Phẫu Thuật Tạo Hình Grabb & Smith’s (Bản Cập Nhật – Kevin C. Chung)

Escharotomy
In patients with full-thickness burns, practitioners should evaluate patients for swelling of the underlying
tissues, beneath a nonexpanding, inflexible eschar. Such situations can limit distal extremity perfusion or
torso expansion. Neurovascular checks are indicated for any partial-thickness or full-thickness near-
circumferential burn of the extremities. A palpable radial pulse and audible Doppler signals in the palmar
arch and digits indicate adequate perfusion to the hand. Any change or decrease in the neurovascular
examination should prompt the clinician to consider performing emergent escharotomies on the involved
extremity. Similarly, limited chest expansion with hypoventilation or elevated intra-abdominal pressures
indicate the need for torso release.
The escharotomy procedure may be performed at bedside under adequate sedation. Electrocautery is
used to divide through the burn wound into deeper uninjured tissue, thereby releasing the pressure that
has been building up underneath the inelastic burned skin. After escharotomies are completed, a follow-
up neurovascular examination should document adequate release and return of pulses and distal
perfusion.
Incision patterns follow mid-axial lines, except over the hand, where they continue over the dorsal hand
(Figure 21.3). Care is needed to prevent damage to underlying superficial structures, including the radial
artery at the wrist, the ulnar nerve at the medial epicondyle of the elbow, and the common peroneal
nerve as it crosses the fibular neck.
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FIGURE 21.3 Full-thickness flame burns of the left arm and hand. A. Before escharotomy. B. After escharotomy.
In severe burns that have a large volume resuscitation or in crush or electrical injuries, fasciotomies may
be indicated in addition to escharotomies. If distal vascular examinations do not improve after adequate
escharotomies, if there appears to be muscle bulging through the fascia, or if compartment pressures are
elevated, then fasciotomies should be performed in the usual manner. Additionally, rhabdomyolysis and
accompanying metabolic and physiologic derangements should be identified and addressed with special
attention to maintaining adequate flow through the kidneys.
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Nutrition and Mediation of Hypermetabolism
The inflammatory cascade generated by large burn wounds causes a systemic hypermetabolic response
with enhanced gluconeogenesis, insulin resistance, and protein catabolism. Initiation of early enteral
feeding is a central component of burn care with the goal of full caloric support within 24 hours after
admission. Patients can be started on a regular diet and should be provided with proteinrich nutrition
supplements. Patients unable to eat for reasons such as age, painful hand or facial burns, or
noncompliance may require placement of an enteral feeding tube.
Consultation with a dietician or nutritionist should be considered for every burn patient. Various
nutritional formulas are available for use to guide caloric requirements, although the Curreri formula is
the most popular:
Protein and multivitamin supplementation are indicated as well. Serial measurements of prealbumin, an
acute phase reactant with a half-life of 3 days, allow monitoring the nutritional status over time. Enteral
nutrition is superior to parenteral nutrition, with gastric feeds preferred over small bowel feeding. Early
feeding provides nourishment of intestinal mucosa and prevents its atrophy and bacterial translocation.
Gastroparesis is common, and prokinetic agents such as metoclopramide and erythromycin are helpful in
promoting gastric emptying. If gastric feeding intolerance occurs, the tube should be advanced to a post
pyloric position. Hemodynamically unstable patients requiring increasing amounts of vasopressor
support may require reduction of enteral feeds to trophic levels to prevent intestinal ischemia.
The response to inadequate enteral nutrition is controversial. We believe adequate nutrition is essential.
In our Unit, parenteral nutrition is indicated in patients with open wounds who fail full enteral feeding.
In a randomized, placebo-controlled trial, Demling and Orgill evaluated the effects of oxandrolone, a
testosterone analogue, in 20 patients with between 40% and 70% TBSA. 15 They found patients receiving
the medication demonstrated decreased muscle loss and improved donor site wound healing compared
with controls. Hepatic dysfunction may develop with long-term or higher dosages, so liver function tests
should be followed and the drug stopped if elevations occur. Oxandrolone should be used cautiously in
children less than 4 years of age.
Beta-blockers can mediate the cholinergic response and also help blunt hypermetabolism by decreasing
the resting heart rate. In a seminal article from 1988, Herndon et al. demonstrated that propranolol
decreased myocardial work (heart rate, left ventricular work, and rate pressure product) in pediatric
patients. 16 Further work in adults substantiated their findings. 17 Propranolol or metoprolol are
commonly used agents.
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Prophylaxis
Burn patients are hypercoagulable and are at an overall higher risk for deep vein thrombosis. Chemical
thromboprophylaxis is generally indicated but must be balanced against bleeding risk from wounds or
after surgery. There is no clear benefit for either unfractionated heparin or low-molecular-weight heparin,
but dosing must be adjusted for the hypermetabolic state. In our Unit, we use subcutaneous heparin three
times daily.
Last, critically ill burn patients are at risk for stress gastritis or upper gastrointestinal stress ulcers
(Curling ulcer). Prophylaxis with an H2 blocker or a PPI is recommended, although intragastric
continuous feeds are protective as well. 18
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Extremes of Age
Pediatric and geriatric patients require special consideration. Their physiology may be different from the
standard healthy adult. Moreover, these are vulnerable patients who are often burned as a consequence
from abuse. This must be ruled out during the initial evaluation. If concern for abuse exists, the
appropriate child protective services or other legal entity should be contacted immediately. This will vary
by hospital policy provider and local laws.
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Inhalation Injury
After the size of the burn, inhalation injury is the most critical determination for survival. 19 Stigma of
inhalation injury include tachypnea, wheezing, singed nasal hair or facial burns, soot in the oropharynx,
increasing oxygen requirements, or dropping transcutaneous saturations. Inhalation injury may be
supraglottic, subglottic, or both. Upper airway inhalation injury is defined by injury to the supraglottic
airway from breathing in hot air. Damage to the supraglottic epithelium can result in edema formation
and potential for obstruction of the airway. This is treated by early endotracheal intubation and
supportive mechanical ventilation until such time when the airway edema resolves, usually in 48 to
72 hours, which can be determined by a cuff leak around the endotracheal tube or endoscopy by an
experienced upper airway endoscopist.
Subglottic inhalation injury is characterized by inhaling the toxic products of combustion and results in a
chemical pneumonitis similar to acute respiratory distress syndrome. Diagnosis is confirmed by
bronchoscopy, and findings may not be immediately evident on chest X-ray. The treatment is also
supportive with mechanical ventilation until the acute lung injury resolves, in this case usually over 5 to
10 days. The high-flow percussive ventilator is a useful adjunct that works by recruiting alveoli with low
pressures and by removing debris from the lower airways. When the percussive ventilator is used,
inhaled heparin and acetylcysteine are helpful to avoid airway desiccation and bleeding.
Carbon monoxide (CO) poisoning should be suspected with any inhalation injury. The CO molecule
competes with oxygen at the binding site on hemoglobin and is not detectible by pulse oximetry.
Carboxyhemoglobin level is measured at time of presentation, and if elevated, treatment is initiated with
inhaled oxygen either by nonrebreather mask or endotracheal tube. Application of 100% oxygen can
reduce the half-life of carbon monoxide in the circulation from 4 hours to 40 to 60 minutes. 20
At all times, established protective ventilatory strategies should be employed as possible to prevent
progressive pulmonary damage. After treatment of CO poisoning, low FiO2 should be attempted to
prevent oxidative damage to the pulmonary parenchyma.
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Infection
Large burn injuries result in systemic immunocompromise, and infectious complications are
commonplace after large burn injuries. Many of these patients are admitted for extended periods of time
and are exposed to pathogenic, hospital-acquired, drug-resistant organisms. Thus, the judicious use of
broad-spectrum antibiotics is required to prevent the emergence of multidrug-resistant pathogens.
The most common sites for infection in burn patients are the respiratory tract, the burn wound, and
imparted devices such as central line–associated bloodstream infections and catheter-associated urinary
tract infections. Differentiating secondary infection and sepsis from the hypermetabolic response of the
burn injury is challenging and should be made with thoughtfulness. Changes in clinical condition such as
worsening or new-onset hyper- or hypothermia, tachycardia, hypotension, insulin resistance,
leukocytosis or leukopenia, rising lactates, or base deficits should prompt a head to toe examination of
the patient for signs of secondary infection and a culture of any suspicious areas.
Broad-spectrum antibiotics can be initiated after cultures are sent but should be de-escalated when the
culture’s sensitivities are returned. Pneumonias are treated with supportive mechanical ventilation until
it resolves. Bloodstream infections are treated by exchanging infected central venous catheters and
evaluating the source of septicemia. Burn wound infections are treated with topical antimicrobial and
broad-spectrum intravenous antibiotics targeting gram-positive organisms and pseudomonas if it
appears the infection has spread outside of the burn wound and into the surrounding soft tissues.
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Surgical Management of Burns
Indications
Superficial partial-thickness thermal injuries that will heal in less than 3 weeks should be managed
nonoperatively. This means local wound care (which may include superficial surgical debridement), good
nutrition, and optimization of medical comorbidities. By not autografting these patients, the burn care
provider limits a painful and deforming donor site while optimizing the appearance and functional
outcomes of the burned tissue. Mixed or indeterminate depth burns should be followed closely for 5 to
7 days to allow possible healing to occur, deeper areas to declare, and surgical plans to be confirmed.
Deep partial-thickness or full-thickness burn wounds are best treated with early excision and
autografting to avoid wound sepsis, decrease systemic inflammation, and achieve best wound healing
outcomes. 21-23 Burke et al. in 1974 were the first to promote early excision and grafting in a series of 200
patients. They found that patients with early (<14 days) excision had improvements in mortality (4%
versus 11%) and faster wound closure. Now, early excision generally refers to removal of all nonviable
burn tissue within 7 to 10 days, and there are data to indicate that ultra-early excision within 72 hours after
injury may lead to better results overall. 23
Burn wound excision and grafting can be staged or concurrent. Depth of excision depends on the depth
of the burn wound. Injured tissue must be completely excised if grafting is being considered. If complete
excision will expose critical, ungraftable structures, leaving questionable tissue in place for 2 or 3 days is a
reasonable temporizing step.
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Surgical Steps
Operative Planning and Communication
There should be careful communication between the burn surgeon and the anesthesiologist at all phases
of the case. Blood loss during excision is expected and can be difficult to quantify. Communication about
transfusions is critical. Similarly, maintaining intraoperative normotension and normothermia is
important to prevent poor postoperative outcomes. Similarly, postoperative hypertension from
inadequate pain control can cause hematomas beneath the skin grafts.
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Debridement and Wound Bed Preparation
The excision of burn wounds occurs by either of two common techniques. The first method, tangential
excision, requires stepwise sharp excision of burned tissue to a level deep to the level of thermal injury.
Serial excision occurs using a Weck or Watson blade until healthy tissue is found, indicated by petechial
bleeding or normal tissue morphology. Benefits to this method are that it preserves as much healthy
tissue as possible, sometimes deep dermis, often subcutaneous tissue. This results in better functional and
aesthetic outcomes. Care must be taken to avoid excessive blood loss during tangential excision,
especially when removing large areas of burn or when operating more than a week after injury.
Preoperative injection of dilute epinephrine solution or extremity tourniquets are useful to decrease blood
loss during excision but may make assessment of the underlying wound bed more difficult. Tangential
excision may not be suitable for a hemodynamically unstable patient who could not tolerate the blood
loss or in cases where the burn is third degree and extends into subcutaneous tissue.
An alternative method of excision is prefascial excision. In this method, the surgeon removes all of the
skin and subcutaneous tissue to the level of the deep investing fascia. This method is quick and reliable,
with less blood loss than with tangential excision. However, by removing all dermis and subcutaneous
tissue, there are significant long-term functional and aesthetic deformities. In general, tangential excision
is preferred to prefascial excision for this reason. Prefascial excision is indicated only in critically ill
patients who would not tolerate long operations or large volume blood loss.
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Hemostasis
After adequate debridement has occurred, meticulous hemostasis must be achieved prior to grafting.
Topical epinephrine soaked sponges may be placed immediately after debridement. Wound bed
irrigation and electrocautery should be used to precisely achieve hemostasis. The use of the
electrocautery device should be judicious so as not to re-create deep and diffuse thermal injury to the
healthy wound bed. If the wound is to be grafted at the same stage, as is most common, meticulous
hemostasis at this point is critical to prevent postoperative graft loss from hematomas.
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Wound Closure
After the wound bed has been adequately prepared, the wound should be closed. Plastic surgery
principles are followed. If primary closure or local flaps can be used, they should be considered. Most
commonly, because of the size of most burn wounds, the wound is closed using autograft or a skin
substitute. If the wound bed is reliable with healthy vascular tissue and the patient is medically stable,
then autografting can be performed in a single stage. If there is doubt as to the integrity of the wound bed
to support an autograft, then skin substitutes should be prioritized and autografting delayed until a
suitable wound bed can be developed. If the procedure is staged and autografting is delayed, there
should be a plan for return to the operating room for wound closure within 3 to 5 days.
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Graft Selection
Skin graft harvest occurs with the standard technique using an electric or air-powered dermatome.
Selecting donor sites should be done carefully with prioritization to limiting donor site morbidity. Prior
to surgery, a discussion should occur with the patient to help select optimal donor site, especially in
smaller burns where a donor site could be selected so that it is hidden under clothes and without visible
scarring. 24 Generally skin grafts are harvested at an intermediate depth most commonly 10 to 12
thousandths of an inch. Pediatric and geriatric patients have thinner reticular dermis than healthy adults,
and skin grafts should generally be harvested at a thinner thickness.
Unmeshed, sheet grafts are the best replacement for the debrided areas of injury. In general, they should
be considered when best long-term functional and aesthetic outcomes are the priority. They are
particularly useful for primary grafting of the face, hands and feet and should be standard care for most
burns in children. Thicker skin grafts have the advantage of less contracture after graft take; however, the
donor sites take longer to heal and have more scarring. Thinner grafts have less metabolic demand and
can take more readily on suboptimal wound bed but contract more. The donor site for thinner grafts heals
faster.
If necessary, the grafts can then be meshed to expand their surface area and limit donor site harvest.
Meshed grafts can cover a larger wound area but have a reticulated appearance after graft takes, as the
interstices in the mesh must heal by contraction. The interstices of the mesh graft allow serum or small
amounts of bleeding to escape which may improve mesh graft take rates when compared to sheet grafts.
Although sheet grafts have a better overall appearance and less contracture than mesh grafts, they do
require meticulous wound care postoperatively and should be checked frequently to ensure seroma or
hematoma formation under the sheet graft is not occurring. If this happens, the fluid collection may be
drained and evacuated with an 18-gauge needle.
Full-thickness grafts have little role in acute burn surgical management. Given the limited amount of full-
thickness skin available, they are best reserved for subsequent reconstruction of areas such as the eyelids
or the palmar surface of the hand.
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Skin Substitutes
There are multiple alternatives to autologous skin grafts. Most commonly used is frozen cadaveric
allograft, which can be used in a staged fashion to aid in wound bed preparation and temporary wound
closure. It encourages angiogenesis within the wound bed and can limit evaporative losses for larger
burns that must be closed in a staged fashion. Allografts are relatively expensive, however, and must be
maintained frozen in an approved skin bank. As the patient regains immunocompetence, the allogenic
skin will reject, which can occur from 10 to 30 days after placement. After temporizing the wound bed
with allografts, autografts must ultimately be placed for durable wound coverage.
When sufficient donor site skin is not available, biosynthetic matrices such as Integra® can be used to
graft wounds. These products create a neodermis after ingrowth of autologous wound cells. The silicone
sheet on the Integra prevents evaporative losses and the underlying vascularized neodermis supports
thinner grafts to be placed to restore epidermal coverage. Integra can also be used to bridge across and
cover areas of questionable vascularity such as bone lacking periosteum or tendons denuded of
paratenon. Drawbacks of such products are that they easily become infected if the burn wound was
inadequate debrided and take a prolonged time, usually around 3 weeks, to become revascularized. They
are all expensive.
Cultured epidermal autografts and spray on keratinocytes have also been described and have found use
in coverage of massive burn areas with limited donor sites. However, they are very expensive, and
outcomes are practitioner dependent.
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Graft Placement
The skin graft should then be precisely adapted to the wound bed with minimal overlap of the graft with
the wound edge. Grafts should not be too small as the seam between the graft and the wound margin will
leave an unsightly and often hypertrophic scar.
The skin graft is then secured to the wound bed with conventional techniques such as sutures or staples.
Fibrin glue has been advocated by some practitioners, in particular for shear-prone areas.
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Dressings
After the skin grafts or substitutes are placed, they should be dressed in compressive dressings. Joints
should be immobilized both one joint above and below the area of grafting. It is critical to be
conscientious about dressing placement, because inadequate dressings may lead to shearing during the
graft healing phase and partial or complete graft loss. Methods of dressings include foam bolsters, tie-
over bolsters, negative pressure wound therapy dressings, and compressive therapy for extremities.
There is no demonstrated superior technique from one to the other. The principle behind the dressing is
such that it maintains adequate pressure downward on the skin graft and immobilizes the area to prevent
sheer. In our Unit, all grafts are treated by some kind of antimicrobial dressing.
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Physical Therapy and Occupational Therapy
There are no more important members of the burn team than physical and occupational therapists. Early
therapeutic intervention is critical to preventing the functional deformities that can develop after burn
injuries. Contractures across joints can require release but can often be entirely avoided with excellent
therapeutic care from the time of injury and dedicated patient compliance. Range of motion and
strengthening exercises should be initiated as soon as possible after the injury and should continue until
the timing of grafting. There are inevitable lapses in therapy after grafting procedures to allow the grafts
time to adhere, mature, and become shear resistant.
The timing of postoperative mobilization is controversial, and different institutions have protocols that
vary widely. There is a balance between early mobilization to fully achieve normal range of motion and
strength versus allowing time for graft healing and maturation to occur. Best outcomes occur when the
therapists are an essential part of the decision team and are crucial for preventing scar contractures from
burn injuries that could lead to worse functional outcomes.
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Other Burn Injuries
Chemical Burns
Chemical burn injuries are the result of chemical rather than thermal trauma. These are very often work
related or industrial accidents. The acid or base denatures cutaneous proteins with acids forming
coagulation necrosis and bases with liquefactive necrosis. Other chemicals can denature tissue through
other mechanisms. Whatever the specifics of the chemical agent is treated by dilution, specifically the
treatment is to irrigate the contact area with regular tap water for a minimum of 15 minutes. Acids and
bases should not be neutralized with an opposing reagent because this could create an exothermic
reaction that could add thermal damage to the already existing chemical damage. One exception to this
rule is hydrofluoric acid, which should be neutralized with calcium gluconate or calcium chloride. Bases
tend to create more significant injury than acids because of deeper penetration from ongoing liquefactive
injury. The depth of chemical injuries may not be readily apparent on the initial evaluation and may
require several days of observation before accurate diagnosis of burn depth can be made. For these
reasons, treatment decisions are usually delayed for 5 to 7 days.
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Electrical Burns
Electrical burns can be the most devastating type of burn injury (Figure 21.4). Although other etiologies of
burn injury can be quantified by a careful evaluation of the skin, electrical burns can be difficult to
diagnose the exact extent of the injury. These types of burns are also often associated with other traumatic
injuries or secondary flash or blast injuries from the superheated air surrounding the electrical current.
FIGURE 21.4 High-voltage electrical burns of the left arm and hand. A and B. Day of the burn injury, before debridement. C.
After multiple staged debridements of nonviable tissues. This patient ultimately required a forearm amputation.
In an electrical burn, electricity travels along the path of least resistance which in human tissue
corresponds directly with the water content of that tissue. Heat is generated according to the resistance of
various body tissues with the amount of heat generated directly proportional to the resistance
encountered. Bone has the highest resistance, followed by fat, tendon, skin, muscle, blood vessels, and
nerve. Injuries to deeper structures may occur at any location within the course of where the electricity
traveled; thus, it is important to locate the contact points on the body and map the course of the
electricity. Areas with low cross-section and high bony content, such as the wrist and ankles, are
particularly susceptible to severe injury.
In the event of deeper compartment or muscular electrical injury, fasciotomies must be performed for
adequate compartment release and perfusion of damage tissues. Additionally, there may be damage to
myocardium or any associated organ that lies within the path of the electricity. If there is concern for
cardiac damage, EKG should be obtained at the initial evaluation. Creatine kinases are drawn for
quantification of muscle damage. Because of the propensity for muscular injury, rhabdomyolysis may
result which can cause secondary acute kidney injuries. Peripheral nerve releases including carpal tunnel
and Guyon canal should be included in surgical management if contact points involve the hand or
extremity.
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Cold Injuries
Frostbite injury can be insidious in presentation and preferentially affects the distal or exposed areas of
the body. Ice crystal formation in the intracellular and extracellular spaces kills cells but does not alter
matrix organization. Secondary inflammatory damage occurs after rewarming and can be variable. As a
result, the full extent of tissue damage and subsequent healing potential can be difficult to assess on first
presentation. The initial management of frostbite injuries should be to restore normothermia. Systemic
hypothermia should be addressed first followed by rapid rewarming in a water bath with temperature
between 40 and 42°C for 30 minutes to the affected areas. After rewarming, the damaged areas should be
gently cleaned, blisters debrided, and treated with local wound care. Some evidence suggests that topical
aloe vera may be a valuable adjunct. Systemic administration of nonsteroidal anti-inflammatory drugs
such as ibuprofen can help prevent ongoing inflammatory damage. If the injury is less than 24 hours old,
angiography with either catheter directed or systemic thrombolytic administration may decrease need for
digital amputation. 25 Surgery should be delayed until full tissue demarcation has occurred, which can
take anywhere from 3 weeks to 3 months.
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Special Anatomic Considerations
Face
Facial burn injury should be managed nonoperatively initially even if they appear to be full-thickness
injuries. The excellent perfusion of facial skin may allow deep-appearing burns to heal, thus
circumventing the need for excision and grafting. After meticulous local wound care, facial burns should
be reevaluated at approximately 10 to 14 days and any nonhealing areas excised and grafted. All facial
burns should be sheet grafted, as mesh grafts on the face are aesthetically and functionally unacceptable.
Sheet grafts should be applied with seams adhering to facial aesthetic subunits, but intact skin should not
be removed (Figure 21.5). Scalp grafts provide optimal color match but are seldom wide enough to fully
graft any aesthetic unit except eyelids. First-pass donor site grafts are preferred to reharvested donor
sites. Sheet grafts should be maintained and dressed as indicated earlier in this chapter. A tracheostomy
provides best care of facial burn wound care and postoperative graft management. Ophthalmology
consultation should be obtained if there is concern for ocular involvement. If severe lid burns exist, eyelid
releases or temporary tarsorrhaphies may be indicated to protect the cornea from further damage from
exposure.
FIGURE 21.5 Deep facial burn injury. A. Preoperative appearance of nonhealing deep facial burns, 18 days after initial injury.
B. Postoperative appearance after excision of burns and placement of sheet grafts to the forehead, right cheek, and right upper
eyelid.
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Neck
Isolated burns of the neck are best managed, like other isolated injuries, by early excision and sheet
grafting. Early therapy will help limit neck flexion contractures. In contrast, in patients with a very large
TBSA burn, facial burns, and inhalation injury, the neck should be grafted early with a meshed graft to
allow early tracheostomy (Figure 21.6). A tracheostomy should not be placed through ungrafted burned
areas because of the unacceptably high risk of mediastinitis. The face can be grafted with a stable airway.
Although this strategy predictably results in neck contractures, it improves the ability to get superior
outcomes with face grafting. A cervical immobilizing collar may be useful in postoperative graft
management.
FIGURE 21.6 Deep partial-thickness facial, neck, and chest flame burns. A. Day of the burn injury. B. Seven days after burn
injury. C. Appearance of sheet-grafted neck burn and meshed grafted of chest burn 5 days after grafting, 14 days after injury.
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Hands
The reflex response, to flex into a fist, combined with thicker palmar skin means that most hand burns are
dorsal. In general, most palmar hand burns heal reasonably well. Dorsal hand burns have best outcomes
with early excision and grafting, allowing for early functional mobilization. In a seminal work from 1979,
Hunt et al. described their experience with early excision and mesh grafting of 60 patients with deep
dermal hand burns. 26 These authors excised and grafted all patients between 3 and 10 days after burn
and reported excellent functional results with full range of motion by 10 days postoperatively. They did
note the appearance of the mesh graft as a drawback to their technique. Since that time, common practice
is to sheet graft dorsal hand burns because of unacceptably high rates of contracture with mesh grafts and
poor appearance. Early initiation of hand therapy prevents long-term stiffness and limits contractures.
Severe hand burns with exposure of tendons or bone may require staging with coverage by skin
substitutes such as Integra or vascularized soft tissue flaps. In cases for which early hand therapy is not
possible and the hand will be immobilized for a prolonged period, Kirschner wires may be placed to
immobilize the interphalangeal and metacarpophalangeal joints with the hand in a position of safety to
prevent tightening of the collateral ligaments.
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Questions
1. Which of the following statements regarding facial burn is correct?
a. The thin skin of the face commonly results in deeper burn injuries
b. Full-thickness facial burns should be grafted with full-thickness skin
c. Treatment of full-thickness facial burns with grafting should be delayed until all healing and
contraction have completed
d. Initial treatment of face burns should not include resecting normal adjacent skin
2. A 4-year-old girl presents with 30% TBSA deep partial-thickness burn injury to her chest, back,
and bilateral lower extremities. What fluid should be used to initiate resuscitation of this patient?
a. Lactated Ringer solution
b. Lactated Ringer solution with 5% dextrose
c. 0.9% (normal) saline
d. 0.9% (normal) saline with 5% dextrose
e. 0.45% (half-normal) saline
3. A 45-year-old man with 70% TBSA partial-thickness and full-thickness burns to the face, torso, and
bilateral upper and lower extremities is admitted to the burn unit. He is actively undergoing
resuscitation with lactated Ringer solution according to the Parkland formula. Which of the
following parameters is best used to titrate his rate of intravenous fluids?
a. Heart rate less than 100 bpm
b. Arterial systolic pressure greater than 80 mm Hg
c. Urinary output of 0.5 mL/kg/h
d. Cardiac output greater than 6 L/min
e. Mean arterial pressure greater than 55 mm Hg
4. An otherwise healthy 30-year-old woman presents with 15% TBSA circumferential superficial and
deep partial-thickness flame burns to her bilateral hands and arms. Her burns are cleaned in the
emergency room. Her pain is controlled with oral medications. Her compartments feel soft, and she
has minimal pain with passive or active range of motion of her hands. Radial pulses are palpable
bilaterally. She is otherwise medically stable. What is the most appropriate next step in management?
a. Placement of silver-based dressings and close outpatient follow-up
b. Emergent escharotomy
c. Immediate surgical excision and autografting
d. Fluid resuscitation with lactated Ringer solution and the Parkland formula
e. Placement in dry dressings and referral to the closest burn center
5. A 60-year-old man has 55% TBSA deep partial-thickness burns of the face, neck, torso, and lower
extremities. Which of the following is the most effective immediate method to deliver nutrition to
this patient?
a. Ad lib oral intake with high-calorie protein shakes
b. Enteral nutrition through gastrostomy tube
c. Enteral nutrition through nasogastric tube
d. Parenteral nutrition through central venous catheter
e. Parenteral nutrition through peripheral intravenous injection
1. Answer: d. Although excision and grafting of facial burns should be done with aesthetic subunits
in mind, normal skin should not be resected during the wound bed preparation. Face burns should
be given 2 weeks for healing to occur, but grafting and wound closure should happen around
3 weeks. Grafting should not be delayed until full-thickness wounds heal. The facial skin as a whole
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is not particularly thin, and given the robust vascular supply, many deeper facial burns will heal
without surgery.
2. Answer: b. Burn patients should be resuscitated with a balanced salt solution such as lactated
Ringer solution, and pediatric patients require the addition of dextrose to the resuscitative fluids to
prevent hypoglycemia. Normal saline should not be used for acute burn resuscitation because it
perpetuates a metabolic acidosis. Lactated ringers is more physiologic. Half-normal saline is not used
in acute burn resuscitation because it is hypotonic and would lead to increased volume of
resuscitation.
3. Answer: c. Maintaining an adequate urine output between 0.5 and 1 mL/kg/h is the gold standard
for resuscitation. Heart rate, systolic pressures, and cardiac output are not end points of resuscitation.
Mean arterial pressure is monitored and should be maintained above 65.
4. Answer: e. This patient has greater than 10% TBSA involvement with partial-thickness burns and
has burns to the hand—both are criteria for referral to a burn center. Failure to initiate prompt
referral may lead to delays in care. Placement of silver dressings would require removal and
replacement when she reaches the burn center. Although she does have circumferential burns, she
does not demonstrate any evidence of compartment syndrome. She only has partial-thickness burns,
which may heal without surgical intervention. Burn resuscitation with the Parkland formula is
reserved for patients with 20% TBSA or greater.
5. Answer: c. Establishing early enteral nutrition is critical in the management of larger burns, and
given the extent of this burn and the resulting increased caloric needs, this patient should have a
nasogastric tube placed and tube feeds initiated as part of his initial management. Oral nutrition is
reasonable in the right patient but should be regimented and calories counted. Placement of a
gastrostomy tube is not indicated as the first step. Parenteral nutrition should be avoided unless
enteral nutrition fails.
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References
American Burn Association. Burn Incidence Fact Sheet. Accessed
August 31, 2018.
Hop, MJ, Polinder, S, van der Vlies, CH, et al. Costs of burn care: a systematic review. Wound Repair Regen. 2014;22(4):436-450.
Tricklebank, S. Modern trends in fluid therapy for burns. Burns. 2009;35(6):757-767.
Hilton, JG, Marullo, DS. Effects of thermal trauma on cardiac force of contraction. Burns Incl Therm Inj. 1986;12(3):167-171.
Horton, JW, Maass, DL, White, DJ, Sanders, B, Murphy, J. Effects of burn serum on myocardial inflammation and function. Shock.
2004;22(5):438-445.
Holm, C, Hörbrand, F, von Donnersmarck, GH, Mühlbauer, W. Acute renal failure in severely burned patients. Burns. 1999;25(2):171-178.
Chrysopoulo, MT, Jeschke, MG, Dziewulski, P, et al. Acute renal dysfunction in severely burned adults. J Trauma. 1999;46(1):141-144.
ISBI Practice Guidelines Committee, Steering Subcommittee, Advisory Subcommittee. ISBI practice guidelines for burn care. Burns.
2016;42(5):953-1021.
CMS.gov. ICD-10. cms.gov. Accessed May 5, 2018.
Sen, CK, Ghatak, S, Gnyawali, SC, et al. Cutaneous imaging technologies in acute burn and chronic wound care. Plast Reconstre Surg.
2016;138(suppl 3):119S-128S.
American Burn Association. Burn Center Referral Criteria.
Accessed August 31, 2018.
Williams, DJ, Walker, JD. A nomogram for calculation of the revised Baux score. Burns. 2015;41(1):85-90.
Gibran, NS, Wiechman, S, Meyer, W, et al. American Burn Association consensus statements. J Burn Care Res. 2013;34:361-385.
Tanaka, H, Matsuda, T, Miyagantani, Y, Yukioka, T, Matsuda, H, Shimazaki, S. Reduction of resuscitation fluid volumes in severely burned
patients using ascorbic acid administration: a randomized, prospective study. Arch Surg. 2000;135(3):326-331.In a randomized controlled trial
comparing ascorbic acid (vitamin C) to lactated Ringer solution alone, these researchers found ascorbic acid at a dose of 66 mg/kg/h for 24 hours
decreased overall volume requirements for resuscitation.
Demling, RH, Orgill, DP. The anticatabolic and wound healing effects of the testosterone analog oxandrolone after severe burn injury. J Crit
Care. 2000;15(1):12-17.In a randomized, placebo controlled trial, these researchers studied the effects of oxandrolone, a testosterone analogue, in 20
patients with between 40% to 70% TBSA. They found patients receiving the medication demonstrated decreased muscle loss and improved donor site
wound healing compared with controls.
Herndon, DN, Barrow, RE, Rutan, TC, et al. Effect of propranolol administration on hemodynamic and metabolic responses of burned
pediatric patients. Ann Surg. 1988;208(4):484-492.In a prospective case-control trial of 47 burned children in 1988, these researchers demonstrated
that propranolol decreased myocardial work (heart rate, left ventricular work, and rate pressure product) while maintaining adequate oxygen delivery
and cardiac output in pediatric patients.
Breitenstein, E, Chioléro, RL, Jéquier, E, et al. Effects of beta-blockade on energy metabolism following burns. Burns. 1990;16(4):259-264.
Yenikomshian, H, Reiss, M, Nabavian, R, Garner, WL. Gastric feedings effectively prophylax against upper gastrointestinal hemorrhage in
burn patients. J Burn Care Res. 2011;32(2):263-268.
Grunwald, TB, Garner, WL. Acute burns. Plast Reconstr Surg. 2008;121(5):311e-319e.
Pace, N, Strajman, E, Walker, EL. Acceleration of carbon monoxide elimination in man by high pressure oxygen. Science. 1950;111(2894):652-
654.
Burke, JF, Bondoc, CC, Quinby, WC. Primary burn excision and immediate grafting: a method shortening illness. J Trauma. 1974;14(5):389-
395.These researchers were the first to promote early excision and grafting in a series of 200 patients treated between 1969 and 1973. They found that
patients with early (<14 days) burn excision and immediate autografting had improvements in mortality (4% versus 11%) and faster wound closure.
Saaiq, M, Zaib, S, Ahmad, S. Early excision and grafting versus delayed excision and grafting of deep thermal burns up to 40% total body
surface area: a comparison of outcome. Ann Burns Fire Disasters. 2012;25(3):143-147.
Keshavarzi, A, Ayaz, M, Dehghankhalili, M. Ultra-early versus early excision and grafting for thermal burns up to 60% total body surface
area: a historical cohort study. Bull Emerg Trauma. 2016;4(4):197-201.
Garcia, E, Stone, E, Chan, LS, Van Vliet, M, Garner, WL. Donor-site preferences in women during autologous skin grafting. Plast Reconstr
Surg. 2014;133(3):378e-382e.
Bruen, KJ, Ballard, JR, Morris, SE, et al. Reduction of the incidence of amputation in frostbite injury with thrombolytic therapy. Arch Surg.
2007;142(6):546-551.
Hunt, JL, Sato, R, Baxter, CR. Early tangential excision and immediate mesh autografting of deep dermal hand burns. Ann Surg.
1979;189(2):147-151.In 1979, these researchers described their experience with early excision and mesh grafting of 60 patients with deep dermal hand
burns. All patients were excised and grafted between 3 to 10 days post burn and reported excellent functional results with full range of motion by
10 days postoperatively.
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C H A P T E R 2 2
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Principles of Burn Reconstruction
Benjamin Levi and Rodney Chan
Key Points
Burn scars are common sequelae following acute burn care.
Hypertrophic burn scars affect appearance and function.
Tension is a key contributing factor for hypertrophic scarring; tension relief with tissue
rearrangement (Z-plasty) or releasing and adding additional tissue (graft or flap) offers the best way
to reconstruct the scar.
Treatment of burn scars requires multimodality treatments from nonsurgical to laser to surgical
procedures.
The location of functional burn scar contractures is most common in areas of mobility including the
periorbita, perioral region, neck, and upper and lower extremities.
Minor burn contractures can be treated with local tissue and Z-plasties alone, but larger contractures
require the addition of new tissue either with a graft or flap.
Laser rehabilitation of burn scars has changed the treatment algorithm of burn scars and primarily
depends on the use of CO2 and pulsed dye lasers.
As survival of patients from large surface area burns has increased because of improved critical care and
acute burn care, surgeons are presented with an increased number of patients with secondary burn
deformities. Burn reconstruction represents one of the earliest types of reconstructive surgery and defined
plastic surgery in World War I when it became clear that standard surgical techniques and the care of
wounded soldiers require more thoughtful approach to restoring function and appearance. Whereas
patients with large surface area burns and deep burn injuries would often succumb to their burns,
patients are now surviving with over 80% and 90% burn injuries. This increased survival has thus led to
more patients living with the social, functional, and physical challenges of burn injury. Concurrent with
this improved overall survival is improved acute care burn principles of early debridement and grafting
and attention to detail of functional and aesthetic subunits. Burn reconstruction spans all areas of plastic
surgery from craniofacial surgery to hand surgery to microsurgery and transplant surgery. Although
some reconstruction procedures can be as simple as a release and grafting, many operations and
reconstructive challenges are more complex and require a multimodal approach. Advances in
microsurgical techniques as well as composite tissue allotransplantation have opened up new avenues for
patients with burn reconstruction. Finally, the recent improvement in fractional laser technologies has
dramatically changed the approach of reconstructive burn surgery and has changed some of the
paradigm for when and how to intervene for severe hypertrophic scars.
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Evaluating the Burn Scar and Timing of Reconstruction
Thermal burn injures can cause tremendous morbidity, leaving the patient with not only cosmetic but
also functional impairments. Hypertrophic scarring is a major complication after burn injury with a
prevalence of 32% to 72%. Several risk factors have been identified that contribute to its development
including the localization of the burn injury, burn depth, time to heal, and skin color. 1,2 Although the
precise mechanism by which hypertrophic scarring occurs remains unclear, strong and persistent
expression of transforming growth factor beta and its receptors have been associated with postburn
hypertrophic scarring. Furthermore, a critical step in the healing process that is altered is the transition
from granulation tissue into normal scarring. During this remodeling process, wound epithelization and
scar collagen formation occur but are accompanied by a gradual decrease in cellularity due to apoptosis.
However, early immature hypertrophic scars caused by burns are hypercellular. During the process of
remodeling and maturing, fibroblast density does not resemble that of normal healing. More specifically,
apoptosis of myofibroblasts occurs 12 days after injury in normal wound healing, but in hypertrophic
scar tissue, the maximum apoptosis occurs much later at 19 to 30 months. These events result in a
significantly higher percentage of myofibroblasts and the hypertrophy of the scar tissue following severe
burn injuries. Although oftentimes hypertrophic scars cannot be avoided, there are several steps that can
optimize a burn scar: (1) Wound closure of a burn that is likely not to heal on its own in 3 weeks. (2)
Avoidance of sun contact of the scar during the first 6 months. (3) Compression garments for those who
can tolerate treatment for up to 1 year. (4) Keeping the scar moist.
One of the key pathologic factors that needs to be addressed in any hypertrophic scar is tension. A new
concept of scar rejuvenation has emerged with the idea being to improve the environment of the scar
without actual excision of the scar. Despite not removing any tissue, a large defect is often created once
the tension is released. This defect can then be treated by adding new tissue such as a full-thickness skin
graft (FTSG) or a thick split-thickness skin graft (STSG). Additional way to relieve tension uses tissue
rearrangements such as a Z-plasty. Alternative V-Y advancements are useful if there is healthy
surrounding tissue.
Current treatment strategies for hypertrophic scars include surgical manipulation, intralesional
corticosteroid injections, cryotherapy, and laser therapy. Surgical manipulation to relieve skin tension
remains the traditional treatment for a hypertrophic scar. Additionally, intralesional corticosteroids
suppress the inflammatory process in wounds, diminish collagen synthesis, and enhance collagen
degradation. 3 Lastly, since the introduction\ of laser treatment in the mid-1980s, additional lasers with
different wavelengths have been used therapeutically. The most encouraging results have been obtained
with the 585 nm wavelength pulsed dye laser (PDL), which has been recognized as an excellent
therapeutic option for the treatment of younger hypertrophic scars. PDL induces the dissociation of
disulfide bonds in collagen fibers and leads to collagen fiber realignment, decreased fibroblast
proliferation, and neocollagenesis. However, it is necessary to treat two to six times, for the optimal
resolution.
Recently, an exciting research demonstrated the benefit of fractional photothermolysis in the treatment of
hypertrophic scarring. Although the exact mechanism is unknown, this concept uses a CO2 laser, which is
an ablative laser that targets water in the underlying tissues (10,600 nm). The laser creates columns of
tissue destruction, which stimulates collagen production in adjacent uninjured columns of tissue. The
adjacent uninjured tissue regenerates tissue rapidly from their follicles and sweat glands. Overall, this
creates a more smooth appearance and for meshed grafts to appear less obvious. 4 Patients described less
tightness as well as decreased pruritus. An important aspect of this treatment modality is the fractionated
nature of the laser for remodeling of the disorganized collagen without undue thermal injury to the
surface. Different strategies are used for fractional CO2 lasers with some clinicians preferring high density
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and low energy and others preferring low density and high energy. Caution must be used to avoid high
energy and high density, which can cause an iatrogenic burn injury. If scars are erythematous and
hypertrophic, then a combination of PDL and CO2 laser can be used (Figure 22.1).
FIGURE 22.1 This patient had undergone Meek reconstruction for full-thickness burn of the back. A. Before laser treatment. B.
After two treatments of pulsed dye laser and CO2 laser.
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General Principles of Burn Scar Rehabilitation
Release With Local Tissue Rearrangement
Z-plasty is a commonly used form of local tissue rearrangement to release linear burn scar contractures. 5,6
In addition to lengthening a scar, it is also useful in redirecting a scar, flattening a raised or depressed
scar, and recreating a webspace. 7-9 The classic Z-plasty design incorporates angles of 60° with three equal
limbs to achieve a theoretical 75% lengthening. This configuration balances the desired increase in length
of the contracture by taking advantage of available lateral skin laxity. Other angles and theoretical
increases in lengths are detailed in Table 22.1. Positioning of this classic Z-plasty in series or in opposition
are both reliable methods to improve burn scar contractures. The double-opposing or jumping man Z-
plasty combines two Z-plasties oriented along a common central limb axis, with advancement of a
triangular flap into a releasing incision made perpendicular to the central axis. This technique is
particularly useful for releasing webspace contractures in which there is significant transverse skin laxity.
Clever variations, including W-plasty and trapeze-plasty, all have their staunch supporters. 1,10-12 The
advantage of a Z-plasty, when it is indicated, is that no additional donor site is incurred and recovery is
short. However, not all burn scars are ideal candidates for this procedure. Use of this procedure in broad
contractures often results in less than satisfactory release. Surgeons need to weigh these benefits against
the risks of inadequate correction and the need for additional operations. Preserving the subdermal blood
supply by maximizing thickness and meticulous handling are paramount to a successful outcome and
minimizes flap-tip necrosis.
TABLE 22.1
Z PLASTY GAIN BASED ON LIMB ANGLE
Angle of Each Lateral Limb of Z-Plasty
Gain in Length of Central Limb
30°
25%
45°
50%
60°
75%
75°
100%
90°
120%
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Incisional Release with Skin Graft
Broad burn scar contractures will require a generous transverse release to restore structures to their
normal anatomic positions for a proper correction. Sound clinical judgment is needed to determine the
adequacy of a surgical release. As a rule, most burn scar contractures that cross a mobile structure, such
as an eyelid or a joint, will require an incision designed across the entire axis of rotation. For instance, an
adequate eyelid release requires an incision from just medial to the medial canthus to the lateral orbital
rim. An antecubital fossa release traverses the medial epicondyle to the lateral epicondyle.
A question sometimes arises whether a broad scar contracture should be excised, either in lieu of or
concurrent with a release. As previously mentioned, scar excision should rarely be contemplated. A
contracture implies a lack of skin. Scar excision only increases the amount of skin replacement needed.
Scar excision may be considered for hypertrophic scarring of the face when the subunit concept is
indicated. Even then, the use of CO2 laser scar resurfacing as an alternative to scar excision should be
considered. 13,14
Many options exist for skin coverage of the resulting defect after a transverse release. Color-matched full-
thickness skin in the form of a graft is ideal but not always available. Thick STSG is a good second choice,
if available. Dermal substitutes have been touted to augment the performance of a thin STSG with
reasonable successes. The superiority of a thicker graft is dependent on the greater quantity of transferred
dermis. Thin grafts, on the other hand, take more easily but with a corollary increase in secondary graft
contraction. Although STSGs can be meshed and expanded, this can result in mesh pattern scars and
should be avoided, if possible, during late reconstructions. 15
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Pedicled Flaps, Tissue Expansion, and the Use of Previously Burned or Grafted Skin
as Flaps
Just as thicker skin grafts provide greater amount of biology for higher quality results, proponents of flap
coverage of burn releases argue that flaps contain the most biological advantage and have the added
advantage of not having to rely on the blood supply of the recipient bed to survive. Should a scar release
result in the exposure of nongraftable structures, pedicled flaps maybe the only option. However, before
using a flap for the coverage of a graftable wound bed, one must balance donor site morbidity.
Furthermore, flap debulking is almost guaranteed. Therefore, although pedicled flaps have been
described for just about any type of burn reconstruction, fasciocutaneous flaps predominate, and the use
of preoperative tissue expansion as a delay strategy has gained popularity to decrease the thickness and
bulk while maximizing vascularity.
Tissue expansion is a valuable tool for the burn reconstructive surgeon when a large contiguous piece of
skin is needed either as a full-thickness graft or a flap. The basis for tissue expansion is placement of
mechanical stress to skin over time, resulting in both mechanical and biologic creep. Mechanical creep
refers to the immediate increase in tissue surface area upon placement of mechanical forces. Biologic
creep involves a series of cellular-level changes induced over time by this stress, including thickening of
the epidermis, thinning of the dermis, cellular hypertrophy, and realignment of collagen fibrils. In
addition, expanded skin exhibits greater vascularity than nonexpanded skin owing to the delay
phenomenon and increases reliability of local flaps.
Prior to placing a tissue expander, the surgeon should understand the amount of expanded skin has to be
enough to cover the width of the tissue expander as well as the width of eventual defect. The incision
used for placement of the tissue expander should be carefully planned so as not to compromise the blood
flow to any future flaps. Furthermore, the surgeon should have a plan for how the expanded skin will be
advanced prior to the placement of the expander. Several authors have described techniques for
maximizing advancements from rectangular tissue expanders. Complications of tissue expansion include
infection, implant exposure, and flap ischemia.
Use of pedicled flaps to reconstruct defects in areas of functional importance or those with exposed
critical structures is often “limited” by the presence of previously burned skin in the surrounding tissues.
Many surgeons are reluctant to include this previously burned or previously grafted skin as part of a
local or regional flap because of concerns about damage to its vascularity. However, these concerns are
often unfounded, as the initial thermal injury is generally limited to the skin and subcutaneous fat, and
the underlying fascia and its axial blood supply are often spared. Many documented cases have been
performed incorporating previously burned 16 or grafted skin 17,18 into fasciocutaneous flaps for the trunk,
hand, and upper extremity reconstruction without significant differences in flap necrosis. 19
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Site-Specific Surgical Interventions for Burn Scars and Contractures
General Face
The face is a complex, three-dimensional structure comprised of myriad tissue components of differing
dermal thicknesses, subcutaneous fat, and underlying muscle. The simplest method of reconstruction
may not be the preferred or optimal approach in burn reconstruction, and thoughtful deviation from the
traditional reconstructive ladder is often appropriate. 20 Burned faces have readily noticeable features:
contractures; decreased pliability; alopecia; variations in surface, color, and texture; and fragility of
tissues. 20 Additionally, these scars frequently cause functional deficits as in ectropion, nasal stenosis,
microstomia, neck contracture, and lip retraction leading to periodontal disease. The eyes, cheeks, nose,
ears, scalp, and lips have different underlying dermal thicknesses, muscles, and functions and must be
approached differently.
The nose and lips are central facial units; they are of critical importance to the appearance of the face. 21
The cheek is a peripheral unit of the face and is of near-critical importance. 21 In his 1995 paper, Rose
describes the following goals: a normal appearance at conversational distance, a face that is balanced and
symmetric, distinct aesthetic units connected by inconspicuous scars, a soft skin texture that will bear
corrective makeup, and the ability for dynamic and natural facial expression. 22 Below, we describe
typical reconstructions for each anatomic site. In addition, with increasing evidence supporting laser
treatment modalities, gradual release of tension and serial laser treatments can dramatically improve
patient outcomes. 13,23,24
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Periorbital Reconstruction
Periorbital reconstruction represents the most complex and functionally important regions of
reconstruction. As in other regions, a good reconstructive outcome depends on appropriate acute
treatment. Burns of the periorbita that are not thought to heal within the first 10 to 14 days should receive
early debridement and grafting. For the actual lid tissue, we recommend thin split-thickness grafts. For
the region below the lower lid, thicker split- or full-thickness grafts can be used. Immediate intervention
should be instated to avoid damage to the globe if ectropion of the upper or lower lid is noted. In
addition to early debridement and grafting, sometimes early release is needed. For periorbital
reconstruction, it is important to address all regions including the medial canthus, lateral canthus, and
upper and lower lids. Additionally, one must assess which lamellae have been damaged. Given that
periorbital burns are often concurrent with cheek burns that pull on the lower lid, it is important to
provide additional support to the lower lid to prevent recurrent contracture and ectropion.
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Upper Lid
The skin distal to the confluence of the orbital septum and the levator is some of the thinnest skin in the
body. When debriding this tissue, extreme caution must be taken to avoid debriding too deeply.
Similarly, for reconstruction, scar release should ensure not to violate the orbicularis oculi. The release
should be performed in the upper eyelid crease along the entire length of the eyelid just beyond the
medial and lateral canthus. Traction sutures make it easer to perform a more exact release. Once release is
performed, a thin STSG should be used. There should be two separate grafts with one over the palpebral
lid and one proximal to the confluence of the septum and levator. This proximal graft can be slightly
thicker. Donor sites should obtain color match by using a supraclavicular region or the inner proximal
arm. Grafts should be bolstered for up to 7 to 10 days, and concurrent temporary tarsorrhaphy sutures
should be placed to prevent recontracture. These tarsorrhaphy sutures can remain for up to 3 weeks, or
permanent tarsorrhaphy sutures can remain for several months (Figure 22.2).
FIGURE 22.2 Burn ectropion. A. Burn ectropion after nontreated burn 3 weeks after injury. B,C. Intraoperative full-thickness
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skin graft and medial and lateral tarsorrhaphy. D. One year postoperatively.
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Lower Lid
Similar to the upper lid, depth of debridement and release must not go too deep. For the lower lid, the
release should be performed using a subciliary incision extending the full length of the eyelid. 25 For the
lower lid, a thicker split- or full-thickness graft can be used. Again, postoperative splinting with
tarsorrhaphy or Frost sutures should be used. If the contracture on the lower lid extends onto the cheek,
often additional support is needed to prevent the lower lid from retracting. If this is the case, we usually
perform a graded approach. If the medial and lateral canthi are still retracted after the release, we
recommend a medial and lateral canthoplasty. Additionally, through the incision made for the release,
the suborbicularis oculi fat can be mobilized and suspended from the inferior orbital rim. Finally, if the
inner or middle lamellae are affected, a release of the conjunctiva and placement of a palatal graft
provides tissue and support.
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Canthi
Webbing of the medial canthus is a common sequela of burns to the periorbita. This webbing, similar to
webbing between fingers, is often best addressed with a five-flap jumping man flap (Figure 22.3). If this is
concurrent with medial canthal ectropion, a concurrent medial canthoplasty should be performed. The
lateral canthus usually does not form a similar web, and a canthoplasty best restores position of the
lateral canthus and prevents ectropion.
FIGURE 22.3 Preoperative (A,B) and postoperative (C) photos of five-flap jumping man rearrangement to improve medial
canthal webbing.
(Courtesy of Paul Cederna, MD, University of Michigan.)
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Perioral Reconstruction
Acute burn care for the perioral region differs somewhat from elsewhere on the face, given their robust
vascularity. Burns to the lips often heal by secondary intention, so excision and grafting of perioral burns
is not typically performed. 26 Two common sequelae of burns to the lips and perioral region are
microstomia and lower lip eversion, which can cause periodontal complications. Similar to periocular and
neck skin, perioral muscles lie close to the surface and often contract strongly with burns in this region.
Microstomia forms after burns to the lips or perioral region either from intrinsic contractures of the lip
itself or from extrinsic contractures caused by burns to the surrounding tissue or even contracture of skin
grafts to surrounding areas. 26 Early occupational therapy and splinting are crucial in the acute burn
phase. Although splinting can prevent or manage mild perioral contractures, the durable, successful
management of microstomia is typically surgical. 26 Contractures at the oral commissure can be incised,
and the mucosa (along with underlying orbicularis oris) can be advanced in a Y-to-V fashion and inset
into the incision to deepen the oral commissure and reconstruct the vermillion. 26
Lip contractures and lip eversion occur when the lower lip is pulled downward and the upper lip is
pulled upward, leading to excessive exposure of the vermillion causing difficulty with oral competence
and drooling. Small amounts of eversion can be corrected by horizontal elliptical excision of the red lip
posterior to the wet-dry border. 20 For more severe contractures and eversion, the surgeon should release
along the entirety of the lip just below the white line and extend beyond the lip slightly. Placing stay
sutures in the vermillion to give counter traction helps. The release should carry down to the orbicularis
oris but not disturb this muscle layer. Then, the entire lip subunit should be replaced with a full- or thick
split-thickness skin graft. For the upper lip, this subunit should extend up laterally to the nasal ala. For
the upper and lower lips, the release should continue lateral to the modiolus.
Persistent incompetence of the lower lip, resulting from burn scarring itself or from scarring and loss of
contour after reconstruction, can be addressed using strips of temporalis muscle and fascia, tunneled in a
subcutaneous plane but over the zygomatic arch, and augmented with fascia lata graft to create a sling
through the reconstructed lower lip. This procedure results in a durable and dynamic restoration of lower
lip competence. 4
More severe burns to the perioral region require more extensive reconstruction. Larger flaps and free
flaps from the scalp, temporoparietal fascia, supraclavicular region, and radial forearm have been
described, in conjunction with other procedures such as fascial slings, to resurface more extensive burn
injuries to the lips and perioral region. 22
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Scalp Reconstruction
The scalp is composed of five layers—skin, subcutaneous tissue, galea aponeurotica, loose areolar tissue,
and periosteum or pericranium. Whereas tension release and laser have avoided tissue expansion in
many regions, this often is insufficient in the scalp where hair-bearing skin needs to be brought in. Thus,
tissue expansion is a useful tool in the scalp to expand and advance local hair-bearing skin. Up to 50% of
the scalp can be reconstructed with tissue expansion. 27 Care should be taken to maintain the normal hair
directional pattern. When choosing an expander size, we usually choose the largest possible size that a
pocket can fit. Using multiple expanders is needed because the scalp will never stretch and advance as
much as one would hope. The expander should be placed in the subgaleal plane above the periosteum.
The region of the scar should not be dissected to prevent the expander migrating in the wrong direction.
If using remote ports, a small pocket should be dissected and the port should be placed over the mastoid
process if possible, as this makes it easy to find and has thin skin over the top of the port. Given the
thickness of the scalp, placing a port elsewhere can at times make it hard to find. When advancing the
flaps, galeal scoring can be performed perpendicular to the desired tissue gain for slightly improved
reach. Standing cutaneous deformities should not be excised as in other regions of the face because they
will usually flatten on their own. 28 If calvarial bone is exposed, a more complex reconstruction might be
required. Small scars can be addressed with a V-Y advancement flap. Larger defect requires large
rotational flaps that incorporate multiple vessels to supply the scalp. These should be bipedicled and
include at least one major artery. 28 The most well described is the Orticochea flap which is most useful
for defects in the occipitoparietal region. If the calvarial bone is viable, then sometimes burring the outer
cortex followed by Integra placement and subsequently skin grafting might be sufficient. If this
conservative approach fails, a free tissue transfer of a flap that will curve over a contoured region such as
a latissimus dorsi flap can provide the most durable coverage. These flaps are plugged into the superficial
temporal artery. If underlying bone is nonviable, then a more complex reconstruction with bone grafts
from a split calvarial or split rib graft and free tissue transfer is required.
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Nasal Reconstruction
The nose poses a unique challenge among facial structures because of its complex three-dimensional
structure and underlying bony and cartilaginous skeleton. The structure is of course divided into the
subunits of radix, dorsum, tip, columella, two sidewalls, two ala, and two soft triangles. These subunits,
as in Mohs reconstruction, should be taken into account during reconstruction. Unlike Mohs
reconstruction, however, the surrounding tissues are also often scarred or previously grafted, making
large local tissue rearrangements less reliable. Thus, surgical delay should be considered when
performing local tissue rearrangements. Functionally, the goal is a functional nose for normal breathing
and speech. As such, the prevention and correction of nasal stenosis is crucial. 3 A common sequela of
patients who are smoking while using home O2 is intranasal burns. These should be treated with
immediate nasal stenting for up to a month to prevent nasal stenosis. If stenosis does develop, it should
be approached by addressing the nasal lining and the nasal aperture. For the nasal lining, depending on
the severity, groups have described a simple approach of release and stenting or release and grafting. For
more dramatic stenosis, additional tissue must be added either from the septal mucosa, nasolabial flaps,
or gingivobuccal mucosal flaps with or without additional cartilage graft support. 29-32 If the nasal
vestibule is patent but the nasal ala is missing, a different approach can be used. Inferiorly based
turndown flap using the dorsum of the nose can be used to reconstruct even severely burned nose and
maintain tip projection and alar contour when the forehead is not an available donor site. 33 This
approach takes the skin, including scar and skin graft, of the nose, incised broadly from the lateral ala,
along the nasofacial sulcus up to the radix bilaterally, and folded down 180° over itself. The resultant
defect is then skin grafted, so that the skin graft makes up the exterior skin of the nose. The turnover
eventually contracts down, taking advantage of the stiff, scarred tissue to recreate a projecting tip and the
appearance of alar lobules even in the absence of cartilage.
If a small nasal alar defect is present, a helical composite graft offers skin and cartilage. These composite
grafts, however, are limited by size and often fail if larger than 1 cm. For a larger alar defect when local
options are not available, a free helical root flap can be performed based on the anterograde or retrograde
branch of the superficial temporal artery (Figure 22.4). This can be plugged into the angular artery if it is
available and size appropriate or to the facial artery using an A-V loop. 34
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FIGURE 22.4 Preoperative (A), intraoperative (B), and postoperative (C) photos of free helical root flap reconstruction of nasal
ala.
(Procedure done in collaboration with Adeyiza Momoh, MD, University of Michigan.)
If burn injury to the nose is superficial with adequate subcutaneous tissue remaining and
bony/cartilaginous structures covered and preserved, burn scars of the external nose can be accomplished
via excision and FTSG. 20 Preferred donor sites are elsewhere on the head and neck above the clavicle or
on the inside of the proximal arm for non–hair-bearing color match. 1 For injuries that involve deeper
structures, resection of larger portions of the nose may be necessary to control the injury and give a
wound bed for reconstruction. The forehead flap is a commonly preferred method of reconstruction; it
can be accomplished even with scarred skin as long as the frontalis muscle is intact. 20
Nasolabial or melolabial flaps can be used for reconstruction of the nasal sidewall, dorsum, tip, and ala
(even if retracted or notched). In the case of inferiorly based melolabial flaps, the lips and columella can
also be resurfaced. These flaps come in three different geometries, all of which take advantage of the
blood supply of facial artery and its anastomoses. Inferiorly and superiorly based flaps are designed with
the medial incision in the melolabial sulcus and the lateral incision on the cheek; after the flaps are
elevated, they are rotated into the defect, and the donor site is closed in the site of the melolabial fold,
camouflaging it.
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Ear Reconstruction
Early treatment of ear burns should follow similar principles of facial reconstruction with early
debridement if the tissue is not expected to heal within 2 to 3 weeks. We often stage the subacute burns
with Integra to cover any exposed cartilage and to support subsequent skin grafts. We typically
recommend STSGs for visualization of the underlying cartilage. During the reconstruction phase, a
common reconstructive challenge is a tethered lobule. This can usually be corrected with a series of Z-
plasties if there is a scar band. Alternatively, a release is made with a V around the lobule and Y
advancement of the tissue inferiorly. The remainder of burned ear reconstruction follows general
principles of ear reconstruction discussed elsewhere in this text. The main challenge in burned ear
reconstruction is that often there is no unburned surrounding tissue, making local flaps difficult. For
complete ear reconstruction, we recommend autologous cartilage grafts from the costochondral cartilages
or a conchal transposition covered by a temporoparietal fascial flap and a STSG (Figure 22.5). The
contralateral ear should serve as a template if available. Despite increased use of porous polyethylene
implants, the surgeon must ensure coverage is adequate. The patient and surgeon should expect a higher
complication rate than autologous tissue.
FIGURE 22.5 Preoperative (A), intraoperative (B,C), and postoperative (D) photos of ear reconstruction with conchal
transposition and temporoparietal fascia flap.
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Cheek Reconstruction
When evaluating cheek burn scars, it is important to assess if the redness or part of the deformities are
caused from more proximal tension from neck scars. If the neck scars are released, often the redness of
the cheeks will improve. In the cheek, it is typically unnecessary to excise all adjacent normal tissue in the
unit just to resurface a segment of it. In the cheek region, muscle tissues are deeper than in the periorbital
and perioral regions.
Functionally, management of cheek scars is important to preserve the function of adjacent structures
including the lower lid and the upper and lower lips. Thick STSGs or FTSGs can be used to resurface
regions of the cheek owing to their technical simplicity, but they are almost by requirement different in
color and texture from their recipient site and can cause a patchy appearance. 21 If they are to be used,
care must be taken to use skin that is most like that of the recipient region, such as supraclavicular skin or
skin from the inner proximal arm. Deep wounds to the cheek can be challenging because of the risk of
facial nerve involvement or scarring around the facial nerve as well as the need for thick soft tissues and a
functional oral lining. 30 When there are deficits of the latter two, fat grafting and de-epithelialized
pedicled or free flaps can provide thickness to the buccal region and oral lining if needed. 26 As in other
regions, the most important step is to relieve tension. For panfacial burns, the contractures often run
along the nasolabial folds and marionette lines. These should be broken up with small Z-plasties to
relieve tension but to avoid altering the normal aesthetic lines. Tissue should be handled gently with skin
hooks rather than forceps. If local flaps are used, they should be made thick enough to ensure
vascularized tissue is included, incorporating the fascia when possible. 1 The tips of small flaps can be
blunted to decrease tip necrosis. 1 In our experience, truncating the tips of Z-plasty flaps appears to
improve the viability of flap tips.
One of the primary challenges in cheek reconstruction after burn injury arises when there is a paucity of
local tissue with which to reconstruct the region, and when adjacent tissues are often damaged by the
precipitating injury as well. Tissue expansion improves options for local reconstruction with similar
tissues including local tissue rearrangement and skin grafting. Tissue expansion is useful in postburn
scars of the face and neck. In two recent series, mostly rectangular expanders were placed in a
subcutaneous plane, filled until the expanded skin was 10%-20% greater in width than the scar to be
excised, and the expander was then removed and the expanded skin used to reconstruct the scarred
region. 35 Tissue expansion is an excellent option in the face and especially the cheek for a number of
reasons (Figure 22.6). It is possible to replace part or all of the aesthetic subunit with skin of similar
qualities to avoid distal donor sites and to provide sensate and hair-bearing tissue. The cheek also serves
as an important subunit when repairing lower lid ectropion because the cheek can often pull down on the
lower lid. Resuspending the superficial muscular aponeurotic system off the midface using a lower lid
transconjunctival approach helps take tension off the lower lid. This is performed by creating a
transconjunctival incision inferior to the lower tarsal border. Dissection is performed to reach the inferior
orbital rim and then to undermine a midface flap in the subperiosteal plane. This flap is then advanced
superiorly and sutured in its new, lifted position to the inferior orbital rim. 36
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FIGURE 22.6 Preoperative (A), intraoperative (B), and postoperative (C) photos of cheek reconstruction with tissue expander
reconstruction.
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Neck Reconstruction
As mentioned earlier, the neck is one of the most common locations for a functional burn contracture to
form. Early debridement and grafting and aggressive splinting are crucial to prevent neck contractures.
The neck is also the first region of the face that should be addressed when beginning reconstruction
because tension in this region can cause disfigurement and discoloration of the entire face. For limited
scar bands, series of Z-plasties can be used. Large Z-plasties (unlike in the hand) can be used owing to the
robust blood supply.
Larger, more diffuse neck contractures represent a more complex challenge with several options
including grafts, local flaps, regional flaps, and free tissue transfer (Table 22.2). Regardless of the tissue
used to fill in the defect after the release, the release itself of the neck should be aggressive expanding
along the entirety of the neck and should have fish tails at the end for the scar to fully open up without
having to chase the scar indefinitely. In general, we do not support excising scars leading to a large
defect. The release should and can include release of the underlying platysma. The placement of the
release should be considered preoperatively. Some surgeons advocate releasing at the base of the chin
subunit. The downside of this placement is that the tissue covering the defect can creep onto the chin by
creating an aesthetically unappealing result. Others recommend releasing in the middle of the neck. If
this approach is taken, attention to the patient’s previous hospital course and the tracheostomy site
should be assessed because an unhealed tracheal fistula can lead to a surgical emergency. We recommend
intraoperative laryngoscopy to evaluate the previous tracheostomy site. The base of the neck is another
location where the release can be performed (Figure 22.7). Benefit of this site is that it provides a flat
surface to bolster a graft. The downside of this placement is that this often leads to the least amount of
release. Once the scar is released, several tissue options exist. A thick split-thickness graft can be used or a
large full-thickness graft from the abdomen using an abdominoplasty technique if this tissue was spared.
The limitation of skin grafting is a high rate of recurrence unless a prolonged course of splinting is
followed.
TABLE 22.2
ALGORITHM FOR NECK CONTRACTURE REPAIR
Neck Contracture
Reconstruction
Scar band
Z-plasty
Moderate contracture
Release plus thick STSG or FTSG
Severe contracture
Release and supraclavicular flap or free fasciocutaneous flap
STSG, split-thickness skin graft; FTSG, full-thickness skin graft.
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FIGURE 22.7 Preoperative (A) and postoperative (B) photos of neck reconstruction with release and graft and Z-plasty. Red
lines and arrows mark area of release for graft, and white lines and arrows demonstrate Z-plasty.
If the supraclavicular region is spared, these flaps serve as outstanding regional flaps with a nice thick
tissue. This donor site can also be expanded preoperatively for a larger neck coverage. 37 Finally, free
tissue transfer offers a good option with likely the least amount of recurrent contracture. Anterolateral
thigh 38 and abdominal-based perforator flaps provide the most tissue. The main challenge with free
tissue transfer is that the anterolateral thigh and abdomen in many Western countries have a significant
amount of adipose tissue. This excess tissue takes away the contour of the neck making it hard to identify
where the chin subunit ends and where the neck subunit begins. A groin flap free tissue transfer based on
the superficial branch of the superficial circumflex iliac artery and superficial epigastric artery provides a
thin flap for reconstruction. 39 The scapular or parascapular fasciocutaneous flaps also contribute to large,
thin skin coverage. 40,41
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Breast and Chest
As in general breast reconstruction, reconstruction of the burned breast should focus on the breast mound
as well as the nipple-areolar complex (NAC). Traditional reconstructive options, as in other regions, have
often included release and grafting. 42-45 This approach is useful during development if the breast is being
restricted. Although useful, at times this approach fails to address the tight skin envelope, parenchyma
asymmetry, and NAC malformations, leaving the patient with suboptimal aesthetic results. Autologous
tissue reconstruction, including local and regional cutaneous, fasciocutaneous, and myocutaneous flaps,
has been used successfully but may not be available depending on the extent of the burn. Alternatives are
placement of tissue expanders through an open or endoscopic method into the breast as well as
surrounding unburned tissue. 46 In the developing breast, the expander can be placed and expanded to
match the contralateral breast. When development is complete, the expander can be exchanged for a
permanent implant alone or an implant plus a latissimus dorsi flap if a scar release is needed at the time
of exchange. As the burned breast often lacks ptosis, a contralateral mastopexy can be performed to
improve symmetry in the developed adult. The NAC can be reconstructed 9 to 12 months after the final
breast reconstruction. Despite the burned tissue, a skate flap 47 can be used with an FTSG to redefine the
areola which can also be tattooed later.
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