Phẫu Thuật Bỏng: Tiếp Cận Và Phương Pháp Điều Trị Từ Trung Quốc (Chinese Burn Surgery)

139
3. Autografting and dressings: the large split-thickness sheet
grafts are laid on the upper limbs perpendicularly to their
longitudinal axis. It enables a circular matching line to
avoid the effects of longitudinal scars on the function of
the upper limbs. The skin grafts are sutured to other grafts
or edges of the wound bed with 3-0 silk sutures. Meshed
grafts or fenestration for drainage are rarely considered or
avoided. Following skin grafting, bulky wet gauze and
dry gauze are laid down before the pressure dressings are
applied. It is also recommended to complete grafting and
dressing procedures below the tourniquet. At 7–10 days
post-grafting, the dressings are changed for the fi rst time
and the sutures are removed.
4. Follow-up: the patients are managed with elastic ban-
dages and functional exercises are recommended. Regular
follow-up visits are required to offer professional sugges-
tions for functional exercises and anti-scar treatment.
7.3.4.2 Typical Case Report
The patient was a 33-year-old man with an overall burns area
of 30 % of the TBSA and a burns area of approximately
10 % of the TBSA on the upper limbs and the shoulder.
Surgical procedures were conducted at 8 days post-burn. The
eschar was shaved completely below the tourniquet and the
bleeding was carefully reduced. The large split-thickness
graft with an area of 1,700 cm 2 was harvested using a drum
dermatome as a whole for sheet autografting. At 10 days
post-grafting, the dressings were changed for the fi rst time
and 100 % of the skin grafts survived. At 1 year post- grafting,
the left upper limb showed favorable functional and cosmetic
features. A webbed scar on the anterior axilla was removed
by performing Z-plasty. No hypertrophic scars were observed
at the donor site (Fig. 7.11a–d ).
7.3.5
Repair of Deep Hand Burns
As one of the most important organs and a major exposure
site, the hand seems to be more vulnerable than any other
site. The incidence of hand burns is approximately
44–52.2 %. The volar aspect of the hand is covered with spe-
cialized glabrous skin, which usually heals. The dorsal skin
usually requires grafting in deep burns because of the special
structural characteristics. It is thin, fl exible, and elastic, and
very few tissues exist under the skin, including only thin
loose connective tissues separating the skin from the extensor
tendon, joint capsule, and articular ligament. Consequently,
the deep burn injury may involve deep tendons, joints, and
bones. Contracture and malfunction of the hand may appear
after the healing of the wound, compromising the patients’
quality of life.
Great attention to detail must be paid to the hand to
achieve optimal functional results. Appropriate early treat-
ment and robust surgery are essential for the recovery of
hand function and the prevention of hand deformities. Early
excision of the burn wound and early functional exercise are
the basis for maintaining maximum hand function. In 1954,
Kong pointed out the principles of local treatment for hand
burns: infection prevention, early wound management, and
early function exercises. In 1962, Gao et al proposed that the
recovery rate for hand function was approximately 90 % for
early eschar excision and skin grafting, compared with
57.1 % for skin grafting on granulation tissues. In 1968, Sun
et al. recommended early eschar excision for deep hand
burns in the light of its advantages of reduced bleeding, low
infection, prolonged survival of skin grafts, and early recov-
ery of hand function. In 1984, Zhong et al. divided the hand
into four functional units: the back, the dorsal surface of the
fi ngers, the thenar and wrist area, and the metacarpophalan-
geal area, and a large sheet of graft is preferable to mesh
graft.
These treatment principles and pertinent surgical proce-
dures not only apparently enhance the treatment standard
for deep hand burns in China, but also exert a far-reaching
impact on patients’ quality of life and recovery of hand func-
tion and appearance, signifi cantly reducing the incidence of
hand deformities. The authors have applied the above-
mentioned principle in clinical practice since the 1980s, and
a
b
c
d
Fig. 7.11 Large sheet skin grafting on the upper limb after a deep burn. ( a ) Eighth day following a deep burn on the left upper limb. ( b , c ) Tenth
day following autografting on the left upper limb. ( d ) The donor site on the back 1 year after grafting

7.3 Large Sheet Skin Autograft for Small/Medium-Sized Deep Burns

140
have observed that the incidence of hand deformities
decreases below 10 % and that most deformities involve
local symptoms, including shallow fi nger webs due to scar-
ring at the joins of skin grafts in the area of the fi nger webs.
In this respect, we have adapted the skin grafting method in
the area of the fi nger webs for deep hand burns. The joint
between the skin grafts on the dorsal skin of the fi ngers is
moved to the middle third of the fi rst phalanx from the area
of the fi nger webs, and the skin graft in the area of the fi nger
webs is connected to the residual normal skin of this area in
the shape of an arch or a triangle. It maintains the appear-
ance of the fi nger webs to the maximum and reduces the
chance of a splice joint at least, apparently reducing the inci-
dence of webbed scars in the area of the fi nger webs.
7.3.5.1 Treatment Scheme
1. Treatment for the burn surface. In partial-thickness
wounds an attempt is made to preserve viable dermis,
whereas in full-thickness injury all necrotic and infected
tissue must be removed leaving a viable wound bed. In
general, most areas are excised with a knife and sharp
excision is preferred for the functional cosmetic out-
comes. To limit blood loss, a useful technique is to defl ate
the tourniquet briefl y and apply epinephrine soaks to the
wound, then reinfl ate the tourniquet after elevation.
Electrocautery is essential during the operation.
Electrocautery is used for hemostasis and can also be
used for full-thickness or fascial burn wound excision.
After hemostasis, the excised wounds are fl ushed repeat-
edly with hydrogen peroxide, normal saline, and metroni-
dazole, and are ready for autograft.
2. Skin harvesting regarding defi ned units of the hand.
Intermediate split-thickness skin grafts are harvested by
using a drum dermatome or an electric dermatome. Large
sheet autografting is performed according to the division
of the four functional units mentioned as above. The joint
between the skin graft on the back of the hand and the
graft on the dorsal surface of the fi ngers is moved to the
middle third of the fi rst phalanx from the area of the fi n-
ger webs, and the skin graft in the area of the fi nger webs
is connected to the residual normal skin of the area of the
fi nger webs in the shape of an arch or a triangle.
Fenestration is avoided for draining. After suturing,
hematoma below the grafts is examined carefully, fol-
lowed by fl ushing with normal saline. The fl uid and gas
below the grafts are squeezed out to press the grafts
against the wound bed for survival of grafts and
coagulation.
3. Dressings. The skin grafts are covered with a layer of
oil gauze as well as bulky wet gauze and dry gauze,
especially in the area of the fi nger webs, followed by
pressure dressing at the functional sites. The whole
grafting and dressing procedures could defl ate the tour-
niquet to reduce bleeding from the suturing edges of
the skin.
7.3.5.2 Typical Case Report
The patient was a 23-year-old man with an overall burn area
of 25 % of the TBSA and particularly deep burns of the
backs of both hands. At 9 days post-burn, the surgical proce-
dure was performed. After the necrotic tissue was shaved,
the bleeding was stanched and the backs of the two hands
were fl ushed. An intermediate split-thickness skin graft with
an area of approximately 600 cm 2 was harvested using a
drum dermatome, followed by a large sheet of autografting
regarding defi ned units of the hand. The fi rst dressing change
was at 10 days post-grafting and 100 % of the skin grafts
survived. At 1 year post-grafting in the follow-up, the cos-
metic and functional features of both hands were desirable
(Fig. 7.12a–f ).
a
b
Fig. 7.12 Sheet skin grafting on a hand with a deep burn regarding defi ned units. ( a , b ) Deep burns of the backs of the hands. ( c , d ) Tenth day
following autografting. ( e , f ) Twentieth day following autografting

7 Burn Wound Care

141
7.4
Treatment of Devastating Burns
(Fourth-Degree Burns)
Bi Chen
Severe deep burns involving skin and a quantity of tissues
beneath the skin such as muscle and tendon are devastating
burns (fourth-degree burns). The deeper the burns, the worse
the prognosis. When a massive amount of tissue or even a
whole limb is devastated, it is hard to avoid a massive tissue
defect, amputation, dysfunction, and deformities, even
though state-of-the-art burn care is applied properly. The
causes include electrical burns, chemical burns, fl ame burns,
combined thermal and crush burns injuries (hot-press injury),
molten iron burns, ret-hot steel bar perforating injury, etc. As
this kind of burn involves not only skin but also underlying
deeper structures such as muscles, tendons, bone and joint,
interosseous muscles, vessels, and nerves, even viscera, the
injured region develops more severe burn edema, with
more exudates, lasts for a longer time (about 5–6 days), and
there is the ensuing possibility of secondary vascular
thrombogenesis, compartment syndrome, progressive necro-
sis, and various other complications; thus the infection rate,
amputation rate, and incidence of complications are higher.
Devastating burns present a great challenge to the burns
team. The treatments for this kind of injury should be planned
as comprehensively as possible, according to different causes
and the patient’s injured condition. The plan should be indi-
vidualized and combined with the patient’s requests and pos-
sibilities. In this section, the focus will be on extensive
full-thickness facial perforated defects and hot-press injuries.
For more on electrical and chemical burns, see Chap. 23 .
7.4.1
Early Debridement
of Devastating Burns
The individual patient’s overall condition and the extent of
damage to the tissues vary considerably, and the treat-
ments for devastating burns are complex, diffi cult, and
vary with the individual’s injured condition. As for fl ame
burns, it is feasible to have a fairly short time frame
c
d
e
f
Fig. 7.12 (continued)
7.4 Treatment of Devastating Burns (Fourth-Degree Burns)

142
(2–3 weeks or so) to wait for a more distinct necrotic
boundary line to form and for the patient’s poor physical
status to improve. As regards electrical or hot-press burns,
it is better to perform debridement within 8 h post-burn if
the patient’s overall status is stable and there is no local
acute infection. During debridement it is preferable to
remove the gross necrotic tissues carefully, to retain viable
tissues totally, to preserve any important structures for
which there is still a glimmer of viable hope and retain
their continuity. If feasible, the wounds should be covered
with viable soft tissue or axial fl aps immediately, or at
least the wound should be covered with allograft/xenograft
or other biological dressings.
7.4.2
Pre-operative Preparation
1. Careful history-taking and comprehensive physical
examination should be performed, including vital organ
functional examinations (heart, lung, kidney, etc.), detect-
ing evidence of shock, anemia, water- electrolyte imbal-
ance, etc.
2. Assess the size and depth of burns, evaluate the extent of
the damage and degree of severity, examine the function
and injured condition of the peripheral nerves and main
vessels of the injured region or extremity so as to sched-
ule the debridement and work out a primary reconstruc-
tive plan including the options of skin grafts, axial skin
fl ap, musculocutaneous fl ap or prefabricated fl ap for
reconstruction of the defect. A Doppler ultrasound fl ow-
meter may aid in detecting the vascular course and blood
fl ow.
3. Clean the burn area, collect the wound secretion for bac-
terial culture and drug resistance testing (including aer-
obe and anaerobe cultures).
4. Preoperative use of effective intravenous antibiotics.
5. Estimate the intraoperative blood loss and prepare enough
blood for transfusion in advance.
7.4.3
Operative Procedures
1. Cleanse the burned area with saline, 1.5 % hydrogen per-
oxide solution and 0.05 % bromogeramine three times;
remove the crust, loosen the scab, loosen the slough, and
rinse the wound again.
2. Make an incision along the margin of deep burns (includ-
ing third-degree and deep second-degree burns), remove
the eschar, carry out fasciotomy, and remove the gross
necrotic tissue thoroughly.
3. During debridement, take care to remove all the obvious
necrotic tissues totally; incise the devitalized muscles
until there is punctate bleeding from the cut surface and
contraction response; remove the undoubtedly nonviable
tendon and nerve; make sutures with black silk at both
ends (proximal and distal) as markers for the localization
of subsequent surgery; the injured artery trunk should be
ligated at the normal part with the arterial wall showing
ruddy shining, about 2 cm from the injured part. If vessel
microsurgery or segmental vein grafts are necessary, safe,
and feasible, early vessel grafting can be carried out. For
safety’s sake, the anastomosis of blood vessels should
choose the normal artery with smooth and intact tunica
intima showing reddish shining, and the arterial lumen
may show arterial ejective hemorrhage when the vessel is
untied. On the other hand, it is desirable to preserve the
partially damaged nerves, tendons, muscles, bones, joint
and joint capsule, and retain the continuity of these
important structures, so that they can undergo subsequent
management. Meticulous hemostasis is essential; the
wound edges should be trimmed so they are suitable for
fl ap transfer or viable tissue/skin substitute coverage. The
wound is rinsed with saline over and over again and the
blood clot and tissue debris are cleaned thoroughly, espe-
cially the dead space and the deep part of the wound.
Wound closure is then achieved by viable soft tissue or
fl ap coverage immediately.
4. Wound closure by immediate fl ap coverage, viable soft
tissue coverage or other reconstructive procedures.
(a) When debridement has been performed fairly early
with necrotic tissues being cleared away completely
and without infection, the wound can be closed with
preoperative planned fl ap transfer/fl ap plus skin graft
or free fl ap graft. When the tendon, nerve, and main
vessels are injured, if vessel and nerve grafting is nec-
essary for the salvage of damaged extremities and the
patient’s condition is stable, revascularization using
vessel grafts and nerve cable grafting should be
attempted with immediate suffi cient viable soft tissue
coverage. Although there are many options for wound
closure, from skin grafts to the free fl ap procedure, it
is preferable to use the pedicled fl ap coverage because
the simple operation can be gratifying with its higher
survival rate and less distress to the patient. In gen-
eral, the local fl ap transfers (including axial, island,
and musculocutaneous fl aps) take priority, then dis-
tant fl ap transfers, and only if it is diffi cult to close the
wound with these fl aps is the free fl ap adopted.
(b) When the wound is extensive and deeper, and com-
plete removal of necrotic tissues is still hard to
confi rm after debridement, the wound is covered with
fresh allo/xeno-skin or banked viable allo-skin imme-
diately. After 2–3 days re-debridement is carried out
until the wound is confi rmed to be suitable for fl ap
transfer, and the wound is closed with fl ap coverage
or skin grafting.
7 Burn Wound Care

143
7.4.4
Postoperative Care
1. Immobilization for 2–3 weeks.
2. Vacuum suction drainage therapy is used beneath the fl ap;
if there is any doubt about infection, effective antibiotics
can be dripped into the wound (beneath the fl ap) for
5–7 days.
3. Continuous drip of chloromycetin 1.0 g, lidocaine 1.0 g,
saline 1,000 ml (CLS) beneath the fl ap for 24–96 h post-
operatively, if the effl uent is turbid, continue the drip until
the effl uent is clear.
4. Dexamethasone 10 mg two times/per day intravenously
for 3 days postoperatively; intravenous administration of
sodium aescinate, a kind of extract from a medicinal herb,
which can ameliorate fl ap edema and benefi t the blood
circulation of the fl ap.
5. Monitor the change in fl ap circulation and infection regu-
larly so as to be treated in a timely manner.
6. Start progressive physical exercises 2 weeks in the proper
order so as to restore mobility and function of the joint,
and to obviate joint rigidity.
7. Care must be taken to prevent and cure various complica-
tions, especially postoperative bleeding and wound infec-
tion: the former is mainly caused by improper hemostasis
or incorrect ligation of the main vessels, e.g., the vessel is
ligated at the impaired part; the latter is largely due to
incomplete or unduly delayed debridement.
As reconstruction of devastating burns is very diffi cult and
complex, the therapeutic plan should be as comprehensive as
possible. It should be considered an integrated approach and
executed conscientiously, with systemic and topical therapy,
peripheral circulation assessment, wound care, graft and
donor site care, etc. being performed in a timely manner and
meticulously so as to gain the optimal outcome.
7.4.5
Reconstruction of Extensive Post-burn
Facial Full-Thickness Composite Defects
(Through-and-Through/Perforated
Defects)
Post-burn facial defects are challenging reconstructive prob-
lems because the defects are relative large and there is lack of
normal tissue around them. Various local/distant fl aps and
reconstructive techniques have been used, such as bilobed
fl aps [ 35 ], folded fl aps [ 36 ], prefabricated lined forehead
fl aps [ 37 ], etc. However, it is necessary to seek a new method
and a much larger fl ap for the reconstruction of extensive
facial full-thickness composite defects. No matter what
method is taken, simultaneous restoration of facial inner and
outer coverage is essential to achieve satisfactory results,
normal open–close function of the mouth, and a relatively
good appearance.
7.4.6
Reconstruction of Large or Extensive
Post-Burn Facial Full-Thickness
Composite Defects
Reconstructions of large or extensive post-burn facial full-
thickness composite defects are diffi cult tasks because the
defects perforate into mouth where plenty of microbes grow,
and around the defects suffi cient healthy skin, oral mucosa, and
other tissues may be unavailable for reconstruction. To over-
come these diffi culties, the following methods were designed:
1. Prefabricated lined axial fl aps [ 38 ] were designed for exten-
sive post-burn full-thickness facial composite defects [ 38 ].
Based on the individual condition of the patient, a large
enough axial fl ap was designed, raised, and an intact medium
split-thickness skin sheet was grafted onto the inner surface
of the fl ap in advance. The fl ap was sutured in situ, about
10 days later the grafted skin “took,” and the fl ap was trans-
ferred to the defect. The prefabricated lining of the fl ap was
used for restoration of intra-oral defects and the skin of the
fl ap for outer facial defects. Typical cases are as follows:
Case 1
A 47-year-old housewife sustained a severe thermal
injury to her left face after a smoke inhalation fol-
lowing carbon monoxide poisoning when her left
face and head made contact with a red-hot stove.
She was referred to our burns center 20 h post-burn
from a regional hospital because of her poor physi-
cal status. On examination, the left-hand side of
her face was seriously burned, and her left ear was
charred. Escharectomy was carried out on the 26th
day post-burn; the necrotic, charred tissue was care-
fully and thoroughly removed. It turned out that she
had suffered an extensive full- thickness facial com-
posite defect with large areas of mandible and zygoma
exposed and charred, the left temporomandibular joint
and numerous teeth were exposed, and the adjacent
gum destroyed. After the necrotic tissues around the
defect were cleared, split-thickness skin was grafted
onto the new wound around the defect. Fifty-two
days after admission, four teeth (4, 5, 6, 7) had to be
extracted, part of the dental alveoli was ablated, the
dead bone of the exposed zygoma and mandible was
carefully removed with an osteotome and rongeur, and
split-thickness skin was grafted onto the bone wound
surface. At the same time, a left delto-pectoral skin
fl ap was designed and raised according to the size of
the defect when the patient’s mouth was wide open.
The fl ap area was 22 × 9 cm, about 15 % larger than
the defect, and a large intact medium split-thickness
7.4 Treatment of Devastating Burns (Fourth-Degree Burns)

144
a
b
c
d
Fig. 7.13 Case 1: a 47-year-old woman who suffered a large
post-burn perforated cheek defect on the left side of the face. A pre-
fabricated lined delto-pectoral fl ap was designed and transferred to
reconstruct the defect. ( a ) The severe deep burns of the left side of
her face 20 h after injury (third- to fourth-degree burns). ( b ) A large
perforated defect of the left side of her face with exposure of the
mandible, the zygomatic and temporal bones, and exposure of the
temporomandibular joint. ( c ) The pre-fabricated lined delto-pecto-
ral fl ap was transferred to the defect. ( d ) Postoperatively the con-
tours and function were satisfactory

7 Burn Wound Care

145
Case 2
A 67-year-old woman was admitted to our burns center
80 days after having sustained a severe burn injury by
falling unconscious and tumbling onto a red-hot stove
because of carbon monoxide poisoning. Her left shoulder,
knee, face, and head were burned, the greater part of her
left face was charred and resulted in an extensive perfo-
rated facial composite defect with complete left ear loss;
her left half upper and lower lips and left oral commissure
were destroyed; mandible, maxilla, and zygoma were
partly exposed and charred. The left facial full-thickness
composite defect was about 9 × 11 cm, with some pinch-
free skin grafts on its peripheral areas. The movement of
the left temporomandibular joint was severely affected.
Three days after admission, a radial forearm reverse
island fl ap of 11 × 13 cm (about 15 % large than the
defect) was designed and raised under general anesthesia,
a large sheet of medium split-thickness skin was grafted
onto the inner surface of the fl ap in advance as the intra-
oral lining, and the fl ap was sutured in situ. At the same
time, debridement was carried out, necrotic tissues and
dead bone were removed thoroughly, and free skin was
grafted onto the bone wound surface to achieve wound
closure. Three weeks later, the prefabricated lined fl ap
was transposed to the defect, the skin graft “took” 100 %
and was sutured with the oral mucosa carefully to secure
a one-stage watertight intraoral closure. The skin of the
fl ap was then sutured with facial skin and the defects of
the upper and lower lip and the left oral commissure were
reconstructed simultaneously. The postoperative stage
was uneventful; the fl ap circulation was good and
achieved primary wound healing. The pedicle of the fl ap
was divided 16 days postoperatively and the wound
healed by primary intention with a good function and
appearance (Fig. 7.14 ). She was discharged 50 days after
admission.
a
b
c
Fig. 7.14 Case 2: a 67-year-old woman sustained a large post-burn
left cheek perforated defect with upper- and lower-lip destruction,
which were reconstructed with a pre-fabricated lined reverse fore-
arm radial island fl ap in one stage. ( a ) A large left perforated cheek
defect with upper- and lower-lip destruction and exposure of the
mandible, zygoma, temporal bone, and temporomandibular joint.
( b ) The pre-fabricated lined reverse forearm radial island fl ap was
raised. ( c ) One year postoperatively the contours and appearance
were satisfactory with normal function of the temporomandibular
joint
skin sheet was grafted onto the inner surface of the fl ap
as a lining for restoration of the intra-oral defect later.
The fl ap was then sutured in situ. The prefabricated lined
delto-pectoral fl ap was transposed to the full-thickness
composite defect 16 days later, the grafted skin “took”
totally, and was sutured with oral mucosa to achieve a
watertight intraoral closure, while the skin of the fl ap was
sutured with face skin. The wound was bandaged in the
mouth-open position. Three weeks after operation, the
fl ap was divided and the wound healed by primary inten-
tion (Fig. 7.13 ), the function of the temporomandibular
joint was good with normal mouth open–close function.

7.4 Treatment of Devastating Burns (Fourth-Degree Burns)

146
Case 3
A 44-year-old housewife was admitted to our burns center
on the day of injury (19 February 1996), having sustained
third- degree thermal burns of 4 % of the TBSA because
of carbon monoxide poisoning, fell unconscious, and
tumbled onto a red-hot stove during bathing. Her left face,
head, left ear and eyeball, her whole nose, and both hands
were charred and all this was accompanied by inhalation
injury. Ten days post- injury, the patient’s condition
became stable after acute management; a left delto-
pectoral skin fl ap was raised and delayed. Fifteen days
later, the eschar on her face was excised. The left eyeball,
orbital zygomatic bone, maxilla, and mandible were
charred and exposed, and the maxillary and frontal
sinuses were open. All the necrotic tissues were excised
with enucleation of the left eyeball before the fl ap was
2. Using a Prefabricated Lined Axial Flap with Cartilage
Implanted in It in Advance for Total Nasal Reconstruction
and Frontal Sinus Closure
a
b
c
d
e
f
g
Fig. 7.15 Case 3: a
44-year-old housewife.
suffered severe burns to
her left face. The large
defect and the whole nose
were reconstructed with
prefabricated fl aps. ( a )
Severe burns of the left
side of her face and head
with the left eye, ear, and
total nose destruction; the
left delto-pectoral fl ap
was pre-fabricated. ( b )
Defect on the left side of
the face was reconstructed
with a delto-pectoral fl ap.
( c ) Pre-fabricated lined
reverse forearm radial
island fl ap. Costal
cartilage was implanted in
the fl ap. ( d ) The
pre-fabricated radial
island fl ap was raised and
the split-thickness free
skin graft ‘took” totally.
( e ) Total nose
reconstruction with repair
of the frontal sinus. ( f , g )
Postoperatively the
contour was improved,
with good ventilation of
the nasal meatus and the
nostrils maintained
patency

7 Burn Wound Care

147
3. Forearm free skin fl ap was combined with pectoralis
major musculocutaneous fl ap for the reconstruction of
large full-thickness cheek defects. A 50-year-old man
sustained post-burn through and through buccal defect
about 5 × 5 cm in size. After removing the necrotic tissues
completely the defect was about 6 × 6 cm. A 6.5 × 6.5 cm
radial forearm free fl ap was designed and elevated, the
skin was sutured with oral mucosa with the epidermis
inward to restore the intra-oral defect and its pedicle ves-
sels were anastomosed with the facial artery and vein.
The outer buccal defect was reconstructed by an 8 × 8 cm
pectoralis major musculocutaneous fl ap tiled on the
defect with the epidermis outward. These two fl aps were
combined together and healed by primary intention with
satisfactory functional and cosmetic outcomes (Fig. 7.16 ).
7.4.7
Several Key Points on the Successful
Reconstruction of Extensive Full-
Thickness Facial Composite Defects
7.4.7.1 Plentiful Blood Supply to the Flap
An extensive post-burn perforated cheek defect is too large
to close with local fl aps, as suffi cient local soft tissues are
unavailable. Even if the defect is small, the condition of the
local tissues around the defect should also be considered, if
there is a lot of scar tissue around the defect with a poor
blood supply, it is diffi cult to use the neighboring tissues as
a local fl ap. In the 1950s, random pattern fl aps had been
used, but this kind of fl ap can only offer a given amount of
tissue with less blood supply and lower resistance to infec-
tion, which is the reason why it is liable to cause infection
a
b
c
d
Fig. 7.16 A 50-year-old man suffered a perforated defect of the right
cheek post-burn, which was reconstructed with use of a pectoralis
major musculocutaneous fl ap combined with a free radial forearm fl ap.
( a ) Perforated defect of the right side of the face. ( b ) The size of the
defect after debridement. ( c ) A reverse forearm radial free fl ap was
designed for reconstruction of the intraoral defect. ( d ) Pectoralis major
musculocutaneous fl ap was designed for reconstruction of the buccal
skin defect
transferred. The pedicle of the fl ap was divided 12 days
later and the wound healed by primary intention. Eleven
months later (17 February 1997) she was admitted to our
center again for further reconstructions. Her left moderate
post-burn alopecia was corrected with a single expanded
scalp fl ap, and her nose was reconstructed with a prefab-
ricated lined axial fl ap. A designed reverse radial forearm
fl ap was raised and prefabricated with a suitable sized
costal cartilage, which was buried in the fl ap as the cyto-
skeleton of the nose reconstruction, and a sheet of split-
thickness skin was grafted under the surface of the fl ap as
the lining of a nasal cavity for the next step. The surgical
reconstruction of the total nasal defect was performed
2 weeks later. The defect of the frontal sinus was repaired
with a fl ap. The surgical correction of microstomia and
oral commissure suspension (with fascia lata) were per-
formed at the same time. The pedicle of the fl ap was
divided 3 weeks later (Fig. 7.15 ). The nostrils remained
patent with good ventilation of the nasal meatus postop-
eratively and the nasal appearance was improved.

7.4 Treatment of Devastating Burns (Fourth-Degree Burns)

148
and lead to failure. Tsuchida [ 40 ] reported that the blood
supply in the subcutaneous element was only 11.5 % of that
in the skin, and the blood supply in muscle was as much as
182 % of that in the skin. However, the blood supply in an
axial pattern fl ap or an artery fl ap is much better than that in
a random pattern fl ap, which is why we should choose an
axial pattern fl ap, an island fl ap, a musculocutaneous fl ap or
a free fl ap for the reconstruction of large/extensive full-
thickness facial composite defects. In the cases mentioned
above, an axial pattern fl ap was used in one case, a radial
forearm reverse island fl ap was adopted in two cases, and a
free skin fl ap in one case. These kinds of fl aps provide a
plentiful blood supply, all of the wounds heal by primary
intention and this is the key to functional and cosmetic
reconstruction.
7.4.7.2 A Good Intraoral Lining Is Essential
to the Success of the Reconstructive
Operation
As suffi cient healthy local tissues are unavailable for the
reconstruction of a large/extensive perforated cheek defect,
various other reconstructive methods have been used for the
restoration of intraoral mucosa. A random fl ap was employed
during the earlier period, but some shortcomings had been
reported, e.g., infection and orocutaneous fi stulas had
occurred. Intraoral lining can be obtained with folded fl aps
[ 36 ], i.e., its distal part was folded and used to restore the
mucosa defect and the proximal part restored the outer cov-
erage [ 36 ]. Although this method is quite simple, the folded
portion of the fl ap may interfere with the blood supply of its
distal part, and result in partial necrosis developed at the oral
lining part of the fl ap; there is a dead space between the two
parts of the folded fl ap where a hematoma can occur and
result in an increased risk of infection, orocutaneous fi stula,
and an unhealed wound. Two axial fl aps combined together
can also reconstruct this kind of defect as the two fl aps are
applied to the cheek region, this area would be bulky with a
poor appearance and often need to be thinned out to provide
an acceptable facial contour. However, the prefabricated
lined axial fl ap or artery fl ap has the free skin grafted onto
the inner surface in advance, and the fl ap is transferred after
the skin has “taken”; thus, there is no dead space between the
grafted skin and fl ap. Moreover, the grafted skin was sutured
with the oral mucosa in a watertight fashion before the exte-
rior skin closure, and the negative pressure drainage setting
is useful for preventing infection. Thus, no infection, fi stula
or unhealed wound has occurred in our series of patients.
The advantages of the reconstructive method we describe
above are mainly the following:
1. The fl ap can provide ample tissue with a plentiful blood
supply and is large enough for an extensive defect.
2. The prefabricated lining survives without dead space
within the fl ap before the grafted skin is sutured with oral
mucosa in a watertight fashion. This is benefi cial to
wound healing and decreases infection.
3. The prefabricated fl ap is not bulky, has a fair cosmetic
outcome, and is saved from secondary trimming.
4. The operation is safe and reliable, simple and easy, and
has a higher success rate and good functional and aes-
thetic outcomes.
7.4.7.3 Preventing Wound Infection Is
the Guarantee of Operative Success
The operative area opens into the oral cavity where a variety
of bacteria grow and post-operative infections often occur.
To reduce the oral bacteria, oral care should be performed
2 days before surgery. In general, Kangwand solution (a dis-
infectant that contains Ag + ) or Dobell’s solution is used for
cleaning the oral cavity four to six times per day. The prefab-
ricated lining of the fl ap should be sutured with oral mucosa
around the defect in a watertight fashion. Postoperative pos-
ture is also quite important; semisupination combined with
lateral recumbency is adopted, and, keeping the side to oper-
ated up, the neck should be inclined toward the direction of
the raised fl ap (about 20−25°) slightly, so as to decrease the
tension at the distant part of the fl ap and benefi t wound heal-
ing. Nasogastric feeding should be used for at least 2 weeks
postoperatively to prevent saliva and food from contaminat-
ing the wound. To control and preclude infection, effective
antibiotics should be used during and after the operation. As
there is a large number of microbes in the oral cavity, the
postoperative gargling solution should be an effective one.
Kangwand is the solution of choice, as it is a colorless, non-
irritant, atoxic, and nonvolatile transparent solution that con-
tains Ag + with great microbicidal and bacteriostatic effect.
Oral hygiene and nursing care are also very important as the
patients cannot gargle by themselves. The attendant should
use a catheter to infuse 15 ml of Kangwand gargle solution
into the oral cavity and keep it there for 4–5 min before
extracting. This infusion and washing should be repeated
two to three times every 4 h. Oral hygiene care should be
maintained for at least 2 weeks postoperatively. In this series
of patients all wounds heal by primary intention without
infection.
7.4.7.4 Preserving the Mouth Wide Open
Position During and After the0
Operation, and Preventing
Temporomandibular Joint Rigidity
The temporomandibular joint is one of the most complicated
joints in the human body, and consists of an articular fossa, a
condylar process, an articular disc, synovium, joint capsule,
and ligaments. This joint can be easily injured in an exten-
sive severe facial burn, joint rigidity or even joint infection
may occur, and have a severed impact on the opening of the
mouth. In order to prevent this severe complication, a simple
7 Burn Wound Care

149
self-made wooden mouth gag was fashioned to the patients’
individual needs and mouth shape preoperatively, which is
similar to terracing, with a trapezoid form, and can adjust the
gape extent of the patient’s mouth. During and after the oper-
ation, having been disinfected, the wooden block is put
between the upper and lower teeth of the healthy side and the
mouth is kept wide open, the head inclined slightly toward
the healthy side with the injured side upward until the wound
has healed. These procedures are benefi cial to oral hygiene
and nursing care, preventing the joint rigidity and are good
for normal functioning of the joint. In all patients in this
series the function of the joint was restored and they can
open their mouths easily and freely.
In conclusion, the reconstructions of extensive post-burn
facial and forehead full-thickness composite defects are very
diffi cult tasks. The prefabricated lined axial fl aps or arterial
fl aps for reconstruction of this kind of defect are simple,
safe, with plentiful blood supply, are relatively easy, and it is
a reliable method for clinical application.
7.5
Repair of Deeply Burned Hands
with Split-Thickness Auto-Skin
Grafting with Preservation
of the Denatured Dermis
Xiaoyuan Huang
Repairing the wound of deep second-degree burns and
mixed-degree burns is always a source of emphasis and dif-
fi culty in the fi eld of burn surgery research. Especially when
it comes to hands, it can easily result in scar contracture.
Whether the methods adopted in the early stages is correct or
not relates to patients’ recovery of function and quality of
life. Preserving the denatured dermis when shaving the eschar
has been a new, effective method of repairing deep second-
degree burns and mixed-degree burns in recent years. It is
simple, and the hands can recover good function and shape.
7.5.1
Surgical Methods
When the patients are admitted to hospital within 24 h after
burning, the burn wound needs complete debridement, and
protection by xenogenic skin (irradiated pig skin) or dressing.
A surgery time is then chosen according to the situation. After
general anesthesia or brachial plexus nerve block, a roller
knife is used, with no tourniquet control, to excise the necrotic
skin of the backs of the hands and fi ngers. If the necrotic tis-
sues begin to dissolve, the axis of the roller knife should be
taken, and then the roller knife or scalpel is allowed to be
vertical with the wound surface, directly shaved necrotic tis-
sues, which begin to dissolve, with preservation of white
dermis tissues (Fig. 7.17 ). Hyaline degeneration is observed
in the preserved denatured dermis by light microscopy
(Fig. 7.18 ). The bed has a lack of brisk bleeding because the
denatured dermis is preserved, and some inactive scatter
bleeding.
When the layers of denatured dermises are too thick,
many “cross”-shaped cuts are made on the layer of dermis
(Fig. 7.19 ). Then the thin to intermediate thickness skin is
obtained and grafted to the wound bed of the back of the
hands or fi ngers. The skin retains some of its natural strain,
and is bound up with a pressurizing dressing. The outer
dressing is changed according to dressing infi ltration after
the operation, and remains bound up. All layers of dressing
are opened and the stitches taken out on the 10th day. The
patient is able to regain some functional activities
gradually.
The relationship between the function of the skin on the
backs of hands and fi ngers and surgery methods
Fig. 7.18 Observed hyaline degeneration by light microscopy (HE×40)
Fig. 7.17 The denatured dermis is preserved after shaving the eschar
on opisthenar


7.5 Repair of Deeply Burned Hands with Split-Thickness Auto-Skin Grafting with Preservation of the Denatured Dermis

150
7.5.2
Characteristics of the Skin on the Backs
of Hands
The skin on the backs of hands is thin, has no fi ngerprint,
only strain lines . There is loose connective tissue under the
skin, without vertical fi bers under the skin to connect the
skin with deeper tissues, as a result of easy gliding. When
grasped, it is not infl uenced by the too tight skin.
7.5.3
Methods of Dealing with Deep Second-
Degree Burns and Mixed Burns
of the Backs of Hands
Once the skin on the backs of hands is burned deeply,
there will be contracture caused by hypertrophic scarring
if not be handled properly. This results in malformation
of the functional activities of the hands, which has a
strong impact on patients’ work and life. There are a lot
of methods of dealing with deep burns of the backs of
hands:
1. Topical medications: as the deep burn wound self-heals it
mainly relies on the growth of residual hair follicles and
sweat gland epithelial cells. A local infection because of a
dressing change may result in a deep wound, in the end
healing with granulation tissue. This inevitably leads to
scar contractures of the hands.
2. Tangential excision: cover the wounds with a biological
dressing. Although the chances of local infection undoubt-
edly decrease, the healed epidermis is so thin that blisters
easily form after operations. Hypertrophic scars also
form, infl uencing the functional activities of the hand.
Although through skin grafting the hands can recover
maximum function, there are still some secondary con-
tracture malformations after transplants. This is because
the traditional tangential excision requires the bleeding
of active normal tissues . The reasons for secondary
contracture malformation are directly connected to the
thickness of grafted skin.
3. Escharectomy. In the past, the proposition for dealing with
mixed-degree burns of the back of the hand was escharec-
tomy, using acellular xenogenic dermis combined with
autologous skin transplant, or full-thickness skin trans-
plant. The former supplies enough dermis and avoids the
formation of hypertrophic scar. It has obtained good clinic
results, but it increases expenditure. In the latter, the donor
site needed skin graft to heal, as it was too hard to stitch it
directly. Moreover, the hand’s early functional activities
were still not ideal. The main reason is that the skin of the
back of hands and subcutaneous loose connective tissues
have been destroyed, and the grafted skin cannot slide
with the joint activity when the fi ngers are moving.
4. Transplant with preserved denatured dermis with autolo-
gous intermediate thickness skin. The denatured dermis is
preserved during tangential excision. The thickness of the
surviving skin graft is close to the normal one. It is soft,
with high resilience, in favor of functional recover in the
early stages. The connection of subcutaneous tissues and
deep tissues is not destroyed, because of preservation of
the original dermis. The grafted skin can slide smoothly as
the fi ngers move. The functions of the hands can recover
to normality by 2 weeks after the operation (Fig. 7.20 ).
7.5.4
Typical Cases
First case : 34-year-old man, with an admission diagnosis of
the face, forearm, and hands – 12 % of the body – having
been burned by high-temperature asphalt (mixed degree).
Tangential excision was performed on the wounds of both
hands
and
thenar-preserving,
denatured
dermis.
Intermediate split-thickness autologous skin was grafted
onto the wounds. The dressing of the right hand was
opened on the 9th day after the operation, with the fi nding
that all the grafted skin was alive and the functional recov-
ery of the hands was satisfactory (Fig. 7.21 ).
Second case : 30-year-old man, with an admission diagnosis
of the head, face, neck, front of the chest, and both upper
limbs – 32 % of the body – having been burned by voltaic
arc (deep second-degree to third-degree). Wounds on the
face, the chest, and most of those on the upper limbs were
superfi cial third-degree burn wounds. Tangential excision
was performed on the wounds of the backs of both hands
on the 3rd day after the burn, with preservation of dena-
tured dermis and an intermediate split-thickness skin
graft. At the same time, the wounds of both forearms and
upper arms were handled with tangential excision and
then covered with glycerol xenogenic skin. The dressings
of both hands were opened on the 9th day, with the fi nd-
ing that all the grafted skin was alive, and the recovery of
the function and shape of both hands was ideal (Fig. 7.22 ).
Fig. 7.19 Many “cross”-shaped cuts are made on the layer of dermis
when the layers of denatured dermises are too thick

7 Burn Wound Care

151
7.5.5
The Standards of Assessing Functional
Recovery of the Hands
1. Excellent
The color of skin is normal or close to normal. The
posture and shape of the hands are normal when they are
resting or making a fi st, with no obvious scar contracture
abnormality. There is more than 1 cm of skin when pinch-
ing the skin of the backs of unbent hands. It can rebound
immediately once it is released. The hand can make a fi st
naturally or the belly of two to fi ve fi ngers can touch the
palm, the wrist, and metacarpophalangeal joint. The
degree of activity of each interphalangeal joint, the degree
of abduction of each webbed fi nger, and the functions of
opponensplasty and grasping, holding, nipping are basi-
cally normal.
2. Good
There is pigmentation of the graft and light hypertro-
phy scarring surrounding the graft skin. There is 0.5–1 cm
of skin when pinching the skin of the backs of unbent
hands. Some force is required to allow the belly of two to
fi ve fi ngers touch the palm when the hand is making a fi st.
The wrist, the metacarpophalangeal joint, the degree of
activity of each interphalangeal joint, the degree of abduc-
tion of each webbed fi nger, the function of opponensplasty
and grasping, holding, and nipping are close to normality.
3. Bad
There is heavy pigmentation of the graft and obvious
hypertrophy scarring projecting normal skin. There is less
than 0.5 cm of skin when pinching the skin of the back of
unbent hands or it cannot be pinched. The bellies of two
to fi ve fi ngers cannot touch the thumb when the hand
makes a fi st with strength. The wrist, metacarpophalan-
geal joint, the degree of activity of each interphalangeal
joint, the degree of abduction of each webbed fi nger is
less than 50 % of the normal level. The hand cannot per-
form opponensplasty, it can only hold large items.
The author’s hospital followed and visited 152 hands (up
to 3.3 years after operation). According to the standards of
assessing function, there were 97 excellent hands, 44 good
hands, and 11 bad hands. The rate of excellent or good status
was 92.8 %. There were 11 hands with a bad appearance and
(or) bad function, 4 hands with only a bad appearance owing
to the pigmentation of the graft, 4 hands only with bad func-
tion, and 3 hands with both bad appearance and bad function.
The main reason for the poor recovery of function was that
a
b
c
d
Fig. 7.20 The functions of the hands can recover to normality by 2 weeks after the operation. ( a ) Left hand before operation. ( b ) Right hand before
operation. ( c and d ) Hands at 2 weeks after operation

7.5 Repair of Deeply Burned Hands with Split-Thickness Auto-Skin Grafting with Preservation of the Denatured Dermis

152
the side of the palm was deeply burned; tangential excision
was not performed on the wounds surrounding the grafted
skin of the back of the fi ngers, the wounds had healed with
dressing after the operations, which led to hypertrophic scar
contracture. The second reason was the thinness of the graft.
7.5.6
The Indications for Preserving
Denatured Dermis and Choosing
the Thickness of Skin
Until recently, there have been no uniform reliable objective
guidelines for diagnosing the depth of a burn. We can esti-
mate it by macroscopic observation and analysis of the clini-
cal traits. The diagnosis of deep second-degree burns is
defi nite, because there are no standards for diagnosing super-
fi cial third-degree burns. The typical cases listed in the article
could both be diagnosed as third-degree burns, and actually
putrescence did not occur on the full layer of skin, with
degenerative FBs. The wound can heal naturally. Unless the
wound has an eschar, the deep-seated dermis is of hyaline
degeneration, and the outcome will be ideal using this method.
During the performance of tangential excision, the
necrotic tissues should be shaved clearly away. How do we
differentiate between necrotic tissues and denatured dermis
tissues? Generally speaking, according to macroscopic
observation, the pale yellow tissue is necrotic and the white
tissue is denatured dermis. According to pathology slice, the
former shows tissue coagulation necrosis; the latter is hyaline
degeneration. When the layer of preserved denatured dermis
is too thick, many “cross”-shaped cuts can be made on the
layer of dermis, without removing the vascular moisture
under the dermis. It is good for plasma effusion, and provides
support for grafted skin with enough nutrition to survive.
After superfi cial tangential excision with the preservation of
denatured dermis, the whole wounds should be covered with
spit-thickness skin. What is more, the thickness of the skin
graft should be adequate, as the thickness of the dermis has
much to do with contracture after operations. The thicker the
dermis is after the operation, the less the contracture. On the
a
b
c
d
Fig. 7.21 Mixed degree burns on forearm and hands. All the grafted skin was alive and the functional recovery of the hands was satisfactory.
( a ) Before operation. ( b – d ) One year after operation

7 Burn Wound Care

153
contrary, the contracture will be more serious, which infl u-
ences functions more apparently. The thickness of the dermis
after the operation consists of the thickness of the denatured
dermis preserved on the wound and the thickness of the dermis
on the skin graft. In order to avoid contracture deformity and
functional barrier after operations as the result of insuffi cient
thickness of the dermis, the surgeon should decide the thick-
ness of the preserved denatured dermis based on the depth of
the wound. Denatured dermis should be preserved as much as
possible under the conditions of ensuring the removal of
necrotic tissue. The dermis thickness of skin grafts should also
be decided according to the thickness of the retained denatured
dermis. The layer of retained denatured dermis is thick; thus,
the skin graft should be thin or of intermediate thickness. The
a
b
c
d
e
f
Fig. 7.22 Deep II and III degree burns on opisthenar. All the grafted skin was alive, and the recovery of the function and shape of both hands
was ideal. ( a and b ) Before operation. ( c – f ) Three months after operation

7.5 Repair of Deeply Burned Hands with Split-Thickness Auto-Skin Grafting with Preservation of the Denatured Dermis

154
layer of retained denatured dermis is thin; therefore, the inter-
mediate-thickness skin graft is needed. Only with this can it
achieve a satisfactory function and appearance recovery. Split-
thickness skin graft is prone to pigmentation and even a certain
degree of contracture may occur, and the appearance and func-
tion may be affected. On the other hand, if the skin graft is too
thick (thick to intermediate thickness), although it survives
well and has a good color and function, the skin graft is higher
than the surrounding skin and the aesthetic of the hand is
affected. Therefore, it is appropriate to choose thin or interme-
diate-thickness skin graft according to the wounds of the hands.
The timing of surgery, in principle, is that it should be
carried out as soon as possible. It should be based on condi-
tion, i.e., the systemic and local conditions. Surgery is usu-
ally performed on the 2nd to 5th days after the burn. For
simple deep burns of the hands or a small area burn with the
hands burned, the patient can have surgery on the 2nd or 3rd
days after the burn, as the systemic conditions are good. For
later wounds when the necrotic tissues have begun to dis-
solve, the scrape scab method should be used, the liquefac-
tive necrotic tissues should be shaved, infection controlled,
and the skin graft transplanted. It is always a success. For
large area burns with deep burns of the hands, the treatments
should be based on the systemic conditions and donor areas.
For particularly large areas of burns, the method is not suit-
able if there is not a large enough donor area.
The necrotic tissues on the surface of the deep burned
wounds of hands should be removed early with preservation of
the denatured dermis, and transplantation of a large sheet of
autologous skin graft onto the denatured dermis. It improves
the quality of the wound recovery of hands with deep burns,
can promise dermal thickness, and avoids the adhesion of a
deep organizational structure. It is then conducive to early func-
tional exercises, to avoid or minimize scar contracture defor-
mity or disability level and improve patients’ quality of life and
ability to work. This method has the following advantages:
1. The denatured dermal tissue layer of deep second-degree,
mixed-degree, and superfi cial third-degree burn wounds
is preserved during surgery, avoiding damage to deep nor-
mal tissue structure, while the tangential excision in the
past removes the layer of denatured dermis, requiring
shaving down to the normal tissue. This damages the deep
normal tissues to different degrees.
2. Atourniquet is not required during limb surgery. Local
wound and ischemia–reperfusion injury caused by tourni-
quet compression should be avoided during past tangen-
tial excision.
3. Surgical procedures are reduced, it is easy to operate,
shortening the operative time greatly. Furthermore, the
injury during the surgery is minor with minimal bleeding,
and does not require blood transfusion. This saves on the
cost of treatment and alleviates the suffering of patients.
Also, the rate of skin graft survival is high.
4. After the skin grafts have survived, the patients can take
active and passive functional exercises at an early stage.
The functional recovery is satisfactory after 2 weeks.
Additionally, the layer of dermis is thick enough and the
texture has a good appearance. The deep organization
structure (such as the subcutaneous tissue, tendon)
under the denatured dermis is completely protected. The
deep adhesion is signifi cantly reduced. Thus, long-term
secondary skin graft contracture deformity and dysfunc-
tion reduce and mitigate, with a corresponding increase
in the patient’s quality of life and ability to work.
Strict aseptic conditions are required during surgery.
Before tangential excision and escharectomy, the wounds
should be washed with 2 % H 2 O 2 , complex iodine solution,
and physiological saline repeatedly. After tangential excision
and escharectomy, the wounds should be washed with physi-
ological saline repeatedly. External application of antibiotic
solution is not required. Following the above treatments,
there will be no infection after surgery and this will ensure
the survival of skin graft.
With retained denatured dermis, is a sebaceous cyst
formed? The dermis mainly consists of connective tissues
and appendage structures. There are defi nitely skin append-
age structures in the retained denatured structures. Are the
cysts that affect the healing effect generated? After follow- up,
the result was that there were no postoperative patients with
sebaceous cysts. The skin appendage is also degenerative
owing to deep-degree burns. The function cannot recover in a
short time. Even if there is residual normal skin appendage,
after being covered by skin, the epithelial component is
degraded because of disuse. Experiments confi rmed that the
sebaceous glands usually disappeared after 2 weeks or so, and
the hair follicles disappeared after 2 months. Therefore, the
possibility of sebaceous cysts occurring after surgery is rare.
7.5.7
Experimental Evidence
7.5.7.1 The Turnover Mechanism of Fibroblasts
in Degenerative Dermis
Could the heat-damaged FBs revert to normal cells? Using
an animal model and heat-damaged degenerative FBs of
human skin in vitro and doing some elementary research, we
can verify that the degenerative FBs can recover. But what
mechanisms do the FBs use to protect itself and stop necro-
sis? This needs further research.
7.5.7.2 Animal Experiments
Deep partial thickness burn wounds 3.5 × 3.5 cm in size were
produced on the backs of Sprague–Dawley rats. Superfi cial
tangential excision was performed with preservation of
denatured dermis. An autologous whole layer obtained from
their necks was pruned to split=thickness skin and trans-
7 Burn Wound Care

155
planted to the wound. Reticulation gauzes were used to pack
with pressure. Discontinuous sutures were used in the areas
supplied with skin. These rats were killed on the 4th, 7th,
9th, 14th, 21st, and 60th day after operation. The whole layer
skin was obtained for examination of skin pathology and
detection of biological strength.
1. Macroscopic observation. The transplanted epidermis
was alive and there was blood supply on the 4th day. But
it was easily disconnected from the wound after the der-
mal sutures were removed. On the 7th day, the trans-
planted skin was so fused to the wound that it was very
diffi cult to separate. There was kermesinus and it was
stiffer than the surrounding skin though even .
2. To be observed by the light microscope
(a) The wound tissue was confi rmed by pathological sec-
tion to be the deep partial-thickness burn wound
(Fig. 7.23 ).
(b) The pathological section of wound dermis was veri-
fi ed to be hyaline degeneration before the transplant
(Fig. 7.24 ).
(c) Hematoxylin–eosin (HE) staining: on the 7th day
after the operation, the papillary layer and reticular
layer appeared, while the epidermis was thinner than
normal. Corpus mucosum cells line up in a columnar
arrangement. There were many hairs and glandulae
sebaceae. On the 9th day after the operation, the epi-
dermis was thickening, but the four layers were
clearly seen: the horny layer, the diaphanotheca, the
granular layer, and the germinal layer. There were
keratinized tissues in the epidermis. The dermis was
thicker than before. The papillary layer and reticular
layer were also observed. The numbers of folliculus
pilis and glandulae sebaceae were reduced compared
with previously. On the 14th day, the four layers and
the keratosic area of the epidermis could be evidently
observed, and the thickness and shape were close to
those of the normal skin (Fig. 7.25 ). The papillary
layer of corium and the reticular layer were thicker
than before. More folliculus pili and glandulae seba-
ceae dried up and shrank. The shape and thickness of
the dermis resembled those of the normal skin.
(d) Van Gieson’s staining: the trabs density of the lacer-
tus became thickened from the 7th to the 21st day. In
the end, they nearly coalesced with each other.
3. Biomechanical test. A curve was drawn showing the ten-
sile strength and maximum train value ε, and the maxi-
mum strain value and the tensile strength were calculated
respectively. According to the statistical analysis, there
were signifi cant differences between the test group 9th,
14th, 21st, 60th days after operation and the normal
group. The differences in tensile strength between the test
group on 9th, 14th, and 21 days after operation and the
normal group were signifi cant, while the differences
between the 60th and the normal were not. The differ-
ences in the maximum strain between the test group on
the 9th and 14th day and the normal group were signifi cant,
while the maximum strain between the test group on the
Fig. 7.23 The pathological changes observed in deep II burns (HE×100)
Fig. 7.24 The hyaline degeneration observed in dermis (HE×100)
Fig. 7.25 The thickness and shape of the wounds on 21 day after oper-
ation were pathologically close to those of the normal skin (HE×100)



7.5 Repair of Deeply Burned Hands with Split-Thickness Auto-Skin Grafting with Preservation of the Denatured Dermis

156
21st and 60th days and the normal group was not signifi -
cant. It can be concluded from the above that the maxi-
mum strain of rats’ skin increased from the 9th to the 60th
day, fi nally approaching that of normal skin.
Morphological Observation of the Turnover of Heat-
Damaged Human Skin Fibroblasts In Vitro
In vitro cell cultivation technology is utilized to deal with
human dermis FBs at different temperatures (50–53 °C) and
different times (30–180 s). The comparison group dealt with
37 °C water for 30 s. The MMT method, reverse microscope,
transmission electron microscope, FCM, and others were
involved in detecting and analyzing the heat-damaged cells.
The results were as follows: the survival rate of FBs treated
with 52 °C water for 30 s is 48–58 % ( p < 0.5), the shape of
cells changed a great deal, and became normal, the cell heat-
sensitive stage was the S stage ( p < 0.01), then heat damage
in a water bath at 52 °C for 30 s was confi rmed for degenera-
tion of skin FBs.
Observation by transmission electron microscope showed
that the membrane was intact 3 h after the FBs were damaged
by heat. The surface of the microvilli was decreased. There
were some vacuoles in the cytoplasm. In the swelling mito-
chondria the ridges had disappeared and stretched out endo-
plasmic reticula could be seen. The shape of the nucleus was
irregular, the ratio of the nucleus to the cytoplasm was small
(Fig. 7.26 ). On the 1st day after the operation, the membrane
was intact. There were a few microvilli and many vacuoles
could be found in the cytoplasm. The mitochondria were swell-
ing and myelinization occurred. Endoplasmic reticula appar-
ently stretched out. The ratio of the nucleus to the cytoplasm
was small and chromatospherites were not obvious (Fig. 7.27 ).
On the 3rd day after the operation, vacuoles in the cyto-
plasm reduced, a little mitochondria myelinization. The ratio
of nucleus to cytoplasm returned to normal. There were two
chromatospherites in some cells (Fig. 7.28 ). On the 5th day
after the operation, the number of mitochondria increased
greatly and the level of swelling reduced (mild swelling).
There were plenty of endoplasmic reticula in the cytoplasm
and chromatospherites were clearly visible (Fig. 7.29 ). On
the 7th day after the operation, the FBs returned to normal
(Fig. 7.30 ).
Judging from the electric microscope images above, the
heat-damaged degeneration of FBs was mainly refl ected in
the cell membrane and cytoplasm. Mitochondria and endo-
plasmic reticula in the cytoplasm were seriously damaged,
and the number greatly reduced. The abnormal substances
clearly increase. The main change in the cell membrane is
hollow membrane. As the FBs gradually recover, the situa-
tions above slowly improve. On the 5th day, cell membrane
and cytoplasm had apparently recovered. On the 7th day, the
shape of the FBs returned to normal. It shows that the recov-
ery time of heat-damaged FBs is 7 days, which is consistent
with the recovery time of FBs in the animal model.
Fig. 7.27 One day after the heat damage
Fig. 7.28 Three days after the heat damage
Fig. 7.26 Three hours after the heat damage (×8000)



7 Burn Wound Care

157
Some Functional Changes of Heat-Damaged
Degenerative Fibroblast of Human Skin In Vitro
Human FBs were cultivated in a 52 °C water bath and heated
for 30 s, forming degenerative cells. LDH kit, Na + -K + -ATP
enzyme kit, a reverse high-performance liquid chromatogra-
phy (HPLC) instrument, a type of collagen and alkaline
fi broblast growth factor (FGF2), ELISA kit, RT-PCR, and
other methods were involved in detecting the changes in
heat-damaged cells, and contrasted them with the compari-
son group. The result showed that the LDH that leaked from
a membrane of the experimental group was much greater
than that in the comparison group. This returned to normal
after 3 days. The Na + -K + -ATP enzyme and mitochondria
ATP in the experimental group were much lower than that in
the comparison group. The activities of the Na + -K + -ATP
enzyme basically returned to normal. The FGF2 was the
same as in the normal group on the 1st, 7th, and 10th days
after heat damage, and lower than the normal group on the
2nd, 3rd, 4th, and 5th days. This remained stable.
The Transcription and Secretion of I Type Collagen
Were the Same as the Normal Group
The cell membrane is the outer barrier of cells. It takes part
in substance transportation, energy metabolism, signal
transduction, and almost all the cell events. The membrane
phospholipids bilayer consists not only of the basic struc-
tural components, but also the micro-environment, which
all kinds of enzymes combine with to carry on functional
activities – many enzyme-induced reactions need special
phospholipids. The heat stimulus reduces the fl uidity of the
cell membrane, which is signifi cant, and apparently affects
the function and metabolism of the cell membrane, and
may be the cause of cell damage, necrosis, and apoptosis.
The LDH whose function is damaged, is one of the three
classic indicators that refl ect cell permeability. From the
experiment we could see that the LDH leak rate increased
greatly 3 days after heat damage. It reached a peak on the
1st day, then decreased gradually, and returned to normal
on the 3rd day after heat damage. The activity of Na + -K + -
ATP enzyme on membrane began to decrease 3 h after heat
damage (95 % of normal), becoming lowest on the 1st day
(61.22 %), and recovering to normal on the 2nd day. All the
results above suggested that the function of the membrane
could return to normal after the membrane suffered degen-
erative heat-damage. At the same time, the activity of the
Na + -K + -ATP enzyme recovered 1 day earlier than that of
LDH. This means that the Na + pump plays an important
role in cell damage recovery, and it is also the basis of
swelling elimination. This research indicated that the time
of phospholipids bilayer heat damage in human dermis FB
is at least 52 °C, for 30 s. Only in this way can it recover
completely.
FGF2 is an important factor in the early stage of FB to
become functional. It can be excreted by macrophage and
FB. It can promote cell mitosis, survival, proliferation,
collagen composite, differentiation, and vascular genera-
tion. FGF2 combines with the receptor on the membrane,
then activates the tyrosinase pathway and the adenylate
cyclase pathway, regulating gene expression and cell
metabolism, which result in cell proliferation. From this
experiment, we fi nd that on the 1st day after heat damage,
the FGF2 secretion between the experimental group and
the normal group showed no signifi cant differences. On
the 2nd to 5th days, it declined gradually, but kept rela-
tively stable. On the 7th to 10th days, it increased to nor-
mal level (Fig. 7.31 ). The critical time after heat damage
for FB is the 1st day, when the damage reaction was most
serious. The quantity of FGF2 reaching the normal level
plays an important role in maintaining cell survival and
proliferation. In our opinion, a certain quantity of FGF2 is
the most important factor for FB survival and recovery
after heat damage.
Fig. 7.29 Five days after the heat damage
Fig. 7.30 Seven days after the heat damage


7.5 Repair of Deeply Burned Hands with Split-Thickness Auto-Skin Grafting with Preservation of the Denatured Dermis

158
The Important Protective Actions of Heat Shock
Protein 90 in Heat-Damaged Human Dermis In Vitro
Fibroblasts of human dermis were cultivated in 52 °C water
for 30 s 24 h after the damage; immunofl uorescence was
used to observe the expression position change and compare
it with the normal group (Fig. 7.32 ). Western blotting was
used to further analyze the expression quantity of heat shock
protein 90 (HSP90) at the 3rd, 6th, 12th, 24th, 48th, 72nd,
96th, 120th h in heat-damaged FBs and those in normal FBs.
The result was that there was overexpression of HSP90 in
cytoplasm and nucleus at the 24th h after heat damage. This
was observed by immunofl uorescence. As shown by western
blotting the expression began to increase at the 3rd h and
reached the peak level at the 24th h. This was maintained
until the 96th h, and recovered to the normal level at the
120th h (Fig. 7.33 ). All of the above shows that the heat dam-
aged of FBs could cause overexpression of HSP90, which
may protect heat-damaged FBs to some degree.
Heat shock protein is a cluster of peptides whose structure
is highly conservative. It is widely available in living cells,
involved in repairing damaged protein in cells, transmem-
brane transportation, signal transduction, inhabiting apopto-
sis, promoting proliferation, etc. In the stress response, the
inactive mono HSPs gather and become active trimers. Then
the heat shock element (HSE) gene is switched on to express
and produce HSP, playing the role of “molecular chaperone.”
Heat shock protein 90 is an important member of the fam-
ily. It mainly helps the damaged proteins to transport, fold,
prevent aggregation, and return to normal structures.
Moreover, it can prohibit cell apoptosis, promote prolifera-
tion, and affect the cell cycle. The expression of HSP90 in
heat-damaged FBs is markedly enhanced at the 24th h, and
there was still ectopic expression in some nucleuses. Western
blotting showed that the expression quantity began to
increase at the 3rd h and reached the peak level at the 24th h.
This was maintained until the 96th h (4th day), and recovered
to the normal level at the 120th h (5th day). The transmission
Fig. 7.32 HSP90 expression increase markedly in both cytoplasm and
nucleus of FB cells at 24 h after heat damage
.44
.42
.40
.38
.36
.34
95 % CI OD
.32
N =
10
10
10
10
10
10
10
10
10 days
7 days
5 days
4 days
3 days
2 days
1 day
Control
Fig. 7.31 Effect of the heat
damage on PGF2 release
in FB cells


7 Burn Wound Care

159
electron microscope showed that the shape of the FBs had
changed most obviously at the 1st h after heat damage. At
the same time, the expression of HSP90 reached its the peak.
This illustrates that elevated expression of HSP90 has a pro-
tective effect on heat-damaged FBs.
7.6
The Relationship Between Subeschar
Tissue Fluid and Early Infection
and Organ Dysfunction Post-burn
Yiping Zhou
Systemic infl ammatory response syndrome and multiple
organ dysfunction remain the major causes of burn-related
death. But the mechanism is not very clear. It is commonly
recognized that early extensive escharectomy can effectively
reduce and interdict early systemic infection and multiple
organ function damage, thus increasing the cure rate of mas-
sive burns. At home and abroad, much attention has been
focused on the patient’s changes (such as infl ammation,
organ dysfunction, and alimentation condition) pre- and
post=escharectomy and the toxicity of necro-skin tissue. At
the beginning of the 1980s, Zhou et al. [ 43 , 44 , 51 ] observed
that during the burn edema reabsorption phase, burns patients
often suffered from toxemia, which may even have been
complicated by systemic infection, and after the burn edema
reabsorption phase, the patient’s vital signs were stable if the
eschars were well kept and the wounds were not obviously
infected. If the necro-skin tissue still existed, why did the
patients’ conditions differ signifi cantly after the burn edema
reabsorption phase? It is hypothesized that the main cause is
whether the subeschar tissue fl uid (STF) is reabsorbed into
the systemic circulation. As the capillary permeability
increased during the burn shock phase, a great deal of STF
infi ltrated into the third space of the tissues, especially at the
deep fascia level. During the burn edema reabsorption phase,
STF becoming absorbed into the general circulation was
possibly the main cause of the great instability of burns
patients. Since 1993, the number of studies on STF has grad-
ually increased, relating to the establishment of the animal
model for STF collection, the component analysis of STF,
the relationships between infl ammatory mediators in STF
and early infection, and organ dysfunction of burns patients,
the toxicity of STF in experimental animals, the protective
effects of prompt escharectomy on scalded animals, etc.. It
has been confi rmed that STF played an important role in sys-
temic infection and organ function damage post-burn and
STF acted as a main “toxin reservoir” in the early stages of
severe burns. These studies provided the new theoretic bases
for extensive escharectomy and skin-grafting during the
early stages of severe burns.
7.6.1
Component Analysis of STF
1. Subeschar tissue fl uid collection. At the fastigium of
edema on the 3rd day post-burn, STF fl owed out when the
pinhead of an 16G needle was punctured through the burn
wound into the superfi cial layer of the deep fascia [ 43 , 44 ].
2. Results. Sixteen burns patients had no systemic infection
or severe toxemia, and had a burnt total surface area of
67.6 ± 22.22 %. The mean third-degree burns was
36.4 ± 30.8 %, were the objects of observation. When the
STF was harvested, blood samples were obtained by
venous puncture. The results are shown in Table 7.12 .
The results showed that the components of STF were
similar to those of blood plasma, but their quantities were
related to their molecular weight. As the electrolytes and the
smaller molecules passed through the wall of capillary vessel
more easily, their STF and plasma contents were similar and
there were no signifi cant statistical differences between them
( p > 0.05). However, the quantities of the larger molecules in
STF, such as G, IgG, IgA, IgM, and C 3 , were obviously lower
than those in blood plasma, and the statistical differences
were very signifi cant ( p < 0.01). The cause of this may be
related to the larger molecules being diffi cult to permeate
through the capillary wall [ 43 , 44 ].
0.089
0.365
0.387
0.395
1.031
0.890
0.736
0.732
0.10
N
3 h
6 h
12 h
24 h
48 h
72 h
96 h
120 h
90
46
hsp90
β-actin
Fig. 7.33 Time-course changes
of HSP90 expression in FB
cells after heat damage

7.6 The Relationship Between Subeschar Tissue Fluid and Early Infection and Organ Dysfunction Post-burn

160
7.6.2
Study on Infl ammatory Mediator in STF
7.6.2.1 The Endotoxin Level in STF
The aims are to explore the quantity and the changes in endo-
toxin in STF early post-burn, to investigate the relationships
among the endotoxin level in STF, the endotoxin level in
blood plasma, and wound infection, and to provide the refer-
ence for clinical practice.
Animal Model Establishment and STF Collection
Filter screen facture. A disposable blood transfusion device
was pruned away under sterile conditions except for the cola-
torium and a length of infusion tube, which connected to the
former. A fi lter screen was embedded into the back of a
healthy guinea pig under aseptic conditions after anesthesia
and hair removal. The skin wound was sewn up carefully and
Opposite gel was sprayed to protect the wound (Figs. 7.34 ,
7.35 ). The back was then immersed in a 100 °C water bath
for 10 s to infl ict the third-degree burn (confi rmed by patho-
logical section). Immediately post-burn, 4 ml/100 g body
weight of normal saline was given intraperitoneally for fl uid
resuscitation and then the guinea pig was housed under iso-
lated (one per single cage) conditions and took food freely.
Sixty experimental animals were randomly divided into the
burns group and the wound sepsis group. In the wound sepsis
group, Pseudomonas aeruginosas were spread on the ani-
mals’ wounds after scalding. STF and blood samples were
harvested at fi ve time periods (8, 16, 24, 48, 72 h post-burn),
six animals in each. Blood was obtained by percutaneous car-
diac puncture. Plasma samples were immediately separated
by trifugation and stored in aliquots at −70 °C until assay.
Results
Subeschar tissue fl uid and endotoxin level increased gradu-
ally over time in the two groups. In the wound sepsis group,
STF and endotoxin level were signifi cantly higher than in the
burn group at all time points. The statistical differences were
very signifi cant (Fig. 7.36 , Table 7.13 ).
7.6.2.2 The Relationship Between STF
and Hemoculture
The positive rate of bacteria culture in the wound sepsis
group (84.0 %) was higher than that in the burns group
(44.8 %), and the bacteria-positive rate of STF culture was
higher than that of hemoculture. The statistical differences
were very signifi cant. Seventy percent of the bacterial spe-
cies in STF culture were identical to those in wound culture
[ 46 , 47 ]. Therefore, it is rationally considered that the sys-
temic infection of burns mainly resulted from wound
infection.
7.6.2.3 Changes in TNFα, IL-6, and IL-8 in STF
and Plasma
Method
The scaled guinea pig models were used to observe the
changes in TNFα, IL-6, and IL-8 in STF and plasma. TNFα,
IL-6, and IL-8 were determined using ELISA.
Fig. 7.34 Backup fi lter
Fig. 7.35 Subcutaneous buried fi lter
Table 7.12 Component comparisons of STF and blood plasma
x
s
±
(
)
Object Unit
N
STF
Plasma
STF/plasma
(%)
A
g/dl
5
2.02 ± 0.37
2.74 ± 0.43
73.7
G
g/dl
5
0.94 ± 0.44
2.22 ± 0.33
42.3 *
IgG
mg/dl
6
157.21 ± 59.70 1,473.98 ± 285.10 10.7 *
IgA
mg/dl
6
45.09 ± 41.28
223.50 ± 70.44
20.2 *
IgM
mg/dl
6
31.78 ± 26.31
122.27 ± 35.49
26.0 *
C 3
mg/dl
6
26.01 ± 23.51
70.97 ± 24.21
36.6 *
K
mEq/L 5
4.26 ± 0.71
4.14 ± 0.32
102.9
Na
mEq/L 5
138.60 ± 11.97 135.20 ± 7.85
102.5
Cl
mEq/L 5
106.00 ± 10.68 102.00 ± 10.95
103.9
Ca
mEq/L 5
3.22 ± 0.31
3.80 ± 0.82
84.7
Glu
mg/dl
5
127.60 ± 18.85 150.80 ± 17.92
82.6
BUN mg/dl
5
15.00 ± 5.74
31.20 ± 19.16
48.1
Cr
mg/dl
5
1.20 ± 0.23
2.64 ± 1.45
45.5
MM
u/dl
13 209.27 ± 28.45 184.91 ± 27.84
113.2 *
* The difference was very signifi cant ( p < 0.01)


7 Burn Wound Care

161
Result
The levels of TNFα and IL-6 in the plasma of guinea pigs
with 30 % third-degree burns were sharply increased at 8 h
post-burn, and reached a peak at 16 h post-burn. IL-8 in
STF and burn plasma had obviously increased within 8 h
after burns and the trend ascended gradually during the
72 h after scald injury. Furthermore, the levels of TNFα,
IL-6, and IL-8 in STF were obviously higher than those in
burn plasma at the respective matched time interval
(Table 7.14 ). The statistical differences were very signifi -
cant [ 48 , 49 ].
The results showed that STF contained many infl amma-
tory mediators, whose content was remarkably higher than
that in plasma. It is imagined that the amount of infl amma-
tory mediators and bacteria reabsorbed into the systemic cir-
culation contributes signifi cantly to the genesis of systemic
infl ammatory response syndrome and multiple organ dys-
function. It is reasonable to explain why the patients with
severe burns who were treated with eschar-reserved therapy
often suffered from toxemia, or even complicated by sys-
temic infection in the burn edema reabsorption phase, and
the patient’s vital signs were stable so that the eschars were
well kept and the wounds were not obviously infected after
the burn edema reabsorption phase.
7.6.3
Organ Dysfunction Induced by STF
To prove whether STF could impair organ function, ECs and
liver cell cultures were carried out in the research laboratory
[ 51 – 54 ].
7.6.3.1 The Deleterious Effect of STF on ECs
Method
Human umbilical vein endothelial cells (HUVECs) were
incubated with STF obtained from patients during the early
post-burn stage. The morphological changes in ECs were
then observed, and the activity of ECs and contents of LDH,
6-keto-PGF1α in media, were determined. The healthy
human blood serum served as the control.
Results
1. The activity of LDH increased gradually after HUVECs
were incubated with STF, and was higher than that mea-
sured after HUVECs were incubated with healthy volun-
teer sera (Table 7.15 ).
2. The content of 6-keto-PGF1α increased gradually after
HUVECs were incubated with STF, and higher than that
measured after HUVECs were incubated with healthy
volunteer’s sera (Table 7.16 ).
0
0.2
0.4
0.6
0.8
1
1.2
1.4
8
16
24
48
72
STF of wound sepsis
STF of single burn
Plasma of wound sepsis
Plasma of single burn
Fig. 7.36 Changes in endotoxin
level in subeschar tissue fl uid
( STF ) and plasma in scalded
guinea pigs
Table 7.13 Changes in
endotoxin level in STF and
plasma in scalded guinea pigs
U
L x
s
/ ,
±
(
)
Post-burn time (h)
8
16
24
48
72
Burn group
STF
404 ± 36
485 ± 77
584 ± 56
872 ± 108
788 ± 63
Plasma
221 ± 45 (1) 329 ± 51 (1), (3)
381 ± 34 (1), (2) 277 ± 67 (1)
377 ± 50 (1), (2)
Wound sepsis group
STF
406 ± 53
590 ± 265
773 ± 96
1,008 ± 196
1,129 ± 134
Plasma
258 ± 64 (4) 330 ± 27 (4)
495 ± 53 (4)
553 ± 31 (4), (5)
508 ± 22 (4), (5)
1 Compared with STF in the same group, p < 0.01; 2 Compared with STF in the burns group, p < 0.05; 3 p < 0.01;
4 Compared with STF in the same group, p < 0.01; 5 Compared with plasma in the burns group, p < 0.05

7.6 The Relationship Between Subeschar Tissue Fluid and Early Infection and Organ Dysfunction Post-burn

162
3. Effect of STF on the activity of ECs. The activity of HUVECs
cultured in 1,640 media had absorbency of 0.753 ± 0.214.
However, the activity of HUVECs cultured in 20 % healthy
human sera media had absorbency of 0.749 ± 0.183, and that
cultured in 20% STF media had absorbency of 0.408 ± 0.09,
which decreased remarkably compared with those in the
control groups (Figs. 7.37 and 7.38 ).
4. Morphological changes in endothelial cells. When endo-
thelial cells were cultured with STF, they became
deformed, showing shrinkage of the cell body and enlarge-
ment of the intercellular space. In addition, small vacuoles
appeared in the cytoplasm with karyopyknosis after 24 h.
5. Effect of STF on EC monolayer permeability. The vascu-
lar permeability of the EC monolayer, which, cultured on
micropore fi lter membrane and perfused with Hanks bal-
anced salt solution (HBSS), was studied to determine the
fi ltration coeffi cient (kf), trans-endothelial cell monolayer
volume fl ux (Jv), and the osmotic refl ection coeffi cient
(б) after ECs were incubated with 1,640 media (group A),
20 % healthy human sera media (group B), and 20 % STF
media for 24 h. The results showed that the mean value of
kf and Jv of ECs incubated with 20 % STF media were
signifi cantly higher than those incubated with 1,460 and
20 % healthy human sera media, and б was decreased
compared with those in group A and group B (Tables 7.17
and 7.18 ).
The results showed that STF could induce a deleterious
effect on ECs, which results in a decrease in cellular activity,
shrinkage of the cellular body, enlargement of the intercel-
Table 7.14 TNFα (ng/ml), IL-6 (pg/ml), IL-8 (pg/ml) in STF and plasma of burnt guinea pigs x
s
±
(
)
Pre-burn
Time of post-burn (h)
8
16
24
48
72
Plasma TNFα
0.13 ± 0.04 0.26 ± 0.09
0.38 ± 0.07
0.28 ± 0.05
0.27 ± 0.06
0.23 ± 0.08
IL-6
<100
431.18 ± 52.75
626.32 ± 195.81
531.65 ± 154.84
307.29 ± 93.46
275.07 ± 81.62
IL-8
<156
293.46 ± 92.10
340.16 ± 86.47
418.6 ± 67.53
585.33 ± 97.64
671.72 ± 127.54
STF
TNFα
0.93 ± 0.11*
1.04 ± 0.12
0.97 ± 0.08
0.75 ± 0.10*
0.62 ± 0.09
IL-6
710.35 ± 116.49*
1,084.52 ± 264.61*
853.72 ± 219.96*
569.10 ± 157.80*
419.26 ± 105.58*
IL-8
318.32 ± 82.71*
482.67 ± 116.11*
597.13 ± 88.91*
680.65 ± 157.42*
813.54 ± 252.70*
* p < 0.01 compared with plasma group; the statistical differences were very signifi cant
Table 7.15 Changes of lactate dehydrogenase (LDH) activity in
culture medium (pg/ml) x
s
±
(
)
Culture time
1
12
24
Control 3.00 ± 0.83
4.37 ± 1.52
5.65 ± 1.83
STF
12.15 ± 2.65 *
19.61 ± 5.27*
26.42 ± 6.37*
*Compared with the group of healthy human sera p < 0.01
Table 7.16 Content of 6-keto-PGF1αin culture medium (pg/ml)
x
s
±
(
)
Culture time (h)
1
12
24
Control 755.62 ± 93.57
868.72 ± 103.52
1,035.46 ± 152.75
STF
1,876.19 ± 103.44* 2,813.69 ± 474.65* 3,328.63 ± 821.04*
*Compared with the group of healthy human sera, p < 0.01
Fig. 7.37 Human umbilical vein endothelial cells (HUVECs) showed
an oval shape at 24 h after incubation with volunteers’ sera (Coomassie
blue staining ×400)
Fig. 7.38 The HUVECs showed a spindle shape and retracted at 24 h
after incubation with STF (Coomassie blue staining ×400)


7 Burn Wound Care

163
lular space, an increase in the kf and Jv and a decrease in б.
It is demonstrated that STF can impair the ECs and result in
an increase in vascular permeability.
7.6.3.2 The Deleterious Effect of STF
on Liver Cells
Method
Liver cells were incubated for 24 h with STF and hepatic
stimulator substance (HSS ) respectively. The activities of
AST and LDH in media were measured at 1, 3, 6, 12, 24 h
respectively. The apoptosis of liver cells that were incubated
with 20 % STF was determined by fl ow cytometry.
Results
1. The activities of AST , and LDH in HSS media gradually
increased with incubation times, but the differences
among them were not signifi cant. However, the activities
of AST, AST, and LDH in STF media increased remark-
ably with incubation times, and there were very signifi -
cant differences among them (Tables 7.19 , 7.20 , and
7.21 ).
2. Apoptosis of liver cells was detected by fl ow cytometry
1 h after incubation with 20 % STF, and the number of
apoptotic cells increased with the duration of incubation.
There were very signifi cant differences compared with
the HSS group at every time phase (Fig. 7.39 , Table 7.22 ).
The Augmentation of Activity of Macrophages
Cultured with STF
The endotoxin, TNF-α, IL-6, and IL-8 contents in STF were
higher than those in plasma [ 46 , 48 , 49 ]. In clinical practice,
burns patients often present the symptoms of SIRS, such as
alteration of body temperature, elevated HR, elevated RR,
etc. To explain the relationship between STF and the immune
system, the activation effect of STF on cultured macrophages
was observed and compared with HSS and blank controls.
The activity and TNF- α and IL-1 production of macrophages
cultured with STF augmented and were stable as macro-
phages were cultured with HSS (Table 7.23 ). It is indicated
that the effects of STF on macrophages were related to the
manifold active substrates in STF.
Studies showed that STF could impair liver cells, which
was not only conducive to liver dysfunction but also directly
promoted the apoptosis of liver cells, augmented the activity
of macrophages cultured with STF, increased TNF-α and
IL-1 production of macrophages, and enhanced EC mono-
layer permeability. All of these are very likely to be the main
causes of early infection and organ damage post-burn.
7.6.4
Systemic Infl ammatory Response
Syndrome Induced by STF
To further validate that SIRS could induce SIRS and organ
dysfunction in healthy rats, STF or HSS was slowly injected
into the jugular vein via an intravenous drip (3–4 drops per
Table 7.17 Changes of volume fl ux (Jv) and fi ltration coeffi cient (kf)
of the endothelial cell monolayer perfused with Hanks balanced salt
solution (HBSS) x
s
±
(
)
Jv (μl/min −1 .cm −2 )
kf (μl/min −1 .cm −2 .kpa −1 )
Group A
25.80 ± 1.83
8.14 ± 1.63
Group B
26.71 ± 2.01
11.02 ± 0.85
Group C
60.35 ± 4.92 *
18.61 ± 1.74 *
* Compared with groups A and B, p < 0.01
Table 7.18 Changes in Jv, kf, and σ of endothelial cell monolayer
perfused with 5 g/L albumin of HBSS x
s
±
(
)
Jv (μl.min −1 .cm −2 )
kf (μl.min −1 .cm −2 .kpa −1 ) σ
Group A
8.34 ± 0.75
3.61 ± 0.52
0.36 ± 0.01
Group B
8.14 ± 0.63
3.77 ± 0.81
0.34 ± 0.06
Group C
25.28 ± 2.64 *
17.45 ± 0.67 *
0.14 ± 0.05 *
* Compared with groups A and B, p < 0.01
Table 7.19 The activity
changes of aspartate
transaminase (AST) in media
(IU/L) x
s
±
(
)
Times (h)
1
3
6
12
24
HSS
4.13 ± 1.08
4.32 ± 1.15
4.60 ± 1.53
4.83 ± 1.26
5.03 ± 1.62
STF
15.75 ± 1.96*
19.67 ± 2.33*
25.85 ± 6.24*
38.92 ± 5.15*
47.34 ± 6.42*
HSS hepatic stimulator substance
* p < 0.01
Table 7.20 The activity
changes of AST in media
(IU/L) x
s
±
(
)
Time (h)
1
3
6
12
24
HSS
3.25 ± 0.86
3.76 ± 1.04
3.83 ± 1.14
4.15 ± 1.28
4.20 ± 1.03
STF
9.75 ± 1.92*
12.25 ± 3.76*
24.65 ± 3.40*
37.50 ± 4.87*
42.67 ± 5.56*
* p < 0.01
Table 7.21 The activity
changes of LDH in media
(IU/L) x
s
±
(
)
Times (h)
1
3
6
12
24
HSS
5.00 ± 1.75
6.82 ± 1.18
7.02 ± 2.40
9.39 ± 1.85
11.52 ± 3.25
STF
31.50 ± 4.46*
37.81 ± 4.52*
43.67 ± 8.77*
59.58 ± 8.95*
73.43 ± 11.26*
* p < 0.01
7.6 The Relationship Between Subeschar Tissue Fluid and Early Infection and Organ Dysfunction Post-burn

164
min). HR and RR were both recorded by a multi-path
physiological recorder at 0, 0.5, 1, 2, 4, and 6 h after STF
infusion. Arterial blood was obtained from the carotid artery
before injection and 6 h post-injection to be measured for
white blood cell count (WBCC). Twenty-four hours after
STF or HSS administration, the rats were sacrifi ced for
pathological examination of the major organs, including the
heart, lung, liver, and kidney [ 54 ].
7.6.4.1 Results
1. Elevated RR became signifi cant at 0.5 h after STF infu-
sion and lasted during the entire observation period
( p < 0.05; Table 7.24 ). HR in rats all became higher than
that before infusion ( p < 0.05; Table 7.25 ). WBCC in arte-
rial blood at 16 h after STF infusion was signifi cantly
higher than before infusion ( p < 0.01; Table 7.26 ).
2. Pathological examination of major organs 24 h after STF
or HSS administration. The rats were sacrifi ced for
pathological examination of major organs, including the
heart, lung, liver, and kidney. Congestion and hemor-
rhage were found in the pulmonary alveolus after STF
administration (Fig. 7.40 ). Ballooning degeneration was
observed in the epithelium of the renal tubule, and blood
casts and protein casts existed in the renal tubule after
STF administration (Fig. 7.41 ). Hepatocytes showed
cloudy swelling, disorganization in the liver lobule, and
red blood cells diffuse in the portal area after STF admin-
istration (Fig. 7.42 ). These results imply that the func-
tions of major organs had been damaged. No change had
been found in the lung, kidney, and liver after HSS
administration.
7.6.5
Protective Effect of Early Escharectomy
on Organs After Severe Burns
It has been proved by animal experiments that early eschar-
ectomy and skin grafting could effectively reduce the level of
infl ammatory mediators early post-burns and protect the
burns from early systemic infection and multiple organ func-
tion damage [ 55 , 14 , 15 ].
7.6.5.1 Effect of Early Escharectomy at Different
Times on the Changes in Infl ammatory
Mediators
Methods
Wistar rats were infl icted with 50 % of the TBSA full-
thickness scalding and randomly divided into four groups:
the control group (C, n = 10), the non-escharectomy group
(NE, n = 50), the prompt escharectomy group (PE, n = 50),
and the delayed escharectomy group (DE, n = 20). The levels
of TNF, NO, ET, malonic aldehyde (MDA), and superoxi-
dase dismutase (SOD) in plasma were detected at 1, 3, 6, 12,
and 24 h post-burn.
Results
The TNF, NO, ET, and MDA levels increased markedly
after scalding in every group, but were signifi cantly lower in
the PE and DE groups than in the NE group after eschar
excision. TNF, NO, ET, and MDA levels were signifi cantly
lower in the PE group than in the DE group. SOD levels
decreased markedly after scalding and escharectomy, but
were signifi cantly higher in the PE group than in the DE
group.
Conclusions
Escharectomy could reduce the production and release of
infl ammatory factors. Prompt escharectomy is better than
delayed escharectomy in an induced uncontrolled infl amma-
tory response.
7.6.5.2 Protective Effect of Early Escharectomy
on Organs
Methods
Twenty rabbits with severe burns were randomized into two
equal groups: a scald group and a prompt escharectomy
group in which the eschar was removed at 72 h post-burn.
Seven days post-burn, the rabbits were sacrifi ced and patho-
logical examinations of the heart, lung, liver, and kidney
were performed [ 55 ].
Fig. 7.39 Apoptosis of liver cells
Table 7.22 Apoptosis of
liver cells induced by STF
x
s
±
(
)
%
Time phase (h)
0
1
3
6
12
24
HSS
7.6 ± 0.3
7.8 ± 0.4
8.1 ± 0.6
8.4 ± 0.5
8.7 ± 0.7
9.0 ± 0.8
STF
7.6 ± 0.3
11.2 ± 2.5*
14.3 ± 2.4*
17.1 ± 5.7*
22.5 ± 8.3*
41.6 ± 9.6*
* p < 0.01

7 Burn Wound Care

165
Results
The pathological examinations showed that the extent of
organ damage in the prompt escharectomy group was smaller
than in the non-escharectomy group (Figs. 7.43 , 7.44 , 7.45 ,
7.46 , 7.47 , and 7.48 ).
7.6.6
Brief Summary
The components of STF were similar to blood plasma;
merely the quantities of the larger molecules in STF were
obviously lower than those in blood plasma, and the bacteria-
positive rate of STF culture was higher than that of hemocul-
ture. The levels of TNFα, IL-6, and IL-8 in STF were
obviously higher than those in burn plasma. Activity of ECs
incubated with STF declined and the vascular permeability
of the EC monolayer increased. STF could induce liver cell
damage and systemic infl ammatory response syndrome, and
resulted in major organ dysfunction. Early escharectomy and
skin grafting could effectively reduce the level of infl amma-
tory mediators early post-burn and protect the burns from
early systemic infection and multiple organ function dam-
age. These studies showed that STF was highly related to
systemic infection and organ function damage and played an
Table 7.23 The effects of STF or HSS on the activity, TNF-α and IL-1
production of macrophages n
x
s
=
±
(
)
6,

Activity of cells (A value)
TNF-α (pg/ml) IL-1 (A value)
STF
622.5 ± 75.5
145.15 ± 22.91
0.790 ± 0.044
HSS
436.2 ± 73.8
76.55 ± 9.72
0.632 ± 0.125
Blank
428.4 ± 65.6
67.75 ± 1.89
0.649 ± 0.063
Table 7.24 The effect of STF or HSS infusion on the RR of rats
n
x
s
=
±
(
)
6,

STF
HHS
0
59.2 ± 3.4
61.8 ± 13.5
0.5 h
65.8 ± 4.4 *
58.3 ± 11.8
1 h
73.2 ± 8.4*
61.3 ± 13.0
2 h
80.2 ± 16.8*
63.0 ± 13.5
4 h
85.2 ± 15.0*
58.0 ± 10.5
6 h
86.7 ± 12.1*
56.3 ± 8.3
* Compared with that of HSS infusion, p < 0.05
Table 7.25 Effect of STF or HHS infusion on the heart rate (HR) of
rats n
x
s
=
±
(
)
6,

STF
HHS
0
333.3 ± 21.6
359.2 ± 29.7
0.5 h
337.5 ± 20.4
363.2 ± 33.3
1 h
372.8 ± 16.7 *
361.7 ± 27.9
4 h
395.8 ± 48.6 *,△
361.7 ± 24.3
6 h
399.7 ± 35.6 *,△
359.2 ± 18.0
* Compared with that of HSS infusion, p < 0.05, △ p <0.01
Table 7.26 Changes of white blood cell count (WBCC) after STF or
HSS infusion x
s
±
(
)
Group
n
WBCC (10 9 /L)
Before
6
6.1 ± 0.5
STF
6
10.9 ± 2.4 *
HSS
6
6.9 ± 1.9
* Compared with that of HSS infusion, p < 0.05
a
b
Fig. 7.40 ( a ) Congestion and hemorrhage in the pulmonary alveolus, and serious hypoventilaton in lung tissue after STF administration; ( b ) No
signifi cant change in lung after hepatic stimulator substance (HSS) administration. Hematoxylin–eosin (HE) ×400

7.6 The Relationship Between Subeschar Tissue Fluid and Early Infection and Organ Dysfunction Post-burn

166
a
b
Fig. 7.41 ( a ) Ballooning degeneration in the epithelium of the renal tubule, and blood casts and protein casts in the renal tubule after STF admin-
istration. ( b ) No signifi cant change in the kidney after HSS administration. HE ×400
a
b
Fig. 7.42 ( a ) Hepatocytes cloudy, swelling, disorganization in the liver lobule, and red blood cell diffusion in the portal area after STF administra-
tion. ( b ) No signifi cant change in the liver after HSS administration. HE ×400


7 Burn Wound Care

167
Fig. 7.43 Many of the hyaline casts and clastic cells in the renal glom-
erulus in the scalds group. HE ×100
Fig. 7.44 Intact confi guration of the renal glomerulus and renal tubule
in the prompt escharectomy group. HE ×100
Fig. 7.45 Desquamative intestinal villus, disorderly confi guration, and
many infl ammatory cells infi ltrate the stroma in the scalds group, HE
×100
Fig. 7.46 Intact confi guration of intestinal villus and a few infl amma-
tory cells infi ltrate the stroma in the prompt escharectomy group. HE
×100
Fig. 7.47 Disorderly confi guration of hepatic lobules, strait hepatic
sinusoid, local cytonecrosis, and lymphocyte infi ltrate the portal area.
HE ×100





7.6 The Relationship Between Subeschar Tissue Fluid and Early Infection and Organ Dysfunction Post-burn

168
important role in systemic infection and organ dysfunction
early post-burn. These studies provided the new theoretical
bases for extensive escharectomy and skin grafting in the
early stages of severe burns.
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Z. Yang, Chinese Burn Surgery, DOI 10.1007/978-94-017-8575-4_8,
© Springer Science+Business Media Dordrecht and People’s Medical Publishing House 2015
Treatment of burns has been improved greatly in the last
half century in China, the survival rate was increased
signifi cantly, and more patients who survived suffered from
hypertrophic scar (HS) , scar contracture (SC), and other
sequelae.
It is imperative to improve the treatment of postburn
abnormal scar. More and more researchers have dedicated
themselves to study the pathogenesis and new therapies of
hypertrophic scar and biomedical engineering skin; great
progresses had been achieved, some therapies had been used
in clinics and reported in public. However, this is an
extremely complex problem and diffi cult task; more exertion
should be done to achieve complete understanding of its
pathogenesis and to develop ideal therapy.
Burn care in China is a developing process as China is the
largest developing country in the world. At the initial stage,
the burn care team mainly consisted of burn surgeons, nurses,
and nutritionist. As psychologist was sparse in China at that
time, while the patients and their families were confronted
by the spectra of pain, life-threatening phenomenon, miser-
able condition, and grotesque disfi gures, it was really a hard
work to comfort the victims and their families. However, the
burn surgeons and nurses had no choice but to shoulder the
psychologists work concurrently and wholeheartedly, with
the “heal the wounded and rescue the dying, practice revolu-
tionary humanitarianism” in mind. They learned from the
psychologists, psychiatrists, and other experts, at the same
time, they integrated the patients, their families, and relatives
as a whole to cure the patient’s burn wounds and spiritual
wound and worked together harmoniously, and thus medical
workers became true friends of the patients and their
relatives, really lifelong friends. This relationship among
medical workers, patients, and patients’ families is benefi cial
to burn care goal, and it is easier for surgeons to plan and
conduct the various therapies and reconstructive operations
in concert with the patient. Moreover, the burn surgeons are
basically plastic surgeons in China; at least lots of them were
originally a plastic reconstructive surgeon and being assigned
as burn surgeon. They are profi cient in burn reconstructive
surgery. Whenever we examined the patients with postburn
deformities or disfi gurements, mixed heavy feelings surged
up. “We succeeded in saving patient’s life but we failed to
help them getting rid of their suffering.” We decided to do
our best to minimize their physical and psychological suffer-
ings. It is clear that, though the survival is the foremost in
burn care, the overall and ultimate goal of burn treatment
must be to improve patient’s quality of life, optimal improve-
ment of functional, aesthetic, and psychological outcomes.
The overall and ultimate goal must be carried out from the
beginning to the end of burn treatment, and the early-phase
and late-phase treatment should be planned as a whole pro-
gram. In this topic, only the following issues will be dis-
cussed briefl y: postburn claw hand deformity, how to use the
extra limited donor skin to cure the extensive severe burn
patient (e.g., a case with 99.5 % of TBSA, third-degree burn
of 80 %, deep second-degree burn of 14.5 %, superfi cial
second- degree burn of 5 %; Fig. 8.1 ), and how to use the
scarred skin, scarred skin expansion, scarred skin fl ap, and
composite skin graft (acellular dermal matrix ,
self-prepared).
Reconstruction of Burn
in the Late Phase
Bi Chen and Xiaoyuan Huang
8

172
8.1
Diagnosis of Postburn Scar
Deformities and General Principles
of Late-Phase Reconstruction [ 1 – 3 ]
Bi Chen
8.1.1
Diagnosis and Evaluation of Postburn
Hypertrophic Scar (HS) and Scar
Contracture (SC)
The most common postburn disfi guration, dysfunction, and
deformities are caused by HS and SC; most of them are on
the body surface and can be seen directly. It seems not
much diffi cult to diagnose; even laymen know grotesque
abnormal “burn scar” and crippling “contracture defor-
mity,” but these sweeping statements provide not much
information to assist treatment or predict the prognosis. As
the pathogenesis of HS and SC is still incompletely clear to
date, the treatment and prevention of HS and CS are com-
plex and diffi cult, and their adverse effects should not be
underestimated.
For example, fl exion contracture of the elbow is a com-
mon sequela of deep burns to the upper limbs. The burn scar
across the elbow tends to contract the mobile, loose, and
supple antecubital skin; the posture or “comfort” position
characterized by fl exion of bodily joints including the elbow
is usually assumed by distressed burn patients; inadequate
exercise and lack of joint splinting are common. All these
factors contribute to formation and development of the fl ex-
ion contracture deformity . Proper and timely joint splinting,
bodily positioning, and physical exercise can reduce its inci-
dence signifi cantly. However, the depth and size of horizon-
tal dermal defects caused by deep burns, the method of
wound closure, and the wound healing time are important
factors contributing to formation and development of HS and
SC; if large dermal defect has not been restored, HS and SC
still would occur.
Long-standing fl exion contractures of the elbow not only
pull the mobile supple skin but also can result in elbow dys-
function, deformity, and secondary changes such as muscu-
lotendinous and neurovascular shortening, ligamentous and
capsular contractures, and subtle ankylosis and even inter-
fere with the growth and development of the involved limbs
in children. Moreover, an eye should be kept on the hetero-
topic ossifi cation, and the elbow is the most commonly
affected joint.
In brief, scar contractures involve not only the skin but
also various important structures in the depths and not only
cause physical sufferings but also mental sufferings.
Despite proper splinting positioning and adequate
physical therapy, contractures of the elbow and other
areas still can occur. Surgical reconstruction of contrac-
tural deformities remains an essential component and
should be combined with nonsurgical therapy to elaborate
a reconstruction plan so as to achieve optimal outcomes.
This requires accurate diagnosis and evaluation of the
patient’s physical condition, scar contracture, secondary
changes, and deformities, and thus it is essential to have
careful case history-taking, comprehensive physical
examination, and special exam. Photographs of pre- and
Fig. 8.1 Extensive burn
patient 99.5 % TBSA, 80 %
third-degree burn

8 Reconstruction of Burn in the Late Phase

173
posttreatment should be taken and preserved as fi les. The
following are ascertained before surgery and nonsurgical
therapy:
A. Detailed history-taking and collecting the factors con-
tributing to HS and SC as much as possible, such as the
cause, size, depth, and location of the burns, wound con-
dition, infection, symptoms, wound healing time, and
personal and family’s scar history, etc.
B. Perform comprehensive physical exam and evaluate
patient’s overall condition, if there are systemic diseases
such as diabetes or osteoporosis, and treatment of the
existing systemic diseases to improve patient’s condition
before surgery.
C. Detailed examination of the HS and SC:
1. Assessing the size, number, location, shape, appear-
ance (scar pigment, vascularity, color, pliability, and
height), and symptoms, evaluating the maturation
stage, differentiating HS from keloid, and examining
scar stability, ulceration, or erosion
2. Assessing scar mobility and thickness with gentle
and proper palpation and ascertaining the thickest
scar and its extent and location (usual across the
joint)
3. Assessing the extent of maturation of the scar tissues
that surround the joint and predicting the wound size
and depth after scar excision or scar releasing (the
corresponding region of the health side can be used as
a parameter)
4. Determining and protecting the location and size of
the available uninjured skin as donor site.
5. Detailed examination and evaluation of dysfunction
and deformities, the cause and extent of the contrac-
ture, and passive and active range of motion (ROM)
(adopt gentle pain-free passive and active motion,
avoid abrupt and forceful passive or active motion)
and analyzing the potential secondary contractures
and changes
6. X-ray test can suggest the structure integrity of bone
and joint. Some special examinations are promising,
such as video computer program analysis. Vancouver
Burn Scar Assessment and other methods are
recommended. Regular examinations are simple, eco-
nomic, easily performed, noninvasive, and effi cient
and remain the basic measures.
The mode of diagnosis of HS and SC remains to be sought
to get a unifi ed pattern. It is favorable to give a succinct, clear
diagnosis about primary and secondary changes and choose
the classifi cation and terms that can assist treatment and
prognosis.
Take the fl exion contracture of the elbow as a case: post-
burn fl exion contracture of the right elbow from the middle
of the arm to the middle of the forearm, elbow stiffness,
ROM 80–40° (fl exion), and web SC.
8.1.2
General Principles of Burn
Reconstruction in Late Phase
The devastating nature of deep burn inevitably results in a
series sequelae of different severity; the patients who sur-
vived extensive severe burn almost have burn scars covering
the whole body surface with numerous deformities, dysfunc-
tions, and grotesque disfi guration. Burn reconstruction for
that kind of patients is a great challenge. With strong convic-
tion of “Put the patient’s interests fi rst, serve the patients
wholeheartedly,” we do our best to restore/improve their
functions and correct/alleviate the deformities and disfi gura-
tion. Having worked in burn care and burn reconstruction for
more than 50 years, the author learned through burn care
practice and showed that the patients’ miserable physical and
psychological sufferings can be reduced greatly, approach-
ing optimal functional and cosmetic outcomes. The follow-
ing are our experience and principles:
A. Put Patient’s Interests in the First Place and Establish
Good Rapport Between Patients and Medical Workers
Listen attentively to the views, complaints of the
patients, patients’ families, and relatives; be concern
with patients’ mental sufferings as well as physical suf-
ferings; take part in the examination of the HS and SC
wounds, dressings changes, stitches removal, and even
some nursing personally. Make a list and chart to record
all the HS, SC, deformities, dysfunctions, and disfi gura-
tions and the available healthy skin and mild scarring
skin; be sure to take pictures and preserve them as fi les,
so as to get the fi rsthand detailed information of the
patients. As we work for the patients’ interests sincerely
and wholeheartedly, it is easy and essential to establish
good rapport between the patients (their families/rela-
tives) and medical worker. Thus the burn surgeon and
burn team, patients, and patients’ family work together
very harmoniously as a trinity.
B. Elaborate a Realistic Comprehensive Reconstruction Plan
The whole reconstruction plan must be based on
detailed examination and analysis of the diagnosis, prob-
lems, and the factors causing them. The reconstruction is
often a long process, which requires multiple procedures,
and these should be done in the order of importance and
urgency (priority). We should do our best to get the opti-
mal outcome and persuade the patient’s family to accept
the reality. All the patients almost want to restore to the
pre-burned condition, but it is still a dream to date. We
have to persuade and encourage them more patiently.
C. Do Not Operate Unprepared
Do Not Operate If You Are Not Sure to Succeed
Cherish a small piece of healthy skin, ensure any
stitch is in the right place, be familiar with the anatomic
variation and dislocation, and be prudent to diminish
tension or torsion of any important structure. Any
8.1 Diagnosis of Postburn Scar Deformities and General Principles of Late-Phase Reconstruction

174
improper practice should be prevented. The size of the
donor site must be adequate for the recreated wound after
scar excision or contracture release, but do not waste a
little bit of valuable skin, even a small piece of matured
scar skin.
D. Create New Methods to Overcome Diffi cult Problems
The most diffi cult problem of reconstruction for
patients who survived extensive severe burn is shortness of
available donor site. To overcome this problem, we use
self-prepared allo-/xeno-acellular dermal matrix (ADM)
as dermal substitution and overlay with thin split- thickness
auto-skin graft to close the recreated wound after scar
excision; develop repeatedly thin split- thickness skin har-
vest techniques . Use matured scar skin, scar skin fl ap ,
expanded scar skin fl ap , and Achilles tendon scar fl aps to
correct the deformities or dysfunction and achieve good
functional results with acceptable appearance. In deep der-
mal burns of the dorsal hand, use early eschar excision or
tangential excision to remove the obvious necrotic tissues
but preserve the denatured dermal tissue and overlay with
skin grafts; this method can prevent the hand from claw
hand deformity and help achieve better appearance.
E. Restoring Function
Restoring function usually precedes the procedure to
improve cosmetic appearance; however, cosmetic recon-
struction will also help patients improve their activities
of daily living and their function and even return to work.
If possible, we should do our best to achieve both goals
simultaneously.
F. Choose an Appropriate Reconstruction Procedure
Individualized for a Specifi c Burn Deformity of the Patient
The specifi c condition, such as size of defect/deformity,
location, severity, etc., varies considerably, and the avail-
able surgical procedures are various and encompass almost
the total plastic reconstructive procedures, from skin graft-
ing to free fl ap transplantation. A thoughtful surgical pro-
cedure should be based on the patient’s specifi c condition
and request, the surgeon’s personal experience, technique,
and facility so as to elaborate a realistic surgical plan.
G. Timing of Reconstruction and Optimal Outcome
If it is possible, reconstruction is postponed until the
scar has matured. Moreover, timing of reconstruction can
affect the functional rehabilitation and physical and psy-
chological conditions directly, for example, deep burn of
the hand should be reconstructed before the formation of
deformity, even if there are unhealing wounds on the
hand or patient’s other part. There is no need to wait the
scar maturation before the hand reconstruction.
H. Be Familiar with Burn Care and Plastic Reconstructive
Surgery
Be familiar with burn care and plastic reconstructive
surgery (from basic theoretics to clinical practice); be
skillful at plastic surgical techniques, from strict aseptic,
painless, noninvasive surgical technique to microsurgical
technique; be good at selecting and using every technique
of reconstructive ladder (from direct tissue closure, skin
graft, tissue expansion, and various fl aps to free tissue/
fl ap transfer) and ancillary techniques. Recently , micro-
surgical techniques are being used for burn reconstruc-
tion more and more and although good results in China
were achieved, surgical anatomy remains to be researched
in more detail.
I. Learn and Master the Relevant Expertise
Plastic surgery and burn surgery are comprehensive
specialty and relate with numerous relevant specialties
closely, such as surgical anatomy, pathophysiology, gen-
eral surgery, orthopedics, ophthalmology otorhinolaryn-
gology,
stomatology,
pediatrics,
oncology,
and
craniocerebral and urinary surgery. Only if we have good
grasp of basic theory and practice of surgery and the exper-
tise of relevant specialty can we keep up with the develop-
ment of plastic reconstructive surgery and create new
treatment and research, e.g., to treat the contracture
deformities of the hand and extremities, it is necessary to
be familiar with the anatomy of the hand and extremities
and the repair techniques for the bone, joint, tendon, nerve,
and vessel as well as to familiarize various brace, traction
technique, massage, physical therapy and exercise, etc.;
besides, to restore jaw facial deformity, it is mandatory to
understand the relevant expertise of ophthalmology, oto-
rhinolaryngology, oral occlusion, and oral surgery before
correct evaluation, diagnosis, and treatment.
J. Burn Reconstruction and Rehabilitation
Burn reconstruction and rehabilitation, like plastic sur-
gery, is a combined specialty of medical science and art; we
should promote our aesthetics and do our best to achieve
optimal functional and aesthetic outcomes and alleviate
patient’s psychological suffering, become close lifelong
friends, and do follow-up. Some patients suffered extensive
severe burn 50 years ago; they are still alive and still com-
municate with us. Though they are around 70 years old, the
burn scar of the patients became much better than 50 years
ago. They returned to work and took care of their lives by
themselves (now some of them had retired).
8.2
One-Stage Surgical Correction
for Severe Postburn Contracture
of the Achilles Tendon and Its Anatomy
Bi Chen
8.2.1
Introduction
Severe deep burns of the lower extremities can result in severe
talipes equinus or equinovarus because of postburn scar
contractures of the posterior leg and ankle, contractures of
injured gastrocnemius muscle and/or Achilles tendon, and
improper burn care. These deformities often cause changes of
the normal positional relationship among the bone of the
8 Reconstruction of Burn in the Late Phase

175
tibia, talus, and calcaneus, calcaneal tendon shortening, and
heel (calx) being lifted. If these deformities are not corrected
in early stages, secondary capsular and ligamentous contrac-
tures often occur; the patient who suffered from these defor-
mities could only stand on their toes with huge diffi culty, and
some patients could not stand up and walk at all. The degree
of severity of these deformities varies considerably, from
mild simple footdrop to severe complicated talipes equin-
ovarus; the latter always results in changes of anatomical
positions of triple articulations (calcaneocuboid, talonavicu-
lar, and subtalar articulations); however the front part of the
foot often presents overextension and subluxation of the
metatarsophalangeal joints owing to dorsal foot contracture.
The severe deformities often cause the patient unable to stand
up and walk and have been a great challenge to burn surgeon
as they involve not only the overlying skin but also the under-
lying Achilles tendon shortening/contracture, secondary cap-
sule and ligamentous contractures, and even joint stiffness. In
the past, the scar tissue over the Achilles tendon and its neigh-
boring site was always replaced with a distant fl ap or multi-
stage skin tube transfer before Achilles tendon lengthening or
triple arthrodesis [ 11 ]; thus the patients used to complain of
heavy physical and mental sufferings, long hospitalization, as
well as multistage surgical procedures. Island adipofascial
fl ap or free skin fl ap with simultaneous Achilles tendon
lengthening procedure was also an alternative method [ 12 –
14 ]. However, if the patient sustained extensive severe burns
and the local tissues of the lower limb were severely dam-
aged, it is diffi cult to fi nd proper vessels for anastomosis and/
or suitable donor site is unavailable. Z-shaped Achilles ten-
don scar composite fl aps had been reported in 2001 to correct
postburn tendon scar contracture with 3.5 cm Achilles tendon
shortening and got good result [ 15 ].
To correct severe complicated postburn talipes equin-
ovarus in one-stage procedure, a new method was designed
in our burn center in 1976. The contracted Achilles tendon
and overlying scar skin tissues were regarded as a whole
and designed as rectangular Achilles tendon scar fl aps with
length/width ratio of 4:1 or even 5:1. The tendon together
with the overlying scar was incised longitudinally along its
midline down to the areolar fat tissue just in front of the
tendon. On both sides of incision, two fl aps were designed
with the pedicle of medical one downward and that of lat-
eral one proximal ward. The Achilles tendon was length-
ened and sutured side by side after the deformity was
corrected to normal position with the foot at neutral posi-
tion (90°). The secondary wounds on both sides were
closed with free skin grafts. Tie-over dressings and plaster
of Paris cast were used to immobilize the ankle at a
functional position. Four patients (8 feet) were treated by
this procedure with fairly good results; they got out of bed
and were able to ambulate 40–65 days postoperatively
(PO). To our surprise, all the eight lateral fl aps totally sur-
vived without any circulatory disturbance, while the fi ve
medical fl aps among 8 feet, whether the fl ap had been
delayed or not, showed some circulatory embarrassment
resulting in necrosis about 2 cm at its distal end, though the
fl ap had the same blood fl ow direction. This problem
attracted us to study its anatomic basis.
8.2.2
Anatomy of Blood Supply
to the Achilles Tendon and Its
Surrounding Skin
The blood supply to the Achilles tendon and its surrounding
skin has not been described in the anatomy textbook in detail
[ 11 , 12 ].
To investigate the blood supply of the fl aps, fresh adult
cadavers were perfused with red latex in their arterial system
followed with antiseptic solution, and transparent arterial
vessel specimens of fresh children and infants had been
made in 1976. A total of seven cadavers were dissected and
observed carefully. The results are described briefl y as
follows.
The lower third of the leg, ankle, and heel are furnished
by the anterior tibial artery, posterior tibial artery, and pero-
neal artery, respectively. Numerous branches arising from
the above three arteries communicate each other and com-
pose arterial networks around the lateral malleolus, medical
malleolus, and heel. In front of the Achilles tendon, there are
two or three communicating branches (diameter 1.0–1.5 mm)
between the posterior tibial artery and peroneal artery. It has
been shown that the collateral circulation and blood supplies
around the ankle joint, Achilles tendon, and heel are rela-
tively abundant (Fig. 8.2 ).
Medial to the Achilles tendon, about 1 cm posterior to the
medial border of the tibia, there were fi ve to six branches
arising from the posterior tibial artery; these branches anas-
tomose with each other, anastomose with medial malleolar
network and calcaneal network, and supply Achilles tendon
and its neighboring soft tissues. When we design the medical
Achilles tendon scar fl ap, the base of the fl ap should be
slightly wider than before, and these branches (Fig. 8.3a )
would be preserved to ensure the blood supply to the
medial fl ap.
Lateral to the Achilles tendon, fi ve to six cutaneous
branches arising from the peroneal artery supply the tendon
and its nearby soft tissues and skin; with communicating
branches, they anastomose with each other and anastomose
with the lateral malleolar network, calcaneal network, and
the nutrient vessel of the sural nerve (Fig. 8.3b ).
Furthermore, posterior and proximal to the lateral malleo-
lus, there are upward branches which arise from the peroneal
artery, ensuring the blood supply of the lateral fl aps
(Figs. 8.2b and 8.3b ).
Based on the anatomical observation, we improve the
design of the Achilles tendon scar composite fl aps [ 16 ].
According to the branches arising from the tibial artery and
peroneal artery and the courses of these branches, the base of
8.2 One-Stage Surgical Correction for Severe Postburn Contracture of the Achilles Tendon and Its Anatomy

176
the fl aps were designed slightly wider than before. The medial
fl ap with its pedicle distalward contains the main branches of
the posterior tibial artery, while the lateral fl ap with its pedicle
proximalward contains three to four branches of the peroneal
artery, and its pedicle comprises the lateral malleolus and cal-
caneal network as well. In fact, medial and lateral Achilles
tendon scar composite fl aps are axial fl aps that are the reason
that the fl aps can survive with a length/width ratio of up to 4:1
or even 5:1. In addition, the pedicle of the lateral fl ap contains
the lateral malleolus calcaneal network as well; thus the rect-
angular lateral fl ap designed previously all survived and no
circulation disturbance had occurred.
8.2.3
Clinical Data
Twenty-nine patients with 51 feet having severe postburn con-
tracture of the Achilles tendon were treated from 1977 to 2009
(including 12 patients with 22 equinovarus being treated in
other hospital). Among them, 19 cases were male and ten
cases female, aged 14–43 years. All the patients suffered from
severe burns in the lower extremities, the wounds were treated
with pinch skin graft or micro-skin/auto-skin grafts, and
postburn talipes equinus or equinovarus developed after burn
wound healing. The surgical corrections were implemented
2–10 years after burn injuries respectively. Preoperative
a
b
Fig. 8.3 Blood supply of the
Achilles tendon fl aps.
( a ) Branches of the posterior
tibial artery to the medial fl ap.
( b ) Branches of the peroneal
artery to the lateral fl ap
a
b
Fig. 8.2 Blood supply around
the Achilles tendon. ( a ) The
subcutaneous vessels of the
lower leg. ( b ) The vessels around
Achilles tendon


8 Reconstruction of Burn in the Late Phase

177
physical examination showed that the distance from the heel to
the ground was 8–19 cm. All the patients suffered from severe
postburn talipes equinus or equinovarus in one foot or both
feet. Five patients were unable to stand and walk, and being
confi ned to bed for a long time (the longest one was 2.5 years),
the other 24 patients limped painfully and unsteadily with
crunches or padding up the heels. In these series of patients,
the severe talipes equinovarus were corrected with the
improved procedure of Achilles tendon scar fl aps. The surgi-
cal technique is described in this section briefl y as follows:
8.2.4
Improved Design of Achilles Tendon
Scar Flaps
Based on the anatomical observation, the pedicles of Achilles
tendon scar composite fl aps were designed about 3.5 cm in
width. The incision for medical fl ap was made about 1.0 cm
posterior to the medial border of the tibia. The medial fl ap
contains the main cutaneous branches arising from the poste-
rior tibial artery; the lateral fl ap contains the main cutaneous
branches arising from the peroneal artery and the calcaneal
and lateral malleolus networks. The shape of both fl aps is
similar to high trapezoid form.
8.2.5
Surgical Procedures and Results
After the Achilles tendon scar fl aps on both sides were designed
and marked, a vertical incision was made along the midline of
the Achilles tendon, cut straight through the full thickness of
the scar and the tendon together, reaching loose connective tis-
sue layer in front of the tendon. The scar skin was sutured with
the Achilles tendon with 3-0 silk thread immediately to prevent
from separation between both tissues. The designed two
Achilles tendon scar composite fl aps on the both sides of the
incision were implemented. The pedicle of the medial one was
distalward, and its distal end was about 1 cm above the attach-
ment of the Achilles tendon; the pedicle of the lateral one was
proximalward, and its upper end was at the junction of the ten-
don and muscular fi ber. Active punctuate bleedings on both
ends could be seen. Blunt dissection was used to separate the
fl ap along the loose connective tissue plane with fi nger gently.
Care must be taken to protect vessel branches and nerves. The
sural nerve should be preserved, if it was not impaired, which
lies alongside with the small saphenous vein. Neurolysis should
be done if there is adhesion or tension on the nerve. After both
fl aps were raised and the scar contracture released, the Achilles
tendon was lengthened and the ankle joint could be corrected to
the normal functional position (90°). If it was severe postburn
complicated talipes equinovarus, with resistance to the defor-
mity correction, accessory incision should be made on the
medial side of the ankle joint, till the varus deformity was
corrected completely. If the ankle could not be restored to neu-
tral position (90°), the posterior capsule of the ankle joint
should be probed with blunt dissection approach with fi nger
gently, and the secondary capsule contracture should be
released carefully as well as blindly. The foot was kept in dor-
sal extension by the assistant surgeon, and the operator probed
and touched the tension part of the contracture capsule and cut
the tension part with a fi nger as guider until the ankle was cor-
rected to functional position. However, the normal position of
the triple joints, which was just corrected, is often unsteady
after the Achilles tendon was lengthened and the deformity was
fully corrected; Steinmann’s pin or thick Kirschner wire was
often used to maintain the normal functional position of the
ankle joint (90°). The Achilles tendon scar fl aps were sutured
side by side carefully, and the subcutaneous tissue dermal layer
and skin were sutured, respectively. Medium split-thickness
skin grafts were used to close the secondary wounds, and tie-
over dressings should be applied to hold the skin grafts in place.
If the triple joints were not fi xed with Steinmann’s pin or
Kirschner wire, the plaster of Paris cast should be used to main-
tain the triple joints in normal position after dressings. Skin
stitches were removed 12 days PO, and Steinmann’s pin or
Kirschner wires were removed 2 weeks PO. The patient got out
of bed to practice walking 23–25 days PO.
8.2.6
Typical Cases
Case 1
A 24-year-old female suffered from extensive severe burns
with 92 % of TBSA and third-degree burn of 74 %; both
lower extremities sustained third-degree burn. Early eschar-
ectomy followed with pinch skin grafting was carried out.
However, the wounds became ulcerated and infected repeat-
edly. Unfortunately, severe talipes equinus with mild talipes
varus occurred after wounds healed, and her heels were
10 cm off the ground when she was helped to stand up. She
was unable to stand up and walk by herself at all and con-
fi ned to bed more than 15 months. Treated with this new
method, the deformities of both feet were corrected fully;
she got out of bed and ambulated 25 days PO. No recurrence
or adverse effect has been encountered (Fig. 8.4 ).
Case 2
A 22-year-old female suffered from severe burns with third-
degree burns of 60 % of TBSA in 1969; both lower limbs
sustained third-degree burns, and the muscles and Achilles
tendons of both legs were partly damaged. Unfortunately,
after the wounds were healed, severe talipes equinovarus of
both feet developed with overextension and subluxation of
the metatarsophalangeal joints. When she was helped trying
to stand up, she could only stand on her toes diffi cultly with
8.2 One-Stage Surgical Correction for Severe Postburn Contracture of the Achilles Tendon and Its Anatomy

178
her heels 19 cm off the ground. She was unable to stand up
and walk at all and confi ned to bed for more than 2.5 years.
Admitted to our hospital, she was treated with the new
method mentioned above. Her severe talipes equinovarus of
both feet were fully corrected in one-stage surgical correc-
tion. She got out of bed and walked a month postoperatively
(Fig. 8.5 ). One year later, she could walk 1 km at one time.
Released her sufferings, she restored her normal life and
could do some farming and household chores. To date no
recurrence or adverse effects had occurred, and she has
achieved satisfactory results and contacted us recently.
In this group of 29 patients, 51 feet had severe postburn talipes
equinus or equinovarus. Treated with the new method mentioned
above, all the 51 talipes equinus or equinovarus were corrected in
one-stage surgical correction. During operation, active punctuate
bleeding even a few small ejective bleeding could be seen; thus
meticulous hemostasis is essential. The blood supply of both
fl aps in this group was abundant without any circulation distur-
bance or necrosis. All the wounds healed by fi rst attention. The
range of follow-up was 6 months to 30 years. All patients had
gotten good results and could walk one or several kilometers. No
recurrence has been encountered.
8.2.7
Several Points Needing Attention
to the New Method
1. Blunt dissection should be adopted along the loose con-
nective tissue layer in front of the tendon when dissecting
Achilles tendon scar fl aps; especially during the dissec-
tion of the pedicles, do not damage the vessels, nerves,
and their branches. The vessels and nerves should be pre-
served as far as possible especially during correcting the
deformity of the ankle joint. And the separation between
tendon and scar should be avoided to prevent the fl aps
from blood supply disturbance.
2. The release and incision of the posterior capsule contrac-
ture of ankle joint. There was often secondary contracture
of the posterior capsule of the joint in the cases of scar-
contracted foot drop that resulted from severe burns, and
the ankle joints were at the excessive plantar fl exion posi-
tion for a long time. Sometimes after tendon lengthening
using the Achilles tendon scar fl aps, the ankle deformity
still could not be fully corrected, and the release of poste-
rior capsule contracture of the ankle joint was often
needed. Sometimes it is necessary to release the contracted
Fig. 8.4 The treatment of the
scar contracture talipes equinus
after burn. ( a , b ) Both feet
suffered from severe talipes
equinus. ( c ) The X-rays of triple
joints preoperatively. ( d ) The
design of the Achilles tendon
scar fl aps. ( e , f ) During
operation. ( g ) The severe talipes
equinus was corrected after
surgical procedure. ( h ) X-rays
postoperatively showed that triple
joints had restored to the normal
position. ( i–k )
Postoperatively, she was standing
up by herself steadily
a
b
c
d
e
f

8 Reconstruction of Burn in the Late Phase

179
scar skin of medial side of ankle joint so as to correct the
foot drop and talipes equinovarus and restore the normal
functional position of the ankle joint at 90° ankle. The
surgeon should touch the posterior wall of the ankle joint
capsule with their forefi ngers carefully to prevent the ves-
sels and nerves from being damaged during incision.
When the ankle joint restored to the position of 90° angle,
this position was kept, and thick Kirschner wires or
Steinmann’s pin were used to fi x the position.
3. Protect the sural nerve. The sural nerve pierces the fascia
propria on the middle region of posterior leg and is accom-
panied by the small saphenous vein. It supplies the skin of
the heel and lateral foot. The sural nerve could be damaged
in the case of severe lower extremity burn. If not damaged,
they should be protected during operation. If there was
adhesion or they impeded the correction of the deformity
of the ankle joint, neurolysis should be made and does not
damage this nerve. The nerves were elongated by 5–6 cm
i
j
g
h
k
Fig. 8.4 (continued)
8.2 One-Stage Surgical Correction for Severe Postburn Contracture of the Achilles Tendon and Its Anatomy

180
Fig. 8.5 The treatment of severe
postburn talipes equinovarus.
( a , b ) Preoperation. ( c , d ) X-rays
of both feet preoperatively. ( e , f )
The design of the Achilles tendon
scar fl aps. ( g , h ) Intraoperation,
fi xation of triple joints with
Kirschner wire. ( i–k ) Ambulated
1 month after operation, she was
practicing walking and going
upstairs
a
b
c
d
e
f

8 Reconstruction of Burn in the Late Phase

181
g
h
i
j
Fig. 8.5 (continued)
8.2 One-Stage Surgical Correction for Severe Postburn Contracture of the Achilles Tendon and Its Anatomy

182
in 3 ft of the patients in this group. And the skin sensation
was favorable postoperatively.
In brief this method is suitable for severe postburn talipes
equinus and talipes equinovarus that resulted from severe
lower extremity burn. It is easy to master and safe. The
period of treatment is short and the results are satisfactory
and reliable, and it is a good method for these patients.
8.3
Reconstruction of Patients with
Multiple Deformities After Extensive
Severe Deep Burns and Lacking
of Donor Skin
Bi Chen
8.3.1
Introduction
With great progress of burn treatment in the past 50 years in
China, more and more patients have survived extensive severe
deep burns. Unfortunately, they always sustained multiple
deformities with heavy physical and mental sufferings, espe-
cially those whose burn ≥90 % of TBSA with third-degree
burns ≥70 %. In the acute phase, patients’ conditions were
critical; numerous life-threatening odds should be overcome.
To achieve rapid wound closure was necessary, but donor skin
was lacking; thus, it was impossible to achieve ideal wound
repair, and multiple deformities usually occurred after wound
healing, which needed reconstruction and rehabilitation
imperatively. Usually, reconstruction of burn deformities is
complex and diffi cult and sometimes even more complicated
than some congenital deformities or other posttraumatic ones.
The reconstruction of burn deformities in convalescence has
something in common with general plastic surgery, while
there are specifi c situations, such as long- term heavy physical
and mental suffering, multiple dysfunctions, disfi gurements,
and deformities. Moreover, the patients always lack donor tis-
sues. Therefore, it is a great challenge to improve and restore
patients’ appearance and function. However, the patients usu-
ally hold high expectations of life quality and want to improve
their looks, restore their original face and contours, and return
to the society and their work. These are expectations of all
burn medical workers as well, and these are our ultimate goal,
while to achieve this goal is a very diffi cult task for burn sur-
geon and all burn team staff. There are some hard nuts to be
cracked.
The patients who survived extensive severe deep burn
always suffered from multiple deformities and disfi gurements
with burn scar almost covering their whole body surface from
head to toes. While they extremely lack healthy normal donor
site, it is really like “making bricks without straw” for burn
surgeon to treat these patients. This is really a crux.
Extensive severe deep burn is a devastating injury; the
patients suffered from heavy physical as well as emotional tor-
tures. Certain patients had even psychological obstacle with
self-accusation and self-abasement and gradually got depressed
and felt hopeless. Owing to extreme agony, some patients even
tried to commit suicide and managed to evade the various physi-
cal therapies. Moreover, a few patients confi ned to bed in “com-
fort” position, even refuse splinting and exercise, especially
those who were burned while on duty, or enjoyed wholly public
health service. Although the family, relatives, friends, and col-
leagues of patients tried their best to console them, encourage-
ment and proper convincement, which might help the patients to
face up to the reality and restore their determination to struggle
against the burn injury and disability, could rarely be seen.
Therefore the self- support abilities of patients were getting
worse, and the patients became reluctant or managed to evade
the dressing changes, operation, and physical therapy as well as
the occupational therapy. These may to a certain extent hinder
the process of deformity correction and rehabilitation.
“To make the wounded still a capable person in spite of
his injury or even disability and remain mentally capable and
determined although physically disabled” has become the
ultimate goal for our burn team.
k
Fig. 8.5 (continued)
8 Reconstruction of Burn in the Late Phase

183
8.3.2
The Principles of Burn Reconstruction
Treatment in the Late Phase [ 17 , 21 ]
The general principles of reconstruction should be followed.
The individualized plan and specialty in treating the patients
who survived the extensive severe deep burns made us learn
that in treating this kind of patients, we should not only serve
them wholeheartedly but also be deliberate and comprehen-
sive, painstaking, and creative, with keen eyes, decisive man-
ner, calmness in emergency, and willingness to bear
responsibility and blame.
8.3.2.1 Establish Harmonious Relationship
Among the Patients, Patients’ Family,
Relatives, and Burn Team Worker
All of us work together to encourage the patient to be coop-
erated with various treatment and exercise and be fi rm and
persistent against the physical and mental sufferings bravely
and to persuade the patient and family to face up to the
reality.
8.3.2.2 Elaborate an Overall Comprehensive
Reconstruction and Rehabilitation
Program (Including Acute-Phase and
Late-Phase Plans)
An experienced burn surgeon (professor or at least attending
surgeon) is assigned to take charge of the whole planning
work. As soon as the patient was admitted to our hospital, the
size, depth, and distribution of burns were recorded and
charted carefully including the subsequent changes of the
wounds. The available donor sites were described and charted
too. Of course, photographs were preserved. Then, the
prediction of the patterns of deformities from wound to scar
contractures, HS, is possible, and the staged tentative plans
were scheduled (which could be modifi ed according to the
changes of patient’s condition). And the reconstruction
should be done in the order of importance and emergency. No
thorough and comprehensive reconstructive program, good
opportunity for reconstruction would be missed. An extensive
severe burn patient was transferred to our hospital 76 h after
burn injury with moderate inhalation injury, complicated with
hypernatremia and hyperchloremia. The fi rst stage plan was
to stabilize the patient’s overall status and inhalation injury, to
control the complicating diseases, and to grasp the good
opportunity to implement early escharectomy. The fi rst
escharectomy to treat 44 % TBSA burn was performed 4 days
PO. and the wounds were closed with large sheet of allo-skin
immediately; the patient’s condition became gradually stable,
and sodium and chloride levels returned to normal 12 h PO.
The second plan was to remove the rejected allo-skin grafts
and replace them with micro- skin grafts which were har-
vested from small, just healed superfi cial second-degree burn
area and small scalp 14 days PO. Then the patient’s condition
became basically stable, and thus the subsequent reconstruc-
tion plan was implemented successfully (Fig. 8.6 ).
8.3.2.3 Timing of Reconstruction and Optimal
Results
Timing of reconstructive surgery will infl uence the physical
and functional results directly, and the chosen time may vary
with patient’s status considerably. Generally, the scar should
be matured before reconstructive surgery. However, deep
burns of the hand should be reconstructed before the hand
deformity develops and forms.
Fig. 8.6 An extensive burn
patient

8.3 Reconstruction of Patients with Multiple Deformities After Extensive Severe Deep Burns and Lacking of Donor Skin

184
8.3.2.4 Give High Consideration to Appearance
Reconstruction as Well as Functional
Restoration, Cherish Every Single Piece
of Donor Skin, and Make the Best Use of
Every Tissues Including Scarred Skin
Generally, functional reconstruction precedes cosmetic
reconstruction. In practice, the realistic situation and the
patient’s and family’s expectations and desires should also
be considered. If possible, endeavor should be attempted to
achieve the two goals simultaneously. Improvement of
appearance would make the patient more confi dent.
Every small piece of donor skin is valuable even a small
scar skin can be made use of, e.g. an extensive severe burn
patient with the face and eyelids was admitted, and ectropion
of the eyelid with cornea exposures was inevitable. Fortunately
the patient had a small piece of abdominal skin sustaining
superfi cial second-degree burn just under the belt. Its size was
just enough for eyelid reconstructions. While waiting for the
wound to heal, the surgery was planned about 12 days post-
burn injury and then performed on the planned time success-
fully with satisfactory cosmetic and functional outcomes.
8.3.2.5 Put Patient’s Interests in the First Place
and Establish Good Rapport Between
Patients and Medical Workers
Concerning patient’s mental as well as physical suffering,
give chances for patient and his/her family to express their
grievances and sufferings, and they need our help and sym-
pathy highly. On the other hand, it is essential to enlighten
them to be realistic and fi rm and struggle against the burn
injury and disaster bravely and encourage them to move for-
ward and to face up reality and future.
8.3.2.6 Choose Proper Surgical Procedures and
Create New Methods
There are various methods, from direct closure to free tissue
transfer, which comprise the armamentarium of the recon-
structive burn surgery. In choosing the procedure, the
patient’s overall status, the specialty of deformity, the avail-
able donor site, personal experience, and the facilities should
be considered, and the surgical plan should be individualized
and discussed with the patient and his/her family. Generally,
the simple effective method with least cost to patient’s body
and health is the choice. The expanded scarred skin [ 22 ],
scar skin fl ap [ 22 ], and composite skin grafts (ADM+ split-
thickness scar skin/normal skin) are new methods. They are
useful for patients who survived the extensive severe deep
burn with extremely limited donor site .
8.3.2.7 Surgical Reconstruction and Nonsurgical
Rehabilitation Therapy Should Be
Combined Closely
Plastic surgical procedures are mainly done to achieve ana-
tomical reconstruction and rehabilitative therapy mainly to
achieve functional reconstruction. Plastic reconstruction
without rehabilitative therapy cannot accomplish the whole
ultimate goal of reconstruction.
There are some other key points written in the topic 9 and
unnecessary to describe here.
8.3.3
Treatment and Results
Functional and aesthetic improvement and restoration of
postburn multiple deformities and organ displacements can
only be attained by proper surgical reconstructions followed
by rehabilitation. Lacking of donor skin is the crux that
should be overcome fi rstly. From the 1960s, some experi-
ments as well as clinical researches were carried out, such as
using scarred skin, cultured epidermal autografts (ECA),
acellular dermal matrix (ADM), and allo/xeno skin treated
with glutaraldehyde.
In 1964, owing to shortage of donor skin, a split-thickness
matured scar skin was used to correct postburn mild defor-
mity clinically for the fi rst time in our hospital and got good
result. Thereafter, medium split-thickness matured scar skin,
scar skin fl ap , composite skin graft (ADM covered with thin
split-thickness scar skin), Achilles tendon scar fl aps , and
expanded scar skins were used successfully in our hospital.
Though scar skin and composite skin grafts are not as good
as healthy normal donor skin, the reconstruction results are
at least acceptable or fairly good.
8.3.4
Clinical Data
Twelve patients with multiple deformities after extensive
severe deep burn were treated in Xijing Hospital from 1960
to 2005. All the patients had sustained burn ≥90 % of TBSA
with deep burn ≥70 % (including deep dermal burns to
fourth-degree burns). Ages ranged from 19 to 54 years, with
an average of 22.5 years (seven male and fi ve female).
Among them, seven patients were admitted to our hospital in
the acute phase; fi ve cases were referred to our burn center
from other hospitals in the late phase, and most of their burn
wounds were healed. All of the patients obtained systematic
surgical reconstruction and rehabilitation and achieved good
functional and cosmetic results.
Three cases in this group were admitted to our hospital in
the 1960s and were treated conservatively. After eschar sepa-
ration and formation of granulation tissue, pinch auto-skin
grafts and/or micro-skin grafts were used to cover the wound
and overlaid with large sheet allo-skin grafts. The remaining
wounds were covered with stamp allografts and pinch auto-
skin grafts. With a total of more than ten times skin grafting,
the burn wounds were fi nally closed 4.5–5 months post burn.
Five cases were admitted from 1989 to 2003. To achieve
rapid wound closure, early escharectomy of the extremities
was performed, followed by micro-skin grafting covered with
large sheet allografts on 2–5 days postburn, and the rest of the
8 Reconstruction of Burn in the Late Phase

185
wounds were treated with staged escharectomy with auto- and
allo-skin intermingled grafting. After the second- degree burn
wounds were healed, thin split-thickness skin sheet was har-
vested from the healed area and grafted onto some functional
region to supersede the scar so as to restore its function, but
scar hyperplasia was obvious and resulted in severe deformity.
Another four patients were referred to our burn center from
other hospitals. They were treated with micro-skin grafts and
staged pinch skin grafting and suffered from multiple severe
deformities accompanying multiple scar ulcers (Table 8.1 ).
In this group, there were a total of 173 deformities needing
reconstructive treatment. Their locations were as follow: 39
scars of various deformities on the head and face, 5 cases of
webbed scars on the neck, 3 cases of severe neck contracture
(mento-chest contracture with chin pulled down to chest), 11
cases, 21 severe axillary scar contracture with adhesion
between arm and chest, 20 elbows with hypertrophic scars
(10 patients), and 17 elbow scars accompanying scar ulcer, 20
hand deformities of 11 cases (14 severe claw hands), 22 pop-
liteal fossae of 11 cases suffering from hypertrophic scars, 10
popliteal fossae with scar ulcer, 16 lower limbs of 9 cases
with anterior knee hypertrophic scars, 11 scar contracture
foot drops (6 cases), 7 mild foot drop and 4 severe ones (2
cases), 5 cases hypertrophic scars on both dorsum of feet
(10 feet HS), 4 cases of scar contracture on the inguinal
region, 2 cases of severe perineum scar contracture.
8.3.5
Methods and Results
Among 173 deformities in this group, 88 deformities were
treated with scar skin grafting; 40 deformities with composite
skin grafting; 11 scar contracture talipes equinus of six
patients with Achilles tendon scar fl aps; and 21 severe axil-
lary contractures of 11 patients with scar skin fl aps or
expanded scar skin from the back or anterior chest; after scar
contracture was released, the fl aps were transferred to the
axillary apices, the rest of the wound above and below the
scar skin fl ap was closed with scar skin or composite skin
grafting. In addition, another four deformities were recon-
structed with scar skin fl aps. In this group, some deformities
were reconstructed with two or three methods combined
together. Three reconstructive methods are described briefl y
as follows.
Table 8.1 Treatment of 12 cases of severe burn patients
Case
Time of
injury
Gender,
age
Burn area
Normal skin
Time
length of
treatment(d) Job
TBSA
III°
Deep
II°
Superfi cial
II°
Sites
TBSA
Meng
1960.04
Male, 19
90
68
12
10
Head,
perineum,
foot
4
135
Head master
of a county
hospital
secretary
Long
1966.03
Female, 22 92
74
10
8
Head,
perineum,
sole of foot
8
152
Farmer
Shang
1969.08
Female, 21 90
60
10
20
Head,
abdomen,
perineum,
sole of foot
10
148
Farmer
Guan
1989.10
Female, 54 90
70
20
Abdomen,
waist, sole of
foot
10
76
Engineer
Cao
1993.06
Male, 20
98
89
5
4
Head
2
136
Merchant
Zhang
2000.10
Male, 38
95
72
18
5
Head, sole of
foot
5
102
Worker
Lei
2000.08
Male, 27
99.5
80
14.5
5
Head
0.5
120
Worker
He
2001.06
Male, 20
96
88
4.5
3.5
Head, right
sole of foot
4
76
Soldier
Liu
2001.06
Male, 22
97
91
4
2
vertex
perineum,
sole of foot
3
730
Soldier
Zhang
2001.06
Male, 21
97
97
Lower
abdomen,
perineum,
sole of foot
3
850
Self-care
Yuan
2003.09
Female, 19 94
30 interspersed 61
3
Head, sole of
foot
6
330
Self-care
Li
2003.09
Female, 19 94
25 interspersed 66
3
Head, sole of
foot
6
330
Self-care
8.3 Reconstruction of Patients with Multiple Deformities After Extensive Severe Deep Burns and Lacking of Donor Skin

186
8.3.5.1 Expanded Scar Skin Graft [ 22 ]
Soft tissue expanders were placed under the matured scar
skin, mostly in the regions of the back, lumbus , chest, and
abdomen. Usually, two 450–500 ml expanders were placed in
the back. The injection saline volume was less than that for
expanding the normal skin properly every time, and the whole
injection process was longer than that for expanding the nor-
mal skin. Usually, it took about 2.5 months to expand the
scarred skin, and 40 cm × 10 cm to 60 cm × 10 cm of scar skin
could be obtained, medium split-thickness skin grafts were
cropped at last by reverse skin harvesting with drum derma-
tome, and the donor sites were closed primarily. After scar
contractures were released, deformities were corrected, or
hypertrophic scar was excised, the expanded scar skin grafts
were used to close the secondary wounds, and tie-over dress-
ings were applied to hold the grafts in place and immobiliza-
tion. The dressings were untied 10–12 days postoperatively;
the grafts took well, occasionally, a few small wounds could
be seen and healed after several dressing changes. A total of
88 defects were treated with this method because of shortage
of normal donor skin; among them are 13 defects of severe
axillary SC (8 cases), 15 defects of elbow HS (8 cases), 5 HS
on the anterior region of the knee joint, 5 claw hands of 3
cases, and 50 defects of the face, neck, wrist, and foot (18
cases). All of the scar skin grafts took well with an average
survival rate of 96 %. The survived scar skin grafts showed
slight unpliableness and contracted at the beginning and then
became fl attened and softened about 3 months PO, and the
color and texture of the grafts were similar to normal split-
thickness skin grafts. Many deformities, such as in the axilla,
elbows, hands, and anterior part of the knee, were repaired by
this method and the function restored well. For example, the
upper limbs could be lifted to 100–160° and the upper arm
could be abducted to 90°.
8.3.5.2 Reconstruction with Scarred Skin
Flaps [ 22 ]
Based on the size and region of the wound needed to be
repaired, axial or local rotation scarred skin fl ap was designed
on the chosen location where the scar had matured and it was
convenient for the fl ap to be transferred to the wound.
The expanded scar skin fl ap on the distant region could be
designed and transferred to the region needing reconstruc-
tion. This method was mostly used for claw hand repair.
Nine claw hands in this group were reconstructed with this
method. The secondary wound was closed primarily after the
wound edge being dissected gently or using scar skin graft-
ing. Twenty-one axillary deformities (11 cases) were recon-
structed with local scar skin fl ap, and the largest fl ap is
25 cm × (9–4) cm. The Achilles tendon scar fl aps were used
for postburn talipes equinus/equinovarus .
A total of 60 scarred skin fl aps were used in this group,
and all of them survived; among them were 37 local scar
fl aps, 12 expanded scar fl aps, and 11 Achilles tendon scar
composite fl aps that were used to repair the severe scar con-
tracture talipes equinus or equinovarus after burn. All of
them were abundant in blood supply and thin, with good
appearance and function.
8.3.5.3 Reconstruction with Composite Skin
Grafts
To overcome the shortage of the donor skin in patient with-
out available sites for expanding, thin split-thickness scar
skin or scalp split-thickness skin was combined with allo-
acellular dermal matrix (ADM) as composite skin graft. Six
axillary scar contractures of three cases were released and
reconstructed with scar fl aps from the back or chest and
transferred to the apices of the axillary fossa, and the remain-
ing wounds were closed by composite skin graft. Sixteen
sides of eight cases popliteal scar ulcer, 11 sides elbow scar
ulcer, 2 perineal scars, 2 neck scars, 2 foot dorsal scars, and
3 scared feet were reconstructed with composite skin. The
scar and scar ulcer should be excised extensively before
reconstruction. The maximal wound after debridement was
42 cm × 13 cm, and the minimal wound was 30 cm × 15 cm.
The procedures of treating scar ulcer were as follows: Wash
the wounds with 1 % hydrogen peroxide solution, sterile
saline, and metronidazole (1.5 g metronidazole, 1.25 g
Chloromycetin in 500 ml) repeatedly (three times at least) to
minimize the amount of the bacteria. Then acellular dermal
matrix was transplanted on the wound and grafted by split-
thickness scar skin harvested by motor dermatome and cov-
ered with tie-over dressings. The dressings were untied
6–10 days PO, and the graft had survived. Pressure dressing
change was then conducted again. The interval of dressing
changes depended on the amount of secretion.
Forty cases of composite skin grafts were used with a sur-
vival rate of 94.4 %. Of which 26 cases were treated with
split-thickness scar skin plus ADM, and the tie-over dress-
ings were untied 8–12 days PO. Occasionally there were a
few residual wounds that healed after several times of dress-
ing changes with some contraction. The other 14 cases were
treated with normal split-thickness skin plus ADM; all of the
grafts survived well PO and softened 3 months PO. The color
and texture of the grafts were similar to the normal medium
split-thickness skin grafts.
8.3.6
Typical Case
A 27 year-old male was burned by the explosion of nitrogen
and hydrogen mixture with burn covering 99.5 % of TBSA,
with third-degree burn of 80 %, mixed third-degree and deep
dermal degree burn of 14.5 %, and superfi cial second-degree
burn of 5 %, complicated with moderate inhalation injury,
hyperchloremia, and hypernatremia. The patient was admit-
ted to Xijing Hospital 76 h after the injury. Early escharec-
tomy of the third-degree burn of 44.0 % of TBSA was
8 Reconstruction of Burn in the Late Phase

187
performed and the wounds were covered with allo-skin
grafts 4 days after burn injury, hypernatremia and hyperchlo-
remia were reduced to normal levels, the patient’s condition
improved, and complications were decreased. Because of the
lack of auto-skin donor site, the autologous skin graft was
undertaken whenever there was an available donor site; the
residual wounds were temporarily covered with allografts.
The wounds were closed by staged auto-skin grafting accord-
ing to the amount of auto-skin source. After the treatments
mentioned above, the patient’s condition was stable and no
obvious complications had occurred. The wounds were
fi nally completely closed through seven operations 106 days
after burn injury. However, the patient sustained more than
30 severe scar contracture deformities. After the scars soft-
ened and matured, the deformities were reconstructed with
scar skin, scar skin fl aps, and composite skin grafts. A total
of 15 reconstructive operations were performed by stage and
good functional restoration and obvious improvement of
appearance was achieved. The patient restored his function
satisfactorily and returned to work 26 months after burn
injury. He remarried his original wife at last and has living a
happy family life. He has been followed up for 8 years
(Fig. 8.7a–o ).
8.3.7
Rehabilitative Care
Functional rehabilitation therapy is essential to the patients
who were severely burned with multiple deformities.
Psychological adaptation should be supported timely, and
the active functional training and passive massage should be
taken constantly. Disabled regions should be reconstructed
and the region of poor ability should be trained.
Twelve cases in this group were all determined to insist
on functional training, such as the patient named Meng with
a burn of 90 % of TBSA and third degree 68 %. Having
insisted on climbing hills every day, which led to the scar on
the popliteal fossa breaking down, the patient recovered
quickly and insisted on studying his/her specialty and
returned to work. He was a very hard worker. Soon he
became the leader of a traditional Chinese medical hospital
in a county and worked more than 40 years (Fig. 8.8 ).
Another patient named Guan was injured at the age of 54
with burn covering 90 % of TBSA, with third-degree burn of
70 %; ten fi ngers were charred and had to be amputated.
After the wounds were closed with auto-skin/micro-skin
graft, she insisted on walking up to 2 km everyday. After
hard training, she mastered calligraphy well. She could do
nearly all the housework except washing with hands. She
had the post of foreign language translator and translated lots
of papers (Fig. 8.9a–j ).
After the extensive severe burn wounds had healed, there
were scars all over the body with itching and function lost.
The patient lost self-care abilities. There were 173 scar con-
tracture deformities in 12 cases of the group with 27 scar
ulcer regions. For lack of the donor skin, the following
should be done to restore the function and improve the
patient’s life quality:
A. Treatment Program Should Be Done Elaboratively and
Seriously
This kind of patient mentioned above lacked donor
skin. Medical staff should work out the optimal plan of
surgical procedures and rehabilitation. Special medical
staff had been assigned to be in charge of elaborating the
plan for each patient in this group. The doctor should
design the plan, conduct the surgical procedure carefully
to minimize the damage of the tissue, be meticulous with
hemostasis, and suture properly. These are the key points
to the success of operation.
B. Harvesting of Scar Skin
The development of scars always follows some regula-
tions, and a specifi c kind of scar will eventually form,
physiological or pathological scar. Pathological scars
include hypertrophic scar, scar contracture, unstable scar,
etc., some of which turn into static, soft, and fl at scar at
last. There were 173 scar contracture deformities in 12
cases of this group. The donor skin used for reconstruction
of eyelid ectropion is a small piece of normal skin, and
normal scalp skin used as donor sites could be harvested
12–15 times in early stage and then used for autograft in
the composite skin graft. The scar skin was the most often
used skin source and survived well. Split- thickness scar
skins were used for the composite skin graft in 26 sites in
this group, and good outcome was achieved.
Expanded scar skin graft, expanded scar skin fl aps,
Achilles tendon scar fl aps, and split-thickness scar skin
were used for reconstruction and satisfying result was
achieved.
The range of follow-up was 6 months to 40 years with
satisfying function and appearance. All the patients
restored self-care abilities; seven of them returned to work.
One of them worked for 40 years. Two patients got mar-
ried and had babies. Up to now, neither obvious complica-
tions nor recurrence of local scar contracture had occurred.
C. Several Key Points for Scar Skin and Scar Flaps Grafting
Attentions should be paid during and after operation
based on the feature that the blood supply of the scar skin
was less than that of the normal skin.
1. Strict aseptic techniques should be followed to
decrease infection. As to scar ulcer, suffi cient prepara-
tion should be made to improve wound condition in
advance and reduce the bacteria preoperatively; during
operation, the wound should be cleaned as mentioned
above repeatedly to minimize the amount of bacteria.
2. The wounds closed with the scar skin grafts healed
slower than that of the normal skin graft. The tie-over
dressings should be untied 12 days PO, if without
infection. The wound of the donor site should be
8.3 Reconstruction of Patients with Multiple Deformities After Extensive Severe Deep Burns and Lacking of Donor Skin

188
a
b
c
d
e
f
Fig. 8.7 Reconstruction of severe deformities resulted from extensive
severe deep burns. ( a ) Burns of 99.5 % of TBSA, third-degree burn of
80 %, deep second-degree burn of 14.5 %, and superfi cial second-
degree burn of 5 %. ( b – f ) Severe deformities after healing. Satisfying
results were achieved after reconstruction with expanded scar skin.
( g , h ) Scar ulcer on the popliteal fossa. ( i , j ) Intraoperation of composite
skin graft. ( k , l ) Small size of split-thickness skin obtained from the
scalp. ( m – o ) Satisfying function was achieved 1 year postoperation

8 Reconstruction of Burn in the Late Phase