Điều Trị Bỏng Toàn Diện (Bản Expert Consult)

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a random skin flap and/or an axial flap at various bodily sites
described in the past. The flaps such as the Bakamjian flap;
the deltopectoral skin flap;9,10 the deltoid flap;21 the Song
radial arm flap,22 etc. are useful, particularly for burn deform­
ity reconstruction in children; unburned bodily sites suitable
as flap donor sites are scarce and the vessel size and length
are small – the factors predestined for graft transfer failure
if ignored.
Summary
It is essential for a surgeon to be versed in the knowledge of
techniques described for burn deformity reconstruction. The
use of a given technique may not be feasible because of
structural alteration induced by the injuries causing the
bodily deformity requiring reconstruction. It is similarly
important and essential for a surgeon to be familiar with the
technical limitations and outcomes derivable with the tech­
niques used. The techniques based upon modification of
the classic interpositional skin flap technique, i.e. 34 z-plasty,
34 FC z-plasty, 34 MC z-plasty, and 34 axial z-plasty tech­
niques are in our experience the most useful approaches in
alleviating contractural deformities noted in burn patients.
The procedures could be used to reconstruct deformities at
any time and the morbidities are nil.
Further reading
Bakamjian VY, Poole M. Maxillo-facial and palatal reconstructions
with the deltopectoral flap. Br J Plast Surg. 1977;30(1):17-37.
Barratt GE, Koopmann Jr CF. Skin grafts: physiology and
clinical considerations. Otolaryngol Clin North Am. 1984;17(2):
335-351.
Bressler RS, Bressler CH. Functional anatomy of the skin. Clin Podiatr
Med Surg. 1989;6(2):229-246.
Heden P, Jurell G, Arnander C. Prediction of skin flap necrosis:
a comparative study between laser Doppler flowmetry and
fluorescein test in a rat model. Ann Plast Surg. 1986;17(6):485-488.
Lewis R, Lang Jr PG. Delayed full-thickness skin grafts revisited.
Dermatol Surg. 2003;29(11):1113-1117.
treatment modality ineffective. The use of a skin flap is
the recommended approach because of its reliability and
predictability.
The task of fabricating a random cutaneous flap, i.e. a skin
flap with a random pattern of vascular supply, is technically
simple. Survival of the flap, on the other hand, may be com­
promised if the flap length to width ratio exceeds 2 : 1.6,7 The
dilemma of circulatory embarrassment in a skin flap is cir­
cumvented by inclusion of known arterial supplies and/or
underlying fascia or muscle in flap design and fabrication,
i.e. an axial skin flap and a fasciocutaneous or musculocuta­
neous flap.20 The ease of flap mobilization, that is the func­
tion of flap arc rotations can be facilitated if the flap
length–width ratio is increased from 2 : 1 in a random skin
flap to 4–5 : 1 in a FC or MC flap. For an axial skin flap, the
length of arterial tree will be the governing factor in deter­
mining the flap length.
The classic z-plasty is executed technically by rotating 90°
in the opposite direction of two triangular skin flaps of 60°
angle formed on either side of a contracted scar band.
Although the increment in tissue dimension, i.e. release of
tightness in a scar band gained with the technique has been
calculated mathematically to be 1.6-fold of the original scar
length, the exact extent of release achievable in practice is
less optimal.15 Differences in skin elasticity and the magni­
tude of scarring surrounding the skin flaps, the factors
affecting the flap advancement, and rotation are the proba­
ble factors responsible for the discrepancy in efficacy of the
technique.
The most important factors governing the efficacy of the
technique in clinical use are the pliability of the skin in the
site of expansion and the pattern of vascular supplies to the
skin in the proposed expansion site. In this regard, the tech­
nique may not be suited to expand the skin in a burned area
as the skin is unpliant and the vascular supply pattern is
aberrant. Incidents of extrusion, the ultimate sign of techni­
cal failure in the TE technique, are common for an implant
placed in the extremity and/or in an area with extensive
scarring.
With the advent of a microsurgical technique of composite
tissue transfer, the students of burn reconstructive proce­
dures have become ignorant of the approaches in fabricating
 
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The use of skin grafts, skin flaps and tissue expansion in burn deformity reconstruction
590.e1
© Copyright 2012 Elsevier, Inc. All rights reserved.
References
1. Bressler RS, Bressler CH. Functional anatomy of the skin. Clin
Podiatr Med Surg. 1989;6(2):229-246.
2. Sassolas B. [Anatomy of normal skin]. Soins. 2010;Sept(748):
28.
3. Nicol NH. Anatomy and physiology of the skin. Dermatol Nurs.
2005;17(1):62.
4. Barratt GE, Koopmann Jr CF. Skin grafts: physiology and
clinical considerations. Otolaryngol Clin North Am. 1984;17(2):
335-351.
5. Lewis R, Lang Jr PG. Delayed full-thickness skin grafts revisited.
Dermatol Surg. 2003;29(11):1113-1117.
6. Zhu B, Gao J, Hyakusoku H. Experimental study on the
relationship between the ratio of pedicle width to flap width and
the surviving length of the random skin flap. Zhonghua Zheng
Xing Shao Shang Wai Ke Za Zhi. 1999;15(6):441-443.
7. Heden P, Jurell G, Arnander C. Prediction of skin flap necrosis:
a comparative study between laser Doppler flowmetry and
fluorescein test in a rat model. Ann Plast Surg. 1986;17(6):
485-488.
8. Kelly CP, Gupta A, Keskin M, et al. A new design of a dorsal flap
in the rat to study skin necrosis and its prevention. J Plast Reconstr
Aesthet Surg. 2010;63(9):1553-1556.
9. Bakamjian VY, Poole M. Maxillo-facial and palatal
reconstructions with the deltopectoral flap. Br J Plast Surg.
1977;30(1):17-37.
10. Rebelo M, Ferreira A, Barbosa R, et al. Deltopectoral flap: an old
but contemporaneous solution for neck reconstruction. J Plast
Reconstr Aesthet Surg. 2009;62(1):137-138.
11. Bey E, Hautier A, Pradier JP, et al. Is the deltopectoral flap born
again? Role in postburn head and neck reconstruction. Burns.
2009;35(1):123-129.
12. Feng GM, Cigna E, Lai HK, et al. Deltopectoral flap revisited: role
of the extended flap in reconstruction of the head and neck.
Scand J Plast Reconstr Surg Hand Surg. 2006;40(5):275-280.
13. Pomaranski MR, Krull EA, Balle MR. Use of the Z-plasty
technique for forehead defects. Dermatol Surg. 2005;31(12):
1720-1723.
14. Bark SE, Keplinger LM, Meyr AJ. Precise intraoperative 60 degrees
Skin Z-plasty. J Foot Ankle Surg. 2010;49(2):191-193.
15. Hove CR, Williams 3rd EF, Rodgers BJ. Z-plasty: a concise review.
Facial Plast Surg. 2001;17(4):289-294.
16. Bennett RG, Hirt MA. History of tissue expansion. Concepts,
controversies, and complications. J Dermatol Surg Oncol.
1993;19(12):1066-1073.
17. Brusselaers N, Pirayesh A, Hoeksema H, et al. Burn scar
assessment: a systematic review of different scar scales. J Surg Res.
2010;164(1):e115-e123.
18. Ladak A, Tredget EE. Pathophysiology and management of the
burn scar. Clin Plast Surg. 2009;36(4):661-674.
19. Wang ZY, Zhang J, Lu SL. Objective evaluation of burn and
post-surgical scars and the accuracy of subjective scar type
judgment. Chin Med J (Engl). 2008;121(24):2517-2520.
20. Ponten B. The fasciocutaneous flap: its use in soft tissue defects of
the lower leg. Br J Plast Surg. 1981;34(2):215-220.
21. Vtiurin BM, Klim KI. [Use of a deltoid-pectoral pedicle skin flap
for restoration of the floor of the mouth in radical operations for
cancer]. Stomatologiia (Mosk). 1978;57(2):36-38.
22. Song R, Gao Y, Song Y, et al. The forearm flap. Clin Plast Surg.
1982;9(1):21-26.

Microvascular technique of composite
tissue transfer
Hiroyuki Sakurai
Introduction
Free tissue transfers using a microvascular technique have
been firmly established since the operating microscope revo­
lutionized the method of flap movement in the 1970s. They
have been used more often in reconstruction after extirpa­
tion of head and neck cancers, breast cancers, and upper and
lower limb trauma. Although skin grafts are generally used
for post-burn reconstruction, the flap coverage is superior in
both functional and aesthetic standpoints under certain situ­
ations. Therefore, burn care has also been included in this
expanding role of the free tissue transfer.
On the other hand, severe burn patients, to whom the free
flap transfers are often adapted, are characterized by a short­
age of available donor tissue for flap elevation. In addition,
one of the major drawbacks of the conventional free flap is
the bulk of the tissue. The technique of tissue expansion first
introduced in the early 1980s1,2 can reduce the donor site
morbidity and the bulkiness of the flaps. In burn patients,
this technique has been well indicated for alopecic deformi­
ties of the scalp. Moreover, it can extend the indication of
the free flap transfer for severe burn patients.3–5
Prefabricated flap is another versatile reconstructive option,
especially in patients with severe burn injuries. In this
method, a vascular carrier is implanted to a new skin terri­
tory. Following a period of maturation and neovasculariza­
tion, the prefabricated flap can be transferred, based on the
implanted pedicle. Washio6 reported the very first attempt of
prefabricated flap in a canine model using an intestinal
seromuscular patch as the vascular carrier. Thereafter, various
types of tissue, such as muscle,7 fascia,8 and vascular pedicle
alone, have been developed for the same purpose. In severe
burn patients, the limited donor site for free flap elevation
can be maximized using these techniques.
Usage of the microvascular technique
for acute burn care
Because the thermal injury induces the damage primarily
to the skin surface, the necessity of microvascular technique
is quite rare for acute burn care. The majority of burn patients
require only debridement and coverage with split-thickness
skin grafts. The exceptional situation necessitating the
microvascular technique is the extremely deep burn involv­
ing underlying structures such as bone, tendon, major vessels
and internal organs. These local conditions cannot support
skin grafts for coverage. Historically, these wounds were
managed with preservation of eschar in expectation of gen­
erating granulation tissue or decortication of bone cortex
to prepare a bed for skin grafts.9 These techniques often
led to long-term morbidity, including extensive necrosis
of underlying structures, persistent skin ulceration and
resultant infections. Therefore, microvascular free tissue
transfer should be considered as a primary method of recon­
struction for extremely deep thermal injury whenever clini­
cally feasible (Fig. 52.1). These reconstructive techniques
offer an early, reliable means of definitive reconstruction,
preserving function, providing uncomplicated healing, and
promoting early rehabilitation.10,11
Free flap to the post-burn neck contracture
Thermal injuries to the anterior neck region are prone to
induce a severe contracture, especially in a case with flame
burn, because the skin of this area is relatively thin and
pliable. The optimal reconstructive method for skin supple­
mentation, namely skin grafting versus flap coverage, is still
controversial. The flap coverage takes advantage regarding
pliability of the reconstructed skin, not necessitating a long-
term splinting, which is mandatory after skin grafting to the
anterior neck region. However, the primary shortcomings of
conventional free flaps have been their bulkiness and the
unavoidability of a secondary defatting procedure. To obtain
a natural neck appearance, particularly the mentocervical
angle, thinning of the flap is essential for achieving an aes­
thetically satisfactory result. A large number of thin free flaps
have been developed for anterior neck reconstruction.12–14
These flaps with a thin layer of fat not only without deep
fascia and fat but also without much of the superficial layer,
are well suited for this purpose. Dense vascular network
located in the subdermal layer can provide reliable vascular­
ity in relatively large flaps, leaving the suprafascial axial
vessels skeletonized from surrounding fat tissue.
The groin flap is the oldest free flap, which is considered
to have minimum donor site morbidity. In 1972, McGregor
and Jackson15 first described the vascular basis of the groin
flap, based on the superficial circumflex iliac vessels, and
©2012 Elsevier Ltd, Inc, BV
DOI: 10.1016/B978-1-4377-2786-9.00052-7
CHAPTER 52 
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592
In recent years, the advancement of imaging with
multidetector-row computed tomography angiography
(MDCTA) has allowed for preoperative determination of
vessels most suitable for flap vascular supply.20 These images
provide three-dimensional information on the course of the
target vessels leading to a significant reduction in surgical
time and a safer elevation of the thin flap.
Post-burn facial reconstruction using
microvascular technique
Severe post-burn scarring of the face presents a formidable
challenge for the reconstructive surgeon. A constriction of
cicatricial tissue may lead to a functional disability with
ectropions of lips and eyelids, oral incontinence and drool­
ing. In addition to functional considerations, the face needs
to be reconstructed with the concept of an aesthetic unit.21
The effort to leave unburned small areas often results in a
rather patchwork result and thus a cosmetically unacceptable
introduced the concept of axial blood supply. The following
year, Daniel and Taylor16 reported the first microvascular
transfer of groin skin. Harii and Ohmori17,18 later described
in detail the vascular supply based on 87 clinical dissections.
Historically, its acceptance had fallen out of favor due to
massive adipose tissue around a short pedicle vessel, and the
development of a plethora of new flaps. However, the versa­
tility of this old flap has been revisited when the above-
mentioned thinning technique is applied.12,19 Because the
groin region is often left intact even in severe burn patients,
the thin groin flap is a good candidate for severe post-burn
neck reconstruction (Fig. 52.2). The advantages of this flap
are as follows: (1) flaps can be thinned radically, which obvi­
ates a secondary defatting procedure; (2) the repositioning
is not required for flap elevation; (3) for flap widths of up
to 12 cm, donor sites are closed primarily12; (4) donor-site
scars are well hidden and no functional deficit results; (5) a
natural neck contour including a sharp mentocervical angle
can be achieved; (6) the postoperative tendency to form
disfiguring lateral scar bands is reduced.
Figure 52.1  (a) An 81-year-old man sustained
extremely deep burns when he lost
consciousness during cooking. (b) Debridement
of the non-viable tissue led to the wide exposure
of the cranium. (c) A free latissimus dorsi
musculocutaneous flap was used for coverage of
the defect, with microvascular anastomoses to
the superficial temporal vessels. (d) Early wound
coverage provided uncomplicated healing, and
promoted early rehabilitation.
A
B
C
D

Microvascular technique of composite tissue transfer
593
some drawbacks, such as frequent partial skin loss, visible
marginal scar, postoperative dark pigmentation, and
contracture. Mismatching of the skin color renders the
surgical outcome cosmetically unacceptable. In addition,
there are more limitations of chin movement in FTSG
than flap. Because full supplementation of dermis and soft
tissue are required to solve a fundamental problem, various
types of free flaps have been used in reconstructing the
perioral area.4,22,23
While severe burn injury is characterized by a shortage of
available donor tissue for reconstruction, the scalp is often
preserved as a precious donor site in this circumstance: the
skin is thick and, when burned, heals faster than other ana­
tomic areas. Since the first report of the frontal visor flaps by
Leon Dufourmentel24 in 1919, usage of scalp flap for lower
face reconstruction had been sporadically reported in male
patients. A study of the vascular supply of the scalp with a
appearance. Each aesthetic unit has an individual preference
for reconstructive options. For example, eyelids are best
reconstructed with skin grafting from the retroauricular
region. Because of the thinness of the skin of eyelids, flap
coverage is less optimal than skin grafting. On the other
hand, flap coverage is mandatory for nasal unit reconstruc­
tion, because the three-dimensionally complicated shape
needs to be maintained overlying nasal support. For this
reason, the median forehead flap is the standard reconstruc­
tive method for nasal deformity following thermal injury.
The indication of the free flap transfer is mostly addressed
to the lower part of the face among patients with severe burn.
Cicatricial deformities that involve the perioral region are
not uncommon consequences of flame burns. Surgical
release of offending scar tissues around the mouth; covering
the resultant defect with a full thickness skin graft (FTSG) is
the mainstay of surgical management. However, FTSG has
Figure 52.2  (a) A 32-year-old man presented a post-burn neck contracture extending to the anterior chest and upper extremity. (b) A thin free groin
flap was applied after contracture release with microvascular anastomoses to the transverse cervical vessels. (c) The contracture was completely released.
(d) The pliability of the thin groin flap allowed full extension of the neck.
A
B
C
D

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units defect, a single vascular carrier may not be sufficient to
perfuse all units to be reconstructed. In these cases, separated
vascular carriers that can nourish each unit independently
are desirable. Within this paradigm, the jejunal seromuscular
patch6 is a good candidate for the vascular carrier, because
the jejunum can be divided into multiple segments, based
on the arcade structure of the vessels. Using this method, the
composite facial defect including the nose, upper lip, and
lower lip can be reconstructed (Fig. 52.4).3
Total face reconstruction using
the microvascular technique
When an entire face needs to be covered, a remarkable
amount of skin is required. The area is deceptively larger
than one expects, because the graft must wrap over a curved
rather than flat surface. From a conceptual point of view, if
particular emphasis on the posterior branch of the superfi­
cial temporal artery revealed that it was possible to transpose
the hair-bearing flap on a long, highly mobile, narrow
pedicle containing this vessel. The major criticism of the
classic scalp flap was its donor site morbidity and resultant
alopecia. Free scalp flap combined with tissue expansion
technique virtually eliminated morbidity at the donor site
(Fig. 52.3).4 However, the usefulness of this method may be
curtailed in a woman because transferring of hair-bearing
tissues to the face could create a cosmetically unacceptable
result. A complete laser depilation is required when utilizing
this method for female patients.
The prefabricated flap is a versatile reconstructive option,
especially in patients with severe burn injuries, because it
can create new donor sites without limitation of natural
vascular territories. Prefabricated flaps have been utilized for
reconstruction of individual aesthetic units such as nose, ear,
cheek, lip and neck.25–27 However, in the case of a composite
Figure 52.3  (a) A 36-year-old man sustained a
48% body surface area burn, including the
anterior chest, neck and lower face. (b) A tissue
expander was inserted to the parietal region for
lower face reconstruction. (c) An expanded scalp
flap was elevated with the isolated superficial
temporal vessels. (d) The results at 3 years after
the surgery. (From Sakurai H, Soejima K, Takeuchi M,
et al. Reconstruction of perioral burn deformities in male
patients by using the expanded frontal scalp. Burns 2007;
33:1059–1064.)
A
B
C
D

Microvascular technique of composite tissue transfer
595
Figure 52.4  (a) A 72-year-old man sustained a 37.5% body surface area burn. After complete wound closure, the patient presented with severe facial
deformities including partial loss of the nose. (b) Jejunal seromuscular patches were transplanted to the supraclavicular region using microvascular
anastomoses. (c) Prefabricated flap created in the left anterior chest. Segment 1: Prefabrication for nasal reconstruction. The costal cartridge was transplanted
between skin and transferred seromuscular layer. Segment 2: Prefabrication for upper lip reconstruction. Segment 3: Prefabrication for lower lip
reconstruction. (d) At 3 years after reconstruction. (From Sakurai H, Takeuchi M, Nakamori D, et al. Prefabricated flap for multiple facial units reconstruction using a jejunal
seromuscular patch as a vascular carrier. Burns 2010; 36:e31–e35.)
A
B
segment 3
segment 2
segment 1
costal cartlige
C
D
Figure 52.5  (a) A 57-year-old patient with severe contracture of the face after burns. (b) Reshape of the transferred flap succeeded in achieving total face
reconstruction. (c) Donor site for the total face reconstruction. (Patient in: Sakurai H, Takeuchi M, Fujiwara O et al. Total face reconstruction with one expanded free flap. Surg
Technol Int 2005; 14:329–333.)
A
B
C

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596
achieved as either local flap or axial flap, in conjunction with
tissue expansion and prefabrication (Fig. 52.5).
Further reading
Fukaya E, Kuwatsuru R, Iimura H, et al. Imaging of the superficial
inferior epigastric vascular anatomy and preoperative planning
for the SIEA flap using MDCTA. J Plast Reconstr Aesthet Surg.
2010;64(1):63-68.
Matsumine H, Sakurai H, Nakajima Y, et al. Use of a bipedicled thin
groin flap in reconstruction of postburn anterior neck contracture.
Plast Reconstr Surg. 2008;122:782-785.
Sakurai H, Soejima K, Takeuchi M, et al. Reconstruction of perioral
burn deformities in male patients by using the expanded frontal
scalp. Burns. 2007;33:1059-1064.
Sakurai H, Takeuchi M, Fujiwara O, et al. Total face reconstruction
with one expanded free flap. Surg Technol Int. 2005;14:329-333.
Sakurai H, Takeuchi M, Nakamori D, et al. Prefabricated flap for
multiple facial units reconstruction using a jejunal seromuscular
patch as a vascular carrier. Burns. 2010;36:e31-e35.
a total face needs to be resurfaced, the color and texture
matching to the original facial skin is less important.
Although each aesthetic unit has an individual preference for
reconstructive options as mentioned before, it is more
important to use a sole donor site that can provide a large
amount of skin flap in the case of total face reconstruction.
When the whole face needs to be reconstructed with a
single skin flap, openings for eyes, nostrils, and a mouth
have to be made. It is well known that a surgical delay and
tissue expansion can lead to vascular ingrowths to the trans­
ferred tissue. Therefore, a tissue-expansion technique is well
adapted for total face reconstruction, not only to reduce the
donor site morbidity, but also to ensure vascular reliability
to the central portion even after the fenestrations.5
Even though the abundant tissue can be transferred to the
face as a single free flap, it becomes flattened when trans­
ferred to the face.28 However, once the skin is reconstructed
as a vascularized tissue, it can be readily moved and shaped
again. It is another superiority of the free flap in contrast to
skin grafting. The shaping of the free flap to the face can be
 
Access the complete reference list online at

Microvascular technique of composite tissue transfer
596.e1
© Copyright 2012 Elsevier, Inc. All rights reserved.
References
1. Radovan C. Breast reconstruction after mastectomy using the
temporary expander. Plast Reconstr Surg. 1982;69:195-208.
2. Radovan C. Tissue expansion in soft-tissue reconstruction. Plast
Reconstr Surg. 1984;74:482-492.
3. Sakurai H, Takeuchi M, Nakamori D, et al. Prefabricated flap for
multiple facial units reconstruction using a jejunal seromuscular
patch as a vascular carrier. Burns. 2010;36:e31-e35.
4. Sakurai H, Soejima K, Takeuchi M, et al. Reconstruction of
perioral burn deformities in male patients by using the expanded
frontal scalp. Burns. 2007;33:1059-1064.
5. Sakurai H, Takeuchi M, Fujiwara O, et al. Total face reconstruction
with one expanded free flap. Surg Technol Int. 2005;14:329-333.
6. Washio H. An intestinal conduit for free transplantation of other
tissues. Plast Reconstr Surg. 1971;48:48-51.
7. Shintomi Y, Ohura T. The use of muscle vascularized pedicle
flaps. Plast Reconstr Surg. 1982;70:725-735.
8. Khouri RK, Ozbek MR, Hruza GJ, et al. Facial reconstruction with
prefabricated induced expanded (PIE) supraclavicular skin flaps.
Plast Reconstr Surg. 1995;95:1007-1015.
9. Asch MJ, Curreri P, Pruit Jr BA. Thermal injury involving bone:
report of 32 cases. J Trauma. 1972;12:135-139.
10. Chick LR, Lister GD, Sowder L. Early free-flap coverage of
electrical and thermal burns. Plast Reconstr Surg. 1992;89:
1013-1019.
11. Stefanacci HA, Vandevender DK, Gamelli RL. The use of free
tissue transfers in acute thermal and electrical extremity injuries.
J Trauma. 2003;55:707-712.
12. Matsumine H, Sakurai H, Nakajima Y, et al. Use of a bipedicled
thin groin flap in reconstruction of postburn anterior neck
contracture. Plast Reconstr Surg. 2008;122:782-785.
13. Mun GH, Jeon BJ, Lim SY, et al. Reconstruction of postburn neck
contractures using free thin thoracodorsal artery perforator flaps
with cervicoplasty. Plast Reconstr Surg. 2007;120:1524-1532.
14. Margulis A, Agam K, Icekson M, et al. The expanded
supraclavicular flap, prefabricated with thoracoacromial vessels,
for reconstruction of postburn anterior cervical contractures. Plast
Reconstr Surg. 2007;119:2072-2077.
15. McGregor IA, Jackson IT. The groin flap. Br J Plast Surg.
1972;25:3.
16. Daniel RK, Taylor GI. Distant transfer of an island flap by
microvascular anastomoses: A clinical technique. Plast Reconstr
Surg. 1973;52:111.
17. Ohmori K, Harii K. Free groin flaps: Their vascular basis. Br J Plast
Surg. 1975;28:238.
18. Harii K, Ohmori K, Torii S, et al. Microvascular free skin flap
transfer. Clin Plast Surg. 1978;5:239.
19. Kimura N, Saitoh M. Free microdissected thin groin flap design
with an extended vascular pedicle. Plast Reconstr Surg. 2006;117:
986-992.
20. Fukaya E, Kuwatsuru R, Iimura H, et al. Imaging of the superficial
inferior epigastric vascular anatomy and preoperative planning for
the SIEA flap using MDCTA. J Plast Reconstr Aesthet Surg. 2010;
64(1):63-68.
21. Gonzalez-Ulloa M. Restoration of the face covering by means of
selected skin in regional aesthetic units. Br J Plast Surg. 1956;9:
212-221.
22. Lee JW, Jang YC, Oh SJ. Esthetic and functional reconstruction for
burn deformities of the lower lip and chin with free radial
forearm flap. Ann Plast Surg. 2006;56:384-386.
23. Rose EH. Aesthetic restoration of the severely disfigured face in
burn victims: a comprehensive strategy. Plast Reconstr Surg.
1995;96:1573-1585.
24. Dufourmentel L. Restauration plastique du menton avec un
lambeau de cuir chevelu complete de griffes diverses. Soc Dermat
et Syph. 1919;12:180-185.
25. Teot L, Cherenfant E, Otman S, et al. Prefabricated vascularised
supraclavicular flaps for face resurfacing after postburns scarring.
Lancet. 2000;355:1695-1696.
26. Pribaz JJ, Fine N, Orgill DP. Flap prefabrication in the head
and neck: a 10-year experience. Plast Reconstr Surg. 1999;103:
808-820.
27. Evans DM. Facial reconstruction after a burn injury using two
circumferential radial forearm flaps, and a dorsalis pedis flap for
the nose. Br J Plast Surg. 1995;48:471-476.
28. Birgfeld CB, Low DW. Total face reconstruction using a pre-
expanded, bilateral, extended, parascapular free flap. Ann Plast
Surg. 2006;56:565-568.

Reconstruction of the head and neck
Matthias B. Donelan, Eric C. Liao
Introduction
Reconstruction of the head and neck following burn injuries
presents great challenges and great opportunities. Successful
treatment requires sound surgical judgment and technical
expertise, as well as a thorough understanding of the patho­
physiology of the burn wound and contractures. Many dis­
ciplines are required to successfully care for patients with
burns of the head and neck. These include skilled nursing,
experienced occupational and physical therapy, and psycho­
logical and social support systems. The surgeon must also
have familiarity and expertise with non-surgical treatment
modalities such as pressure therapy, steroids, and laser
therapy. Realistic expectations on the part of both patients
and surgeons are essential to achieve successful treatment
outcomes. Burns to the head and neck of a serious nature
result in tissue injury with scarring and complete removal of
scars is not possible. A scar can only be modified or exchanged
for a scar or scars of a different variety. Despite this funda­
mental limitation, reconstruction of the burned face and
neck creates great opportunities for plastic surgery to signifi­
cantly improve functional and aesthetic deformities result­
ing in profound improvement for this large group of
challenging patients.
Burn injuries constrict and deform the face, distorting its
features, proportions and expression.1 Burns also alter the
surface of the facial mask by causing scars and altering
texture and pigmentation. The changes to the surface of the
skin are deforming but are much less important to facial
appearance than are the changes in proportion, features, and
expression. The removal of scars should not be the primary
goal of facial burn reconstruction. A normal looking face
with scars is always better looking than an even slightly
grotesque looking face with fewer scars. Mature scars that
result from burn injury will often be less conspicuous than
surgically created scars or surgically transferred flaps or
grafts. The subtle and gradual transition between unburned
skin and burn scar is an excellent example of nature’s cam­
ouflage and can render scarring remarkably inconspicuous.
The principal goal of facial burn reconstruction should be
the restoration of a pleasing and tension-free facial appear­
ance with appropriate animation and expression.2 If this
goal is kept in mind and pursued with persistence and deter­
mination, the amount of improvement that can result
after severe facial burn injury can be remarkable. Ignoring
this basic principle can result in iatrogenic catastrophes
during reconstructive surgery of the head and neck following
burn injury.
Successful reconstruction of burn deformities of the head
and neck requires a well-functioning and extensive team.3
Major burn deformities in this area can be intimidating and
overwhelming. Experience and a specialized infrastructure
are required to take care of these patients comfortably and
successfully. Familiarity with their unique problems and a
firm commitment to correcting their challenging deformities
is required from all members of the reconstructive team. The
care of a patient from the onset of a major burn involving
the head and neck to a successful reconstructive outcome
requires skill, patience, determination, and enthusiasm from
all who are involved.
Acute management
Although the main focus of this chapter is the reconstruction
of established facial burn deformities, an understanding of
the acute care of facial burn injuries is necessary in order for
the surgeon to have an accurate perspective. Excision and
grafting of deep second-degree and full-thickness burns has
become the standard of care since it was first proposed in
1947.4–6 It remains controversial whether this is the optimum
treatment for facial burn injuries. Early excision and grafting
of the face is problematic because of the difficulty in diag­
nosing the depth of the facial burn and accurately predicting
an individual patient’s long-term prognosis both function­
ally and aesthetically. The overwhelming majority of facial
burns treated conservatively with a moist regimen of topical
antibiotics will be healed within 3 weeks. Burns which are
clearly full-thickness are best treated by early excision and
grafting within 7–10 days to promote early wound closure
and minimize contractile forces (Fig. 53.1). The problem
cases are those where healing has not occurred by 3–4 weeks
or longer. Early tangential excision and grafting has been
proposed for these patients in order to achieve more favora­
ble healing with less eventual contracture deformities.7 Pro­
ponents of conservative therapy argue that early excision and
grafting may result in a patient with a grafted face who
would otherwise have healed favorably by successfully epi­
thelializing their partial-thickness burn from skin append­
ages.8 Conservative management has been facilitated by the
myriad ancillary techniques currently available to favorably
influence the healing of facial burns such as pressure,
©2012 Elsevier Ltd, Inc, BV
DOI: 10.1016/B978-1-4377-2786-9.00053-9
CHAPTER 53 
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Pathogenesis
Superficial second-degree burns usually heal without
scarring or pigmentary changes. Medium-thickness second-
degree burns which epithelialize in 10–14 days usually heal
without scarring, although there can be long-term changes
in skin texture and pigmentation. Deep second-degree burns
which epithelialize after 21 days or longer must be carefully
managed for they have a propensity to develop severe late
silicone,
silicone-lined
computer-generated
facemasks,
topical and interlesional steroids, vitamin E, massage, and
treatment with the pulsed-dye laser. Impressive results have
been obtained by advocates for early excision and grafting.9
Very good outcomes, however, can also be achieved by being
more conservative with this difficult group of patients (Fig.
53.2). The majority of acute facial burns are treated conserva­
tively in most burn centers, with early excision and grafting
limited to those cases where it is clear that a full-thickness
burn injury has occurred.
Figure 53.1  (a) A 5-year-old Native American girl, 3 days after deep second- and third-degree burns to her face. (b) Tangential excision and split-thickness
autografting were performed on the 10th postburn day. (c) Five years after facial excision and grafting. She has had a subsequent nasal reconstruction.
A
B
C
Figure 53.2  (a) Ungrafted facial burn injury
30 days following 85% burn in a 34-year-old
electrician. Wound closure was obtained with
split-thickness grafts at 5 weeks. (b) Four years
following burn injury. Lower lids and alar lobules
have been released and grafted.
A
B

Reconstruction of the head and neck
599
in the development of early hypertrophic scarring, relief of
the tension with either focal z-plasty or judicious release and
grafting can be very helpful. Full-thickness facial burns
should usually be excised and grafted unless focal and small.
Evaluation of facial burn deformities
Facial burn reconstruction should be based on an overall
strategy and a clear understanding of the fundamental prob­
lems. Many reconstructive techniques have been described
in the literature and most can be successful if the strategic
goals are appropriate.10–12 The best reconstructive plan is
usually a judicious combination of contracture releases by
z-plasty, grafts, and flaps, followed by appropriate scar
revision.2
Deep second- and third-degree burns heal by contraction
and epithelialization. The more severe the burn injury, the
more contraction takes place during the healing process. The
changes in facial appearance following a deep second-degree
burn injury are dramatically demonstrated in Figure 53.5.
Three weeks following a deep second-degree burn, the
patient’s facial features and proportions remain essentially
normal. Six months later, contractile forces have deformed
the facies in a pattern that is repeated to a variable degree in
virtually all severe facial burns. These changes make up the
stigmata of facial burn injury and are listed in Box 53.1. The
eyelids are distorted with ectropion, the nose is foreshort­
ened with ala flaring, the upper lip is shortened and retruded
with loss of philtral contour, the lower lip is everted and
inferiorly displaced, the lower lip is wider than the upper lip
in anterior view. The tissues of the face and neck are drawn
into the same plane with loss of jawline definition. The
severity of these changes is proportional to the severity of
the injury.
Fortunately, the majority of facial burn injuries are not
severe and do not involve the entire face. A relatively small
hypertrophic scarring (Fig. 53.3). These patients should be
closely monitored after initial healing and at the first sign of
hypertrophy must be managed with all available ancillary
treatment modalities. Pressure garments have been shown
over several decades to be effective in suppressing and revers­
ing hypertrophic scarring. Adding silicone to pressure therapy
seems to increase its efficacy. Computer-generated clear face
masks lined with silicone have improved the ability to
deliver pressure to facial hypertrophic scars and are better
tolerated by patients (Fig. 53.4). When tension plays a role
Figure 53.3  (a) One month following a flash
burn, the right cheek is epithelialized. (b) Ten
months later there is massive hypertrophy
despite conservative therapy with pressure.
A
B
Figure 53.4  Computer-generated clear silicone-lined masks are well
tolerated and more efficacious than previous devices.

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600
number of patients sustain injuries which deeply involve the
entire face such as shown in Figure 53.5. It can be helpful to
separate patients with facial burn deformities into two fun­
damentally different categories as described in Box 53.2.
Type I deformities consist of essentially normal faces that
have focal or diffuse scarring from their burns and may have
associated contractures. Type II deformities make up a much
smaller number of patients who have ‘pan-facial’ burn
deformities with some or even all of the facial burn stigmata.
Although these categories are not rigidly defined and there
are some patients who do not fit neatly into one or the other,
understanding the fundamental difference between these
Figure 53.5  (a) Three weeks following a deep
second-degree burn with essentially normal facial
features and proportions. (b) Six months later,
contraction and hypertrophy have created facial
burn stigmata.
A
B
Box 53.1  Stigmata of facial burns
•
Lower eyelid ectropion
•
Short nose with ala flaring
•
Short retruded upper lip
•
Lower lip eversion
•
Lower lip inferior displacement
•
Flat facial features
•
Loss of jawline definition
Box 53.2  Facial burn categories
Type I
Essentially normal faces with focal or diffuse burn scarring with or
without contractures.
Type II
Pan-facial burn deformities with some or all of the stigmata of facial
burns.
two groups of patients can help define treatment goals. It
can also aid in selecting the most appropriate methods for
reconstructive surgery.
Patients with type I deformities have an essentially normal
facial appearance despite scars from their burns. In these
patients, one must be certain that surgical intervention does
not adversely alter normal facial features or create distortion
from iatrogenically induced tension. Overall facial appear­
ance should not be sacrificed in an effort to ‘excise scars.’ The
best reconstructive options for patients with type I facial
burn deformities are usually scar release and revision with
z-plasties, full-thickness skin grafts, or tissue rearrangement
with local flaps. The pulsed-dye laser can be helpful for
decreasing post-burn erythema and treating persistently ery­
thematous burn scars. Full-thickness skin grafts are excellent
for focal contractures. Z-plasties in combination with the
pulsed-dye laser can be a powerful scar-improving combina­
tion (Fig. 53.6). Excision of scars and resurfacing operations
in aesthetic units and major flap transpositions with or
without tissue expansion are rarely indicated.
The much less frequently encountered group of patients
with type II facial burn deformities presents a completely
different clinical situation. Examples of patients falling into
the type II category are shown in Figure 53.7. The surgical
goals for this group of patients should be the restoration of
normal facial proportion and as much as possible the resto­
ration of the position and shape of normal facial features.
The intrinsic and extrinsic contractures that exist in these
patients require large amounts of skin. The correction of
these contractures should be carried out in a carefully
planned and staged fashion. The sequence of operations is
usually the following: eyelids, lower lip and chin, upper lip,
cheeks, nose, and then other residual deformities. As each
area is reconstructed, the addition of skin results in the relief
of tension, which benefits other areas of the face. Excision
of normal skin or elastic healed second-degree burned skin
is almost never indicated. After facial proportion has been

Reconstruction of the head and neck
601
Figure 53.6  (a) Hypertrophic scarring of both cheeks, lips and chin 6 months following flame burn. (b) Multiple z-plasties release tension on facial scars.
(c) Pulsed-dye laser therapy can be used to decrease erythema. (d) Improved appearance 3 years following burn. No scars have been excised.
A
B
C
D
achieved and facial features have been restored to their
normal location and shape without tension, scar revision
can be carried out to smooth and blend the remaining junc­
tional scars (Fig. 53.8).
Normal faces are a mosaic of colors, textures, wrinkles and
irregularities. In a face which has undergone major burn
injury, a mosaic appearance of scars, grafts, pigmentary
abnormalities and other flaws can be attractive as long as the
facial features are restored to a normal location and are suf­
ficiently loose and mobile for normal and appropriate facial
expression. Cosmetics can be useful for blending and cam­
ouflaging areas of pigmentary and texture abnormalities,
particularly in females.
Fundamental principles and techniques
Contractures
Burn injuries result in open wounds which either heal by
contraction and epithelialization, or are closed by skin graft­
ing. Contractures result from both of these forms of wound
healing. Contractures are either intrinsic or extrinsic. Intrin­
sic contractures result from loss of tissue in the injured area
with subsequent distortion of the involved anatomic part.
Extrinsic contractures are those in which the loss of tissue
is at a distance from the affected area but the distorted
structures such as eyelids or lips are not injured themselves.

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Figure 53.7  (a,b) Typical examples of patients
with ‘pan-facial’ burns resulting in type II facial
deformities.
A
B
Corrective measures should be directed at the cause of the
contracture in order to provide optimal benefit and prevent
iatrogenic deformities. It is helpful to minimize the amount
of skin and scar which is excised when correcting facial con­
tractures. When tension is released, many scars will mature
favorably and become inconspicuous. Even long-standing
scars will respond to a change in their environment. Healed
second-degree burns under tension may be unattractive but
when restored to a tension-free state can be superior in func­
tion and appearance to any replacement tissue. Minimizing
excision also decreases the amount of new skin which must
be provided in the reconstruction. Every effort should be
made to relieve tension from the face when performing burn
reconstruction. Tight faces are never attractive. Tight scars are
always hypertrophic and erythematous. Relaxed scars are
‘happy’ scars.
Aesthetic units
The concept of facial aesthetic units has profoundly affected
plastic surgical thinking since its introduction by Gonzalez-
Ulloa.13 Initially conceived as the ideal approach for resur­
facing the face following burn injury, this important concept
has been emphasized in virtually all subsequent writings
about facial burns. It is important to keep facial aesthetic
units in mind during burn reconstruction but the desire to
adhere to this concept should not supersede common sense.
When small unburned and unimportant islands of skin are
in an aesthetic unit that is being resurfaced, they can be
sacrificed. Otherwise, the excision of normal facial skin is
rarely indicated in burn reconstruction. All burned faces to
some degree are mosaic. Scar revision with z-plasties is an
excellent technique to camouflage scars in a burned face.
Mosaic faces which are proportional, tension free, and nor­
mally expressive appear much better in real life than they do
in images.
Z-plasty
The z-plasty operation is a powerful tool in the surgeon’s
armamentarium for facial burn reconstruction. The z-plasty
has been used for over 150 years to lengthen linear scars by
recruiting lax adjacent lateral tissue.14 Z-plasty can also cause
a profound beneficial influence on the physiology of scar
tissue when it is carried out within the scarred tissues rather
than after excising them.15 The physiology of this phenom­
enon is related to the immediate and continuing breakdown
of collagen which occurs in hypertrophic scars following the
relief of tension.16 Z-plasty also narrows scars at the same
time that it lengthens them. In addition, the z-plasty adds
to scar camouflage by making the borders of the scar more
irregular. In order for z-plasties to lengthen a burn scar and
restore elasticity, the lateral limbs of the z-plasty must extend
beyond the margins of the scar. The improvement in the
appearance of facial scars following z-plasty and without any
scar excision can be dramatic, particularly when combined
with pulsed-dye laser treatment (Fig. 53.6).
Laser therapy
Hypertrophic scarring is a frequent complication after
partial-thickness facial burn injuries which take longer than
3 weeks to completely epithelialize.17 Despite conservative
management and close monitoring, hypertrophic scarring
can become severe during the first two years after the burn
(Fig. 53.3).18–20 The pulsed-dye laser (PDL) has emerged as
a successful treatment modality during this period of scar
proliferation and is an effective alternative to scar excision
in patients with hypertrophic facial burn scars.21,22 Multiple
studies have demonstrated its beneficial effect on scar
erythema and hypertrophy.23–27 The PDL also rapidly
decreases pruritus and pain23,24 and provides an additional,
low-morbidity, therapeutic intervention for patients and
their families during the often prolonged period of scar

Reconstruction of the head and neck
603
intervention and the postoperative management of grafts
often determine the success or failure of facial burn recon­
struction. Split-thickness skin grafts contract more than full-
thickness grafts, wrinkle more, and always remain shiny with
a ‘glossy finish’ look. Split-thickness skin grafts should be
used primarily in the periphery of the face unless the limited
availability of donor sites requires their use in more promi­
nent areas. Split-thickness skin grafts can be excellent for
upper eyelid releasing and resurfacing. Hyperpigmentation
of split-thickness grafts on the face is a frequently occurring
problem in dark-skinned patients, particularly of African
descent.
The full-thickness skin graft is a reliable workhorse in
facial burn reconstruction. The broad, central, conspicuous
maturation. Restoration of hypertrophic facial scars to their
pre­vious state of a flat, epithelialized surface is a superior
outcome to surgical excision with its concomitant increase
in facial tension.22 The development of fractional ablative
and non-ablative laser therapy using various types of lasers
including CO2 and Erbium-YAG offer promising new
options for the management of facial burn scars in the future
(Fig. 53.9).28
Grafts
Skin grafts are an essential part of facial burn reconstruction.
Surgical decisions regarding donor site selection, the use
of split-thickness versus full-thickness grafts, the timing of
Figure 53.8  (a,b) A 29-year-old firefighter with
‘pan-facial’ burn deformity causing facial burn
stigmata. (c,d) Seven years later, following the
reconstructive sequence outlined in the text.
Facial features and proportion have been
restored. Note philtral reconstruction with
composite graft from ear triangular fossa.
A
B
C
D

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604
skin. The face is tight following burn injury and flaps tend
to contract when transferred. They can, therefore, compress
or obscure underlying tissue contours. Transposing or
advancing flaps from the neck and chest up to the face can
easily create extrinsic contractures that adversely affect facial
appearance. When flaps have been enlarged by tissue expan­
sion, they are even more dangerous in this regard. Contrac­
tures with a downward vector create a ‘sad’ facial appearance
that is distressing to patients. Cervicopectoral flaps provide
the best color match in color and texture to facial skin.
Distant flaps, whether transferred by traditional technique
or microsurgery, share the common flaw of poor match in
terms of color and texture.
Tissue expansion
Tissue expanders must be used with caution in the recon­
struction of the head and neck. The underlying theme of
almost all burn deformities is tension secondary to tissue
deficiency. Stretching adjacent tissue in order to carry out
areas of the face such as the cheeks, upper and lower lips,
and dorsum of the nose are excellent sites for the use of full-
thickness grafts. The missing or damaged parts in the vast
majority of even severe facial thermal burns are the epider­
mis and the dermis and that is what full-thickness skin grafts
provide. After facial burns, the subcutaneous fat may be
compressed or distorted by contractures but it is rare that it
is lost or injured. Adequate skin must be provided when
doing definitive resurfacing operations with full-thickness
grafts. Contractures must be overcorrected and postoperative
management with conformers and pressure is essential. Full-
thickness skin grafts are very reliable when used electively in
the face for reconstruction after burns.29
Flaps
Flaps can be useful for facial burn reconstruction but they
must be used judiciously and skillfully, recognizing their
problems and limitations. The thickness of skin flaps from
all distant donor sites is greater than that of the normal facial
Figure 53.9  Treatment of burn scar by synergy
of laser and z-plasty. (a,b) An 11-year-old girl
presented 2 years after a partial thickness facial
burn with hypertrophic scarring and ectropion of
the lower lip. (c,d) Patient is shown 4 years later
after two z-plasty procedures to decrease scar
tension and 12 pulsed dye laser treatments. Her
scars have become pale, flat, and soft with
resolution of the lower lip ectropion.
A
B
C
D

Reconstruction of the head and neck
605
as a pursestring, resulting in diminished oral opening (Fig.
53.11). This can compromise alimentation and airway access.
Microstomia is best addressed by the acute release of the oral
commissures taking care to avoid extensive transverse releas­
ing incisions in the aesthetic units of the cheek. Overcorrec­
tion can easily result in macrostomia. As soon as adequate
oral opening is achieved for feeding and airway access, defini­
tive reconstruction is best left for the post-acute period.
Macrostomia is caused by rapid contraction of open
wounds or grafts in the cheek and perioral region, resulting
in eversion of the upper and lower lips and lateral movement
of the oral commissures (Fig. 53.12). The loss of an effective
oral sphincter causes drooling and desiccation of the oral
mucosa, and can result in irreversible damage to the denti­
tion. Early intervention with release and grafting of the lower
and/or upper lips should be carried out as soon as possible.
Definitive reconstruction is best carried out at a later period.
Cervical deformities
Anterior neck contractures in the acute period are best pre­
vented by aggressive splinting and incisional releases and
grafting when indicated.34 When severe anterior neck flexion
contractures occur, early release and grafting is necessary
to allow for adequate airway access and to minimize
scar excision can easily result in an increase in tension and,
therefore, create iatrogenic contour abnormalities. The com­
plication rate of tissue expansion following burn injury is
high, especially in the neck area and the extremities.30–32
However, the scalp is a privileged site that tolerates tissue
expansion quite well.33 As noted before, care must be taken
when advancing or transposing expanded flaps from the
cervicopectoral area to the face as it can create extrinsic con­
tractures with a downward vector.
Timing of reconstructive surgery
The timing of reconstructive plastic surgery following facial
burn injury falls into three separate phases: acute, intermedi­
ate, and late. Specialized burn centers create an ideal patient-
care environment where acute care and reconstructive surgery
can be planned and carried out in optimal circumstances with
collaboration among acute and reconstructive physicians and
surgeons. The reconstruction of facial burn injuries to the
head and neck should optimally begin with the acute care.
Acute reconstructive surgery occurs during the first months
following the burn injury and includes urgent procedures
which are required to facilitate patient care or to prevent
acute contractures from causing permanent secondary
damage. Acute reconstructive intervention is most frequently
indicated in the eyelid, perioral, and cervical areas. Interme­
diate reconstructive surgery takes place during the months
to years after wounds are closed and the scar maturation
process is proceeding. During this phase of recovery, some
patients will present to the reconstructive surgeon after
having received their acute burn care at another facility.
Timely intervention when indicated is important in this
group of patients as it can positively influence further matu­
ration of scars and grafts. Late-phase reconstructive patients
present to the reconstructive surgeon with established facial
burn deformities many years following their acute injury.
Acute-phase reconstruction
Eyelids
Upper and lower eyelid ectropion can occur from burn inju­
ries to the periorbital region (intrinsic contracture) or may
arise secondarily as a result of the contracture of open
wounds and skin grafts at more distant sites (extrinsic con­
tracture). With severe ectropion such as shown in Figure
53.10a, early intervention is mandatory in order to prevent
irreversible injury to the cornea. Conservative measures to
protect the cornea, such as temporary sutures or contact
lenses, are often ineffective. Tarsorrhaphy can cause irrevers­
ible iatrogenic injury and should not be used. The best treat­
ment is early intervention with release of contracture and
resurfacing with split-thickness skin grafts (Fig. 53.10b).
Release of even extreme contractures with grafting can be
done in the presence of open wounds and effectively restores
protective eyelid function.
Perioral deformities
Microstomia occurs from circumferential scarring at the junc­
tion between lips and cheek. Perioral scarring from either
open wounds or contraction of skin graft suture lines can act
Figure 53.10  (a) Extreme eyelid ectropion during early acute phase.
(b) Successful correction of ectropion with release and graft despite
operative wounds.
A
B

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606
acute wound closure. The treatment options during this
period are multifaceted and are continuing to evolve. Sig­
nificant progress is being made with these types of
interventions.
It is often recommended that definitive reconstructive
surgery be carried out after facial scars and skin grafts are
mature, soft, and supple. This process takes at least a year
and frequently takes many years to fully occur. The matura­
tion of facial burn scars takes much longer than is generally
appreciated by patients and reconstructive surgeons alike. If
scars are continuing to improve, it is usually best to allow
them to continue to mature. If scars are not maturing
favorably, well-timed and well-conceived surgical interven­
tion to favorably influence the scar maturation process
can be beneficial. The scar maturation process after facial
burns is influenced by multiple factors. The most important
factor other than the initial severity of the injury is the
amount of tension present in the face and acting on the
scars. Surgical procedures to decrease tension and to favo­
rably alter the direction and contour of scars can achieve
significant improvement in scar maturation for many
years following a burn. Whenever healing burns cross
concave surfaces, there is a tendency for hypertrophic scar­
ring to develop. Examples in the face are the glabella, the
nasojugal groove, the crus helicis of the ear, and the infra­
commissural folds. Relieving tension with z-plasties without
scar excision is very effective in correcting hypertrophy
(Fig. 53.14). Steroids, both topically and intralesionally,
can be helpful during this period but must be used sparingly
to avoid atrophy, telangiectasias, and erythema. Tension
can also be relieved by judiciously placed releases and
skin grafts. The skin grafts can be of either split-thickness
or full-thickness variety. Split-thickness skin grafts are
best used where the location of the graft will be inconspicu­
ous or where large amounts of skin are required to relieve
the contractures. This is frequently indicated when there
are associated neck contractures. Tension from the neck
must be eliminated as much as possible to allow for favo­
rable maturation of facial burn scars. The use of full-
thickness skin grafts during the intermediate phase of
reconstruction should be rare and limited to circumstances
where definitive repair is being carried out and there is little
chance that further skin will be required in that region. The
pulsed-dye laser is a promising adjunctive therapy which
can decrease erythema and speed the rate of scar maturation
(Fig. 53.6).
Late-phase reconstruction
Late-phase reconstructive surgery takes place when scars are
mature and the patient’s deformities are essentially stable. In
some patients, scars will be soft and supple, but in others,
even long-standing scars may be hypertrophic and hypere­
mic many years following the burn injury because of persist­
ing tension or unfavorable orientation. Scars can remain
indurated and hyperemic for decades following a facial burn.
Reorientation in this late phase with z-plasties and treatment
with the pulsed-dye laser can result in remarkable improve­
ment (Fig. 53.15). Scar excision can often be avoided with
its concomitant increase in facial skin tension and distortion
of facial features.
hypertrophic scarring as a result of excessive and persistent
tension (Fig. 53.13). Although secondary releases and grafts
are often necessary, permanent correction of neck contrac­
tures with split-thickness skin grafts is frequently possible
when postoperative management includes proper splinting
and pressure (Fig. 53.13).34
Intermediate-phase reconstruction
The intermediate phase of plastic surgical intervention con­
sists of scar modification designed to favorably influence
the healing process in the early months to years following
Figure 53.11  Microstomia during acute phase as a result of circum-oral
contracture.
Figure 53.12  Macrostomia secondary to contracture of open wounds and
grafts with lip eversion and loss of oral competence.

Reconstruction of the head and neck
607
Previously described reconstruction techniques include
serial excision, rotational scalp flaps, free hair follicle trans­
plantation, and staged scalp tissue expansion.37 Of patients
with scalp injuries, associated adjacent burn deformities
were commonly found involving the ear, nose, and eyebrow.38
These injuries included ear deformity (46%), nasal deform­
ity (27%), and eyebrow deformity (46%). Therefore, in plan­
ning the surgical reconstruction for pediatric scalp alopecia,
it is helpful to evaluate each patient for adjacent structure
burn injuries requiring reconstruction. Therefore, as one
plans the stages of tissue expansion procedures, one can plan
concurrent reconstruction of associated burn injuries, some­
times taking advantage of the region of expected alopecia
excision.
Reconstruction of specific areas of
the head and neck
Scalp
Scalp alopecia is seen in as many as 25% of children who
suffer burn injuries of the head and neck.35 McCauley et al.
devised a system of classification for burn alopecia based on
the pattern and extent of deformity.36 They describe the
pattern of alopecia as uniform, segmental, patchy, or total
(types I–IV, respectively) and the extent of alopecia as 25%
of the scalp, 25–50%, 50–75%, or >75% (subtypes A–D,
respectively). Their system serves as both the means of
description and an initial step in planning operative care.
Figure 53.13  (a,b) Extreme anterior cervical
contracture secondary to burns of the entire
chest and neck. (c,d) At 23 years post-burn after
release and split-thickness skin grafting. Two
additional releases and grafts were required.
A
B
C
D

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608
artery island flaps for eyelid or eyebrow reconstruction have
been used for many years.41–43 When used for eyebrow recon­
struction, they can be bushy and conspicuous and should be
used with caution, particularly when carrying out unilateral
eyebrow reconstruction.
Burn injuries of the scalp and upper face often result in
scars that distort the relative positions of the anterior hair­
line, eyebrows and upper eyelid. Contour of the brow is
distorted with exaggerated elevation of the central peak.
Further, scar contracture involving the upper eyelid can result
in cicatricial ectropion, associated with effacement of the
supratarsal fold and corneal exposure. This stereotypic set of
upper facial deformity can be treated with tissue expansion
Eyebrows
Eyebrow reconstruction following complete loss is an
unsolved surgical problem. Composite grafts of hair-bearing
scalp from carefully selected sites in the retroauricular area
can satisfactorily transfer hair.39–41 Unfortunately, the hair is
scalp hair which grows rapidly and is more projecting than
the tangential delicate hair of the normal eyebrow. For com­
plete eyebrow replacement, the technique of composite
grafting as described by Brent39 is most useful. For partial
eyebrow loss, micro- and mini-grafting of scalp hair can be
efficacious. Occasionally, borrowing composite grafts from a
contralateral unburned eyebrow is appropriate. Temporal
Figure 53.14  (a,b) Diffuse, hypertrophic scarring
of cheeks, chin, and lips 8 months following flame
burn injury. (c,d) At 12 years post-burn after
treatment with pressure therapy, steroid
injections, and multiple z-plasties within the scar
tissue. No scar tissue was excised.
A
B
C
D

Reconstruction of the head and neck
609
abundant skin graft. Upper eyelid resurfacing is best carried
out with split-thickness skin grafts from the best available
donor site.41 Full-thickness skin grafts in the upper eyelid
usually transfer a thick dermal component which compro­
mises the delicate contour of the supratarsal fold. Lower
eyelid resurfacing may be done with either split-thickness
skin grafts or appropriate full-thickness grafts when indi­
cated. For minor contractures of either upper or lower
eyelids, the perfect reconstructive material can be obtained
from an unburned contralateral upper eyelid. Medial canthal
folds are best corrected with z-plasties when there is not a
significant tissue deficiency.45
Lower lip and chin
Deformities of the lower lip and chin usually occur in com­
bination. Contracting forces result in inferior dislocation
and eversion of the lower lip. In addition, there is compres­
sion of the soft-tissue contours of the chin prominence.
Release should be carried out at the vermillion scar junction
and the lower lip carefully unfurled taking care to prevent
iatrogenic injury to the underlying orbicularis oris muscle.11
The resulting defect is then resurfaced with split-thickness
skin grafts or full-thickness grafts when indicated. Restora­
tion of chin contour can be improved with chin implants.
Upper lip deformities
The upper lip is usually shortened and retruded by severe
facial burn injuries. Releasing and grafting should be carried
out, taking care not to overcorrect the deformity and create
a long upper lip.11 Full-thickness grafts from the best avail­
able donor sites are usually the best option for resurfacing.
Reconstruction of the philtrum when indicated is best
and antegrade foreheadplasty.44 In this technique, the scalp
and forehead areas are tissue expanded. The tissue expander
is removed and the scalp aponeurosis is advanced antegrade
and loaded in redundant fashion over the brows at the level
of the arcus marginalis. Accounting for the fourth dimension
of time and tissue recoil, the brows are returned to a natural
contour and improved position (Figs 53.16, 53.17).
Eyelids
Correction of upper and lower eyelid contractures in the late
reconstructive period can be a daunting and humbling chal­
lenge. The periorbital region is made up of complex three
dimensional anatomy and requires abundant skin to appro­
priately drape the contours of both the upper and lower
eyelids. The slightest amount of excessive tension from either
the eyelid skin itself or contractures in adjacent regions such
as the forehead or cheek can profoundly and adversely effect
eyelid function and appearance. Reconstructive goals should
be restoration of a normally shaped palpebral fissure with
appropriate orientation of upper and lower eyelashes at rest
and in the open position whenever possible. This often
requires extensive releasing incisions extending medial to
the medial canthus and lateral to the lateral canthus in order
to adequately release all the contracted tissues. When ectro­
pion is the result of a distant contracture, the normal eyelid
skin should always be returned to its normal location. Inci­
sions should not be made at the eyelid margin, thereby
separating the normal eyelid skin from the ciliary line and
replacing it with a graft. When overlying scar is released, care
must be taken to prevent injury to the underlying orbicularis
oculi muscle. This is often rolled up and contracted and is
rarely completely lost. It must be unfolded to its normal
flat broad shape and the resulting defect resurfaced with
Figure 53.15  (a) A 16-year-old female 11 years following contact burn. Right cheek scar remains erythematous, indurated, and conspicuous. (b) Relaxation
and reorientation of scar tissue with z-plasty. (c) Five years later after six treatments with the pulsed-dye laser.
A
B
C

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610
Figure 53.16  Tissue expanded antegrade
forehead-plasty. This patient suffered flame
burn injury to the scalp and forehead. The
hyperpigmented skin graft on the scalp serves as
a marker illustrating movement of the expanded
scalp and forehead tissue. Before the forehead-
plasty, the patient suffered from upper lid
ectropion and exposure of the left cornea. Note
the over-elevated eyebrows and effacement of
the supratarsal fold in the left upper eyelid (a).
A tissue expander was placed (b). Antegrade
foreheadplasty was performed and forehead
tissue was loaded in a redundant fashion above
the brows, with overcorrection to account for
tissue recoil (c). At 1 month post-operation, note
the extent of antegrade forehead movement,
where the hyperpigmented skin graft is observed
to move from the scalp to mid-forehead region.
At 2 years following the operation, the forehead
tissue has flattened out and the eyebrows
restored to an improved position over the orbital
rims. Note the restoration of the supratarsal fold
to the left upper eyelid, and partial recoil of the
hyperpigmented skin graft (d).
A
B
C
D
Figure 53.17  Diagram illustrating tissue movements of antegrade forehead-plasty. Scalp tissue is maximally expanded, with consequent further
exaggeration of eyebrow elevation (left). Tissue expander is removed and the expanded scalp and forehead skin are advanced anteriorly, loaded in
redundant fashion over the eyebrows (middle). Over time, the redundant skin recoils, restoring the eyebrows to a more natural position (right).

Reconstruction of the head and neck
611
Nasal deformities
Burn injuries to the nose result in a broad range of deformi­
ties which can be focal and minor or can result in complete
nasal amputation. Minor deformities are best dealt with by
local scar revision, particularly with z-plasties to relieve con­
tractures, or releases in combination with full-thickness skin
grafting. Shortening of the nose with flaring or partial loss
of the alar rims is common in more severe facial burns. Local
release of the alar lobules with full-thickness skin grafts is a
useful technique for minor to moderate contractures. Com­
plete excision of dorsal scar and graft in an aesthetic unit
with a full-thickness skin graft is useful for more severe
shortening. When the lower third of the nose has been
amputated by the burn injury, inferiorly-based, turn-down
flaps of the dorsal nasal tissues can provide satisfactory
lengthening and improved contour to the tip and alar
lobules. More severe cases of nasal deformity can be treated
performed by the technique of Schmid46 using a composite
graft from the triangular fossa of the ear (Figs 53.8, 53.18).
Electrical burns of the oral commissure
Electrical burns of the oral commissure constitute a unique
and challenging burn injury to the head and neck. The injury
occurs in small children and usually results from placing a
live extension cord outlet in the mouth. Most of these inju­
ries are minor and all should be treated conservatively in the
acute period. If there has been minimal tissue loss, recon­
structive surgery using local flaps can improve aesthetics.47–49
When there has been extensive full-thickness loss of skin,
vermillion, mucosa, and muscle, as shown in Figure 53.19,
reconstruction with a ventral tongue flap can be advanta­
geous.50 Releasing the contracture associated with the
deformity can help restore normal mobility and facial
expression (Fig. 53.20).
A
B
C
D
Figure 53.18  (a) A 3-year-old female 10 months following severe facial burn with subtotal nasal amputation. (b) Intraoperative design of a nasal turn-down
flap. (c) Split-thickness skin grafting to nasal dorsum following turn-down flap and contracture releases. (d) At 16 years following turn-down flap after second
release and graft.

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612
reconstruction with a conchal transposition flap and skin
graft.54 Complete ear loss can be masked by the use of a
prosthesis. Fixation has been improved by the use of osteo-
integrated implants but cost and color changes remain prob­
lematic. Selected patients can be appropriate candidates
for total ear reconstruction using autologous cartilage and
soft-tissue coverage from either temporalis fascia flaps, or
expanded local tissue.55 Alloplastic materials should not be
used in the reconstruction of postburn ear deformities due
to an acceptably high extrusion rate.56
by either dorsal turn-down flaps or other forms of total nasal
reconstruction. The dorsal turn-down flap usually requires
at least two stages but can be effective in even near total nasal
amputation (Fig. 53.18). Forehead flaps are usually unavail­
able in patients who have sustained facial burns severe
enough to result in total nasal amputation. Distant flaps can
be used with either microsurgical transfer using a radial
forearm flap or using the frequently unburned skin of the
upper inner arm for a Tagliacozzi flap. If the face is otherwise
composed of burn scar and graft, these distant flap nasal
reconstructions have the disadvantage of appearing to be
‘stuck on’ and stand out in the midst of the otherwise mosaic
appearance of the face. When the face has required resurfac­
ing with flaps, a nasal reconstruction with flap tissue is the
best option (Fig. 53.21).
Ear deformities
Improved care in the acute phase of burn injury has greatly
decreased the incidence of helical chondritis and the result­
ing associated deformities of crumpled or lost cartilage.
Minor ear deformities are often seen in patients with little
or no hair loss and can easily be camouflaged. Larger defects
can be treated by myriad local reconstructive techniques.12,51–53
Subtotal ear amputation (Fig. 53.22) often lends itself to
Figure 53.19  (a) Severe oral commissure burns destroy vermillion, mucosa,
muscle, and the skin of the lip and cheek. (b) Extensive contracture results
with thickening of the leading edge of the commissure.
A
B
Figure 53.20  (a) At 16 years following devastating right oral commissure
electrical burn. Some 40% of lip circumference is lost and the commissure
is thick and immobile. (b) Following tongue flap reconstruction, the
commissure is thin and mobile and facial expression is restored.
A
B

Reconstruction of the head and neck
613
Figure 53.21  (a,b) Pan-facial burn deformity in a
14-year-old male. Cervicopectoral flap resurfacing
was chosen for reconstruction of the cheeks
and chin. (c,d) Nasal appearance following
reconstruction with a Tagliacozzi flap. A scalp flap
was used to reconstruct the upper lip and create
a moustache.
A
B
C
D
A
B
Figure 53.22  (a) Typical post-burn pattern of
peripheral helical loss. (b) Reconstructed ear
following expansion with conchal transposition
flap and skin grafts.

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614
cervical contractures during the acute period as burn scars
and grafted areas contract include splinting, physical therapy,
neck collars, and the use of a three-quarter mattress to
encourage neck extension.
Release and grafting
The majority of anterior neck contractures can be satisfac­
torily treated with release and skin grafting. Extensive con­
tractures usually require split-thickness skin grafting. Focal
contractures can be appropriate for full-thickness grafting,
which will result in a superior outcome from both a
functional and aesthetic standpoint. When neck contrac­
tures are extensive, the lower face and chest are usually a
Burn neck contractures
Prevention
Cervical contractures are a major problem in burns involving
the chest, neck, and face. The anterior neck skin is thin and
the neck is a highly mobile flexion area easily prone to con­
tracture. As noted previously, severe neck flexion neck con­
tractures in the acute phase often require early reconstruction
to aid in airway management. Neck contractures should
usually be dealt with prior to carrying out facial burn recon­
struction as the extrinsic contractile forces from the neck
cause facial deformities and can adversely affect the matura­
tion of scars on the face. Preventive methods to minimize
Figure 53.23  (a,b) Persistent, anterior neck
contracture following repeated inadequate
split-thickness skin grafting. (c,d) Release and
anterior neck resurfacing was carried out with
bilateral shoulder flaps. Secondary midline
z-plasties improved the vertical release and
created an aesthetic neck contour. Chin
augmentation improved the patient’s profile.
A
B
C
D

Reconstruction of the head and neck
615
to the anterior neck is that they can be thick and bulky,
requiring multiple defattings and secondary revisions. The
free flap can also appear to be an island in the midst of a
broad area of healed graft and burn scar.
Further reading
Davis JS. The relaxation of scar contractures by means of the z-, or
reversed z-type incision: stressing the use of scar infiltrated tissues.
Ann Surg. 1931;94:871-884.
Donelan MB. Conchal transposition flap for postburn ear deformities.
Plast Reconstr Surg. 1989;83:641-654.
Janzekovic ZA. New concepts in the early excision and immediate
grafting of burns. J Trauma. 1970;10:1103-1108.
Longacre JJ, Berry HK, Basom CR, et al. The effects of Z plasty
on hypertrophic scars. Scand J Plast Reconstr Surg. 1976;10:
113-128.
Parrett BM, Donelan MB. Pulsed dye laser in burn scars: current
concepts and future directions. Burns. 2010;36:443-449.
Pisarski GP, Mertens D, Warden GD, et al. Tissue expander
complications in the pediatric burn patient. Plast Reconstr Surg.
1998;102:1008-1012.
combination of healed skin graft and scar. Split-thickness
skin grafts represent ‘like tissue’ and will blend into the area
(Fig. 53.13).
Local flap reconstruction
When split-thickness skin grafting is unsuccessful because of
recurrent contracture or does not provide a satisfactory aes­
thetic result, local flap reconstruction of the anterior neck is
an excellent technique if there is available tissue. Flaps can
either be unilateral or bilateral. When bilateral flaps are
available, midline z-plasties secondarily can help to improve
neck contour (Fig. 53.23). Donor site morbidity is usually
minimal as the upper chest in these patients has frequently
been disfigured to some degree by the burn injury.
Distant flap reconstruction
Free flaps have been advocated for the treatment of anterior
neck contractures.57 Excellent outcomes can be obtained but
require microsurgical technique and create the possibility of
complete flap loss. Another potential negative of free flaps
 
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Reconstruction of the head and neck
615.e1
© Copyright 2012 Elsevier, Inc. All rights reserved.
References
1. Douglas MB. Facial burn treatment principles. In: McCarthy JG,
Galiano RD, Boutros S, eds. Current therapy in plastic surgery.
Philadelphia: Elsevier; 2006:184-193.
2. McIndoe A. Total facial reconstruction following burns. Postgrad
Med. 1949;6:187-200.
3. Engrav L, Donelan MB. Face burns: acute care and reconstruction.
Oper Tech Plast Reconstr Surg. 1997;4:53-85.
4. Cope O, Langohr JL, Moore FD, et al. Expeditious care of
full-thickness burn wounds by surgical excision and grafting. Ann
Surg. 1947;125:1-22.
5. Jackson D, Topley E, Cason JS, et al. Primary excision and grafting
of large burns. Ann Surg. 1960;152:167-189.
6. Janzekovic ZA. new concept in the early excision and immediate
grafting of burns. J Trauma. 1970;10:1103-1108.
7. Engrav LH, Heimbach DM, Walkinshaw MD, et al. Excision of
burns of the face. Plast Reconstr Surg. 1986;77:744-751.
8. Neale HW, Billmire DA, Carey JP. Reconstruction following head
and neck burns. Clin Plast Surg. 1986;13:119-136.
9. Cole JK, Engrav LH, Heimbach DM, et al. Early excision and
grafting of face and neck burns in patients over 20 years. Plast
Reconstr Surg. 2002;109:1266-1273.
10. Achauer BM. Reconstructing the burned face. Clin Plast Surg.
1992;19:623-636.
11. Engrav LH, Heimbach DM, Walkishaw MD, et al. Acute care and
reconstruction of facial burns. In: Mathes SJ, Hentz VR, eds.
Plastic surgery. The head and neck. Vol 2. Philadelphia: Saunders
Elsevier; 2006:45-76.
12. Feldman J. Facial burns. In: McCarthy JG, ed. Plastic surgery.
Philadelphia: WB Saunders; 1990:2153-2236.
13. Gonzalez-Ulloa M, Castillo A, Stevens E, et al. Preliminary study
of the total restoration of the facial skin. Plast Reconstr Surg
(1946). 1954;13:151-161.
14. Ivy RH. Who originated the Z-plasty? (Charles Pierre
Denonvilliers). Plast Reconstr Surg. 1971;47:67-72.
15. Davis JS. The relaxation of scar contractures by means of the z-,
or reversed z-type incision: stressing the use of scar infiltrated
tissues. Ann Surg. 1931;94:871-884.
16. Longacre JJ, Berry HK, Basom CR, et al. The effects of Z plasty
on hypertrophic scars. Scand J Plast Reconstr Surg. 1976;10:
113-128.
17. Alster TS, Tanzi EL. Hypertrophic scars and keloids: etiology and
management. Am J Clin Dermatol. 2003;4:235-243.
18. Engrav LH, Gottlieb JR, Millard SP, et al. A comparison of
intramarginal and extramarginal excision of hypertrophic burn
scars. Plast Reconstr Surg. 1988;81:40-45.
19. Ketchum LD, Robinson DW, Masters FW. Follow-up on treatment
of hypertrophic scars and keloids with triamcinolone. Plast
Reconstr Surg. 1971;48:256-259.
20. Tavares Filho JM, Belerique M, Franco D, et al. Tissue expansion
in burn sequelae repair. Burns. 2007;33:246-251.
21. Allison KP, Kiernan MN, Waters RA, et al. Pulsed dye laser
treatment of burn scars. Alleviation or irritation? Burns.
2003;29:207-213.
22. Donelan MB, Parrett BM, Sheridan RL. Pulsed dye laser therapy
and z-plasty for facial burn scars: the alternative to excision. Ann
Plast Surg. 2008;60:480-486.
23. Alster TS, Williams CM. Treatment of keloid sternotomy scars
with 585 nm flashlamp-pumped pulsed-dye laser. Lancet.
1995;345:1198-1200.
24. Kuo YR, Wu WS, Jeng SF, et al. Activation of ERK and p38 kinase
mediated keloid fibroblast apoptosis after flashlamp pulsed-dye
laser treatment. Lasers Surg Med. 2005;36:31-37.
25. Reiken SR, Wolfort SF, Berthiaume F, et al. Control of
hypertrophic scar growth using selective photothermolysis. Lasers
Surg Med. 1997;21:7-12.
26. Smith CJ, Smith JC, Finn MC. The possible role of mast cells
(allergy) in the production of keloid and hypertrophic scarring.
J Burn Care Rehabil. 1987;8:126-131.
27. Parrett BM, Donelan MB. Pulsed dye laser in burn scars: current
concepts and future directions. Burns. 2010;36:443-449.
28. Henderson DL, Cromwell TA, Mes LG. Argon and carbon dioxide
laser treatment of hypertrophic and keloid scars. Lasers Surg Med.
1984;3:271-277.
29. Donelan M, Silverman RP. Full-thickness skin grafts for elective
facial burn reconstruction; review of 237 consecutive cases. J Burn
Care Rehabil. 2002;2:S68.
30. Friedman R, Ingram AE, Rohrich RJ, et al. Risk factors for
complications in pediatric tissue expansion. Plast Reconstr Surg.
1996;98:1242-1246.
31. Neale HW, High RM, Billmire DA, et al. Complications of
controlled tissue expansion in the pediatric burn patient. Plast
Reconstr Surg. 1988;82:840-848.
32. Pisarski GP, Mertens D, Warden GD, et al. Tissue expander
complications in the pediatric burn patient. Plast Reconstr Surg.
1998;102:1008-1012.
33. Barret JP, Dziewulski P, Wolf SE, et al. Outcome of scalp donor
sites in 450 consecutive pediatric burn patients. Plast Reconstr
Surg. 1999;103:1139-1142.
34. Cronin TD. The use of a molded splint to prevent contracture
after split skin grafting on the neck. Plast Reconstr Surg. 1961;
27:7-18.
35. Huang TT, Larson DL, Lewis SR. Burn alopecia. Plast Reconstr Surg.
1977;60:763-767.
36. McCauley RL, Oliphant JR, Robson MC. Tissue expansion in the
correction of burn alopecia: classification and methods of
correction. Ann Plast Surg. 1990;25:103-115.
37. Buhrer DP, Huang TT, Yee HW, et al. Treatment of burn alopecia
with tissue expanders in children. Plast Reconstr Surg. 1988;81:
512-515.
38. Ridgway EB, Cowan JB, Donelan MB, et al. Pediatric burn-related
scalp alopecia treated with tissue expansion and the incidence of
associated facial burn injuries. J Burn Care Res. 2010;31:409-413.
39. Brent B. Reconstruction of ear, eyebrow, and sideburn in the
burned patient. Plast Reconstr Surg. 1975;55:312-317.
40. Pensler JM, Dillon B, Parry SW. Reconstruction of the eyebrow
in the pediatric burn patient. Plast Reconstr Surg. 1985;76:
434-440.
41. Sloan DF, Huang TT, Larson DL, et al. Reconstruction of eyelids
and eyebrows in burned patients. Plast Reconstr Surg. 1976;58:
340-346.
42. Conway H, Stark RB, Kavanaugh JD. Variations of the temporal
flap. Plast Reconstr Surg (1946). 1952;9:410-423.
43. Monks GH. The restoration of a lower eyelid by a new method.
Boston Med Surg J. 1898;139:385-387.
44. Liao EC, Driscoll DN, Donelan MB. Restoration of brow position
and contour with tissue-expanded antegrade foreheadplasty. Plast
Reconstr Surg. 2010;125:1263-1267.
45. Converse JM, McCarthy JG, Dobhovsky M, et al. Facial burns. In:
Converse JM, ed. Reconstructive plastic surgery. Philadelphia: WB
Saunders; 1977:1628-1631.
46. Schmid E. The use of auricular cartilage and composite grafts
in reconstruction of the upper lip, with special reference to
reconstruction of the philtrum. In: Broadbent TR, ed. Transactions
of the Third International Congress of Plastic Surgery. Amsterdam:
Excerpta Medica; 1964:306.
47. Gilles H, Millard Jr DR. The principles and art of plastic surgery.
Boston: Little, Brown; 1957.
48. Converse JM. Technique of elongation of the oral fissure and
restoration of the angle of the mouth. In: Kazanjian JM, Converse
JM, eds. The surgical management of facial injuries. Baltimore MD:
Williams and Wilkins; 1959:795.
49. Kazanjian VH, Roopenian A. The treatment of lip deformities
resulting from electric burns. Am J Surg. 1954;88:884-890.

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50. Donelan MB. Reconstruction of electrical burns of the oral
commissure with a ventral tongue flap. Plast Reconstr Surg.
1995;95:1155-1164.
51. Antia NH, Buch VI. Chondrocutaneous advancement flap for the
marginal defect of the ear. Plast Reconstr Surg. 1967;39:472-477.
52. Brent B. Reconstruction of the auricle. In: McCarthy JG, ed. Plastic
surgery. Philadelphia: WB Saunders; 1990:2094-2152.
53. Davis J. Aesthetic and Reconstructive Otoplasty. New York: Springer-
Verlag; 1987.
54. Donelan MB. Conchal transposition flap for postburn ear
deformities. Plast Reconstr Surg. 1989;83:641-654.
55. Brent B, Byrd HS. Secondary ear reconstruction with cartilage
grafts covered by axial, random, and free flaps of temporoparietal
fascia. Plast Reconstr Surg. 1983;72:141-152.
56. Lynch JB, Pousti A, Doyle JE, et al. Our experiences with silastic
ear implants. Plast Reconstr Surg. 1972;49:283-285.
57. Angrigiani C. Aesthetic microsurgical reconstruction of anterior
neck burn deformities. Plast Reconstr Surg. 1994;93:507-518.

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©2012 Elsevier Ltd, Inc, BV
DOI: 10.1016/B978-1-4377-2786-9.00054-0
Correction of burn alopecia
Robert McCauley
Introduction
Patients who sustain large total body surface area burns have
involvement of the head and neck between 25% and 45%
of the time.1,2 Since human skin does not regenerate itself,
scarring is the end result of the healing process. Such scarring
can not only be disfiguring but also can lead to contractures
which can affect function. The ultimate effect of deep burns
to the scalp is loss of hair leading to cicatricial alopecia. The
management of this problem is multifactorial. It includes
the analysis of the size of the defect, its location, the surface
area of the remaining scalp and the condition of the remain­
ing hair-bearing scalp. The treatment can range from exci­
sion with primary closure to the use of multiple tissue
expanders.
The scalp is a popular donor site for the harvesting of split
thickness skin grafts to resurface patients with large total
body surface area burns. Multiple harvestings of skin grafts
from the scalp may also lead to cicatricial alopecia. However,
the incidence of alopecia associated with graft harvesting
remains controversial. In 1990, Brou et al.3 reported a 61%
incidence of alopecia in patients with existing scalp burns,
in which skin grafts were harvested from the injured scalp.
Yet, only a 2.2% incidence of alopecia was noted in patients
without burns to the scalp who underwent harvesting of
scalp grafts for closure of burn wounds.4 Reconstructive sur­
geons have a number of tools available to address the cor­
rection of problems associated with burn patients. However,
one must keep in mind that inherent in all techniques can
be problems associated with color match, texture, and donor
site disfigurement. Certainly, primary closure of burn alo­
pecia can eliminate these problems using local flap advance­
ment. Now, tissue expansion is an example of how skin
responds to mechanical stress. It offers a number of advan­
tages when compared with other modalities of reconstruc­
tion. Such advantages as color match, sensation and minimal
donor site morbidity are not to be taken lightly. However,
tissue expansion is not for everyone. But, it is such a valuable
technique that it has become an integral part of the arma­
mentarium for reconstruction surgeons who are charged
with the reconstruction of burn patients.
Histomorphology of tissue expansion
It is noted that tissue expansion occurs under natural condi­
tions (i.e. pregnancy, breast development) and in abnormal
circumstances (expansion of the neck, earlobes). As part of
the aesthetics in various societies, tissue expansion has been
noted to document positions of social hierarchy.5,6 The first
clinical case of soft tissue expansion was reported by
Neumann in 1957.7 In a case of partial traumatic ear loss in
a 52-year-old man, Neumann inserted a rubber balloon
above the ear to create an expanded flap to cover his carti­
laginous framework. However, in spite of this remarkable
case, the idea of soft tissue expansion to correct traumatic
defects remained dormant for another 20 years. In 1975,
both Austad et al. and Radovan began pioneering work on
soft tissue expansion.8–10 Experimental data on the histomor­
phology of tissue expansion largely came from animal data.
Although Austad reported the laboratory experience with
tissue expansion prior to clinical use, Radovan is noted as
the first surgeon to claim extensive use with tissue expanders
clinically.
Epidermis
The response of the epidermis to tissue expansion is quite
interesting. The examples of tissue from both guinea pigs
and humans reveal epidermal thickening.8–11 Additional
studies by Pasyk et al. noted that epidermal thickening can
last up to two years after expansion. Pasyk also showed
that the epidermal thickening occurred in the stratum spon­
giosum.11 However, there is no correlation between epider­
mal thickening with expansion time, location, volume or
patient age. Interestingly, with expansion, light microscopy
reveals an undulated basal lamina. The basal and prickle
cells show an increase in the bundles of tonofibrils within
the tonofilaments. Such findings along with a decrease in
the intracellular spaces, in all of the epidermal layers, suggest
increased mitosis. These findings were later supported by
Austad, who documented increased mitotic activity using
tritiated thymidine. The three-fold increase in epidermal
mitosis occurred during expansion but returned to baseline
in 2–5 days.9
Dermis
The expansile and recoil properties of the skin are related to
the amount of collagen and elastin fibers in the dermis.12,13
Similarly, the epidermis, like the dermis, undergoes signifi­
cant changes during the expansion process. However, the
thickness of the dermis is reduced dramatically. This is not
related to expander volume or anatomic location.10 Most of
the dermal thinning occurs in the reticular dermis, with thin­
ning of the papillary dermis being less dramatic. During the
CHAPTER 54 
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IN THIS CHAPTER
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modulate its effects chemically may be a rich source for
future research.
Clinical application: correction of
burn alopecia
Primary closure
In 1978, Huang et al. categorized the extent of burn alopecia
as it related to correction of this problem. At this time, the
authors used primary excision and rotation flaps as a means
to either eliminate or camouflage burn alopecia.19 This group
discovered that alopecia greater than 15% of the hair-bearing
scalp was not amenable to correction using serial excision.
The next stage in the evolution of closure of scalp defects
came from Orticochea. The use of three and four limb Ortico­
chea flaps was successful in the closure of scalp defects greater
than 15%.20 The Juri flap, a pedicled, laterally-based scalp
flap, was described to re-establish the anterior hairline in
bald patients. The use of the Juri flap along with tissue expan­
sion has also been described.21,22 It is clear that the use of
primary closure in the correction of burn alopecia without
the use of tissue expansion is possible. However, the extent of
closure is less than 20–25% (Table 54.1). In general, if more
than two operations are required to close a scalp defect, tissue
expansion should be given serious consideration.
Burn alopecia classification
Many investigators have demonstrated the safety and efficacy
of tissue expansion in the correction of burn alopecia.23–25
McCauley et al. developed a classification based on both
the pattern of alopecia and the extent of alopecia.25 This
classification system was designed as a template by which
first few weeks of expansion, the dermis thins significantly
but less so towards the end of the expansion process. After
expansion, the reticular dermis is noted to have increased
amounts of thick bundles of collagen fibers parallel to the
skin. In addition, the elastic fibers in the expanded dermis
were thicker and longer. It is believed that the presence of
increased numbers of active fibroblasts in the dermis is
responsible for the immature collagen fibers. Collagen
bundles populate both the reticular and papillary dermis
from the multiplication of fibroblasts.12,13
Skin has the ability to stretch and recoil. Elastin fibers are
linked to each other by end-to-side junctions, and inter­
spersed among collagen fibers, which are often larger and
unlinked to another. Elastin fibers, unlike collagen, have the
ability to stretch and retract. Collagen fibers in their relaxed
state are disoriented and unparalleled. These fibers, in the
presence of applied stress, align in a parallel fashion.10 This
response is believed to be linearly proportional to the mag­
nitude of the applied stress. However, too much stress during
expansion of skin can cause constriction in the tiny blood
vessels, inducing ischemia. The goal of reconstructive sur­
geons is to take advantage of this regenerative process
without causing flap loss secondary to ischemia. It should
be noted that sebaceous glands and sweat glands, and
sensory nerves might undergo subtle changes. Hair follicles
remain unchanged qualitatively but remain active. The
lumens of various glands remain open even though adjacent
structures have been compressed.12,13 It is believed that
sensory fibers do not under go any appreciable structural
changes.10
Blood vessels
Several investigators have noted a significant proliferation of
blood vessels associated with tissue expansion. This prolif­
eration occurs primarily at the junction of the capsule and
host tissues. Within days of expansion, small capillaries
become distended, and in addition, the number of arterioles
and venules increase. Cherry et al. noted an increase in the
surviving length of expanded random-patterned skin flaps
when compared with delayed skin flaps.14 Sasaki and Pang
confirmed previous studies by documenting increased blood
flow in expanded flaps.15 Lantieri et al. later suggested that
vascular endothelial growth factor (VEGF) may play a part
in the development of the increased vascularity of expanded
flaps as VEGF was only expressed in expanded flap.16
Molecular basis of tissue expansion
Clearly, several studies have documented an increased
mitotic index in the epidermis with tissue expansion.9,17 Yet,
Takei et al. thought the mechanism of action was through
the activation of growth factors.18 This group postulated that
platelet derived growth factors and other growth factors
could stimulate cutaneous cellular activity. It is well known
that transforming growth factor-B (TGFβ) can not only influ­
ence extracellular matrix production but can also enhance
fibroblast proliferation. In addition, it is felt that membrane
bound molecules can play a role in the regulation of signal
transduction pathways (Fig. 54.1). Although it is clear that
strain has an effect on skin biology, whether or not we can
Figure 54.1  Influence of tissue expansion on the expression of growth
factors and the production of extracellular matrix. EGF, epidermal growth
factor; TGF-β, transforming growth factor-β; PDGF, platelet-derived growth
factor. (Reproduced with permission from Takei et al. Molecular basis for tissue expansion:
clinical implications for the surgeon. Plast Reconstr Surg 1998; 102:247–258.)
Tissue expander
Stretch
Epidermis
Subcutaneous
Growth factors
Molecular
effects
EGF, PDGF
Cell membrane
Cytoskeleton
Focal adhesion
plaques
TGF-β
Extracellular
matrix
Dermis

Correction of burn alopecia
619
reluctant to address burn alopecia >50% of the hair-bearing
scalp, citing poor results. However, alternatives to resurfacing
of the scalp are limited and some patients feel that some hair
is better than no hair (Fig. 54.4).
Principles of tissue expansion
As previously noted, if primary closure of burn alopecia
requires more than two operations, tissue expansion should
be the operation of choice to achieve closure. Not only is
patient selection crucial, so is individualized preoperative
planning. Although some authors claim that subgaleal
expansion yields better results with greater ease of expan­
sion, most authors routinely use the supragaleal approach.26
The expectations of the patient and those of the surgeon
should match. Patient acceptance of the weekly or biweekly
injection processes and the progressive deformity caused by
the expander is essential. Several parameters must be con­
sidered prior to expansion. Issues related to the insertion
Table 54.1  Classification and sex distribution of burn alopecia
Male
Female
Total
Group A (<15%)
Adults
3
2
Children
29
17
51
Group B (16–30%)
Adults
6
0
Children
11
19
36
Group C (31–60%)
Adults
1
0
Children
10
8
19
Group D (>61%)
Adults
4
1
Children
3
3
11
Adapted with permission from Huang TT, Larson DL, Lewis SR. Burn alopecia. Plast
Reconstr Surg 1977; 60:763–767.
Table 54.2  Classification of burn alopecia
Type 1
Single alopecia segment
A.
Less than 25% of the hair-bearing scalp
B.
25–50% of the hair-bearing scalp
C.
50–75% of the hair-bearing scalp
D. 75% of the hair-bearing scalp
Type II
Multiple alopecia segments amenable to tissue
expansion placement
Type III
Patchy burn alopecia not amenable to tissue expansion
Type IV
Total alopecia
Reproduced with permission from McCauley RL. Correction of burn alopecia. In:
Herndon DN, ed. Total burn care, 3rd edn. London: WB Saunders; 2007:690–694.
Figure 54.2  (a) Type 1C burn alopecia. (b) Complete inflation with a 800 cc tissue expander. (c) Three year follow-up after correction of alopecia. (Reprinted
with permission from Garavito E, McCauley RL, Verbitzky J. Reconstruction of the burned scalp. In: McCauley RL, ed. Functional and aesthetic reconstruction of the burn patient. New York:
Taylor & Francis; 2005:217–226.)
A
B
C
reconstruction efforts could be designed to address specific
problems with burn alopecia. (Table 54.2) The classification
scheme is based on the type of alopecia (type 1–type 4) and
the extent of alopecia (A, B, C, or D). Such classification is
useful in the preoperative planning for correction of this
problem.
Patients with type 1A or 1B burn alopecia can be corrected
with a single expansion, although over-inflation may be nec­
essary. Patients with type 1C and 1D burn alopecia may
require multiple expanders either together and/or sequen­
tially to correct these large areas of alopecia (Figs 54.2, 54.3).
Patients with type IIA or IIB alopecia may also be corrected
with a single expansion. However, patients with type IIC and
IID alopecia require intricate flap designs to correct the
problem. It is important to note that scalp expansion only
allows redistribution of a healthy scalp tissue without
creating new hair follicles. It has been noted that the inter­
follicular distance can increase two-fold without noticeable
thinning of the hair.24 Several investigators have been

Total Burn Care
54
620
is required for insertion of expanders. In addition, no sta­
tistically sound data has proven that infection rates, wound
dehiscence rates, and implant exposure rates are signifi­
cantly different. Pro­ponents of the remote incision believe
that healthy tissue approximated to healthy tissue affords
better healing. The migration of expanders during the
expansion process will not interfere with the weakest point
in the skin, the incision. Complication rates have been cited
to be less. However, several factors may influence this data.
Currently, no controlled, randomized studies exist on site-
specific expansion to settle this controversy. Complications
may simply be related to the quality and quantity of tissues
undergoing expansion.
Tissue expanders come in all shapes and sizes. They can
be bought ‘off the rack’ or custom made. The choices of
remote versus in situ ports are also available. In addition,
differential expanders are also currently utilized. In 1984,
Gibney recommended the use of expanders with a base
width that is 2.5–3 times the width of the defect to be
covered.23 Later, Manders et al. recommended the use of as
process are less controversial. Most surgeons feel that the use
of perioperative antibiotics is crucial. However, other issues
are more debatable.2 The type of incision, paralesional or
remote, is still under scrutiny. The orientation and the
number of expanders have also been scrutinized. What size
expander should one use and how much flap advancement
can be expected? These are still debated issues. Internal
versus external port placement may be individualized based
on circumstances. How this affects the success of expansion
is not always clear.
Techniques of tissue expansion
The type of incision used to insert a tissue expander is still
an issue. One issue that does not appear to be controversial
is size: regardless of the type of incision used, it should be
as small as possible. Proponents of paralesional incisions
(i.e. incisions at the junction of normal tissue and the
scarred area) believe that minimal undermining of tissues
Figure 54.3  (a,b) Type 1C burn alopecia. (c) After inflation of a 800 cc tissue expander. (d,e) Eight years after correction of burn alopecia.
A
B
C
D
E

Correction of burn alopecia
621
Figure 54.4  (a,b) A 6-year-old with Type 1A burn
alopecia. (c,d) Post-operation viewed 6 months
later. (Reprinted with permission from McCauley RL.
Correction of burn alopecia. In: Herndon DN, ed. Total burn
care, 2nd edn. London: WB Saunders; 2001:692.)
A
B
C
D
large an expander as possible27 Brobmann and Huber, in an
experimental study on pigs, addressed the issue of expander
size and shape relative to the amount of expansion obtained.
It was determined that less time, pressure, and volume are
needed in a larger expander to achieve gain in the same
surface area when compared with smaller implants.28 Several
investigators have proposed the use of a mathematical model
for determining the size, amount of inflation required, and
expected advancement.29,30 However, the complexity of this
model has not led to widespread use. When expanders are
placed over rigid flat surfaces, predicting the amount of flap
advancement is straightforward. It is only when expanders
are placed under soft tissues with the tendency toward
inward compression (i.e. the abdomen in children) or in
areas of concavity (i.e. the neck) that the prediction of
advancement is less reliable. In the scalp, prediction of
flap advancement is reliable. In the author’s experience,
measuring the dome of the expander and subtracting the
width of the expander is fairly accurate in determining the
length of flap advancement.
Some investigators have looked at the issue of external
port placement31,32 in the pediatric population; the use of
external ports can alleviate pain and anxiety associated with
weekly injects. However, as long as safety issues are addressed,
individualized circumstances best determine how and where
ports are placed. If internal ports are used, placement should
be in normal tissue to avoid exposure. If this is not possible,
the best tissue possible should be used for port placement,
preferably in an area that will be excised once the expansion
process is complete.

Total Burn Care
54
expansions were associated with increased complication
rates.6 In 1998, Pisarski et al. shed a different light on multi-
site expansion studies by detailing their complication rates
over two separate time periods.36 Refinements in techniques,
protocols, and surgeon maturity, when all sites are included,
reduced complication rates from 30% to 18%. To date, it
appears that the overall complication rate for tissue expan­
sion is around 15–20% despite advances in techniques and
strict protocol procedures.
The number of site-specific studies lends crucial insight
into complications associated with expansion of different
regions in the body. Scalp expansion for correction of burn
alopecia is well documented.2,25,26,33 As noted in scalp expan­
sion reviews, the use of expanders for the correction of burn
alopecia has virtually solved this problem.
Conclusion
Burn alopecia remains a significant problem in patients
with large total body surface area burns. Even with refine­
ments in technique, complication rates remain moderate.
Direct closure of this problem without tissue expansion
removes around 15% of the scalp. Even with the use of
Orticochea flaps, coverage of large scalp alopecia beyond
25% is limited. Tissue expansion has numerous advantages:
color match, texture match and minimal donor site morbid­
ity. The disadvantages are well known and include a pro­
tracted time period for completion of the expansion process
and a significant complication rate. All patients who are
victims of burn injury want to look and function at their
best. Tissue expansion in certain patients offers this advan­
tage. As we continue to refine our approach to certain prob­
lems using tissue expansion, it is important to communicate
to our patients that although the process may be long and
complicated, the end results can be quite beneficial.
Further reading
Argenta LC, Marks MW, Pasyk KA. Advances in tissue expansion. Clin
Plast Surg. 1985;12(2):159-171.
Cherry GW, Austad E, Pasyk K, et al. Increased survival and vascularity
of random-pattern skin flaps elevated in controlled, expanded skin.
Plast Reconstr Surg. 1983;72(5):680-687.
Feldman G. Post-thermal burn alopecia and its treatment using
extensive horizontal scalp reduction in combination with a Juni
flap. Plast Reconstr Surg. 1994;93:1268-1272.
Jackson IT, Sharpe DT, Polley J, et al. Use of external reservoirs in
tissue expansion. Plast Reconstr Surg. 1987;80(2):266-273.
Manders EK, Graham 3rd WP, Schenden MJ, et al. Skin expansion to
eliminate large scalp defects. Ann Plast Surg. 1984;12(4):305-312.
Pitanguy I, Gontijo de Amorim NF, Radwanski HN, et al. Repeated
expansion in burn sequela. Burns. 2002;28(5):494-499.
Radovan C. Tissue expansion in soft-tissue reconstruction. Plast
Reconstr Surg. 1984;74(4):482-492.
Takei T, Mills I, Arai K, et al. Molecular basis for tissue expansion:
clinical implications for the surgeon. Plast Reconstr Surg.
1998;102(1):247-258.
Complications of tissue expansion
Major
Reports of complications with tissue expansion are numer­
ous. Manders et al. published their experience with 41
expanders in 35 patients as a multi-site review.33 They defined
complications as major and minor. Major complications of
expansion were those that interrupted the expansion process
(Table 54.3). In their review, 25% of patients had major
complications requiring alterations in the treatment plan.
Zellweger and Künzi had similar problems with 5 of 21
patients requiring premature removal of the expander
(22%).34 Governa et al. documented their experience in 157
patients with 262 expanders.35 Complete resurfacing of the
intended area, however, was obtained in only 62% of the
patients. Complications occurred in 27.9% of the expanders.
However, 41% of these problems could not be solved and
may be classified as major complications (12.6%). Although
it is important to note expander complications, the number
of patients who experience major complications is more
important. This study suggests failure in 10 of 157 patients.
Minor
Minor complications were defined as problems that were
resolved without failure of the procedure. Manders reported
17% minor complications in his study. In a retrospective
review of 346 expanders in 132 patients, Pitanguy addressed
the issue of re-expansion. Although the overall complication
rate was only 7.5%, it is unclear as to whether repeat
Table 54.3  Major complications of soft tissue expansion
Complications
Patients (n)
Infection
3
Expander exposure
  Dehiscence of incision
5 (two more incipient
exposures)
  Erosion of envelope fold through skin
1
  Erosion of envelope or reservoir through
inadequate covering tissue
1 (two incipient)
  Manipulated by psychotic patients
2
Implant failure
  Remote port connector
1
  Physician assembly may be faulty
1
  Injection port may lack proper back
1
  Envelope may be perforated by needle
1
Induced ischemia
  Flaps may become ischemic when
expanded
1 (recognized and no
problem)
  Irradiated tissue may not survive elevation
1
A total of 24% of expansions were attended by a major complication. (Reproduced
with permission from Manders ED, Schenden MJ, Ferrey JA, et al. Soft tissue
expansion: concepts and complications. Plast Reconstr Surg 1984; 74(4):493–507.)
 
Access the complete reference list online at

Correction of burn alopecia
622.e1
© Copyright 2012 Elsevier, Inc. All rights reserved.
References
1. Codivilla A. On a means of lengthening the muscle vs tissues of
the lower limbs which are shortened and highly deformed. Am J
Orthop Surg. 1905;2.
2. McCauley R. Tissue expansion reconstruction of the scalp. Semin
Plast Surg. 2005;19(2).
3. Brou J, Vu T, McCauley RL, et al. The scalp as a donor site:
revisited. J Trauma. 1990;30(5):579-581.
4. Barret JP, Dziewulski P, Wolf SE, et al. Outcome of scalp donor
sites in 450 consecutive pediatric burn patients. Plast Reconstr
Surg. 1999;103(4):1139-1142.
5. Saszki GJ, Krizle MJ, Mathes TJ, et al. Tissue expansion. Plastic
surgery principles and practice. St Louis, MO: Mosby; 1990.
6. Pitanguy I, Gontijo de Amorim NF, Radwanski HN, et al.
Repeated expansion in burn sequela. Burns. 2002;28(5):494-499.
7. Neumann CG. The expansion of an area of skin by progressive
distention of a subcutaneous balloon; use of the method for
securing skin for subtotal reconstruction of the ear. Plast Reconstr
Surg (1946). 1957;19(2):124-130.
8. Radovan C. Tissue expansion in soft-tissue reconstruction. Plast
Reconstr Surg. 1984;74(4):482-492.
9. Austad ED, Pasyk KA, McClatchey KD, et al. Histomorphologic
evaluation of guinea pig skin and soft tissue after controlled
tissue expansion. Plast Reconstr Surg. 1982;70(6):704-710.
10. Austad ED, Thomas SB, Pasyk K. Tissue expansion: dividend or
loan? Plast Reconstr Surg. 1986;78(1):63-67.
11. Pasyk KA, Argenta LC, Austad ED. Histopathology of human
expanded skin. Clin Plast Surg. 1987;14(3):435-445.
12. Pasyk KA, Austad ED, McClatchey KD, et al. Electron microscopic
evaluation of guinea pig skin and soft tissues ‘expanded’ with a
self-inflating silicone implant. Plast Reconstr Surg. 1982;70(1):
37-45.
13. Argenta LC, Marks MW, Pasyk KA. Advances in tissue expansion.
Clin Plast Surg. 1985;12(2):159-171.
14. Cherry GW, Austad E, Pasyk K, et al. Increased survival and
vascularity of random-pattern skin flaps elevated in controlled,
expanded skin. Plast Reconstr Surg. 1983;72(5):680-687.
15. Sasaki GH, Pang CY. Pathophysiology of skin flaps raised on
expanded pig skin. Plast Reconstr Surg. 1984;74(1):59-67.
16. Lantieri LA, Martin-Garcia N, Wechsler J, et al. Vascular
endothelial growth factor expression in expanded tissue: a
possible mechanism of angiogenesis in tissue expansion. Plast
Reconstr Surg. 1998;101(2):392-398.
17. Squier CA. The stretching of mouse skin in vivo: effect on
epidermal proliferation and thickness. J Invest Dermatol.
1980;74(2):68-71.
18. Takei T, Mills I, Arai K, et al. Molecular basis for tissue expansion:
clinical implications for the surgeon. Plast Reconstr Surg.
1998;102(1):247-258.
19. Huang TT, Larson DL, Lewis SR. Burn alopecia. Plast Reconstr Surg.
1977;60(5):763-767.
20. Orticochea M. Four flap scalp reconstruction technique. Br J Plast
Surg. 1967;20(2):159-171.
21. Juri J. Use of parieto-occipital flaps in the surgical treatment of
baldness. Plast Reconstr Surg. 1975;55(4):456-460.
22. Juri J, Juri C. Aesthetic aspects of reconstructive scalp surgery. Clin
Plast Surg. 1981;8(2):243-254.
23. Gibney R. Tissue expansion in reconstructive surgery. Las Vegas:
American Society of Plastic Surgery; 1984.
24. Feldman G. Post-thermal burn alopecia and its treatment using
extensive horizontal scalp reduction in combination with a Juni
flap. Plast Reconstr Surg. 1994;93:1268-1272.
25. McCauley RL, Oliphant JR, Robson MC. Tissue expansion in the
correction of burn alopecia: classification and methods of
correction. Ann Plast Surg. 1990;25(2):103-115.
26. Buhrer DP, Huang TT, Yee HW, et al. Treatment of burn alopecia
with tissue expanders in children. Plast Reconstr Surg. 1988;81:
512-515.
27. Manders EK, Graham 3rd WP, Schenden MJ, et al. Skin expansion
to eliminate large scalp defects. Ann Plast Surg. 1984;12(4):
305-312.
28. Brobmann GF, Huber J. Effects of different-shaped tissue
expanders on transluminal pressure, oxygen tension,
histopathologic changes, and skin expansion in pigs. Plast Reconstr
Surg. 1985;76(5):731-736.
29. Duits EH, Molenaar J, van Rappard JH. The modeling of skin
expanders. Plast Reconstr Surg. 1989;83(2):362-367.
30. van Rappard JH, Molenaar J, van Doorn K, et al. Surface area
increase in tissue expansion. Plast Reconstr Surg. 1988;82:833-837.
31. Jackson IT, Sharpe DT, Polley J, et al. Use of external reservoirs in
tissue expansion. Plast Reconstr Surg. 1987;80(2):266-273.
32. Lozano S, Drucker M. Use of tissue expanders with external ports.
Ann Plast Surg. 2000;44(1):14-17.
33. Manders EK, Schenden MJ, Furrey JA , et al. Soft tissue
expansion: concepts and complications. Plast Reconstr Surg.
2003;56:784-790.
34. Zellweger G, Kunzi W. Tissue expanders in reconstruction of burn
sequelae. Ann Plast Surg. 1991;26(4):380-388.
35. Governa M, Bonolani A, Beghini D, et al. Skin expansion in burn
sequelae: results and complications. Acta Chir Plast. 1996;38:
146-153.
36. Pisarski GP, Mertens D, Warden GD, et al. Tissue expander
complications in the pediatric burn patient. Plast Reconstr Surg.
1998;102(4):1008-1012.

©2012 Elsevier Ltd, Inc, BV
DOI: 10.1016/B978-1-4377-2786-9.00055-2
Reconstruction of the burned breast
Peter Dziewulski, Jorge Leon Villapalos
Introduction
The breast is important in both function and appearance in
females and males. The prominent anatomic location of the
breast and the nipple-areolar complex makes these structures
prone to damage in all types of burn injury to the anterior
chest wall. Burns to the breast can potentially impair and
destroy both function and aesthetics. Due to its anatomical
location, the breast is commonly injured in both small and
large burn injuries, commonly scald injuries in children and
as part of an injury to the whole trunk in major full-thickness
flame injuries.
The management of the burned breast is undertaken con­
currently with the management of the patient and their
injury as a whole. Initially, stabilization airway control and
resuscitation are a priority followed by wound management
and optimization of healing potential depending on the
depth and extent of injury. After healing, scar management
and surveillance become important particularly in the female
child to monitor development and growth of the breast
during puberty.
The later effects of burns injury, which are related to loss
of normal tissue and scarring, include limitation of move­
ment, pain, disfigurement, and social embarrassment.
Damage to the breast is particularly important in the prepu­
bescent young girl. Absence of a nipple is a noticeable and
striking concern to both male and female burn patients, even
when more extensive burns and scarring are present else­
where. Reconstruction of the burned breast is dependent on
optimal early wound healing to prevent deformity. Once
disfigurement and deformity are established accurate assess­
ment, characterization and planning are crucial to timely
and successful reconstruction.1
Breast anatomy
The breast is made up of both fatty tissue and glandular
milk-producing tissues. The ratio of fatty tissue to glandular
tissue varies among individuals. The relative amount of fatty
tissue changes over time as the glandular tissue initially
grows then diminishes. The glandular tissue is arranged in a
series of lobules and ducts which are connected to the nipple
areolar complex (NAC). The gland in children lies 4–8 mm
beneath the skin and is attached to the nipple by the pars
infundibularis of the milk ducts. The ducts themselves
are lined by epithelial cells which can act as a source of
proliferating cells to resurface the nipple and areolar area. In
addition, there is an intimate approximation of the NAC and
breast gland bud in children which is important as excisional
surgery may result in unnecessary removal of the breast bud
with subsequent damage to the growth potential of the
breast.2
The breast overlies the pectoralis major muscle as well as
the uppermost portion of the rectus abdominis muscle infer­
omedially. The nipple should lie above the inframammary
crease and is usually level with the fourth rib and just lateral
to the mid-clavicular line. The average nipple-to-sternal
notch measurement in a youthful, well-developed breast
is 21–22 cm; an equilateral triangle formed between
the nipples and sternal notch measures an average of 21 cm
per side.2
Epidemiology
Burn injury to the trunk is common and can lead to signifi­
cant problems.3 It has been reported as the second most
commonly injured area following the upper extremity, with
the breast being the most frequently injured area on the
trunk.4
Burn injury to the breast can occur at any age and to either
sex but causes most problems in the female. Aetiology is
varied but in one study 66% of injuries to the female breast
were due to scald injury with a significant number having
isolated breast burns.5
In particular two patterns of injury emerge. Scald injury
usually affecting the upper torso and breast in children and
trunk burns involving the breasts in patients who have exten­
sive flame burn injury.
In prepubescent females, most of the burns to the anterior
chest wall are scalds, and depending on burn depth, the
subcutaneous tissue may remain viable, thus preserving the
breast bud. During puberty, if healing has led to abnormal
scarring, the breast parenchyma develops under the scar and
can result in breast contracture and disfigurement. The breast
mound and the nipple-areolar complex are displaced, the
contours are ill-defined, and the inframammary fold is
effaced.6
Chest wall burns in the prepubescent female can be deva­
stating to both the child and the parents, as normal breast
growth and development may be compromised. Attention to
detail and avoidance of excision of the breast bud is required
to preserve the development of the breast in prepubescent
CHAPTER 55 
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IN THIS CHAPTER
PowerPoint Presentation Online

Total Burn Care
55
624
non-lactating breast requires a very careful excision of all
non-viable tissue.
Debridement and grafting of the breast, especially the
large pendulous breast, is a technically challenging under­
taking. Debridement of a complex convex surface while
trying to avoid injury to the nipple areolar complex needs a
judicious approach. In the pendulous breast, tissue traction
may be applied by tissue forceps or towel clips to allow an
even tangential excision plane. Resurfacing of the breast
must be undertaken with prevention of future deformity in
mind. Cosmetic units of the breast must be preserved and
grafts placed to avoid future disfiguring contractures. Sheet
grafts often do not contour well and a narrowly meshed
unexpended autograft (1 : 1.5, 1 : 2) is preferred.
Post-skin grafting positioning of the patient and the breast
is important to avoid shearing of grafts on the lateral border
and the inframammary area where friction can be signifi­
cant. Abduction of the upper limb is important for this
reason as well as preventing axillary contracture. In addition
tie-over bolsters can be used on the breast to reduce graft
shear. Despite all these measures, the take of grafts on the
large pendulous breast is often unsatisfactory in the
inframammary and lateral borders leading to graft loss,
re-grafting and suboptimal outcome, which can give rise to
post-burn contracture and deformity.
Burns during pregnancy and lactation
Burns to the breast during pregnancy are in general uncom­
mon but have increased incidence in certain societies.10 The
use of topical agents can be limited due to concerns regard­
ing absorption and toxicity and in general the use of silver
sulfadiazine, cerium nitrate, and povidone-iodine are not
recommended during pregnancy or lactation. Combination
antibiotic ointments provide the best local care until wounds
can be treated by tissue coverage. Early coverage of the burns
by tangential excision and split-thickness skin grafts facili­
tates healing of the wounds and minimizes septic complica­
tions, thus improving maternal and fetal outcome.11
If residual breast tissue is preserved, successful breast-
feeding after sustaining burns to the breast while pregnant
has been reported.12 Absence of a nipple-areolar complex
precludes breast-feeding; distortion of the complex does not.
Split-thickness skin grafts and customized pressure therapy
is used to correct a contracture deformity.
In a retrospective review of 25 pregnant burned patients,
the prognosis was the same as that of other burned patients.
Pregnancy does not adversely affect maternal outcome.13
Prophylactic management of burned lactating breasts with
bromocriptine produced cessation of lactation and induced
breast involution. Once the engorgement is dissipated, surgi­
cal excision of the burn and tissue coverage can proceed as
previously described.14
Burns to large breasts
The current system for determining the percentage of total
body surface area (TBSA) burned may underestimate that
percentage for burns of the anterior trunk in women with
large breasts. In a review of 60 volunteers to determine the
difference in TBSA of the anterior trunk between men and
women, large-breasted women (cup size D and greater) were
girls. Young girls with burns to the anterior chest wall must
have long-term care to help ensure proper development and
aesthetic appearance of the breasts during and after puberty.6
There are no prospective trials available on the longitudi­
nal results of burns to the anterior chest wall in prepubescent
females, nor are there any retrospective reviews with large
numbers of young girls.
In a retrospective review of anterior chest wall burns in
prepubescent girls treated with surgical debridement and
split-thickness skin grafts, long-term problems with scarring
and impaired breast development requiring reconstructive
surgery many years after the initial burn were identified. In
this single-institution study, 193 prepubescent girls were
treated for anterior chest wall burns over 20 years; 52 (27%)
were treated with surgical debridement and split-thickness
skin grafts, and 11 with documented burns to the breast
and nipple-areolar complex were available for long-term
follow-up. In this small sample, the mean timeframe from
burn to follow-up was 26.5 years (range 19–32 years). All 11
women required reconstructive procedures after the onset of
breast development to improve breast appearance. Compli­
cations of the burns included breast asymmetry, distortion,
banding, and unpleasant skin texture.3
In a longitudinal assessment of 28 prepubescent girls with
severe burns to the anterior chest wall, 17 (61%) lost the
nipple-areolar complex, but all developed breast tissue at
puberty. However, 20 (71%) of these young patients experi­
enced entrapment of the breast and required surgical inter­
vention and incisional releases of the anterior chest wall to
allow for proper breast development.7
Acute care
Burns to the breast are initially gently washed and debrided
and dressed with topical antimicrobials and dressings prior
to surgical excision if the burns are too deep to warrant
spontaneous healing. The burn eschar should not be excised
from the nipple-areolar complex, as healing occurs from the
deep glandular structures. The eschar should be allowed to
separate spontaneously.1
Minor and superficial partial-thickness burns to the ant­
erior chest wall are treated with local antimicrobial agents
and dressings, while deeper burns are treated with excision
and soft tissue coverage. Spontaneous eschar separation and
grafting versus tangential excision of the eschar and grafting
after burn demarcation are two options for the management
of the burned breast. Surgical experience, the overall condi­
tion of the patient, and the extensiveness of the burn will
help determine the best approach.8
It is well recognized that even with nipple loss, breast
development can occur6 and that conservative management
of the NAC is beneficial as the breast bud underneath is
viable
and
retains
the
potential
for
growth
and
development.
If surgery is required, care should be taken not to excise
the breast bud from the anterior chest wall of pre-pubertal
girls during the debridement of the burned skin.9 The
mammary gland in children is located 4–8 mm deep in
the subcutaneous tissue.4 Nor should the breast mound
be excised, if at all possible, in adult females. The relative
avascular adipose tissue and connective tissue of the

Reconstruction of the burned breast
625
When assessing a patient with post-burn breast deformity
all the above must be taken into account when formulating
a treatment plan to restore breast size, shape, NAC and
symmetry.
Principles of reconstruction
The basic aim of any burn reconstruction is to improve
function, comfort, and appearance. A realistic approach is
necessary to counsel patients’ expectations to the probable
outcomes of reconstructive surgery. A strong patient–surgeon
relationship is necessary in order to negotiate a master plan
and agree on priorities.16
The ideal time to reconstruct the burned prepubescent
breast is once breast maturity is attained. Growth, develop­
ment, and patient cooperation must be considered when
planning reconstructive procedures. It is generally best to
allow the scar to mature prior to reconstructing the breast
and to perform the procedures during early adulthood. If the
release of the contracture is ill-timed, the post-pubertal
development and growth of the breast parenchyma acquires
a splayed, hypoplastic, and flattened form. In severe cases,
however, staged procedures throughout puberty may be
required to optimize the aesthetic result.
In addition to the general measures above, other specific
assessments would be to identify the problems described
above as post-burn sequelae in the breast. In particular it is
important to elucidate the patient’s concerns about the
breast, which breast is preferred and what the perceived goals
of reconstruction are.
Specifics to note on physical examination include the
quality of the skin and scar, intrinsic or extrinsic scar contrac­
ture, the position of the NAC, the sternal notch to nipple
distance, the breast base size in cm and any differences
between the breasts in terms of symmetry, shape and size. In
addition it is important to note what tissues are left, what
parts are missing, and what sort of donor sites are available.
Analysis of donor sites is crucial and must include areas for
harvesting both full- and split-thickness skin grafts, the back
to examine the latissimus dorsi donor site and all areas where
potential flaps can be harvested for free tissue transfer such as
the lower abdomen (DIEP flap), inner thigh (TUG flap)
and the buttock (SGAP flap). In addition areas of fat deposi­
tion on flanks, buttocks, and upper abdomen must also be
examined as potential sites of fat harvest for autologous fat
transfer.
This will help to determine the techniques available for
burn reconstruction. Reconstructive techniques to improve
breast development and appearance include simple contrac­
ture releases, z-plasty, skin grafting, nipple reconstruction,
breast augmentation with an implant, replacement of lost
breast volume with autologous fat transfer or with free tissue
transfer, and reduction of the contralateral unburned breast
to match the under-developed burned breast.
The principles used to reconstruct the burned breast are
described in Box 55.1.
Release and resurfacing scar
Release of scar contracture will entail expansion of breast
skin surface either by release contractures and split-thickness
found to have a significantly greater amount of TBSA on the
anterior chest compared with men. For every increase in cup
size, the TBSA of a woman’s anterior trunk increases by a
factor of 0.1, relative to the posterior trunk.15
Post-burn aftercare
Once wound healing has been achieved, patients should go
into scar management programs consisting of the judicious
use of pressure garments, massage and moisturizing therapy
to optimize scar maturation.
In young females, it is important to assess breast develop­
ment with frequent follow-up and to plan release and/or
reconstruction if the breast is entrapped in burn scar or fails
to develop.
Classification of post-burn sequelae
In order to plan reconstruction, the post-breast-burn deform­
ity must be evaluated and analysed so that a systematic
approach may be undertaken. However, in major burn
injury, donor sites may be sparse and the tissue available for
reconstruction may be less than optimal.16 With limited
donor sites, a systematic approach may not be possible and
the patient’s requests and desires, coupled with judicious use
of tissue and realistic expectations, may be the optimal solu­
tion. Post-burn breast sequelae can be classified according to
the description in Table 55.1.
Burn scar and deformity of the breast can affect one or
both breasts and can affect part or the whole of the breast.
It can involve development of the breast mound leaving
discrepancies in shape, size and position of the mound and
can also affect the nipple-areolar complex in a similar way.
Deformity can be classified according to its causes, includ­
ing scar contracture within and without the boundaries of
the breast giving rise to intrinsic and extrinsic contracture.
A pathognomonic feature of burn scar that crosses the
inframammary fold area is loss of definition and flattening
of the inframammary fold. Complete entrapment of the
breast can prevent breast growth and mimic hypoplasia or
aplasia of the breast gland. Similarly, if the gland has been
partially or totally destroyed or removed, this can lead to
hypoplasia or aplasia of the breast.
Finally, symmetry of the breast is an important issue as no
matter how good the shape or size of the breast, significant
asymmetry will always be apparent and distressing.
Table 55.1  Classification of post-burn breast deformity
Location
Unilateral
Bilateral
Extent
Total
Subtotal
Anatomical
Breast mound
NAC
Inframammary fold
Deformity
Contracture – intrinsic/extrinsic
Hypoplasia
Aplasia
Symmetry

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626
Box 55.1  Principles of post-burn breast reconstruction
•
Release scar contracture
•
Resurface unsightly or painful scar
•
Replace missing parts including breast mound and NAC
•
Re-establish symmetry.
skin grafting or the use of dermal regeneration templates
combined with skin grafting at the infra-mammary fold,
peri-areolar area, sternal area, and anterior axillary line.
Release of such contractures and resurfacing of the breast
skin can allow near-normal mammary gland development
and will improve shape and volume (Fig. 55.1). The expan­
sion of breast skin may sometimes need tissue expansion or
the use of distal or free flap tissue cover.4,17–19
The distortion of the inframammary fold is functionally
disabling and aesthetically disfiguring.20 The reconstruction
and redefinition of the inframammary fold as a major land­
mark in successful breast reconstruction can be performed
by simple scar release and grafting of the area. Replacement
of scarred skin and subdermal tissue with a normal skin
advancement flap provides a natural and aesthetic solution.
Flap reconstruction provides well vascularized tissue with
superior pliability, elasticity and durability when compared
to skin grafting. The expanded reverse abdominoplasty
can recreate the inframammary crease in a multi-staged
process.20,21 The possibility of pre-expansion allows extra
tissue to recreate this breast anatomical landmark with
healthy pliable skin. This technique can provide an optimal
aesthetic result, but its use is limited if burn scars involve the
abdomen. Infection, hematoma, seroma, fat necrosis, flap
loss, and abnormally shaped umbilicus and breast are com­
plications of this procedure.
The use of dermal regeneration templates in breast recon­
struction following burns are reported to reduce the recur­
rence of scar contracture and to provide pliability to the
reconstruction. Prevention of infection of the template is
fundamental to success. There should be regular reviews
until the second stage of reconstruction is achieved. Topical
negative pressure therapy can be used to keep the template
and the graft in place.22
Replacement of missing parts
Breast mound reconstruction
In addition to contracture release, volume replacement is the
key to restoration of breast symmetry and appearance.
Volume replacement can be achieved by the two broad
categories of technique used for traditional post-oncological
breast reconstruction. These include prosthetic implant-
based reconstruction and autologous tissue reconstruction
to restore shape and volume.2
The generally held convention that scar tissue lacks elastic­
ity and pliability, cannot be expanded with tissue expanders
and limits adequate volume reconstruction of the breast
mound has been challenged. It is recognized that burn scar
can be stretched and expanded and this allows the use of
tissue expanders for volume (Fig. 55.2).23,24
In a retrospective review of 15 women with burns to the
breasts reconstructed with contracture release and tissue
expanders, there were no significant differences in major
complications, operative time, and amount of time to expan­
sion, compared with the same reconstruction procedures in
20 women with congenital breast anomalies.25 Endoscopi­
cally assisted tissue expanders had significantly fewer major
complications, required less operative time, and required
less time to expand for the burn patients compared with
expanders placed by the traditional open method.26
Tissue expanders and breast prostheses used to perform
breast volume augmentation must always be covered by an
adequate tissue envelope to prevent exposure and extrusion
of the implant. This usually requires submuscular placement
of the implant and will occasionally require importing of
muscle and uninjured skin to provide more substantial soft
tissue cover using a pedicled latissimus dorsi flap.
The use of a dermal regeneration template (Integra) fol­
lowed by tissue expansion as a staged procedure for post-
burn breast hypoplasia appears to be reliable and safe.27,28
The first stage includes release and excision of contractures
and scars, submuscular insertion of anatomical tissue
expander, and coverage of the anterior chest wall with
Integra. The second stage is performed 1 month later and
involves removal of the outer silicone layer of Integra,
applying a split-thickness skin autograft to the areas, and
partially inflating expander. The expander is then overin­
flated, removed, and replaced with a permanent silicone
implant in the third stage of reconstruction. Patient satisfac­
tion and short-term evaluation of this technique is promis­
ing,27,28 but no long-term studies or clinical trials are available
for further assessment.
In the uncommon event of breast aplasia following
destruction or more commonly unintended excision of the
breast bud a total breast reconstruction will be required. This
will usually involve replacement of both skin and breast
volume, though submuscular tissue expansion can provide
satisfactory reconstruction. If the breast bud has been
destroyed and skin graft scar is adherent to the pectoralis
fascia or muscle then extra tissue must be imported into the
area. As described above, a pedicled latissimus dorsi flap
with a submuscular tissue expander will give good volume
replacement.
The other option is to undertake autologous reconstruc­
tion using free tissue transfer. The free flap of choice is the
deep inferior epigastric perforator (DIEP)29,30 flap or the
transverse rectus abdominis myocutaneous (TRAM) flap,31
which require uninjured abdominal tissues. Other alterna­
tives include the superior gluteal artery perforator (SGAP)
flap32 and the transverse upper gracilis (TUG) flap.33 Although
technically more demanding, the use of free tissue transfer
flap reconstruction provides autologous volume replace­
ment and obviates the need for a prosthetic implant with
the inherent risks of infection and extrusion. Occasionally,
both free tissue transfer and an implant may be required for
reconstruction (Fig. 55.3).34 In addition to the technical
demands of the surgery free tissue transfers are longer opera­
tive procedures and are potentially not suitable for medically
unfit patients. In addition, failure of autologous reconstruc­
tion deprives the patient of healthy tissue and increases the
possibility of unsightly donor site scarring.
Autologous fat transfer has become increasing popular as
a method of volume replacement in the breast, particularly
for aesthetic volume augmentation and for post-oncological

Reconstruction of the burned breast
627
Figure 55.1  Breast contracture release. (a.i) Planned release of symmastia and inframammary fold contractures to release breast mound. (a.ii) Following
incisional release – note skin deficit. (a.iii) Resurfacing with dermal template. (a.iv) Use of topical negative pressure to secure dermal template and prevent
shearing. (a.v) Dermal template ready for autografting. (a.vi) Second stage resurfacing of dermal template with sheet autograft. (b.i–b.iii) Preoperative views.
(b.iv–b.vi) Postoperative views following NAC reconstruction showing improvement in projection, cleavage, inframammary fold.
Ai
Aii
Aiii
Aiv
Av
Avi
Bi
Bii
Biii
Biv
Bv
Bvi

Total Burn Care
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628
and pressure therapy have been described to release the
contracture.40
Total NAC reconstruction is based on principles and
techniques used in post oncological reconstruction.41 Nipple
reconstruction can be achieved using local flaps but is limited
by the lack of pliability of scarred skin There are many tech­
niques described for post-oncologic reconstruction, includ­
ing the skate flap42 and the C-V flap;43 however all suffer from
loss of nipple projection. Despite there being many tech­
niques there have been very few comparative studies.44 A
modification of the star flap has produced promising results
in terms of maintenance of nipple projection.45 The burn
scar in and around the NAC area is not pliable and leads to
loss of projection of the nipple and potential flap necrosis
of the reconstruction. Nipple sharing or the insertion of
composite grafts subcutaneously are alternative options.41
The areola can be reconstructed by using full-thickness
skin grafts from the inner thigh or labia.41 These areas
usually give a darker graft mimicking the pigmentation of
the areola. However, this technique has significant donor site
morbidity in terms of wound healing and infective compli­
cations and usually results in a colour mismatch with the
contralateral NAC.
A good alternative is to tattoo both the reconstructed
nipple and surrounding areolar area to match colour to the
reconstruction.35 Non-autologous substances have also been
used for cosmetic augmentation but their effects are tempo­
rary. The steps involved in autologous fat transfer include
identification of donor sites, harvesting, preparation, and
injection of the fat. The implications for burn patients center
around choice of donor sites where adequate amounts of fat
may be sparse. The procedure can be lengthy and may not
be suitable for high anesthetic risk patients. Complications
include pain, infection, bruising, edema, contour irregularity
and defect. The potential use of adipose derived stem cells
opens an exciting prospect for the use of fat in the recon­
struction of the burned breast in addition to potential ben­
efits in scar modulation.36–39
Nipple-areola complex reconstruction
Reconstruction of the nipple-areola complex (NAC) can be
divided into subtotal or total reconstruction depending on
how much of it is preserved following burn injury. Nipple-
areolar complex reconstruction is usually performed at a
second stage once breast mound volume and shape have
been addressed.
Subtotal reconstruction of a partially preserved NAC can
be challenging due to excessive nipple flattening and
surrounding peri-areolar scarring. Split-thickness skin grafts
Figure 55.2  Post-burn breast mound reconstruction using tissue expanders. (a–c) Preoperative views showing characteristic flattening of breast, ptosis and
poor definition of cleavage. (d–f) 5-year postoperative insertion of bilateral tissue expanders showing improved projection, cleavage and volume.
A
B
C
D
E
F

Reconstruction of the burned breast
629
Figure 55.3  Reconstruction of breast with DIEP flap. (a) Isolated burn scar left breast in lady requiring mastectomy for breast cancer. (b) Markings for DIEP
including perforators. (c) Following mastectomy subpectoral implant placement. (d) DIEP flap in place for skin cover. (e) Postoperative appearance following
NAC reconstruction and contralateral mastopexy for symmetrization. (Case courtesy of Mr V Ramakrishnan FRCS (Plast) Consultant Plastic and Reconstructive Surgeon,
St Andrews Centre for Plastic Surgery, Chelmsford, Essex, UK.)
A
B
C
D
E
contralateral unburned nipple-areolar complex. Tattooing of
scar is unpredictable and probably best done once the scar
is mature. Tattooing provides an excellent option to enhance
the appearance of the nipple-areolar complex (Fig. 55.1b).
Asymmetry
The correction of asymmetry plays an important part in post-
burn breast reconstruction. Asymmetry following burn
injury to the breast can be due to pre-existing asymmetry,
scar contracture or impaired maturation of the breast gland.
Attempts to improve appearance and symmetry can focus on
the injured breast or on the contralateral uninjured breast.
Symmetrization procedures performed on the contralat­
eral breast can be aimed at matching size using breast
augmentation or reduction and shape using mastopexy/
reduction techniques. Burned breasts are less likely to
develop a natural ptosis so mastopexy and breast reduction
techniques undertaken on the contralateral breast will
restore balance and symmetry.
Post-burn deformity of the large breast can produce nipple
areolar complex displacement, burn scar contracture, and
scarring. In a retrospective review of 11 women with deep
thermal burns to ptotic and hypertrophied breasts with
post-burn deformities, reconstruction with the inferior
pedicle dermal flap resulted in reduction of the large breast
size, elimination or reduction of burn scars and relocation
of the nipple areolar complex to a normal position.46
Mammary hyperplasia can occur in patients with previous
full-thickness burns of their breasts. Reduction mamma­
plasty has been generally avoided due to concern regarding
devascularization of the skin graft or the nipple-areola
complex. In a retrospective review of six patients with full-
thickness burns of the breasts and subsequent skin graft
coverage, there was no nipple loss, hematoma, infection, or
major loss of skin flaps. Reduction mammaplasty in this
group of patients is safe and carries minimal risk.47
Summary
Initial care of burns of the breast should follow general
principles of burn management, including resuscitation,
judicious wound debridement to maximize tissue preserva­
tion followed by periodic review to monitor development
of breast anatomy. This approach should ensure that post-
burn deformity is minimized and that developmental and
reconstructive potential is maximized. In particular, care in

Total Burn Care
55
630
or augmentation, may be necessary in the contralateral
unburned breast.
Multidisciplinary involvement and psychological support
are fundamental in achieving success, especially in the young
developing female.
Further reading
Maxwell GP, Gabriel A. Breast reconstruction. In: Aston SJ, Steinbrech
DS, Walden JL, eds. Aesthetic plastic surgery. Philadelphia: Elsevier;
2009:Ch. 57.
McCauley RL. Reconstruction of the burned breast. In: Herndon DN,
ed. Total burn care. 3rd ed. London: Saunders Elsevier; 2007:741.
ELFadl D, Garimella V, Mahapatra TK, et al. Lipomodelling of the
breast: a review. Breast. 2010;19(3):202-209.
Foley P, Jeeves A, Davey RB, et al. Breast burns are not benign:
long-term outcomes of burns to the breast in pre-pubertal girls.
Burns. 2008;34:412.
Grishkevich VM. Restoration of the shape, location and skin of the
severe burn-damaged breast. Burns. 2009;35:1026.
Nahabedian MY. Nipple reconstruction. Clin Plast Surg. 2007;
34(1):131-137.
treatment should avoid permanent loss of breast volume and
cosmetic deformity.
The initial debridement must ensure preservation of the
nipple-areola complex to allow breast development. Exces­
sive debridement of this area will lead to permanent breast
mound underdevelopment
Deep burns of both the developing and adult breast will
inevitably lead to contracture and deformity of breast
mound, inframammary fold and nipple-areola complex.
Adequate timing of reconstruction of the prepubescent
burned breast will avoid lasting deformity.
The principles of reconstruction include preservation and
restoration of: breast mound volume, breast mound shape,
the inframammary fold, and nipple-areola complex and
breast symmetry. Breast shape and volume restoration
depend on the availability of remaining breast tissue, and
local and distant unburned tissue. Following excision of
burn scar or contracture, cover can be achieved by applying
recon­structive ladder principles of ascending complexity.
These include skin grafting with or without dermal tem­
plates, local, regional, distal and free flaps and tissue expan­
sion techniques. Symmetrization procedures, either reduction
 
Access the complete reference list online at

Reconstruction of the burned breast
630.e1
© Copyright 2012 Elsevier, Inc. All rights reserved.
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Management of contractural
deformities involving the shoulder
(axilla), elbow, hip and knee joints
in burned patients
Ted Huang, Jui-Yung Yang
Introduction
Burn injuries, regardless of the etiology, rarely involve a joint
itself. However, the joint function is often impaired because
of burns. The joint problems and joint deformities noted
in burn patients are mostly due to physical inactivity com­
bined with limitation of joint movement because of scar
contracture.
The regimen of burn management, especially during the
period immediately following the injury, seldom includes
plans to care for the joint. Instead, the treatment is focused
upon resuscitative efforts to restore fluid balance and to
maintain functional integrity of the circulatory and the pul­
monary systems. The consequence of joint dysfunction is
usually left for later reconstruction.
Contractural deformities of the shoulder
(axilla), elbow, hip and knee observed in
a burned patient
The factors leading to formation of
the contractural deformities
Folding bodily joints in flexion, a so-called posture of
‘comfort’, is a characteristic body posture seen commonly in
a distressed individual. Although the exact reasons are not
entirely clear, contraction of muscle fibers at rest and con­
tractile force difference between the flexor muscle and the
extensor muscle play an important role in the genesis of this
body posture. The magnitude of joint flexion, furthermore,
increases as an individual loses voluntary control of muscle
movement, as frequently occurs in a burn victim (Fig. 56.1).
A prolonged period of physical inactivity associated with
burn treatment and scar tissue contraction around the joint
structures as the recovery ensues, further impedes the joint
mobility.
Incidence of burn contracture involving
the shoulder (axilla), elbow and knee joints
Burn treatment that requires a long period of bed confine­
ment and physical inactivity as well as restriction of joint
movement will lead to joint dysfunction. Consequently,
every bodily joint, i.e. the vertebral, mandibular, shoulder,
elbow, finger, hip, knee and toe joints, are susceptible to
changes. Of various bodily joints involved, the contractural
deformities of the shoulder (axilla), elbow, hip and the knee
are relatively common. Factors such as a wide range of joint
movement and an asynchronous muscular control charac­
teristic features of these joints, when combined with a high
vulnerability to burn injuries, are the probable reasons
accounting for the high incidence encountered. Recent
review of the records of 1005 patients treated at the Shriners
Burns Hospital in Galveston, Texas, over the past 25 years,
indicated that the elbow was the joint most commonly
affected. There were 397 patients with elbow joint deformity
followed by 283 knee contractures. There were 248 axillary
deformities. The hip joint contracture was the deformity
least encountered and was noted in only 77 patients
(Table 56.1).
The efficacy of splinting in controlling burn
contractures of shoulder (axilla), elbow
and knee joints
Although Cronin in 1955 demonstrated that the neck splint
was effective in preventing recurrence of neck contracture
following surgical release,1 the routine use of splinting for
burn patients did not become a part of the regimen of burn
wound care in Galveston until 1968 when Larson, the former
Surgeon-in-Chief and Willis, the former Chief Occupational
Therapist at the Shriners Burns Institute, began to fabricate
splints with thermoplastic materials to brace the neck and
extremities.2–5
©2012 Elsevier Ltd, Inc, BV
DOI: 10.1016/B978-1-4377-2786-9.00056-4
CHAPTER 56 
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Total Burn Care
56
632
The effectiveness of splinting was diminished to 55% if
splinting was discontinued within 6 months. For compari­
son, the incidence of contractural deformity ascertained
in 219 patients who had never worn the splint was 62%
(Table 56.2).
Although splinting and bracing were shown to be effective
in minimizing joint contracture, it was not entirely clear if
restriction of joint movement would affect the quality of scar
tissues formed across the joint surface. The effects were
assessed by determining the frequency of secondary surgery
performed in this group of patients. Over 90% of 219
individuals who did not use the splint/bracing, required
reconstructive surgery. In contrast, the need for surgical
reconstruction in individuals who wore splints was 25%.6
Management during the acute phase
of recovery
It is believed that inadequate physical exercise and lack of
joint splinting and bracing, while allowing a patient to
assume the posture of ‘comfort,’ are the main factors respon­
sible for the genesis of contractural deformities seen in burn
patients during the acute phase of recovery from burn inju­
ries. The deformities, furthermore, are made worse because
of skin involvement and burn scar contracture. In order to
minimize this undesirable consequence of burn injuries,
proper body positioning and splinting of the joint structures
must be incorporated in the regimen of burn treatment. The
treatment should be implemented as soon as the patient’s
condition becomes stable.
Body positioning and joint splinting
Bodily position
Although a supine position is preferred, the patient may be
placed in a lateral decubitus position while confined in bed.
The head should be placed in a neutral position with the
neck slightly extended. For a patient placed in a supine posi­
tion, neck extension is achieved by placing a small pad
between the scapulae to facilitate the scapular traction. A
neck brace may be used if a patient is placed in other body
positions.
Figure 56.1  The posture of ‘comfort’ characterized by flexion of shoulder
(axilla) and elbow joints, plus hip and knee joints is assumed by patients
under distress, as in burn patients.
Table 56.1  The distribution of joint deformities
Joint involved
n
Shoulder (axilla)
248
Elbow
397
Hip
77
Knee
283
Total
1005
Table 56.2  The incidence of contractures across the shoulder
(axilla), elbow and knee joints
Without
splint
With splint
<6 months
>6 months
Shoulder
  Severe/moderate
137
24
23
  Mild/none
37
6
129
Elbow
  Severe/moderate
75
17
10
  Mild/none
61
33
161
Knee
  Severe/moderate
26
4
2
  Mild/none
45
16
155
For more than three decades, a neck brace, a three-point
extension splint, and a molded brace fabricated from ther­
moplastic materials, the prototypes of devices used to splint
the neck, elbow and the knee joints, were used in the man­
agement of burn patients at the Shriners Burns Hospital and
the University of Texas Medical Branch Hospitals in Galves­
ton, Texas. An ‘airplane splint’ similarly made of thermoplas­
tic materials was also used to splint the axilla during the
period where the use of other splinting and bracing tech­
niques, such as a ‘figure-of-eight’ bandage, is not feasible.
A study was conducted in 1977 to determine the efficacy
of splinting across large joint structures such as the elbow,
axilla and knee joints by reviewing the records of 625
patients. There were 961 burns over these joints in this group
of patients. Of these, 356 had involved the axillae, while 357
and 248, respectively, involved the elbow and the knee joint.
The incidence of contractural deformities encountered in
these joints was, as expected, low with the use of splints.
The incidence of contractures in these joints was 7.3%,
provided that patients had worn the splints for 6 months.