gan­
glion blockade.90
Electrical injury to the upper extremity commonly results
in peripheral nerve injury to the median and ulnar nerves.
The clinical findings may resemble upper-extremity com­
pression syndromes or peripheral neuropathy.91,92 Nerve
lesions may be caused by secondary factors such as incor­
rect positioning and splinting, constricting dressings, or

57  •  Electrical Injury: Reconstructive Problems
632
include major joint contractures and limited function of the
extremities.
Another common late complication of electrical burns is
heterotopic calcifications in periarticular tissue of large
joints, especially the elbows. Causative factors include
forced passive mobilization, secondary articular bleeding,
and calcium precipitation and deposition in damaged or
degenerating muscle and connective tissue. Particularly for
electrical injury, heterotopic bone formation also occurs in
amputation stumps of long bones. This, as well as the
common formation of bone cysts in the amputation stump,
may lead to secondary skin erosion, inflammation, and dif­
ficult adjustment to a prosthesis. In both situations surgical
excision and wound closure may be adequate therapy.126
Conclusion
Electrical injuries result in deceptively large tissue loss often
leading to amputation of involved extremities. After initial
resuscitation, early debridement, necessary decompression
of neurovascular structures, and early wound closure are
essential to successful restoration of function. Extensive
surgical procedures including free soft-tissue transfer may
be necessary to achieve wound closure and to save and
restore limb function. Sometimes, however, early amputa­
tion may provide easier and earlier recovery and reintegra­
tion into daily life. Long-term complications such as central
nervous sequelae, cataracts, and heterotopic ossification
must be considered and addressed early in the rehabilitation
process.
Complete references available online at http://

Further Reading
Brumback RA, Feedback DL, Leech RW. Rhabdomyolysis following electri­
cal injury. Sem Neurol. 1995;15:329-334.
Saint-Cyr M, Daigle JP. Early free tissue transfer for extremity reconstruc­
tion following high-voltage electrical burn injuries. J Reconstr Microsurg.
2008;24(4):259-266.
Sauerbier M, Ofer N, Germann G, et al. Microvascular reconstruction in
burn and electrical burn injuries of the severely traumatized upper
extremity. Plast Reconstr Surg. 2007;119(2):605-615.
Smith M, Muehlberger T, Dellon AL. Peripheral nerve compression associ­
ated with low-voltage electrical injury without associated significant
cutaneous burn. Plast Reconstr Surg. 2002;109:137-143.
Spies C, Trohman RG. Narrative review: electrocution and life-threatening
electrical injuries. Ann Intern Med. 2006;145:531-537.
OCULAR MANIFESTATIONS OF
ELECTRICAL INJURY
An increased incidence of cataract formation has been
described after electrical injury, varying from 1% to 8% in
different reports.110,111 Patients with head and neck wounds
appear to be most at risk. However the path of the current
and the location of the entry point were not related to the
development of ocular sequelae. Cataracts may also occur
without injury to the head and appear even years after
injury. Common initial complaints are blurred vision or
diminished visual acuity.112
Cataracts usually develop from 1 month to 2 years after
injury but may occur as soon as within several hours.113
The mechanisms for formation are debated and several
theories have been proposed, such as decreased permeabil­
ity of the lens capsule, direct coagulative effect on the lens
proteins, a disturbance in nutritional mechanisms of the
lens cells due to iritis or impaired circulation, and exposure
to ultraviolet and infrared radiation.114
Lightning strikes are a common cause of ophthalmic
injuries, and the most common permanent sequela by far is
lightning-induced cataract.115 The lens of the eye is seem­
ingly very sensitive to electrical current or the resultant
heat, and prompt evaluation by an ophthalmologist is
imperative.116 Iritis and uveitis have also been described as
possible sequelae after electrical injury.117 Visual prognosis
in patients with lightning-induced ocular injury will depend
on the extent of irreversible retinal damage and optic nerve
damage. Long-term follow-up of these patients is recom­
mended according to the late onset of pigmentary changes
at the fovea and papillomacular bundle, which may further
prevent visual improvement.118
Patients should undergo serial ophthalmologic examina­
tions, and treatment should be started immediately when
abnormalities are recognized.
Skeletal Injury
In addition to direct tissue destruction through electrical
energy, additional trauma can be indirectly inflicted by elec­
tric current. Fractures occur due to secondary falls or with
forceful tetanic muscle contractions. These are mostly seen
in the shoulder,119 wrists,120,124,125 femurs,121,123 and spine122
and may require open reduction and internal fixation. Late
sequelae of electrical injury similar to severe thermal burns

632.e1
57  •  Electrical Injury: Reconstructive Problems
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633
The Role of Alternative Wound
Substitutes in Major Burn
Wounds and Burn Scar
Resurfacing
NAIEM S. MOIEMEN and KWANG CHEAR LEE
58 
widely meshed skin grafts, and, occasionally, skin graft
donor sites.
For partial-thickness burns, temporary substitutes, in
contrast to traditional wound dressings, provide a biological
wound cover that promotes healing by reducing moisture
loss and accelerating epithelialization. However they are
not incorporated into the architecture of the healed wound,
as in the case of permanent substitutes. In addition, most
of these products (such as Biobrane, Suprathel, and amni­
otic membrane) are applied only once. This is a significant
advantage, especially for children, because it avoids the pain
and associated psychological trauma of repeated wound
dressing changes.
For full-thickness excised burn wounds, temporary alter­
native substitutes can provide cover if skin grafting or appli­
cation of a permanent substitute is planned as a staged
procedure. In certain circumstances, to allow for a reduc­
tion in wound exudate and to ensure complete hemostasis,
this may be delayed for 24–48 hours after wound excision
in a major burn. Due to lack of available donor sites for skin
graft harvest, it may be decided to apply a permanent sub­
stitute, and “take” can be optimized by staging the proce­
dure; during this time a temporary substitute can be very
helpful.
Temporary substitutes are very valuable for covering
widely meshed skin grafts (the Alexander technique). Alex­
ander described applying allograft on top of widely meshed
autograft to provide biological wound closure that protects
the open wound within the interstices (gaps) of the meshed
graft. While allograft tends to adhere to the wound bed and
may in fact interfere with epithelization of the interstices,
E-Z Derm dries out after a week of its application with
almost complete epithelization underneath. This may also
represent a cost saving.
Rapid healing of skin graft donor sites is critical to
patients with major burns. Expanded pre-confluent autolo­
gous epidermal cells (ReCell) or sprayed CEA may accelerate
epithelization and allow more frequent harvesting from the
limited donor sites in these situations. However wider use is
prohibited by cost and efficacy. ReCell has also been shown
to accelerate healing of partial-thickness burn wounds
when covered with widely meshed skin grafts.
Permanent alternative wound substitutes are used to cover
full-thickness wounds after burn excision. One example of
a bilayer acellular substitute is Integra, which has been
used for decades in patients with major burns and has
Introduction
Early excision of major burns has been shown to improve
patient outcomes. The lack of available donor sites from which
to harvest conventional autologous skin grafts to achieve
wound closure is challenging. Burke and Yannas in the early
1960s pioneered the introduction of alternative wound cover
after burn excision. They invented a dermal scaffold com­
posed of bovine collagen and shark glycosaminoglycan matrix
with an epithelial equivalent, the silicon layer. This became
known as Integra. During that same period, Rheinwald and
Green, in 1975, described the technique of cultured epider­
mal autografts (CEA), which provided another alternative to
help achieve wound cover. The first multicenter clinical trial
using Integra was published in 1988.1 Integra was eventually
granted approval by the U.S. Food and Drug Administration
(FDA) in 1996 for use in acute burns.
Alternative wound substitutes provide biological wound
cover either on a temporary or permanent basis. Permanent
substitutes are mostly in the form of scaffolds that become
integrated into the wound and eventually are replaced by
host cells, with the scaffold itself finally undergoing reab­
sorption. Temporary substitutes, on the other hand, do not
integrate into the wound; they temporarily adhere to the
wound bed and may induce growth and promote healing of
the underlying wound.
Classification of Alternative
Wound Substitutes
The wide variety of alternative wound cover products may
be classified into temporary or permanent (Tables 58.1 and
58.2). Other classifications include autologous, allogenic,
or xenograft; biological or synthetic; cellular or acellular,
and single layer or composite.
Clinical Applications of
Alternative Wound Substitutes in
Major Burn Wounds
Temporary alternative wound substitutes are used to cover
partial-thickness burns, full-thickness excised burn wounds,

Table 58.1  List of Temporary Skin Substitutes and Their Biological Value
Example
Structure
Biological Value/Mechanism of Action
Amniotic membrane
The innermost layer of the placenta; it consists
of a single epithelial layer, a basement layer,
and an avascular stroma. Available in frozen
or glycerol-preserved forms
Promotes migration and adhesion of epithelial cells. It
has high concentration of hyaluronan and Decorin and
has anti-inflammatory, antiangiogenic, antimicrobial,
and antiscarring actions
Allograft
Human cadaveric split-thickness skin grafts.
Can be either cryo- or glycerol-preserved
Allogenic skin graft vascularizes initially as per autograft;
however, it is eventually rejected by the host within
3–4 weeks
Xenograft
Animal-derived skin graft (usually porcine,
although frog skin has been used). Examples
include EZ Derm (acellular dermis)
Used as an alternative to allografts. It does not
vascularize. It adheres to wounds and provides
temporary coverage
Biobrane (Smith & Nephew,
London and Hull, United
Kingdom)
Consists of a silicone membrane bonded to a
nylon mesh that is impregnated with
porcine dermal collagen peptides
The collagen peptide coating enhances adherence to the
wound. Biobrane has no inherent antimicrobial
properties
Suprathel (PolyMedics
Innovations GmbH,
Denkendorf, Germany)
Entirely synthetic and composed of synthetic
copolymers, mostly polylactic acid
This has similar indications to Biobrane and is used for
temporary cover of partial-thickness burns and donor
sites
Oasis (Smith & Nephew, London
and Hull, United Kingdom)
Acellular porcine intestinal submucosa
Indicated as a single-application dressings for deep
dermal burns
Omiderm (Omikron Scientific
Ltd., Rehovot, Israel)
Synthetic polymer made from hydrophilized
polyurethane
Indications are similar to Biobrane and Suprathel
Table 58.2  List of Permanent Skin Substitutes and Their Biological Value
Example
Structure
Biological Value/Mechanism of Action
Epicel (Vericel Corporation,
Ann Arbor, Michigan,
United States)
Consists of a petroleum gauze and autologous
keratinocyte sheets that have been
co-cultured with murine cells
Indicated for deep dermal and full-thickness burns; sheets are 2–8
cell layers thick
ReCell (Avita Medical,
Cambridge, United
Kingdom)
Pre-confluent autologous keratinocytes
obtained by trypsinizing a small biopsy and
directly sprayed onto the wound
Other cells such as fibroblasts and melanocytes are also delivered
Alloderm (Lifecell
Corporation, Branchburg
Township, New Jersey,
United States)
Donated human skin that is processed to
remove the epidermis and cells leaving an
acellular matrix
Acellular dermis acts as a scaffold for fibroblast and vascular
ingrowth, split-thickness skin grafts are applied over it during the
same procedure
PriMatrix (TEI Biosciences
Inc., South Boston,
United States)
Acellular fetal bovine dermal scaffold
A scaffold to support new dermis formation
Matriderm (Medskin
solutions, Billerbeck,
Germany)
A single layer of matrix of non-crosslinked
bovine collagen and tendon-derived elastin
hydrolysate. Available in 1- and 2-mm
thicknesses
A scaffold that promotes the regeneration of a new dermis.
Split-thickness skin graft is applied on top as a single-stage
procedure
Orcel (Forticell Bioscience
Inc., New York, United
States)
Bilayered collagen constructs seeded with
allogenic keratinocytes and fibroblasts
derived from neonatal foreskin
The matrix acts as a scaffold, and the allogenic cells produce growth
factors and are eventually replaced by the host own cells within a
few weeks
Apligraf (Organogenesis
Inc., Massachusetts,
United States)
Similar to Orcel, it is formed from collagen
type I constructs seeded with allogenic
keratinocytes and fibroblasts derived from
neonatal foreskin
As with Orcel, the matrix acts as a scaffold and the cells induce a
suitable environment for host cells to migrate into and populate.
However, unlike Orcel, the top layer of keratinocytes is exposed to
the atmosphere during manufacture, forming a stratified layer
with better barrier function
Stratagraft (Stratatech
Corporation, Madison,
Wisconsin, United
States)
Bilayered construct with a dermal layer with
human dermal fibroblasts and an epidermal
layer that is produced by near-diploid
immortalized keratinocyte S (NIKS) cells
A fully stratified multilayered epidermal equivalent is generated by
the NIKS cells, which are a pathogen-free keratinocyte cell line.
The substitute releases bioactive molecules that condition the
wound for healing
Permaderm (Regenicin
Inc., New Jersey, United
States)
Bilayered collagen matrix with basement
membrane seeded with autologous
keratinocytes and fibroblasts
A permanent alternate substitute that can provide complete wound
cover and closure. Only a small autologous skin biopsy can
potentially be used to cover the entire body after 3–4 weeks. It
has been used in major burns
Integra (Integra
LifeSciences, New Jersey,
United States)
These consist of an outer silicone epidermal
equivalent and a lower cross-linked bovine
collagen and shark glycosaminoglycan.
Single layer of collagen only is also available
The bilayered dermal template is widely used in burns. This requires
a two-stage procedure while the single layer is used as a
single-stage procedure. The single layer is used both in acute
burns and in reconstruction. Cross-linked collagen provides the
stability of the dermal construct
Pelnac (Gunze Limited,
Kyoto, Japan)
Consists of cross-linked calf collagen with a
thin silicon outer layer
Very similar to Integra but the silicon layer is thinner for better
pliability and conformity to the wound bed

58  •  The Role of Alternative Wound Substitutes in Major Burn Wounds and Burn Scar Resurfacing
635
Molnlycke Health Care, Gothenburg, Sweden.) to reduce
the risk of hematoma and to allow antimicrobials to access
the wound bed. Surgifix (BSN medical GmbH, Hamburg,
Germany) applied directly onto the silicon layer can be
very useful to prevent early silicon separation, especially
if the second stage is to be delayed for several weeks until
donor sites are available (Fig. 58.2). Antimicrobial dress­
ings followed by an absorbent gauze layer are applied over
the Surgifix, and a firm bandage completes the dressing.
When compared to Integra application for scar resurfacing,
wound care in acute burns is of paramount importance
because early identification of complications can avoid
disastrous consequences with loss of the entire Integra
layer and the potential for sepsis. Frequent inspection of
the matrix, especially during the first week, by a member
of the team with experience in the use of Integra is crucial.
To ensure successful Integra engraftment, the whole mul­
tidisciplinary team should be aware of how to mobilize
yielded favorable short- and long-term outcomes.2 The
matrix vascularization and formation of the “neodermis”
occurs over a period of 3–4 weeks (Fig. 58.1)3 under the
protective cover of the silicon epithelial-equivalent layer.
This allows wound closure during the critical time of
waiting for limited donor sites to heal and be ready for
reharvesting. In fact, the fully matured vascularized matrix
can be left in place, even for several further weeks, as long
as the silicon layer remains adherent to it.
When Integra is used in acute major burns, immediate
or early burn excision is important. This allows adherence
of the matrix to the wound bed before wound colonization
occurs, thus decreasing the risk of infection. If immediate
excision has been performed, it is prudent to delay appli­
cation of Integra for 24–48 hours, as mentioned earlier.
Fibrin sealant may be useful to promote adherence and
prevent hematoma formation. Integra may also be meshed
at a 1 : 1 ratio with a noncrushing mesher (Brennen,
A
B
C
D
E
F
Fig. 58.1  Stages of Integra vascularization. Matrix color is correlated with the stage of vascularization. Clinical (left) and histological appearances (right).
Appearance at first stage, day 0 with pale colored matrix (A,B); matrix developing a pinkish color at day 21 (C,D); and a peachy color at 4 weeks (E,F).
CD31-stained endothelial cells in the superficial layer of the neodermis (F). (From Moiemen NS, Vlachou E, Staiano JJ, Thawy Y, Frame JD. Reconstructive
surgery with Integra dermal regeneration template: histologic study. Clinical evaluation and current practice. Plast Reconstruct Surg. 2006;117(7
Suppl.):160S–174S.)

58  •  The Role of Alternative Wound Substitutes in Major Burn Wounds and Burn Scar Resurfacing
636
require only a very limited skin biopsy from the patient.4
ESS has been granted orphan status by the FDA for use in
acute burns and a phase II multicenter trial will soon be
under way.
Clinical Applications of
Alternative Wound Substitutes in
Burn Scar Resurfacing
Resurfacing of extensive postburn hypertrophic scars has
become possible with the availability of permanent alterna­
tive wound substitutes such as Integra. The outcome is
superior to that of partial-thickness skin grafts, but it falls
short of full-thickness skin grafts that are still the gold stan­
dard option for scar resurfacing. However, following major
burns there can be limited availability of donor sites for
full-thickness grafts.
The timing of scar resurfacing is important. The wisdom
of experience has shown that extensive resurfacing
and turn the patient and perform therapy, including chest
therapy, without disturbing the matrix. Wound care after
the second stage (removal of the silicon layer and appli­
cation of partial-thickness grafts) is the same as in other
major burns.
Matriderm is mainly used as a single-stage procedure,
with the skin graft applied onto the matrix in the same
operation. It has applications in burns where function and
aesthetics are important (e.g., in the hand over joints or on
the face). However the requirement for immediate grafting
is a limitation in major burns when donor sites are sparse.
Matriderm, being formed of noncross-linked collagen, is
vascularized more quickly than Integra and also resorbs
more quickly; however additional analysis of long-term
results is still needed.
Other bilayer cellular substitutes include Apligraft, Orcel,
and the Engineered Skin Substitute (ESS or Permaderm).
Only ESS, which was first introduced by Steven Boyce of
the Shriners Hospitals for Children, Cincinnati, contains
autologous epithelial cells and fibroblasts that, once pro­
duced, allow complete wound cover of major burns and
A
B
C
D
E
F
G
H
I
Fig. 58.2  Acute early burn excision and Integra application with 7-year follow-up. Top row: 14-year-old female with 60% total body surface area (TBSA)
flame burn (A), post-excision of burn on back (B) and legs (C). Middle row: Day 9 post-excision appearance of burn wound and application of Integra
on back (D). Day 18 appearance of abdominal (E) and leg (F) burn wounds postexcision and application of Integra. Bottom row: Appearance of the
healed burn wounds 7 years post burn of back (G), abdominal area (H), and lower limbs (I).

58  •  The Role of Alternative Wound Substitutes in Major Burn Wounds and Burn Scar Resurfacing
637
procedures are more successful when the scars have
matured and become pale in color. At early stages of post­
burn scarring, other surgical approaches including flaps or
modalities such as laser may be more appropriate. Radical
excision of all scar tissue, especially at the depth of the
excised wound bed, is important to achieve good results
with skin substitutes and to avoid recurrence of any con­
tracture. Certain anatomical areas are challenging to
reconstruct, such as the neck, axillae, and groin. Transposi­
tion flaps, if possible, may be used to avoid applying Integra
directly over joints. Negative-pressure therapy (NPT) can
assist with adherence and minimize shear; whether or not
it accelerates vascularization and cell migration is debat­
able (Fig. 58.3). The skin substitute is covered with an
antimicrobial dressing (e.g., Acticoat, Smith & Nephew,
London and Hull, United Kingdom), then a layer of gauze
(Kerlix, Medtronic, Dublin, Republic of Ireland) and a
bandage. For resurfacing on the limbs, a foam circumfer­
ential cylinder firmly applied provides gentle pressure and
may prevent complications including shear and hematoma
formation.
Aftercare following surgery is very important to detect
any early signs of infection. In the author’s practice, patients
are usually discharged home the day following surgery in
extensive resurfacing or on the day of surgery in smaller
cases. Patients are reviewed by a member of the team with
experience in dealing with Integra. Readmission for the
second stage to apply the partial-thickness skin graft
(0.008–0.010 inch) occurs 3–4 weeks after the first stage.
The same dressings are applied as at the first stage for 1
week, and the patient is followed-up weekly. Patients are
seen regularly by the therapy team during the postoperative
period, and the same splinting and scar management as for
conventional skin grafts is applied.
A
B
C
D
Fig. 58.3  Long-term outcome of Integra scar resurfacing. Post-excision of a scar on the back of a child and application of Integra (A), which is further
secured with negative-pressure dressing (B), and final appearance of dressing (C). Appearance of resurfaced burn wound scar 4 years postop (D).

58  •  The Role of Alternative Wound Substitutes in Major Burn Wounds and Burn Scar Resurfacing
638
A
B
C
D
E
F
Fig. 58.4  Long-term outcome of Matriderm resurfacing. Excision of hypertrophic burn scar (A), post application of Matriderm and split-thickness skin
graft (B), appearance at 2 weeks (C), appearance at 3 weeks (D), and appearance of healed scar at 3 months (E) and 9 months with good range of
motion at the elbow joint (F).

58  •  The Role of Alternative Wound Substitutes in Major Burn Wounds and Burn Scar Resurfacing
639
Matriderm operative and postoperative care is similar to
that of Integra; however occlusive dressings that are not
disturbed for 1 week usually give good results because the
skin graft overlying the Matriderm requires a moist envi­
ronment until vascularization occurs (Fig. 58.4). Since
Matriderm does not have a silicon layer, NPT should be used
with caution because it may shrink the matrix.
Future Directions
Permanent alternative wound substitutes can improve sur­
vival and outcome in burn patients but remain prohibitively
expensive. Ninety-five percent of patients with major burns
live in low- and middle-income countries where these prod­
ucts are not easily affordable. New products that could be
produced less expensively on a large scale may reduce the
cost and help these patients.
Unlocking the regenerative potential of skin, together
with new innovations such as scaffolds that deliver mol­
ecules to the wound bed to promote healing and reduce
scarring, are exciting directions for the future.
Complete references available online at

639.e1
58  •  The Role of Alternative Wound Substitutes in Major Burn Wounds and Burn Scar Resurfacing
References
1. Heimbach D, Luterman A, Burke J, et al. Artificial dermis for
major burns. A multi-center randomized clinical trial. Ann Surg.
1988;208(3):313-320.
2. Branski LK, Herndon DN, Pereira C, et al. Longitudinal assessment of
Integra in primary burn management: a randomized pediatric clinical
trial. Crit Care Med. 2007;35(11):2615-2623.
3. Moiemen NS, Vlachou E, Staiano JJ, et al. Reconstructive surgery
with Integra dermal regeneration template: histologic study, clinical
evaluation, and current practice. Plast Reconstr Surg. 2006;117(7
suppl):160S-174S.
4. Boyce STKR, Meyer NA, Yakuboff KP, et al. The 1999 clinical research
award. Cultured skin substitutes combined with Integra Artificial Skin
to replace native skin autograft and allograft for the closure of excised
full-thickness burns. J Burn Care Rehabil. 1999;20(6):453-461.

640
Aesthetic Reconstruction in
Burn Patients
JUAN P. BARRET
59 
59.1). Thus, positioning in bed is one of the most impor­
tant ways to prevent deformities (Box 59.2). It is not the
responsibility only of rehabilitation services, but of the
whole burn team as well. Exercise reduces edema, main­
tains joint motion and strength, reduces scars, and, in the
pediatric patient, maintains development level. Ambula­
tion can begin as soon as the patient is deemed medically
stable, with wounds properly dressed and doubly wrapped
lower limbs.
Prevention by positioning and splinting affects many
problems in the care of burned patients. Static and dynamic
splints are used for either immobilization or mobilization,
respectively. Initially splints are used at all times except for
exercise and immediately postop during the immobilization
period. As active range of motion increases and is main­
tained, the protocol changes to night-only splinting. Skele­
tal traction and fixation also are used on a limited basis to
prevent and correct burn scar contracture formation and
are always tailored to the patient’s needs.8
Timing of Reconstruction
It has been advocated that definitive correction of burn
scarring should be delayed for 1 year or longer after healing
in the acute period. It is certainly true that unaesthetic and
ugly scars mature over time, and, with the effect of pressure
and splints, many of them do not require surgery once the
acute phase of scar maturation has taken place. Patience is
often the best tool of the reconstructive surgeon. However
some problems encountered early during the recovery
phase must be dealt with and operated on before the golden
period of scar maturation is over. In these circumstances it
must be absolutely certain that an operation is needed to
correct the deformity. Urgent procedures must be planned
to correct functions that are not amenable to other treat­
ments, often because time is of the essence. An eyelid release
to protect an exposed cornea, correction of distracted or
entrapped neurovascular bundles, severe fourth-degree
contractures, and severe microstomia fall into this group.
Intense rehabilitation, splinting, and pressure therapy are
mandatory after correction of these deformities. In some
patients deformity may be addressed nonoperatively, but if
this approach does not lead to appropriate results, an opera­
tion may be considered. In this section fall all burn scar
contractures that do not respond to rehabilitation and
hypertrophic scarring and contractures that prevent the
patient from eating, bathing, moving, and performing
activities of daily living.
Most of the problems that patients may present are aes­
thetic ones and scar contractures that, although not
Introduction
The severity of injury and deformity from burn trauma
range from relatively minor to severe.1 The psychological
and social impact of sequelae do not parallel the severity of
the deformity; even minor disfigurements can have severe
psychologic and social impacts on the patient. Basic con­
cerns common to all burned patients include function,
comfort, and appearance.2 The approach is that of total
patient care; it must include all healthcare team members
and it is predicated on aesthetic and functional reconstruc­
tion. Burn reconstruction is a complex and long process
that starts when the patient is admitted in the acute phase
and lasts until the patient’s expectations have been reached
and/or there is nothing more to offer. It is normally a life-
long commitment, and, even if there may be no other
possibilities to offer at that point, the patient–surgeon rela­
tionship still continues. It is preferable, although not imper­
ative, that burn reconstruction be performed in close
vicinity to the burn center and that it has the constant
support of and coordinated treatment with the multidisci­
plinary burn team. If this is not the case, good communica­
tion with the team referring the patient is desirable.3
Preventing and minimizing scarring and deformity in
burn patients starts during the acute phase. Reducing the
inflammatory and catabolic responses after burn injury
using a team approach and early closure of the burn wound
is paramount to control wound healing in these patients.4
It is preferable that the surgeon managing the acute
injury be responsible for later reconstruction. If this is not
the case, the reconstructive surgeon should be consulted
early on so that the needs for reconstruction enter into the
plan of the acute care.5
Different procedures are important during the acute
phase to minimize later reconstruction. Splints, face masks,
silicone gel sheets, early pressure therapy and ambulation,
and skeletal traction and fixation are of great importance
to produce the best result and avoid future operations
(Fig. 59.1).
Burn trauma requires aggressive intervention by reha­
bilitation services to prevent debilitating deformities. Burn
distribution as well as burn depth is a good predictor of
rehabilitation outcomes. Prevention of burn deformities
includes proper positioning with or without splints, exercise
to maintain joint range of motion, maintenance of muscle
strength and muscle tone, and early mobilization. All this
is true not only for the acute period, but also for the recon­
structive period.6,7
Burn patients tend to assume the position of comfort,
which is often responsible for deformities that require
reconstructive surgery later during the recovery phase (Box

59  •  Aesthetic Reconstruction in Burn Patients
641
Psychologic and socioeconomic factors are very important
when making this decision. The patient’s mood plays an
important role because an unmotivated or depressed patient
will not appreciate the procedure as much as a healthy
patient. Moreover, operating on such a patient may produce
discomfort and discouragement that, eventually, can jeop­
ardize the patient’s compliance and prevent further recon­
struction. The social status of the patient is also of great
relevance. Emotional support received from friends, family,
and co-workers is important, as is the patient’s economic
status. When making a treatment plan, all these particular
circumstances need to be taken into account when consid­
ering the number of procedures to be done at a time, recov­
ery time, family support in the recovery phase, and what is
to be done first.5
Patient–Surgeon Relationship
Burn patients require an intense and good relationship with
their surgeon. The relationship is normally a long-lasting
one, many times extending to a lifetime. Patients require a
surgeon’s professional expertise, but also the surgeon’s
time, a good dose of optimism, and compassion. The initial
meeting is one of the most important events in burn recon­
struction. A patient presents with a set of complaints that
have to be evaluated together with the patient’s motivation
for surgery and his or her psychologic status. Chief com­
plaints, patient motivation, and expectations are evaluated.
Limitations of surgery and any relevant technique are
explained, together with the master plan for reconstruction
and the order of reconstructive priorities. Photographic
workup is extremely important to document the case, assist
in definitive preoperative planning, and for documentation.
When dealing with long-term scars and burn deformities,
different problems may be encountered intraoperatively
that might require a complementary technique. These spe­
cific issues of burn reconstructive surgery have to be
explained in detail to the patient, and the surgeon needs to
foresee and include them in the preoperative planning and
prominent, produce great discomfort. Many of these prob­
lems disappear in the first 2 years postburn with appropri­
ate care, and these problems benefit most from patience and
time. Many important deformities seen a few months post
burn improve with time and can be treated with simple or
less extensive procedures later (Fig. 59.2).
Many factors other than scar maturation, however, affect
the decision of whether to operate on burn scars.
B
A
Fig. 59.1  (A) Sixty percent full-thickness total body surface area (TBSA) burn. (B) A comprehensive rehabilitation team approach is necessary to achieve
good functional and aesthetic outcomes.
Box 59.1  Position of Comfort After Burn
Trauma (to be Avoided)
1. Neck flexion
2. Shoulder protraction
3. Elbow flexion
4. Metacarpal extension
5. Interphalangeal flexion
6. Wrist flexion
7. Hip flexion
8. Knee flexion
9. Ankle plantar flexion
Box 59.2  Prevention of Deformity: Positioning
in Bed
1. Maintain straight alignment of the trunk and neck
2. Neck should be in slight extension
3. Arms should be elevated in the neutral plane or in line with
the glenoid at approximately 15–20 degrees of horizontal
flexion and 80 degrees of abduction
4. Elbow should be in full extension
5. Hand should be in the intrinsic plus position with the thumb
in flexion and abduction
6. Hips should be in extension and abduction
7. Knees should be in full extension
8. Foot should be in neutral position and with 90 degrees or
greater dorsiflexion

59  •  Aesthetic Reconstruction in Burn Patients
642
maintains an abnormal position to overcome the deformity.
A complete X-ray workup must be obtained to explore the
status of bones and joints. In severe restriction of function,
good radiological imaging must be obtained to rule out het­
erotopic calcification.
The needs for physiotherapy, occupational therapy, and
pressure garments have to be considered at this time. The
the informed consent meetings so that unpleasant surprises
are not encountered later.9
Patients need to be reassured frequently. A burn recon­
struction project involves several operations, many clinic
visits, and often a long time to make a final assessment.
The patient’s feelings and impressions must be addressed
continuously and any trouble, minor disappointment,
or depression detected early on and treated as needed
(Box 59.3).
Pre- and Postoperative Care in
Burn Reconstruction
A complete record of all encountered problems has to be
performed during the initial and any follow-up visits before
surgery. Quality and color of the skin in the affected areas
must be noted, including abnormal scars, hyper- or hypopig­
mentation, contractures, atrophy, and open wounds. Func­
tion has to be addressed next: all involved joints are explored,
range of motion noted, and skeletal deformities addressed.
Often scar contractures distract joints and the body
C
B
A
Fig. 59.2  (A) Second-degree burn to the lower extremities. (B) Same patient at 2 months. Erythema, hyperpigmentation, and scarring are present. (C)
Result at 18 months with conservative treatment. Scarring is minimal with good overall result. In many cases scar maturation renders optimal outcomes
and allows good planning for reconstructive planning if necessary. (From Color atlas of burn care, London 2001, First Edition, Elsevier.)
Box 59.3  Characteristics of Burn Reconstructive
Plastic Surgery
1. Starts during acute period
2. Strong patient–surgeon relationship
3. Development of a “master plan”
4. Involvement of the burn team using a multidisciplinary
approach
5. Long and staged procedures
6. Complex and technological implications
7. Involvement of plastic surgery and aesthetic surgery/medicine
techniques

59  •  Aesthetic Reconstruction in Burn Patients
643
antistaphylococcal agents. If a skin flap or introduction of
alloplastic material is to be performed, antibiotics should be
continued in the postoperative period for at least two more
doses.
Probiotics are also advised to avoid any antibiotic side
effect. Intraoperatively large doses of local anesthetics are
to be avoided, and the extensive use of electric coagulation
is minimized because it increases the risk of necrosis of
scarred skin. Similarly the use of subcutaneous epinephrine
is limited because of the same risks.
A smooth emergence from general anesthesia, one free
of coughing and vomiting, is essential in burn reconstruc­
tive surgery, as are controlling high or low blood pressure
episodes, nausea, and vomiting. Hyperactive and anxious
patients may benefit from anxiolytic medication to avoid
sudden and uncontrolled movements in the immediate
postoperative period. Light dressings are applied after
surgery and any high pressure avoided since it can injure
burned tissue. When aesthetic procedures are planned
(such as fat grafting, CO2 laser therapy, chemical peels, aes­
thetic surgery), patients are left without dressings to allow
accurate and correct wound healing. Immobilization is kept
to a minimum, and passive and active range of motion is
started as soon as possible in the postoperative period.
Movement helps to avoid edema formation, congestion, and
recurrence of contractures. Splints, prostheses, and pres­
sure garments must be used either immediately or very
soon after the operation. Rehabilitation is normally part of
the reconstructive master plan, so it must be included and
started after surgery. Silicone inserts in grafted areas have
been found helpful in controlling the early phase of scar
maturation because they apply gentle and uniform pressure
to the wounds and position joints properly.
It is also very important to administer good pain control
because having a comfortable and cooperative patient helps
positioning, rehabilitation, and the success of any opera­
tion. Patient-assisted analgesia is the best option if the
patient is able to use it. Other than that, scheduled hydro­
codone and morphine are good alternatives. Anxiolytics
must always be considered as part of the pain control
program, and the addition of antiitch medications and anti­
emetics such as diphenhydramine and droperidol is very
helpful.
Finally, providing the patient and family an environment
that is cozy and relaxing helps them and the burn recon­
structive team to cope better with periodic admissions and
decreases fear and anxiety before every step in the progress
of the reconstructive plan.10,11
Surgical Approach to the Burn
Reconstructive Patient: The Role
of the Reconstructive Ladder
Some progress has been made in burn reconstructive
surgery in the past decades, although its impact is not as
dramatic as in other areas of plastic surgery. Burn recon­
structive surgery involved for many decades incisional or
excisional releases of the affected scars and skin autograft­
ing. Today, however, the first approaches that the recon­
structive surgeon should bear in mind are local or regional
patient is referred to the rehabilitation department for con­
sideration. Finally, an inventory of all possible sites for
donor tissue is made.
All reconstructive possibilities are discussed with the
patient, and the timing and order of such procedures are
outlined. All important points and pitfalls are explained to
the patient. The importance of addressing all urgent, essen­
tial, and functional problems first has to be understood by
the patient. This is essential because the patient can become
extremely upset when important cosmetic problems are dis­
regarded at the beginning while other not so obvious prob­
lems (to them) are addressed first.
Finally, in children, it is also important to perform as
many procedures as possible during the preschool years and
to offer the patient multiple, simultaneous procedures.
Time, effort, and money are then best invested. Essentials
of burn reconstruction are summarized in Box 59.4.
Pre-, intra-, and postoperative care of burn reconstruc­
tive patients include all techniques and special treatments
of general plastic surgery and any state-of-the-art special
plastic surgery techniques. The scope of procedures per­
formed in burn reconstructive surgery ranges from split-
thickness grafts to tissue expansion and microsurgery.
More recently composite vascularized allotransplantation
has emerged as a new technique for catastrophic burn
deformities.
The plastic surgeon operating on burn patients works
most of the time with scarred and injured skin. In this par­
ticular setting, it is very important to handle all tissues with
extreme care because vascularization in the area is nor­
mally altered. Patients are instructed to stop smoking for at
least 3 weeks before surgery. All meals and drinks contain­
ing active vascular substances need to be tapered and any
medications noted so that all unnecessary drugs can be
stopped. The patient is instructed also to avoid medications
such as aspirin that may increase intraoperative and post­
operative bleeding. Uncontrolled hypertension, cough,
nausea, and disorders of coagulation need to be known by
the surgeon and treated as needed since they are known to
increase the risk for hematoma. It is always advisable that
the patient presents for surgery with a responsible adult to
take care of them after surgery.
The evening before surgery the patient is instructed to
have the skin cleansed with bacteria-reducing soap, and a
light dinner is advised. Burn patients normally have hyper­
trophic scarring, seams, and intradermal cysts that
are prone to a high bacterial load. It is also advisable to
include in the operative planning the perioperative use of
Box 59.4  Essentials of Burn Reconstruction
1. Strong patient–surgeon relationship
2. Psychological support
3. Clarify expectations
4. Explain priorities
5. Note all available donor sites
6. Start with a “winner” (easy and quick operation)
7. As many surgeries as possible in the preschool years
8. Offer multiple, simultaneous procedures
9. Reassure and support the patients

59  •  Aesthetic Reconstruction in Burn Patients
644
HEAD AND NECK
Burns to the head and neck are still a challenge to the burn
team. Residual deformities produce severe distortion, with
disfigurement and functional limitations. Bridging scars
from chin to neck to anterior shoulder result in exaggerated
kyphosis with neck flexion and protraction of the shoul­
ders. The most frequent deformity in the periorbital area is
ectropion, although more severe cases present distraction
of the canthal folds, fusion of part of the eyelids, and distor­
tion of the lacrimal punctate. Release of upper and lower
eyelid contractures has to be performed separately, with
undermining of the surrounding tissues. Full-thickness
grafts are most suitable for lower eyelids where stability is
the goal, while split-thickness skin autografts are used on
upper eyelids to improve mobility.17 Fat grafting has been
successfully used to restore the aesthetic appearance of the
upper eyelid. Lower eyelid ectropion may also benefit from
fat grafting. Good repositioning of deep structures can be
achieved by this technique, often solving difficult ectropion
problems.18 Eyelashes and eyebrows can be restored by
monofollicular or multiple-follicular hair transplantation,
rendering in many situations better outcomes than tradi­
tional techniques. Micropigmentation is another good solu­
tion in selected patients, restoring normal appearance and
even providing the disguising look of three-dimensional
facial architecture.19,20
The nose anatomy deserves careful attention. Small
deformities may be corrected by secondary rhinoplasty and
dermabrasion with or without sprayed keratinocyte cells.
More extreme deformities (destruction of the columella or
alar rims) are good indications for helical rim free flaps,
whereas subtotal or total destruction of the nose calls for a
flaps.5 They provide new and vascularized tissue to the area,
they grow in children, and they render the best functional
and cosmetic results. These flaps can be raised either with
normal skin or burn scar. Even though it is generally true
that burned tissues present a high tendency to congestion,
ischemia, and necrosis, such tissue can be used as a reliable
flap if extreme care is used while raising the flap and the
injured skin is left attached to the underlying tissues.12 This
expands burn reconstruction into new territories and
techniques.
Moreover, tissue expansion offers reconstructive sur­
geons the possibility to produce new pre-expanded flaps
that may be transferred as free flaps or tailored or prefabri­
cated flaps.13–15
For years surgeons used to evaluate the chief complaint
or complaints and wait for immature scars or increasing
deformities to mature with time and the use of pressure
garments. Only then, after the deformity was stable, would
they begin with simple techniques. At that point, depending
on the type of deformity, skin grafts or simple techniques
such as z-plasties or the like were used. Today, the burn
reconstruction plan needs to be tailored to the individual
patient, and complex and advanced techniques are utilized
since they offer better function and cosmesis.5
Aesthetic Reconstruction of
Burned Patients
The evaluation of reconstructive needs in burn victims
should follow a holistic approach. In the best hands, the
approach is developed under the umbrella of a group of
experienced plastic, reconstructive, and aesthetic physi­
cians in which all techniques are mastered. Not only have
simple, traditional plastic surgery operations to be contem­
plated, but also new additions in aesthetic surgery and aes­
thetic medicine (Box 59.5). These include skin grafts to free
flaps, composite vascularized allotransplantation, fat graft­
ing, hair transplantation, and laser treatments or chemical
peels.16 Fig. 59.3 summarizes a master aesthetic burn
reconstructive plan.
Box 59.5  Techniques Available for Aesthetic
Burn Reconstruction
1. Classic workhorse techniques: skin grafts, cartilage grafts,
z-plasty, local and regional flaps, keystone flaps
2. Dermal regeneration templates
3. Tissue expansion with or without flap prelamination/
prefabrication
4. Free flaps, with or without prelamination
5. Fractional CO2 laser and others
6. Fat grafting and stem cell therapy/keratinocytes
7. Aesthetic plastic surgery techniques: liposuction, rhinoplasty,
facelifts, breast surgery, etc.
8. Chemical peels
9. Hair transplantation
10. Osseointegration and dental surgery
11. Micropigmentation
12. Composite vascularized allotransplantation
Fig. 59.3  Burn wound sequelae to the face. Aesthetic master plan
includes pre-expanded flaps, full-thickness skin grafts, scar revision,
commissuroplasties and lip correction, fat grafting, vertical subperios­
teal mid face lift, monofollicular hair transplantation, ear reconstruc­
tion, osseointegrated implants, CO2 fractional laser treatment, and
micropigmentation. Mastering all techniques of reconstructive surgery,
aesthetic surgery, and aesthetic medicine is a must to provide excellent
outcomes.

59  •  Aesthetic Reconstruction in Burn Patients
645
McCauley et al. classified burned scalp alopecia in terms of
the pattern and extension (Box 59.6). This classification has
proved very useful in our approach. Patchy burn alopecia
extending across the entire scalp or total alopecia are not
suitable for classical reconstruction.25 However micropig­
mentation or even monofollicular hair transplantation has
produced great results and provided new tools for burn
reconstruction of these difficult problems.19 On the other
hand, alopecia extending to up to 50% of the scalp can be
corrected with single expansion and closure, whereas larger
areas of alopecia or different concomitant segments of alo­
pecia can be managed with sequential expansion. Many
times overinflation of the expander is necessary, and it is
important to bear in mind that expanded tissue normally
contracts by 20% of the initial surface. Care of these patients
is similar to that of any patient undergoing tissue expan­
sion. In our hands rectangular tissue expanders with over­
expansion are the best possible solution for these types of
problems.
Selected patients with good-quality scars and limited
areas of burn alopecia may be offered hair transplanta­
tion. If this technique is selected, the same tenets and after­
care utilized in male pattern alopecia restoration apply. It is
important to recognize the male pattern alopecia areas in
the subject of relatives to select the appropriate donor site.26
traditional nose reconstruction with paramedian forehead
flap (if this donor site is absent, a prelaminated free flap is a
good option).21
Lip deformities and microstomia are normally addressed
with local flaps, commissuroplasties, and skin grafts.
Micropigmentation is a good aid to finish the reconstruction
and to restore the vermilion border. Fat grafting can be uti­
lized for lip volume, whereas laser treatment and dermabra­
sion clear superficial irregularities. Loss of hair follicles in
male patients has been traditionally reconstructed by means
of scalp grafts or flaps, but monofollicular hair restoration
is the ultimate solution for this problem.22
Another area that deserves aesthetic (and indeed func­
tional) attention is dental malocclusion. It is not uncom­
mon for burn patients to lose teeth and present with an
altered smile and poor projection. The growing child
deserves extra attention too. Tight scars, inelastic skin, and
scar contractures may alter the correct growth of facial
bones and produce malocclusion. If these anomalies are
detected, orthodontics, tooth replacement, osseointegrated
implants, and even orthognathic surgery may be required.23
Other passive deformities include ear deformities. Ear
reconstruction in burned patients can be done with rib car­
tilage grafts. If there is no suitable subcutaneous pocket, a
superficial temporalis fascial flap can be used to wrap the
framework, with a split-thickness skin graft on top. Other
times, tissue expansion to the retroauricular area can be
performed prior to the creation of a rib cartilage
framework.24
BURN ALOPECIA
One of the areas where the effects of burn injury are most
noticeable is the scalp. Healing of deep partial- and full-
thickness burns very often leads to areas of scalp alopecia.
This produces an important psychologic impact for the
patient because it affects self-esteem and image. Small areas
of patchy alopecia can be effectively treated with excision
and direct closure; however, tissue expansion is still the gold
standard of treatment for burn alopecia (Fig. 59.4).
B
A
Fig. 59.4  (A) Burn scar alopecia, including the anterior hairline. (B) Result after reconstruction with scalp tissue expansion with rectangular tissue
expanders.
Box 59.6  Classification of Burn Alopecia (after
McCauley et al.)
Type 1: Single alopecia segment
– A, <25%
– B, 25–50%
– C, 50–75%
– D, 75%
Type 2: Multiple alopecia segments amenable for tissue
expansion
Type 3: Patchy burn alopecia
Type 4: Total alopecia

59  •  Aesthetic Reconstruction in Burn Patients
646
contractures are best reconstructed with local flaps. Fascial
free flaps are also often utilized, covered with dermal regen­
eration templates in a two-stage operation. Occasionally a
skin autograft is necessary to add length to the reconstruc­
tion of the linear contractures. Boutonniere deformities
need reconstruction of the extensor mechanism. If contrac­
ture to the palmar surface co-exists, a full-thickness graft or
a cross-finger flap is necessary. However, in our experience,
full release of the contracture followed by a fascial free flap
and skin graft, versus a single- or two-stage dermal regen­
eration template procedure, together with the injection of
platelet-rich plasma is a great solution. Extensor tendon
destruction or adhesion is normally treated with tenolysis,
and, if tendon repair is necessary, a flap must be considered.
Stem cell therapy often helps in controlling excessive scar­
ring, although future clinical research will show its real
indications in burn care reconstruction. Finger transfers,
thumb lengthening, and internal and external fixation are
to be considered in severe and selected problems.5
Other available techniques that provide better cosmetic
outcomes include fat grafting, chemical peels, and frac­
tional ablative CO2 laser therapy.27
One of the most important parts of the reconstruction of
the burned hand is the rehabilitation plan. It must be started
as soon as the skin coverage is stable. Pressure therapy, web
spacers, and night splints are necessary to achieve the
expected results.28
BREASTS
Breast deformity, asymmetry, and displacement of the
nipple areola complex (NAC) is a commonly encountered
deformity. Even though they may affect both genders, the
presence of a breast deformity and NAC alteration has a
deeper emotional and psychosocial impact in the female
population.
Traditional techniques for treatment include release and
autografting. Novel additions to the reconstructive arma­
mentarium are integral and other dermal templates, which
provide pliability and elasticity with good recreation of the
breast mound and submammary fold. They also aid in the
growing breast, allowing for better symmetry and good aes­
thetic outcome.
Other patients require augmentation mammoplasty with
breast implants or fat grafting. In this situation it is not
uncommon for patients to require the temporary placement
of a breast tissue expander to augment the tissue envelope
and better accommodate a definitive implant with enhanced
symmetry and breast aesthetics.24
LOWER EXTREMITY
Severe burns to the lower extremity can be a source of
important morbidity. Deformity to the feet can affect gait
and normal living. Severe destruction may even prevent the
patient from standing. Patients are often concerned about
the appearance and correct positioning of the feet, plus the
correction of nail deformities; fractional ablative laser
therapy and fat grafting are parts of an integral functional
and cosmetic reconstruction. A good and durable skin cov­
ering must be supplied to these areas to improve weight-
bearing and ambulation. Good acute care can prevent some
UPPER EXTREMITY
Hypertrophic scars and contractures to the upper extremity
promote the position of comfort: protraction and adduction
of the shoulder, elbow in flexion, and the “burned hand
position” with wrist in flexion, metacarpophalangeal exten­
sion, interphalangeal flexion, and first metacarpal exten­
sion and adduction. The overall appearance of the hand is
that of a “claw deformity” (Fig. 59.5). Many of these prob­
lems can be prevented with correct acute care and splint­
ing, which include the arm elevated in the neutral plane or
in line with the glenoid at approximately 15–20 degrees of
horizontal flexion and 80 degrees of abduction, elbow in
full extension, and hand in intrinsic plus position with
thumb in flexion and abduction.
Linear contractures to the shoulder can be addressed
with local flaps, keystone flaps, or two-staged dermal regen­
eration burn reconstruction techniques. The addition of fat
grafting and stem cell therapy are promising grounds for
best outcomes and clinical research. Often four- and five-
flap z-plasties are very useful. When the contracture extends
to all or nearly all of the axilla, incisional release and auto­
grafting is preferable, although regional rotational flaps or
free flaps can be used if available. It has to be noted, however,
that a contracture to the axilla cannot be released at the
same time a neck release is performed since it is not possible
to maintain correct neck hyperextension while abducting
the shoulders in the postoperative period. The neck needs to
be addressed first, followed by the shoulder release, thus
allowing a perfect result in each operation.
Contractures to the elbow normally include flexion defor­
mity, which is best addressed with local z-plasties or, when
not possible, incisional release and autografting. It must be
noted, however, that heterotopic calcification has to be
ruled out when dealing with limitations of extension. In
some cases, peripheral nerves, in particular the ulnar nerve,
need to be transposed for complete functional correction of
the deformity.
The most common deformities of the hand are wrist and
dorsal contractures with extension, web space contrac­
tures, and boutonniere deformities. Extension deformity to
the wrist and dorsum of the hand normally requires an
incisional release and autografting, whereas web space
Fig. 59.5  Typical hand deformity. A comprehensive approach with a
program of functional reconstruction and aesthetic consideration of
skin coverage is advocated.