Phẫu Thuật Tạo Hình (Tập 4): Chi Dưới, Thân Mình Và Bỏng – Neligan (Ấn bản 4)

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SECTION III
CHAPTER 19 • Extremity burn reconstruction
from positioning the hand for optimal function. In addition,
severe knee contracture will interfere with correct walking. It
is not easy to specify which extremity burns will or will not
be disabling. As specified in other sections in this chapter, the
result depends on various factors such as the burn’s etiology,
its location, acute and post-acute phase treatment, and patient
compliance.
In cases of particularly deep burns in the upper extremities
complicated by BICS and necrosis involving the deepest
structures, it is common to witness the phenomena of osteo­
myelitis and necrotizing fasciitis. These severe complications
often result in the amputation of the affected extremity.
The most serious burns from the point of view of complica­
tions are certainly those of electrical origin. They are frequently
“subdued” burns, in a relatively small area, but with vast
underlying damage. Muscle tissue, the vascular and neural
fasciae, the joints, and bones are frequently involved, often
associated with very severe tissue damage.
Muscle and tendon necrosis may be extensive, with their
loss resulting in severe functional deficits.
Massive involvement of the extremities can result in
decreased ROM, mobility, vascular, and aesthetic defects that
are hardly ever totally resolved.
Axillary contractures (Fig. 19.12)
Of all burn-related contractures, that of the axilla is the
commonest.
Managing burn of the axilla is difficult, especially in pedi­
atric patients. The preferred antalgic position of a patient with
burns in this area is commonly in adduction. This unfavorable
anatomic position is further complicated by the difficulty to
immobilize the shoulder joint resulting in frozen shoulder.
Preventing these complications by early debridement (enzy­
matic is the easiest in this area) and early autograft closure
seems to be the most practical approach.
Kurtzman and Stern’s classification (1990)45,46 divides axil­
lary contractures into three main types, on the basis of their
anatomic characteristics:
■ Type 1: Contracture involving either the anterior (1A) or
the posterior (1B) axillary fold alone
■ Type 2: Contracture involving both the anterior and the
posterior axillary fold but not the skin in the axillary
dome
■ Type 3: Contracture involving both axillary folds and the
axillary dome.
The surgery plan has to consider the type of contracture in
order to tackle the local problem in the best possible way.
In types 1 and 2, it is normally possible to use local flaps,
while in type 3 it is necessary to extend the surgical area to
the trunk, using large flaps from the latissimus dorsi and
pectoral area.
Elbow contractures
After axilla contractures, the joint most frequently involved is
the elbow. Most contractures at this level are caused by skin
scars, which exert such a powerful effect that they limit the
range of movement of the forearm and upper arm.
We usually distinguish between intra-articular and extra-
articular contractures, depending on whether the joint struc­
tures are involved or not. The majority of elbow contractures
Outcomes, prognosis,
and complications
Unstable healing: Marjolin’s ulcer
The healing of large burn areas may lead to large scars that
may become unstable, creating sequelae, and representing the
first complication specialists have to face in the follow-up of
burn patients. Non-healing wounds, especially full-thickness
ones, in some areas tend to develop hypergranulation rather
than epithelialize, while some areas that have healed sponta­
neously may ulcerate or develop hypertrophic scars.
The continued presence of heavy scar tissue that from time
to time ulcerates has a negative effect on rehabilitation proce­
dures. Sharp pain and the lack of solid skin coverage severely
limit the use of splints, massage therapy, and the use of pres­
sure garments and silicone. In some patients, the scarring
phase is so unstable that it can go on for months, without
reaching completion. In such cases, it is advisable to consider
an extensive excision of the entire scar tissue and autograft it.
Repeated ulcerations that continue for months, or even years,
can lead to malignant changes developing an invasive squa­
mous cell carcinoma at the burn areas.
Marjolin’s ulcer is an infiltrating squamous cell carcinoma,
with a low level of differentiation, which forms in unstable
scar areas. Statistically, its rate of incidence is 2% in burn scars,
with a higher prevalence in the limbs, especially the lower
limbs. As it occurs in areas with a history of instability and
ulceration, it is rarely diagnosed early because of confusion
with other ulcerative processes. The first histologic sign of this
highly invasive type of carcinoma occurs at the edge of the
ulcer. There is early development of lymph node metastases
in 30% of cases, with a 5-year survival in <10% of cases.44,45
Treatment is strictly surgical with wide excision and histo­
logic control of the surgical margins with sentinel lymph node
biopsy. In the event of metastasis, lymph nodes can be radi­
cally excised. There are no reports of preventative lymph node
excision improving prognosis.
In some cases, when bone or deep levels are affected,
proximal limb amputation may be necessary.
Scar contraction
As in any other trauma, burns may also result in scarring
tissue, which if not properly treated, can develop into hyper­
trophic scarring. The deeper the burns, the more healing by
secondary intention (granulation and scarring), the greater
the risk of becoming hypertrophic scars in the future. Burn
scars may take a very long average time, >2 years, to become
stable.
Some factors related to burns pathophysiology are decisive
for the healing of severely injured patients and the outcome.
The commonest and most evident complication is scarring of
the skin. Contracting scarring tissue may cause significant
functional limitation and physical deformity, which may
eventually lead to permanent damage at the musculoskeletal
level, deforming the joints and, in children, pathologic bone
growth.
Full hand motion in the burned patient is useless if signifi­
cant contractures of the elbow and axilla prevent the patient

435
Outcomes, prognosis, and complications
Heterotopic bone formation is a complication that occurs
when new bone develops in soft tissues that do not normally
ossify. It is coupled with important joint movement deficit.
There are many possible causes of heterotopic ossification, but
the real etiology is still not well known. Usually the severity
of the burn injury is considered more likely to be responsible
than its extension or location. Unnecessary joint manipulation
with related microtraumas has also been considered as a pos­
sible cause of the initial micro-ossification of the musculo-
tendinous tissues. The elbow is the joint most frequently
involved, followed by the shoulder and hip joints. The knee
is rarely involved.
The most serious clinical picture is bridge ossification, in
which the new bone tissue links the jointed bones in a condi­
tion of structural stability. The joint remains blocked even
after the patient has recovered from the burns. If the new bone
has not established any structural continuity, it may regress
and sometimes, especially in children, even completely disap­
pear. This ossification process usually starts a few weeks
post-burn injury, the average being 10–15 weeks. The symp­
toms (i.e., loss of ROM and joint pain) may be preceded by
radiologic evidence. Thus physical/occupational therapy is
prescribed without excessive joint stress, which seems to
stimulate the ossification process.
Surgical treatment is necessary only in the case of a com­
plete osseous bridge, and it is better to treat only mature
new-formed bone, in order to be able to proceed with its
complete removal. Particular attention must be paid to the
ulnar nerve, which is sometimes trapped inside the new bone,
and the nerve must be identified and carefully isolated in
order to preserve it. In the postoperative period, it is necessary
to apply a splint in the flexed position, if the blocking was in
extension, and in extension if the ankylosis was in flexion.
Early physical/occupational therapy should start within 10
days and continue throughout healing.47,48
Skeletal–muscle complications:
bone exposure
In elbow and knee joint burns, the olecranon and patella bone
is often exposed (see Fig. 19.14A). In spite of the local and
general conditions, osteomyelitis is rare, and after surgical
debridement of the affected cortex, the underlying bone is
viable. The cortex of these areas is thick and resists exposure-
related infection and necrosis for some time, especially
if properly treated by grafting. In order to create a proper
graft recipient bed over the bony surface, granulation or
other soft tissue is needed. By punching the cortex down
to the vascular layer, granulation tissue will grow over the
exposed bone.
Additional considerations are needed for injuries involving
open fractures associated with burns, where infection is
perhaps inevitable. But also in this case, the infection remains
localized to the fracture site for a long time, with rare involve­
ment of the entire bone segment.
In these patients, the stabilization system should be care­
fully chosen. Many surgeons strongly oppose plaster splints
because they prevent easy inspection and care of the burn area
and instead recommend external fixation. This procedure –
now considered the most appropriate – is not free of risk in
burn patients because often the pins have to pass through the
burned skin, transferring bacteria to the bone.
are extra-articular, in flexion, caused only by skin scars, while
extension contractures are quite rare in burn sequelae.
With regard to articular contractures, the use of local flaps
or incisional release and grafting will usually suffice. In very
large scar retractions, in which the excised scar tissue involves
the upper arm and forearm, fasciocutaneous flaps from the
chest or abdomen are recommended. Excellent results have
been reported with the use of Integra in the reconstruction of
anterior and posterior elbow defects.
In the postoperative period, the use of extension splints
is recommended, along with early physical/occupational
therapy exercises to maintain the movement range obtained
with surgery.
Heterotopic ossification
Heterotopic bone formation in burn patients is a rare occur­
rence but, functionally speaking, it is a major complication.
Only 3% of burn patients develop this complication, but if
periarticular calcifications are included, which are a false form
of heterotrophic ossification, about 30% of patients develop
the complication.
Fig. 19.12  Axillary contracture (A) before and (B) after Z-plasty release. (Courtesy
of Department of Plastic Surgery and Burn Therapy, ARNAS Ospedale Civico,
Palermo, Italy.)
A
B

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SECTION III
CHAPTER 19 • Extremity burn reconstruction
angled at 90°. This technique is also called the 3 4 Z-plasty
technique (Figs. 19.14 & 19.15).
In ankle and knee injuries, Z-type fasciocutaneous flaps are
used. These skin flaps are prepared including the skin, the
subcutaneous tissue, and the muscular fascia, leaving in place
the muscular belly. For the ankle, both frontally and posteri­
orly, the flaps should be prepared including the paratenon
with its entire vascular network; thus these flaps are quite
strong and viable and well adapted to cover critical areas such
as those described. This procedure, if well planned, can be
performed under local or local-regional anesthesia.
In general, in flexion areas where the cause of the retraction
is a longitudinal hypertrophic scar band with workable skin
on both sides, it is possible to use a simple or multiple Z-plasty.
When we observe surrounding scar tissue, with involvement
of three-quarters of the circumference, we need a large
transverse excision of the scar tissue and skin grafting of the
entire area.
Skin grafts
As in the previous case, this is also a primary technique for
the treatment of burn scars. After thorough debridement of
the retracted scar, it is necessary to interpose a full-thickness
or at least a thick partial-thickness graft on the residual viable
bed. The donor area should be of intact, healthy skin. Harvest­
ing such skin from the groin or abdomen can be easily closed
primarily. The removed skin should be defatted with scissors
up to the dermis before being applied onto the wound bed
and stabilized by tie-over dressing. The grafting should be
Surgical coverage of these exposed areas should be per­
formed rapidly on cleared tissues. In this context, a negative
pressure unit is particularly useful (V.A.C., Renasys, etc.), as
this quickly promotes cleansing of the bed and promotes
vascularization and granulation.
Secondary procedures
Minor or major surgical procedures on the extremities are
usually indicated when rehabilitation therapy has been inef­
fective or when joint functionality is compromised. Apart
from the cases just described, surgery on the joints usually
occurs at this stage and not during the acute phase.
Reconstructive surgery can also be delayed when particu­
larly deeply burned areas remain exposed for long periods
and become scarred.
Patients with secondary indication for surgery are:
■ Patients with scar sequelae not resolvable by physical/
occupational therapy
■ Patients with debilitating scar sequelae
■ Patients with chronic skin tissue loss and exposure of
nerve–vascular structures, bone, and tendons
■ Patients with ROM or articulation deficit
■ Patients with nervous deficit.
Before planning any surgery, the specialist should take into
account certain aspects, summarized as follows:
■ Scar location
■ Scar thickness and quality
■ Joint deficit assessment
■ Extent skin loss and careful evaluation of exposed tissues
■ Local conditions (presence of normal surrounding skin,
surgical options).
It is appropriate to plan the surgical procedure when the scar
tissue is completely stabilized and after obtaining the best
possible result in terms of joint mobility.
Reduced joint mobility may depend on various factors. The
commonest is obviously the contraction of scar tissue around
the joint itself. Scarring masses that are so firm that they do
not allow proper excision of bone segments can aggravate this
condition.
In joint surgery, particular attention should be paid to
vascular nerve fasciae in the armpit, elbow, and wrist. Unless
there are special surgical needs, it is always best to maintain
the integrity of the joint capsule and the articular face.
Z-plasty
This technique is the basis of the surgical treatment of burns
sequelae. Z-plasty is feasible in the presence of surrounding
healthy tissue. It exploits the principle that it is possible to
stretch a scarred area by the interposition of two or more
triangular flaps rotated from immediately adjacent areas, with
maximum elongation, using flaps with an angle of 60°. In
scarring and contractures of the armpit and elbow, multiple
Z-plasties remain one of the most effective techniques (Fig.
19.13). There are many variations to the normal Z-type plastic
technique, described by various authors, identifying different
angles between two or more interposed flaps. It is possible,
especially when treating armpits, to use two asymmetric flaps
Fig. 19.13  (A) Severe ankle contracture. (B) Ankle contracture from Fig. 19.17,
treated with multiple Z-plasties.
A
B

437
Secondary procedures
Fig. 19.14  (A) Designing a 34 Z-plasty for the treatment of an axillary contracture. (B,C) Raising the flaps of the 34 Z-plasty designed in Fig. 19.19.
A
B
C
A
B
C
Fig. 19.15  (A,B) Severe retraction of axilla hollows. (C) Multiple Z-plasty plan. (D) Final result after 2 months. (Courtesy of the International Association of Humanitarian
Medicine.)
D

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CHAPTER 19 • Extremity burn reconstruction
Due to the unfavorable angle of rotation, large flaps are
frequently required to correct small defects. It is therefore
recommended that this surgical solution should be carefully
considered.
Fasciocutaneous flaps from the lateral region of the arm, sup­
plied by branches of the radial collateral artery and sometimes
used as “island flaps”, have good mobility and are a reliable
solution for reconstruction of the lateral and posterior region
of the elbow.
In reconstructive surgery of the upper extremities, the
forearm flap based on the radial artery plays an important role,
thanks to its versatility. This flap, based on fasciocutaneous
branches of the radial artery and used as an “island flap” with
its proximal base on the radial artery, is useful for coverage
of defects in the entire region of the elbow, including large
defects with olecranon exposure.
Among myocutaneous flaps, the latissimus dorsi with and
without skin are of particular importance for correction of
large defects of the proximal third of the arm and axilla, while
flexor carpi radialis flaps are important for coverage of defects
of the forearm and elbow.
The medial or lateral gastrocnemius flaps are particularly
recommended for coverage of defects of the proximal third of
the leg. The same flap can be used to cover the defects in the
knee. The soleus muscle flap, prepared by preserving half the
muscle, is useful in the reconstruction of defects of the medial
third of the leg. Because of their segmental vasculature, the
muscles of the lower third of the leg are less suitable for
rotation and can be used to cover adjacent skin deficits. The
partial soleus muscle flap can also be for used for defects of
the distal third of the leg. When properly detached from its
distal pedicle, it can be rotated on its pedicle more proximally
to cover large areas up to about 5–6 cm above the ankle.
The extensor hallucis longus myocutaneous flap, as with the
extensor digitorum longus muscle flap, can be used to cover
defects just above the medial malleolus, while short peroneal
muscle flaps are useful just above the lateral malleolus.
A fasciocutaneous flap of greatest interest for coverage of
the distal part of the leg and ankle is the retrograde fibular flap,
the blood supply of which is based on the peroneal artery
retrograde flow. However, it is essential that the connection
between the anterior and posterior tibia artery should be
intact because the retrograde blood supply will come from the
terminal part. The long pedicle that can be obtained allows
the flap to move easily and to be used in the entire leg and
ankle (Table 19.2).
Skin expansion
The principle for the use of skin expansion lies in the positive
response of live dermal tissue when it is subjected to mechani­
cal stretching stimulation. The expanded tissue undergoes
significant histologic changes such as cell hyperplasia, an
increase in the number of basal cells in the mitotic phase, an
increase in vascular atrophy, and the loss of adipose tissue.49
In addition, the soft tissues of the extremities can also be
expanded. The placement of the expander should be carefully
studied in order to obtain the maximum return in terms of
tissue gain, also considering scar tissue healing and potential
poor blood supply of the legs: theoretically, only healthy skin
should be expanded but, if necessary, it is possible to expand,
very carefully, scarred skin. In such cases, however, the
monitored for 4–5 days post-surgery after removal of the
dressing.
This procedure can be performed under local or regional
anesthesia too, with minimal discomfort to the patient. Func­
tional rehabilitation can be cautiously resumed 3 weeks after
surgery.
Dermal substitutes in the surgical
treatment of sequelae
The use of dermal substitutes in today’s surgical practice is
increasingly widespread. It allows the adding of new tissue
in scarring characterized by a basic tissue deficit with greater
advantages than those offered by simple free grafts of skin.
In the surgical treatment of retractions of the armpit, elbow,
and kneecap, Integra has proved to be highly effective for
ensuring a good basis for epidermis tissue grafts, permitting
the use of thinner autografts with less morbidity in donor
areas.
Integra vascularizes after about 21–28 days, being ready to
receive a thin partial-thickness free skin graft. The result is a
softer and more durable grafted area than one produced by
simple free skin grafts, even compared with the full-thickness
technique. The resulting scar also has better quality.
Dermal substitutes (i.e., Integra, Matriderm) are very
helpful in the surgical treatment of burns sequelae and specifi­
cally in the treatment of critical areas.35–37
Flaps
Numerous rotation, transposition, and other forms of local
flaps (see Fig. 19.14) are described in all treatises on plastic
surgery, representing a technical heritage through which the
plastic surgeon can effectively tackle full-thickness skin
defects reaching good functional and aesthetic results. These
local flaps guarantee the same texture, thickness, and color as
the adjacent skin sometimes with a minimal donor area.
Flaps are indicated without question when it is necessary
to cover important “noble” structures such as the vascular–
nerve fasciae or areas with bone or tendon exposure and
joints.
As in all surgical procedures, local flaps should be carefully
studied, prepared, and well arranged. Large flaps can be
designed in the scapular region for the resolution of major
scarring of the axilla. Large flaps taken from the thoracic or
flank region are useful in reconstructive surgery of the elbow.
However, at the elbow or ankle level, it is sufficient to use
small local flaps or simple Z-type plasties. The flap must be
designed in such a way that its margins are never placed
longitudinally over the joint.
The monitoring of the flap should be followed for the first
7–10 days. If there are no signs of suffering, it is possible to
resume positioning of the limb and physical/occupational
therapy after 15–21 days, depending on the area involved.
Fasciocutaneous and myocutaneous flaps
Reconstructive surgery of the limbs may involve extensive
use of fasciocutaneous and myocutaneous flaps, which success­
fully cover full-thickness loss of skin and soft tissue, especially
at elbow and knee joint level and the proximal third and
middle limb (Figs. 19.16 & 19.17).

439
Secondary procedures
Fig. 19.16  (A) Bone exposed secondary to severe burn. (B) Exposed knee joint. (C) Dermal graft for coverage of exposed knee joint. (D) Dermal grafts in place
reconstructing joint capsule; fasciocutaneous flap has been raised. (E) Fasciocutaneous flap inset to provide definitive joint coverage superficial to dermal graft. (F) Final
result of knee reconstruction.
A
B
C
D
E
F
Fig. 19.17  (A) Severe axillary contracture.
(B) Axillary release and reconstruction with
locoregional flaps.
A
B
expansion will be very limited; it will also be painful for the
patient.
Choosing the correct place to position the expander is
crucial. It must be possible to advance or rotate the expanded
skin without tension, ensuring complete coverage of the area
that is going to be excised.
In the upper limb, it is preferable to use radial positioning
in order to avoid compression of the neurovascular structures.
Expansion with medial and lateral advancement is indicated
in all cases rather than unlikely advancement towards a distal
position.
For skin expanders used in the lower extremities, it is
necessary to take into account local lymphatic drainage, arte­
rial blood supply, and the quality of the tissue conditions as
all may cause skin necrosis and tissue expander exposure
(Fig. 19.18).

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CHAPTER 19 • Extremity burn reconstruction
flap transfer is commonest in secondary procedures of the leg,
or in elbow and knee reconstructions, for example after elec­
trical burns.
For simplicity, we will discuss separately the shoulder, the
upper extremity, and the lower extremity.
Typically, defects at the shoulder and axillary cavity are
corrected, as described earlier, with local flaps or skin grafts.
Multiple local solutions can be chosen for this area, due to the
thickness and quality of the soft tissues. Rarely, free flaps are
needed in this area.
Otherwise, the region of the elbow is prone to tissue loss
because of thin soft-tissue coverage and the presence of
underlying structures such as bones, nerves, and vessels. In
this area, reconstruction with skin grafts is often inadequate.
The parascapular flap and the anterolateral thigh flap are both
excellent choices for such region.
The lower extremity is the classical target for free flap
reconstruction and aims mainly to restore the function
and cover the tissue deficit that mostly consists of exposed
bone, joints, tendons, nerves, and vessels. Muscle free
flaps are generally preferred in lower extremity in order to
restore 3D defects and to cover exposed bone or other vital
structures. Having the most reliable vascular supply of all,
free flaps help to reduce the infection by increasing tissue
oxygenation.50,51
Skin grafts and local flaps are usually the first choice for
scar contractures of the popliteal region (Fig. 19.19).
Nerve repair
In a step-by-step approach to reconstruction, the surgical
repair of nerves comes after immediate, successful burn
coverage.
Table 19.2  Local flaps indication
Elbow
• forearm flap based on the radial artery
• flexor radial carpis flaps
• lateral arm flap
Proximal third of
arm and axilla
• latissimus dorsi flap
• scapular and parascapular flaps
Knee and popliteal
cavity
• medial or lateral gastrocnemius flap
• reverse vastus lateralis flap
Proximal third
of leg
• medial or lateral gastrocnemius flap
• soleus flap
Distal third of the
leg and ankle
• extensor hallucis longus
myocutaneous flap
• extensor digitorum longus muscle flap
• retrograde fibular flap
• posterior tibial artery perforator flaps
Free flap
Considering the steps of the reconstructive ladder, acute
burns are usually treated by skin grafts applied on good
vascularized tissue of the debrided (enzymatically or surgi­
cally) wound bed. If joints, bone, vessels, or nerves are
exposed, the next step is the use of local flaps. However,
damage of soft tissues surrounding the zone of injury may
require the use of flap harvested from far away areas.
Fortunately, the use of free flaps in the reconstruction of
severely burned extremities is infrequent in routine clinical
practice. According to several studies, only 1–2% of burn
patients are treated with free flaps,38 so the use of free flaps is
more frequent in secondary reconstruction procedures. Free
Fig. 19.18  (A) This case illustrates the painful after-burn scar strongly adherent to the joint. (B) The use of skin expansion of the lower medial thigh region. (C) The result
of the use of skin expansion of lower medial thigh region, for an after-burn scar.
A
B
C

441
Secondary procedures
A
B
C
D
E
Fig. 19.19  (A) Knee: severe retraction. (B) Donor area. (C) Expansion of latissimus dorsi flap. (D) Microsurgical session. (E) Free pre-expanded flap. (F) Result.
F

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CHAPTER 19 • Extremity burn reconstruction
Amputation
Patients who have suffered high-voltage electrical burns
account for amputations where no other therapeutic solution
is available.
The main objective is to obtain a healthy stump so that the
amputated limb can serve as an excellent base for affixing
prosthesis.
The point where an amputation should be performed is
dictated primarily by the presence of blood supply and venous
drainage, viable tissues, and by surgical techniques. The
stump should be covered with local skin and muscle flaps, in
order to obtain a soft and viable cushion. If this is not possible,
it is advisable, at least initially, to proceed with full-thickness
skin grafts and secondary reconstructive surgery to follow.
The lower limb usually requires amputation closer to the
thick, healthy tissue, while in the upper limb, it is necessary
to preserve the maximum possible length in order to have
better control over the future prosthesis. For the same reason,
in forearm amputations it is always correct to preserve the
tendon’s prono-supination structures. When it is necessary to
have a stump that is too short for application of prosthesis, it
is possible to proceed with bone distraction techniques such
as the Ilizarov technique.
Lipofilling
The technique of lipostructure, originally created for aesthetic
purposes, now plays a primary role in the treatment of scars.
The surgical technique is now standardized and entails the
liposuction of adipose tissue, and its grafting below the areas
of scarring or even minute quantities into the scar mass. The
quality of the scar (texture, color, and elasticity) treated with
this technique improves dramatically due to the action of
adipose tissue, and more probably of the stem cells inside it,
that histologically determine increased vascularization and
remodeling of collagen fibers in the treated areas.53
The use of serial lipofilling in the extremities is particularly
recommended for reconstituting normal volume, which is
sometimes lost during surgery, thereby restoring the extremi­
ties’ conical-cylindrical characteristics.54
Laser
In recent years, we have witnessed a steady growth of laser
therapy in the domain of the plastic surgeon. Even though
this technique is still under scrutiny, the results have been
encouraging.
The final outcome of scar tissue is variable, and many dif­
ferent types of lasers are available for different needs.
The vascular laser, such as the Nd:YAG 1064, is indicated in
areas of scarring that are immature and have a particularly
strong vascular component. The reduction in the blood supply
induces an involution of the scar tissue treated.
The fractional laser (ablative and non-ablative) plays an impor­
tant role in the remodeling of fibrotic scar tissue, with the
interruption and regeneration of collagen and elastic fibers in
the dermis resulting in softening and thinning of the scar
itself. Their action also makes the coloring of scar areas more
homogeneous, compacting their texture (Fig. 19.21).55
IPL and Q-switched lasers act on hyperpigmentation and
discoloring in certain areas of scarring (Table 19.3).
Neural deficit in burn patients is usually associated with
electrical burns or related trauma. The usual damage consists
of interruptions of various length at some point in the nerve,
which have to be bridged using grafts from other nerves.
Statistics tell us that the nerves most frequently damaged are
the ulnar and the median nerves, as a result of their exposed
position.
Normally, the best donor nerve is the sural nerve, which can
be used for grafts even in excess of 10 cm. This is because it is
possible to maintain the continuity of the medial sural cutaneous
nerve connected to the communicating branch of the peroneus
nerve, providing up to 30 cm of nerve. The points of reference
to be guided by are the external malleolus and the inferior
saphenous.
Patients with third-degree burns to the lower extremity,
who therefore have no sural nerve to be removed, can receive
grafts, albeit much shorter, from the upper extremity. The
medial and lateral cutaneous antebrachial nerves are the candi­
dates of choice because their use causes only a limited sensory
deficit with little functional effect.
The medial cutaneous antebrachial nerve is located medially
in the groove between the biceps and the triceps, adjacent to
the basilic vein. Of its two branches, anterior and posterior, the
anterior one sensitizes the anterior part of the forearm, the
posterior branch the elbow, and the remainder of the forearm
on all the rest. Using only the anterior branch is less incapaci­
tating for the patient.
The lateral cutaneous antebrachial nerve runs along the ulnar
border of the brachioradialis muscle, next to the cephalic vein.
Resulting insensible areas are usually well tolerated by the
patient, since the areas involved overlap the sensitive branch
of the radial nerve.52
If the gap is small (<3 cm), it is possible to achieve nerve
regeneration guided by biodegradable laboratory-produced
ducts. The findings of clinical tests have been found to be
comparable with the results of small nerve grafts.
Surgery of tendon retraction
The scar contractures of the joints may cause secondary
damage to the tendon structures that are involved in the
deformity. Hyperflexion or hyperextension of a joint will
ultimately induce length changes of the tendons, shortening
on the flexion side and lengthening on the opposite side. If
the deformity remains untreated for a long time, it will become
permanent.
It is possible to intervene with lengthening plastic
reconstruction (Fig. 19.20). The technique usually employed
consists of a partial horizontal section of the tendon in two
distant points, continuing with a median longitudinal section
that unites them. This allows the use of two halves of tendons
that can slide side-by-side and then be sutured together in
the new location. Once healed, the tendon is longer but
thinner.
For this reason, it would be useful to reinforce the elongated
tendon with a dermal patch, harvested from a thick skin
donor site,39 as described for joint reconstruction, or with
polycaprolactone-based polyurethane urea patch (such as
Artelon tissue reinforcement implant) wrapped around the
tendon.40 It gives more resistance and better recovery in the
postoperative period.

443
Secondary procedures
Fig. 19.20  (A) Scar contracture about ankle leading to imbalances in the underlying tendons. (B) Lengthening design and dermal patch. (C) Tendon lengthened and
reinforced by dermal patch. (D) Resurfaced ankle after underlying tendons have been rebalanced. (E) Postoperative result after tendon rebalancing and ankle resurfacing.
(Courtesy of the Department of Plastic Surgery and Burn Therapy, ARNAS Ospedale Civico, Palermo, Italy.)
A
B
C
D
E
Fig. 19.21  Elbow area before (A) and after (B) 6 treatments with non-ablative fractional laser. Better color matching and more quality of skin texture.
A
B

444
SECTION III
CHAPTER 19 • Extremity burn reconstruction
Table 19.3  Laser in scar treatment
Nd:YAG 1064
Scars immature, with vessels
IPL
Hyperpigmentation
Scar with vessels
Fractional laser
  Ablative
Mature scars with heterogeneous surface
  Non-ablative
Mature scars, fibrotic, thick
1. Vyrostek SB, Annest JL, Ryan GW. Surveillance for fatal and non
fatal injuries – United States 2001. Office of Statistics and
Programming. National Center for Injury Prevention and Control.
CDC/NCIPC/OSP; 2001. This comprehensive government publication
reports demographic and mechanistic data for all injuries sustained in the
United States during 2001. A 0.5% mortality rate is reported for injured
individuals varying by age, sex, and mechanism.
3. American Burn Association. Guidelines for service standards and
severity classifications in the treatment of burn injury. Bull Am Coll
Surg. 1984;69:24–29.
9. McCauley RL, Asuku ME. Upper extremity burn reconstruction. In:
Mathes SJ, Hentz VR, eds. Plastic Surgery. Vol VII. 2nd ed.
Philadelphia: Saunders Elsevier; 2005:605–619. This encyclopedic book
chapter covers upper extremity burn care from primary excision and
grafting to secondary procedures. An informative historical perspective is
also provided.
18. Purdue GF, Arnoldo BD, Hunt JL. Electrical injuries. In: Herndon
DN, ed. Total Burn Care. 3rd ed. Philadelphia: WB Saunders;
2008:513–520.
31. Heimbach DM, Logsetty S. Modern technique for wound coverage
of the thermally injured upper extremity. Hand Clin. 2000;16:205–
214. Advanced modalities in burn reconstruction are discussed. The
authors stress, however, that the split-thickness skin graft remains the
“gold standard” in burn reconstruction.
32. Borghese L, Latorre S, Montagnese A, et al. Retrospective analysis
of 200 severe post-burn cases in Cambodia and Bangladesh. Ann
Burns Fire Disast. 2005;18(1). The authors discuss the standard of care
and controversial issues in hand and upper extremity burns.
33. Smith MA, Munster AM, Spence RJ. Burns of the hand and upper
limb – a review. Burns. 1998;24:493–505.
35. Atiyeh BS, Hayek SN, Gunn SWA. New technologies for burn
wound closure and healing – review of the literature. Burns.
2005;31:944–956. The authors of this review note the limitations of
autologous skin grafting in burn reconstruction. Alternative replacement
modalities are surveyed.
39. Masellis M, Conte F, Fortezza GS. Use of dermis to reconstruct
hand joint capsules. Ann Plast Surg. 1982;9:72–80.
41. Beasley RW. Burns of the axilla and elbow. In: Converse JM, ed.
Reconstructive Plastic Surgery. Vol 6. Philadelphia: WB Saunders;
1977:3391–3402.
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444.e1
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also provided.
10. Rosenberg L, Krieger Y, Bogdanov-Berezovski A, et al. A novel
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enzymatic debridement of deeply burned hands. Burns.
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14. Rosenberg L. Enzymatic debridement of burn wounds. In: Herndon
DN, ed. Total Burn Care. 4th ed. Edinburgh: Elsevier; 2012:131–135.
15. Lee RC, Kolodney MS. Electrical injury mechanism: dynamics of
the thermal response. Plast Reconstr Surg. 1987;80:663–671.
16. Yowler MJ, Mozingo DW, Ryan JB, et al. Factors contributing to
delayed extremity amputation in burn patients. J Trauma.
1998;45:522–526.
17. Barisoni D. Le ustioni ed il loro trattamento. Piccin Ed.
1984;265–272.
18. Purdue GF, Arnoldo BD, Hunt JL. Electrical injuries. In: Herndon
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19. Lee RC, Kolodney MS. Electrical injury mechanism: electrical
breakdown of cell membranes. Plast Reconstr Surg. 1987;80:672–680.
20. Brumback RA, Feedback DL, Leech RW. Rhabdomyolysis following
electrical injury. Semin Neurol. 1995;15:329–334.
21. Arnoldo B, Klein M, Gibran NS. Practice guidelines for the
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22. Cerepani MJ, Leonard L, Slater H, et al. The strategic management
of the high-voltage electrical injury. Ann Burns Fire Disast.
1997;10(3).
23. Lee RC, Capelli-Schellpfeffer M, Kelley KM. Electrical Injury: A
Multidisciplinary Approach to Therapy. Prevention and Rehabilitation.
New York: Annals of the New York Academy of Sciences; 1994:720.
24. Duman H, Kopal C, Selmanpakoglu N. Bilateral shoulder fractures
following low-voltage electrical injury. Ann Burns Fire Disast.
2000;13:3.
25. Cascio BM, Wilckens JH, Ain MC, et al. Documentation of acute
compartment syndrome at an academic health-care center. J Bone
Joint Surg Am. 2005;87:346–350.
26. Achauer B, Applebaum R, Van der Kam VM. Electrical burn injury
to the upper extremity. Br J Plast Surg. 1994;47:331–340.
27. Mann R, Gibran N, Engrav L, et al. Is immediate decompression of
high voltage electrical injuries to the upper extremity always
necessary? J Trauma. 1996;40:584–589.
28. Costagliola M, Rougé D. Les syndromes des loges de la main
brulee. Ann Burns Fire Disast. 1992;5(4).
29. Napoli B, D’Arpa N, Gullo S, et al. Epidemiology clinical treatment
and therapy in electrically burned children. Ann Burns Fire Disast.
1994;11(4).
30. Greenhalgh DG. Management of acute burn injuries of the upper
extremity in the pediatric population. Hand Clin. 2000;16:175–186.
31. Heimbach DM, Logsetty S. Modern technique for wound coverage
of the thermally injured upper extremity. Hand Clin. 2000;16:205–
214. Advanced modalities in burn reconstruction are discussed. The
authors stress, however, that the split-thickness skin graft remains the
“gold standard” in burn reconstruction.
32. Borghese L, Latorre S, Montagnese A, et al. Retrospective analysis
of 200 severe post-burn cases in Cambodia and Bangladesh. Ann
Burns Fire Disast. 2005;18(1).
33. Smith MA, Munster AM, Spence RJ. Burns of the hand and upper
limb – a review. Burns. 1998;24:493–505. The authors discuss the
standard of care and controversial issues in hand and upper extremity
burns.
34. Yang J-Y, Hwuang J-Y, Chuang S-S. Clinical experience in using the
water jet in burn wound debridement. Ann Burns Fire Disast.
2007;20(2).
35. Atiyeh BS, Hayek SN, Gunn SWA. New technologies for burn
wound closure and healing – review of the literature. Burns.
2005;31:944–956. The authors of this review note the limitations of
autologous skin grafting in burn reconstruction. Alternative replacement
modalities are surveyed.
36. Dantzer E, Braye FM. Reconstructive surgery using an artificial
dermis (Integra): results with 39 grafts. Br J Plast Surg.
2001;54:659–664.
37. Wainwright DJ. Use of an acellular allograft dermal matrix
(AlloDerm) in the management of full thickness burns. Burns.
1995;21:243–248.
38. Oni G, Saint-Cyr M, Mojallal A. Free tissue transfer in acute burns.
J Reconstr Microsurg. 2012;28:77–84.
39. Masellis M, Conte F, Fortezza GS. Use of dermis to reconstruct
hand joint capsules. Ann Plast Surg. 1982;9:72–80.
40. Gisselfält K, Edberg B, Flodin P. Synthesis and properties of
degradable poly(urethane urea)s to be used for ligament
reconstructions. Biomacromolecules. 2002;3:951–958.
41. Beasley RW. Burns of the axilla and elbow. In: Converse JM, ed.
Reconstructive Plastic Surgery. Vol 6. Philadelphia: WB Saunders;
1977:3391–3402.
42. Tilley W, McMahon S, Shukalak B. Rehabilitation of the burned
upper extremity. Hand Clin. 2000;16:303–318.
43. Huang TT, Blackwell SJ, Lewis SR. Ten Years of experience in
managing patients with burn contracture of axilla, elbow, wrist and
knee joints. Plast Reconstr Surg. 1978;61:70–76.
44. Ryan RF, Litwin MS, Krementz E. A new concept in the
management of Marjolin’s ulcers. Ann Surg. 1981;193:598–605.
45. Thio D, Clarkson JH, Misra A, et al. Malignant change after 18
months in a lower limb ulcer: acute Marjolin’s ulcer revisited. Br J
Plast Surg. 2003;56:825–828.
46. Kurtzman LC, Stern PJ. Upper extremity burn contractures. Hand
Clin. 1990;6:261–279.
47. Teppermann PS, Hilbert L, Peters WJ, et al. Heterotopic ossification
in burns. J Burn Care Rehabil. 1984;5:283.
48. Chung D, Hatfield S, Dougherty ME, et al. Heterotopic ossification of
the elbow in burn patients: results after early surgical treatment.

444.e2
SECTION III
CHAPTER 19 • Extremity burn reconstruction
Proceedings of the 38th Annual meeting of American Burn
Association. Las Vegas, NV: American Burn Association; 2006:
April 4–7.
49. Pasyk KA, Argenta LC, Austed ED. Histopathology of human
expanded tissue. Clin Plast Surg. 1987;14:435–445.
50. Winograd J. Lifei Guo, Upper extremity. In: Wei F, Mardini S, eds.
Flaps and Reconstructive Surgery. 1st ed. Edinburgh: Elsevier
Saunders; 2009:51–62.
51. Scott Levin L, Baumeister S. Lower extremity. In: Wei F, Mardini S,
eds. Flaps and Reconstructive Surgery. 1st ed. Edinburgh: Elsevier
Saunders; 2009:63–70.
52. Higgins JP, Fisher S, Serletti JM, Orlando GS. Assessment of nerve
graft donor sites used for reconstruction of traumatic digital nerve
defects. J Hand Surg Am. 2002;27:286–292.
53. Coleman SR. My view: structural fat grafting. Aesth Surg J.
1998;September/October.
54. Klinger M, Marazzi M, Vigo D, et al. Fat injection for cases of
severe burn outcomes: a new perspective of scar remodeling and
reduction. Aesth Plast Surg. 2008;32:465–469.
55. Masellis A, Ferrara MM, Masellis M. L’uso del LASER frazionato non
ablativo nel trattamento degli esiti cicatriziali da ustione e post-traumatici.
59th National Congress Società Italiana Chirurgia Plastica
Ricostruttiva ed Estetica: SICPRE; 2009; Sept 28–Oct 1.

SECTION III • Burns Surgery
20 
Management of the burned face
SYNOPSIS
■ The human face is the seat of expression and beauty and the burned
face is a physical and psychological insult to the patient
■ The facial skin drapes over a complex anatomy of muscles and
sphincters, it has a rich blood supply and burn depth assessment is
an important step in early management
■ Airway control and topical wound care are the mainstays of early
facial burn management
■ Goals of acute facial burn management include obtaining early
reepithelisation, minimizing functional sequelae and preserving
aesthetic landmarks
■ Secondary management of post burn deformities of the face is a
challenging task involving detailed clinical assessment, meticulous
planning, counseling and consenting of the patient
■ Surgical management is by applying the aesthetic subunit principle,
utilizing various reconstructive options according to principles and
staging surgeries to optimize outcomes
■ Increasing knowledge of stem cell application, 3D printing
and advances in the field of face transplantation may
herald future directions in facing challenges posed by
facial burns.
Introduction
The face is what defines a person’s identity. Symmetry and
balance of facial features and tone and texture of the skin
have long been yardsticks to measure individual beauty. The
human face is unique in development for its complexity in
structural architecture, its seamless symphony in functional­
ity, and its ability to emote and express a myriad of thoughts
and feelings. The face is the cover by which people judge
the book. It is hence not overstating facts when it is said that
burns involving the face are a challenge and an opportunity
like no other to the reconstructive surgeon and leaves him
wishing for more and more weaponry in his ever-expanding
armamentarium to tackle this difficult problem. Burns of the
head, face, and neck region occur in almost 50% of all burn
injuries. Fortunately due to the relatively higher vascularity
of the region helping to dissipate the heat rapidly, burns of
the face are often partial thickness. At the same time facial
burns can be an indicator towards the more serious and
life-threatening problem of inhalation injury. Management of
the burned face in the acute scenario has been a matter of
debate with evidence accumulating on both sides of either
conservative therapy with dressings or an early excision
approach. What is accepted without argument is the fact
that management of the burned face calls for a multipronged
team approach involving the trained burn surgeon, the
skilled nurse, the physiotherapist, the occupational thera­
pist, psychological, and social support systems right from
the outset.
The face has been divided into aesthetic units by Gonzalez-
Ulloa in 1987. These subunits show consistent color, texture,
thickness, and pliability. Care should be taken during the
management of facial burns to respect these boundaries to
minimize scar appearance.1 Facial scars can cause distortion
of features, skin thickening, and pigmentary problems. Scars
are inevitable in the continuum of treatment, but deformities
are a highly preventable aspect of burn management in
general, and of the face in particular. Timely use of all avail­
able modalities like scar massage, pressure garments, silicone
gel (sheets or liquid), intralesional steroids, and laser therapy
will go a long way in appearance of scars and prevention of
deformities.
Facial burns (Fig. 20.1
) are a problem that may be associ­
ated with considerable psychological distress to the patient.
This is a major determinant of social reintegration of the
patient after recovery from the treatment of their physical
problems. It is hence important to show the patient empathy,
understand the patient’s desires, weigh their expectations
against what is practically achievable, and counsel them
accordingly.
Fig. 20.1 appears online only.
Vinita Puri and Venkateshwaran N

445.e1
Introduction
Fig. 20.1  Woman with an acute facial burns less than 24 hours since burns.

446
SECTION III
CHAPTER 20 • Management of the burned face
preserve aesthetic landmarks. Facial burns are similar to
hand burns in that, in the absence of both of these, there is
faster clinical and psychosocial recovery and rehabilitation
of the survivor.1 Certain special features that make facial
burns unique are the rich vascularity, which hastens healing
and reduces infection rate, difficulty in accurate depth
assessment, and the potential to cause contour deformities
by aggressive surgical management.
The treatment principles can be broadly classified into
three groups based on the depth of the burn:
1) In patients who have sustained epidermal and
superficial partial-thickness burns, spontaneous healing
is the rule. The mainstay of treatment involves open
dressings and topical care (Fig. 20.2).
2) In patients who have sustained deep or full-thickness
burns apparent at initial evaluation, the obvious next
step is to proceed with workup and early excision of the
burn wound with coverage (autograft or allograft).
Further management of the patient entails graft care,
prevention of scar and graft junction area hypertrophy
by use of ancillary modalities like pressure therapy, and
topical silicone use.
3) The third group of patients with intermediate or
indeterminate thickness of burns incites the most
controversy or dilemmas in management. These patients
if allowed to heal spontaneously may form hypertrophic
scars that may transgress borders of aesthetic subunits
and relaxed skin tension lines. If excised too early, the
surgeon may be guilty of giving the patient grafts in
areas that may have appeared aesthetically superior if
allowed to heal conservatively. Herein lays the role of
newer diagnostic tools for diagnosing burn depth. One
such advancement is the laser Doppler techniques.4–6 A
treatment decision delayed until 10 days may help in
determining the areas that are deeper and will require
surgery, whereas areas that may heal in three weeks
may be left alone. At best, the experienced clinician’s
judgment is sound only 65% of the time (Figs. 20.3 &
20.4).7
Laser Doppler evaluation
Laser Doppler imaging can be a useful adjunct and can supple­
ment a good clinical call, but due a lack of randomized con­
trolled level 1 evidence supporting its use, it cannot substitute
sound clinical judgement.
Managing the airway
Facial burns share an intimate relation to the airways and
often act as a marker for upper or lower airway injury. An
early decision has to be made regarding intubation or for
elective tracheostomy before signs of laryngeal edema become
obvious. Special care has to be taken to prevent tube pressure
necrosis.1
Wound care
The facial burn wound, similar to burn wounds elsewhere,
has to be thoroughly cleansed with normal saline. All loose
debris and necrotic material has to be removed. Tiny blisters
can be left to heal, but larger blisters can be deroofed. In case
Anatomy and pathophysiology
An understanding of the anatomy of this region is essential
before proceeding to outline the management of facial burn
injuries. The face is an extremely complex anatomic structure
consisting of skin, fat, and muscle draped over the facial bony
architecture. The face has important sphincter structures and
vital sensory organs of sight, hearing, smell, taste, and touch.
Skin forms a protective mechanical barrier against trauma,
bacteria, noxious substances, heat, and ultraviolet radiation.
Other important functions include sensation, immunologic
surveillance, and heat and fluid homeostasis.1
The head and neck region can be involved in burns caused
by transfer of thermal, chemical, electrical, or lightning energy
to the skin. Injury to the epidermal layer alone comprises first
degree burn. The common example of this is the sunburn. The
tissue healing occurs by sloughing of the dead epidermal
layer with re-epithelization within one week. With increasing
energy and contact duration, increasing depths of the dermis
are also damaged. This constitutes denaturation of collagen
and thrombosis of blood vessels. Appearance of the dermal
layer acts as a guide to burn depth. When the epidermal layer
alone is damaged, the dermal layer appears pink due to the
superficial location of the underlying blood vessels. As the
burn depth increases the collagen becomes pale and the color
turns white.
Another guide to the depth of burn injury is the pain
quotient. Superficial burns are painful to touch because of the
exposed nerve endings. As the depth of burn increases, the
wound becomes less painful.2
Burn wound re-epithelizes from the remnant adnexal
structures like pilosebaceous units, sweat glands, and apo­
crine glands. The face and scalp contain a high density of
sebaceous glands and epidermal appendages that are located
in the deep dermis and subdermal fat.1 The regenerative
process in epidermal and superficial partial thickness burns
is completed in two weeks with minimal scarring. However,
burns deeper than this can take up to three weeks to heal and
can cause considerable scarring with a tendency towards
hypertrophy. Thus a rule of thumb for intervening surgically
is in wounds that may not heal in 3 weeks. However, this
decision needs to be taken by the end of the first week of
treatment and is based solely on the experience and clinical
judgment of the treating burn surgeon.3 Another factor that
has a bearing on the burn depth is the skin thickness, which
varies with the age, sex, and anatomic location on the face.
Children have relatively thinner skin. Skin thickens with age
and starts thinning again after the fifth decade of life. Men
have thicker skin compared to women. Eyelid and postauricu­
lar skin is thinner (0.5 mm thick) than other anatomic areas
on the face.1
Acute facial burn management
General principles
The management principles of facial burns follow principles
used elsewhere in the body. Goals of facial burn manage­
ment are to obtain early wound re-epithelization, pain
control, to minimize functional sequelae while taking care to

447
Acute facial burn management
Fig. 20.2  (A) Superficial second degree
burns on day 1. (B) On day 21 with
complete healing but with some minor
mixed pigmentation.
A
B
Fig. 20.3  (A) Deeper second degree burns in a patient with high TBSA burns on day 1. (B) At 112 months with large areas of hypopigmentation. (C) At 7 months with
return of most of the pigmentation.
A
B
C
of chemical burns the face is washed with copious amounts
of saline or running water as is the practice in the unit for as
long as 45 minutes to completely remove the noxious agent
or to neutralize it. A dilute solution of antiseptic can be used
for the final round of cleansing. The wound can then be
covered with a generous application of topical antimicrobial
agent.
It is the practice in the authors’ unit to cover all facial burn
injuries with synthetic bovine collagen dressing readily avail­
able in most centers of the country after the initial cleansing
is completed. This helps in maintaining a closed environment,
reducing the pain and distress, retaining moisture, and
helping in rapid re-epithelization in case of first and second
degree burns. The collagen dressing remains closely adherent
to the wound and gradually peels off when the underlying
wound heals (Fig. 20.5
). In deeper burns this dressing does
not adhere well to the wounds and is seen to peel off within
48 hours following which other conventional antimicrobial
agents can be used for dressing or a decision regarding early
surgical excision can be made. Thus this also acts as a guide
in burns of indeterminate depth.
Fig. 20.5A & C appear online only.

447.e1
Acute facial burn management
The laser Doppler technique works on the Doppler effect
described by Austrian physicist Christian Doppler. According
to this there is an alteration in frequency of laser waves
reflected from a moving object, which in this case are the
moving red blood cells in the wound. This change in frequency
is proportional to the tissue perfusion. Two techniques evolved
on this principle, that of laser flowmetry and that of laser
Doppler imaging. A study by Waxman et al. studying laser
flowmetry showed that burn wounds with blood flow more
than 6 mL/100 g/min at a temperature of 35° would heal in
three weeks (100% specificity but low sensitivity). But laser
flowmetry has the obvious disadvantage that the probe has
to be in touch with the burnt tissue, which will cause patient
discomfort, and assessing larger areas will be difficult owing
to the small zone of coverage by the probe in each reading.5
Laser Doppler imaging (LDI) overcame these drawbacks as it
did not require wound contact. In a prospective study con­
ducted by Pape et al., the LDI done between 48 and 72 hours
post-burn injury was shown to predict depth with an accuracy
of 97% when compared to 70% accuracy of clinical
judgement.6

448
SECTION III
CHAPTER 20 • Management of the burned face
Antimicrobials
An ideal prophylactic topical antimicrobial should have a
broad spectrum of activity, low toxicity, good eschar penetra­
tion, and low systemic absorption. It should be inexpensive,
easily available, and have a good shelf life.8
Silver preparations
Silver has always found a place in wound care either in the
solid form (silver wires placed in wounds), as solutions of
silver salts used to cleanse wounds (silver nitrate solution),
and more recently in the form of creams and gels containing
a silver antibiotic compound (silver sulfadiazine cream or SSD
cream).9
Recently, advancements in delivery systems of silver have
spawned a plethora of products that claim advantages like
Topical agents
Topical agents used in facial burn management can be
grouped into antiseptics, antimicrobials, enzymatic debride­
ment agents, and dressings.8
Antiseptics
These are topical agents that limit (bacteriostatic) or
eliminate (bactericidal) the load of microorganisms in the
wound. These mainly include chlorhexidine and povi­
done iodine products that are used in cleansing at the
time of admission as well on a day-to-day basis during
dressings. They cover Gram-positive and Gram-negative
bacteria.
Povidone
products
have
a
broad-spectrum
coverage, including fungi, viruses, spores, yeasts, and
protozoa.
Fig. 20.5  (B) Collagen sheets have been
applied. (D) At 6 months post-burn.
B
D
Fig. 20.4  (A) Deep partial-thickness and full-thickness burns in a patient with high TBSA burns on day 10. (B) Managed by conservative treatment and no surgical
intervention, healing at 4 weeks. (C) Hypertrophic scarring at 4 months.
A
B
C

448.e1
Acute facial burn management
A
C
(A) 7-year-old child with facial burns due
to firecrackers. Collagen sheets have been applied.
(C) Showing healing by day 7 with complete
separation of collagen sheet.
Fig. 20.5

449
Acute facial burn management
Another patented preparation, Aquacel Ag (Convatec),
incorporates ionic silver into a hydrofiber dressing, which
gets converted to a gel form on wound contact. Silvercel
(Johnson & Johnson) is a patented product combining the
advantages of silver with the benefits of alginate.15 Alginate
is a polysaccharide found in the cell walls of algae that is able
to absorb 200 times its weight in water. This property helps
when used in heavily exudative wounds.
Mafenide acetate
This is a deep eschar penetrating agent with good antimicro­
bial spectrum. Available commercially as 5 and 11.1% solu­
tions, it has been recommended for areas of the face like ears,
where cartilaginous framework is exposed by burns. It
requires frequent applications and has been reported to cause
pain, inflammation, and allergic reactions.13
Hypochlorite solutions:
Its use has been described since the First World War and has
been used in facial burn management also. Its optimal anti­
microbial activity was seen at 0.025% and was termed as
“modified Dakin’s solution”. Its contact with non-burned skin
can cause irritation and maceration.8
Antibiotics and Antifungals
Commonly used preparations include neosporin, polysporin,
and bacitracin.8
Enzymatic debriding agents
These agents also referred to as chemical debriding agents are
the non-surgical alternative to removal of necrotic tissues
from the wound surface. This is definitely attractive and desir­
able but has not always delivered uniform results. They are
principally divided based on origin into two groups:
■ Group one are bacterial origin compounds and include
collagenase (Clostridium histolyticum), sutilains (Bacillus
subtilis), and varidase (Streptococcus).
■ Group two constitute agents originating from plants and
include Accuzyme (papaya origin combined with urea)
and Debridase (bromelain/pineapple derived).8
Alternative remedies
Honey has been long considered a “folk remedy” for burn
wounds. Honey owes its antibacterial powers to its high
osmolarity and its ability to form hydrogen peroxide in a
sustained release manner when in contact with wound fluid.
This is due to the presence of enzyme glucose oxidase in
honey. In a clinical trial it was found to be superior in wound
healing and infection control properties to boiled potato peel
dressings.16
Moist exposed burn ointment (MEBO) was developed using
a traditional Chinese method and contains sesame oil, beta
sitosterol, berberine, and other plant extracts. Trials using
MEBO in patients with partial-thickness burns less than 40%
total body surface area (TBSA) have shown results matching
conventional therapy using SSD.17
Papaya fruit extracts containing enzymes chymopapain
and papain have been used in countries like Africa due to
less messy application, high wound antimicrobial concentra­
tion, maintaining a moist wound environment, and better
chances of autolytic debridement.
In the elemental form (as silver metal), silver does not kill
bacteria. But in the aqueous wound environment, silver atom
loses an electron to form activated silver ions, which are
bactericidal. They disrupt bacterial cell membranes, destabi­
lize bacterial biofilm matrices, and increase bacterial suscep­
tibility to antibiotic action.
Creams
Silver sulfadiazine (SSD) cream
SSD cream is the mainstay of burn wound management in
many burn units worldwide. The introduction of this water-
based cream by Fox in 1968 containing silver sulfadiazine in
the micronized form, revolutionized burn wound care. It
requires to be applied twice a day in a thick layer to be most
effective. It can produce adverse effects like leukopenia,
methemoglobinemia, and sulfa allergy. It forms a pseudo-
eschar that may be quite indistinguishable in appearance
from full-thickness burns.1 Though SSD cream has been long
considered the gold standard, it has been proved to have
deleterious effects on wound healing. This effect of SSD can
be countered by epidermal growth factor (EGF) and in future
a combined preparation of the two may be more effective.10
Cerium nitrate
It is an excellent antiseptic with a broad spectrum of activity.
Its use is popular in European burn units and is usually used
in combination with silver sulfadiazine (as flammacerium).
It hardens burn eschar, thus isolating potentially necrotic
areas and improves burn wound milia. However, no clear
advantage of its use in combination with SSD had been dem­
onstrated in controlled studies when compared to the use of
SSD alone.11
Silver solution
Silver nitrate solution (0.5%) covers the same antimicrobial
spectrum as SSD but has lesser eschar penetration. Its main
disadvantage lies in the fact that it stains tissues and dressings
black and causes electrolyte disturbances like hypokalemia
and hyponatremia.12
Nanocrystalline silver
Elemental silver in small crystals that are about 10–100 nano­
meters in diameter are delivered through a colloidal gel
medium or as surface-coated foam dressings. A popular form
of nano silver dressing is Acticoat (Smith and Nephew), which
is a bilayered polyethylene dressing with nanocrystalline
silver particle coating. The cited advantages of these sustained
release silver preparations are that they reduce wound infec­
tion, promote wound healing, reduce frequency of dressing
changes, pain associated with dressings, and overall cost.13
Mepilex Ag is a patented (Mölnlycke) silver foam dressing
that was shown to be superior to other silver dressings in
terms of ease of use, pain control, and speed of wound
re-epithelization in a randomized controlled trial.14 The use of
this product is common for partial thickness burns and also
for donor area dressings at the authors’ institution and has
yielded good results in terms of re-epithelization and pain
control at dressing changes.

450
SECTION III
CHAPTER 20 • Management of the burned face
■ Integra (Integra LifeSciences): This has been used
extensively when there is a lack of donor skin and in
facial burns with the aim of avoiding pigmentary
problems and graft junctional hypertrophy in
aesthetically significant regions.20
Other skin substitutes
The other skin substitutes of notable mention include Xeno­
derm,21 Alloderm,21 Apligraf,15 and Epicel.15
Cadaver allografts
These are usually used after excision of full-thickness burns,
but their use has also been described as a dressing material in
partial-thickness facial burns and has been shown by a pro­
spective study to be superior to open dressings with SSD.22
Xenografts
These are porcine skin grafts used as temporary wound cover
in facial burn topical management. It is usually not assimilated
in the wound and has occasionally reported to have caused
imprinting artifacts.8
Surgical management of the facial
burn wound – early excision
Tangential excision of the burn wound and coverage is now
accepted as the standard of care universally. The face wound
in particular incited controversy due to its aesthetic signifi­
cance, vascularity, and excellent spontaneous healing proper­
ties being well endowed with pilosebaceous units. However
the general consensus agrees that a face wound that would
require 3 weeks or more to heal spontaneously is a candidate
for early excision. The early excision is, however, delayed for
a period of 7–10 days to definitely ascertain without a doubt
as to which areas would heal spontaneously and the areas that
would require excision.
Once the decision to excise has been made, further delay is
avoided and the patient is taken up for surgery after optimiza­
tion with respect to hemodynamic stability, hemoglobin and
protein levels, and with due explanation and informed
consent. It would be helpful to discuss the options available
in terms of pros and cons with the patient and the concerned
relatives. The nature of the surgery and the procedure is
explained to the assisting operating theatre staff and require­
ments in terms of blood products, homografts, skin substitutes,
etc., should be prearranged.
The surgery is performed under general anesthesia with
the patient in a reverse Trendelenburg position. The endotra­
cheal and feeding tubes are kept out of the field by suspending
them from overhead hooks. The eyes can be protected with
silicone pads, cornea shields, or temporary tarsorrhaphy
sutures. Certain points have to be borne in mind while excis­
ing facial burns. When excising facial burns in a patient with
large TBSA burns, it may be worthwhile to excise the face in
multiple sittings using the minimal amount of available
autograft per sitting. Instead temporary skin substitutes like
allograft and acellular dermis can be used and thin autograft­
ing may be done as a separate session. The principle of relook
or second stage surgery is very useful to prevent graft loss
limitations in resources. These agents show effective des­
loughing of wounds and help in wound bed preparation for
grafting.18
Aloe vera preparations have been shown to speed up the
healing process and re-epithelization in first and second
degree burns.19
Wound dressings or skin substitutes
Studies done to test the efficacy of temporary wound dress­
ings or skin substitutes suggest that their use facilitates
healing and minimizes infection. Even though they are not
antimicrobials these studies indicate that they serve as barri­
ers to microbial colonization and infection. Some trials have
shown improved scar characteristics like better elasticity and
flexibility in burns healed after use of these agents. This
indirectly may lead to a decrease in the number of secondary
procedures the patient may have to undergo. Skin substitutes
may find a special niche for use in pediatric burns, which are
usually small area burns, partial-thickness, and need only
dressings for their management. Skin substitutes reduce the
frequency of dressings, associated pain and emotional trauma,
promote an early return to activities, and at the same time
provide a cost-effective solution.15
Wound dressings that provide temporary cover can be
classified into the following categories.
Biologic dressings, e.g., amnion
Amniotic membrane has been shown in clinical trials to be
effective as a temporary wound cover, reducing pain and
helping rapid re-epithelization. It is readily available, non-
immunogenic, and reduces water loss from the wound.
However, no long-term advantage could be demonstrated in
terms of scar appearance.8
Synthetic dressings
These provide a moist wound environment and effectively
seal off the wound. Some of these are water vapor permeable
and allow the wound to respire. Commonly used brands
include DuoDERM, OmniDerm, Opsite, and Suprathel.
Biosynthetic materials
These combine a biologic component with a synthetic one.
Some commonly used examples include:
■ Biobrane (Smith & Nephew): In trials this has showed
results superior to conventional dressings for superficial
partial-thickness burns. There are reports of mesh
imprinting or punctuate scarring using this product.15
■ TransCyte (Smith & Nephew and Advanced Tissue
Sciences): This is transparent, allowing wound
monitoring and the fibroblasts in the nylon mesh to
proliferate producing human dermal collagen, matrix
proteins, and growth factors essential for wound healing.
■ Dermagraft (Advanced Biohealing): This is a
cryopreserved dermal substitute manufactured from
human neonatal foreskin tissue-derived fibroblasts
seeded onto a polyglactin mesh that is bioabsorbable. The
fibroblasts fill the interstices of the scaffold and produce
human collagen, matrix proteins, and growth factors.15

450.e1
Surgical management of the facial burn wound – early excision
■ Xenoderm and AlloDerm (LifeCell Corporation): These
are acellular dermal matrices derived from porcine and
human cadaver skin respectively. The cells are removed
while maintaining structural and biochemical properties
of the tissues. Use of Xenoderm in partial-thickness burns
has been shown to be beneficial in terms of recovery
time, infection rates, and length of stay in comparison to
use of 1% SSD.21
■ Apligraf (Organogenesis Inc): This is a living bilayered
skin substitute, the epidermal layer formed by human
keratinocytes and a dermal layer composed of human
fibroblasts in a bovine Type I collagen lattice.15
■ Epicel (Genzyme Biosurgery): It is a sheet of skin cells
ranging 2–8 cell layers thick. Patients’ own skin is used to
produce the cells after processing to separate the
epidermal cells and subjecting them to tissue culture
methods.15

451
Surgical management of the facial burn wound – early excision
while hemostasis is being ensured on the face using the
Padgett dermatome. The grafts are then laid on the wound
bed and secured as previously described. Small darts are
made in the graft margin, and small local Z-plasty flaps can
be fed into the areas opened up by the darts. This breaks the
margin and prevents contracture band formation.23
The other options for cover after excision include acellular
dermis,26 xenografts, MatriDerm,27 Integra,20 and cultured
epithelial autografts.28,29
Problems of specific parts of the face
Eyelids
An eyelid burn can signify underlying ocular damage and
warrants a detailed ophthalmologic examination, which may
include a slit lamp microscopy, fluorescein staining, and fun­
doscopy. The crow’s feet area is a reliable clinical marker. If
spared, it can predict an uninjured cornea to a high degree of
accuracy.1 The eyes should be kept moist with lubricants and
topical antimicrobials. Early excision and grafting with thick
split-thickness or full-thickness grafts prevents ectropion,
exposure keratitis, conjunctivitis, and corneal ulceration.
Nose and ears
These structures have a cartilaginous framework closely
covered by the skin. Deep thermal burns involving these
structures would lead to exposure of cartilage or its deformi­
ties due to the inevitable chondritis that will follow their
exposure. Even though early excision has been described,
equally common is the concept of conservative management
in these organs. The ear burn is managed by a constant use of
topical antimicrobials. A dressing conforming to the shapes
and whorls of the cartilage can help to prevent deformities
that may develop due to chondritis. Often a neglected ear
burn may present as a pus-filled, inflamed, featureless, boggy
mass. All normal architecture is obliterated. This condition
requires an aggressive approach of incision and drainage with
liberal use of topical antimicrobials. The ear may heal with
scarring and deformities that may have to be managed at a
later date with reconstructive measures.
Lips
Lips are prone to scab and crust formation. These must be
cleaned repeatedly, and the lips should be kept moist with a
petroleum jelly or liquid paraffin. In hair-bearing areas of the
lips and chin, repeated trimming or shaving of hair prevents
build-up of necrotic material that may later lead to infection
and folliculitis.
Scalp
The scalp, even though separate anatomically, can be described
along with the face as a contiguous area. The scalp is enriched
with a dense supply of hair follicles both in dermal and
subdermal levels. This greatly facilitates re-epithelization
even in deep dermal burns. Hence, the management of scalp
burns is essentially conservative. This constitutes wound care
measures like repeated cleaning of debris, shaving the region,
and moist wound dressings combined with generous use of
topical antimicrobials.
due to hematoma formation and also to assess the adequacy
of the depth of excision. Also, in aesthetically sensitive areas
like the ala of the nose, tip of the nose, chin, ear, etc., it may
be better to err on the side of excising less and giving a second
look at a later session rather than to do a deep excision and
face contour problems in the future. For maintaining a uniform
appearance, aesthetic units have to be excised in toto even if
this means sacrificing a small region that may be unburnt or
that may heal spontaneously.1,23
In areas of mixed depth injuries, excision should be per­
formed to a uniform depth to avoid problems of retention of
skin appendages like inclusion cysts, pits, and folliculitis.
Excision is performed with the help of a dermatome
(Goulian) set to 0.008-inch thickness. This can tackle most
areas except for certain areas like the medial canthal region,
ears, philtral area, etc. For such areas, the use of the Versajet
(Smith & Nephew) has been recommended. This is a hydro­
surgery system, which uses a high-pressure jet of sterile
normal saline to debride wounds, drawing tissue debris and
fluid into a chamber via the Venturi effect created by the
normal saline jet.24,25
Excision in the face is usually commenced with the central
T-shaped area constituting the eyelids, nose, upper and lower
lips, and chin.
Having completed the excision of the central T area of the
face, attention is shifted to the four outlying flat areas: the
cheeks, forehead, and neck. These are excised in a similar
manner. The dermatome can be set at 0.010- or 0.012-inch
thickness. The eyebrow area is spared while excising a fore­
head burn. The amount of bleeding from a full face excision
can be quite copious, and hemostasis has to be quick and
adequate. A watchful eye has to be kept also on volume
replacement, and blood transfusion can be given if necessary.
It is better if all these areas are not excised in the same session
and their excision can be staggered over multiple sessions to
reduce the blood loss.23
Ear burns require a special mention as the instrumentation
available does not allow a suitable excision of this architectur­
ally complex structure. It can follow the traditional method of
allowing an eschar to form and separate. Topical antimicrobi­
als and moist dressings can be used to assist healing. Split skin
grafting can be done as and when required.
Post-excision options
Allograft and split skin use
Allograft, if available, is used initially for coverage of the
excised areas. The use of allograft has its own advantages over
xenograft. Allograft adheres to the wound bed if the depth
of excision is adequate and healthy. However, if the depth of
excision is inadequate, it does not adhere and easily comes off.
One week postoperatively the patient is examined in the
operation theatre for allograft adherence. The allograft is
gently removed. The area of the face to be covered determines
the donor area to be used. The scalp skin is a good match in
terms of color match and texture. It is sufficient for partial face
coverage. But the scalp may be an insufficient donor area for
a complete face excision. Thick autografts are then harvested
from elsewhere in the body to the extent of 0.008 to 0.012
inches. The thicker grafts prevent secondary contracture and
have a better aesthetic appearance. Autografts are harvested

451.e1
Surgical management of the facial burn wound – early excision
Versajet mode of action: The hand piece is angled 45° to
facilitate dissection in narrow and difficult areas. The saline
is ejected through a nozzle in the hand piece, which in turn is
attached to a console that operates the hand piece via a foot
pedal. The jet of high-pressure saline acts like a knife and can
help in a tangential excision-like manner preserving healthy
dermal elements.25 The hand piece is single use and costs can
be a deterrent in some healthcare systems. Available evidence
suggests that this system is not recommended for full-
thickness burn debridement. It has also not shown histologi­
cally superior results in the leftover normal tissue in
comparison to standard dermatome use. There is also no
significant difference in the scar patterns during follow-up on
comparing the wounds treated by Versajet or with the use of
the standard dermatome.24,25
Procedure of facial wound excision: Starting with the lids,
tarsorrhaphy stitches may be taken to protect the eyes. It is
more useful to take stitches for traction at the lid margin to
obtain a uniform plane for excision. The endpoint of excision
is the orbicularis oculi muscle, a layer of which may also
need to be excised. Punctuate bleeding is the endpoint to
look out for. After excision, pads soaked in saline epineph­
rine solution (1 in 10 000) can be used for hemostasis. Caution
has to be exerted during the use of the agent epinephrine, as
if it is allowed to spread to neighboring tissues that are
unexcised, it may interfere with the accurate determination
of the endpoint due to its vasoconstricting effect. The medial
canthal regions are next. This is a narrow curved part, and
the dermatome may not do the trick. Instead, if available,
the Versajet may be used or else excision may be performed
with a number 15 scalpel blade and curved scissors in a
piecemeal fashion.
The next area to be excised is the nose. The upper part of
the nose being well supported by the bony and cartilaginous
framework can be easily excised using the dermatome.
However, caution has to be exerted at the ala and nasal tip
where anatomic distortion can very easily occur with a deeper
excision. Hence, it is recommended to go easy on these parts
and err on the side of removing less, saving subsequent exci­
sion for a later session.
The upper lip and philtral region, even though lying ante­
rior to the bony maxilla, are mobile structures that are difficult
to excise. Care must be taken to excise the minimum possible
tissue from the philtral region as it lends character to the
appearance of the face. Bipolar cautery can be used in addi­
tion to epinephrine for hemostasis.
The lower lip and chin are excised in a similar cautious
manner. A special mention is made again, while excising the
chin, to exercise restraint and save further excision for a later
session than risk flattening the chin.
and stapling of grafts are preferably avoided. It is not common,
but when both lids have to be grafted, traction sutures are
placed on the margins of the lids to stretch them out for the
graft placement. Sutures of the lower lids are then passed
under the upper lid and brought out through the upper lid
and tied over with the help of bolsters. The upper lid is then
stretched and sutured to appropriate points on the cheek. In
the neck, care has to be taken in the lateral aspect not to have
a straight line. Instead small darts are made in the graft margin
and small local Z-plasty flaps can be fed into the areas opened
up by the darts. This breaks the margin and prevents contrac­
ture band formation.23 Dressing consists of a layer of non-
adherent paraffin-impregnated gauze. This is covered by
layers of absorbent gauze. Foam pads can be used to provide
uniform pressure. Lastly the bubble mask or pressure garment
is applied. For the neck, in the authors’ institution an elaborate
mold using plaster of Paris is made maintaining the important
landmarks like the cervicomental angle. This is given over
layers of gauze held in place with Dynaplast placing a bolster
behind the shoulder blades producing an attitude of extension
of the neck. After the period of graft stabilization the neck
extension can be maintained with the help of a hard cervical
collar or splints made of thermoplastic materials by the occu­
pational therapists. Grafts are inspected for hematomas in the
event of which small nicks along the relaxed skin tension lines
are made for evacuation. Large hematomas require the patient
to be shifted to the theatre for evacuation. The patient is kept
nil by mouth for at least 3 days, during which enteral feeding
can be continued via nasogastric tube, and is asked to refrain
from talking. This prevents graft loss that may occur in the
perioral regions due to food contamination and jaw
movements.
Acellular dermis
Acellular dermal matrix covered in a single stage with razor
thin autograft has been used successfully in the treatment of
full- and partial-thickness burn injuries and in late reconstruc­
tion. Long-term follow-up results were good in terms of color,
texture, appearance, and elasticity. Hypertrophic scarring and
junctional scarring was minimal.26 The one-stage approach
shortened the hospitalization and wound healing time allow­
ing earlier physiotherapy, and the razor thin autografts
allowed rapid donor area healing and the potential for
repeated harvests.
Grafting post-excision: The scalp is shaved preoperatively,
and a Mayfield-type neurosurgical headrest is placed sup­
porting the neck exposing the scalp for graft harvest. The
scalp is infiltrated with tumescent solution of normal saline
having adrenaline in the concentration of 1 in 500 000. This
provides a firm uniform plane for graft removal. With a
Padgett dermatome at least 4 strips of autograft can be har­
vested. The grafts are placed on the wound bed and fixed
meticulously with plain catgut, vicryl, or fine monocryl
sutures (4-0) depending on the surgeon’s preference. Meshing
Xenograft
This is similar to allograft use in all respects except for the fact
that xenograft never adheres to the wound bed. Hence, it
cannot be used as an indicator for sufficiency of the depth of
excision. But its use is common in a number of centers where
its availability is easy.
Matriderm and Integra
These collagen–elastin27 and collagen glucoaminoglycan20
type dressings have been used successfully to cover deep
burns after excision. Some cited advantages of these include
the ability to cover tendon and bone, good scar elasticity, and
cosmesis. However, they do require thin autograft for cover
and are expensive. The availability of these dressings is poor
in low- and middle-income countries (LMIC).

451.e2
SECTION III
CHAPTER 20 • Management of the burned face
Cultured epithelial autograft
The use of cultured epithelial autografts in the form of cell
layers and sprays has been described by various studies.28,29
A split-thickness skin biopsy from unburnt area of about
4 × 4 cm is sent to the laboratory after prior consent at the time
of admission. This skin sample undergoes processing and
keratinocyte extraction, which is then subcultured to produce
a keratinocyte suspension in the culture medium. This can
be sprayed on the wound bed, which has been prepared
by enzymatic debriding agents and minimal surgical
debridement.
The cell spray is available by 8–10 days after sending the
skin biopsy sample. The studies conducted in patients with
deep dermal burns report a faster healing time, better cosme­
sis, and preservation of donor areas as advantages in this
technique.28

452
SECTION III
CHAPTER 20 • Management of the burned face
burn management, i.e., scar management. The rehabilitation
of a facial burn starts on the day of the patient’s admission
just like burns elsewhere on the body. During the patient’s
inpatient stay it is mandatory to ensure adequate facial mobi­
lization exercises. Also, special care is to be paid to the eyelids,
lips, and oral commissures to prevent ectropion and microsto­
mia formation, respectively. The use of oral splints in prevent­
ing microstomia formation and nasal silicone splints to
prevent nostril stenosis cannot be overemphasized. These
splints are also of paramount importance when a conservative
line of management is being pursued (Fig. 20.6
). In ear
burns, use of splints is recommended whether the patient is
managed conservatively or by early excision. The splint in ear
burn serves to maintain the postauricular sulcus and preserve
the overall cartilage architecture. The therapist and the
surgeon have to work in close coordination in this phase to
evaluate the patient in terms of goals of rehabilitation, areas
needing special care, areas at risk of developing scar hyper­
trophy, or contractures.
Fig. 20.6 appears online only.
Most commonly used intervention modalities include scar
moisturization30 and massage therapy, compression garment
use,31–33 topical silicone use in the form of liquid or sheets,34
and sunscreen use to avoid pigmentary problems.
Ancillary measures
Despite the best of measures, the patient may develop
hypertrophic scarring and contractures for which secondary
reconstructive procedures may be required. An acute facial
burn is a psychologically distressing injury as this leads to
alteration in perception of image and reduces the self confi­
dence. These patients have to be regularly counseled with
empathy and have to be enrolled in burn camps and survi­
vor groups as part of their psychological rehabilitation. The
burn camp concept, which is well accepted and popular in
the west, is now slowly being embraced by the Middle
Eastern and Asian burn units. The authors’ institution con­
ducted the first ever pediatric burn survivor camp in India
and has found the camp to be an uplifting experience for the
participants, doctors, and patients alike.35 In LMIC often
these patients are neglected and abandoned by their families,
and they need legal and vocational support as well. The
management of the scars should not be limited to the physi­
cal element alone, as the psychological aspect of care com­
pletes the circle of treatment for both the patient and the
treating surgeon.
Management of facial
post-burn deformities
Scarring is the natural endpoint of all healing. But the scar­
ring process is dynamic and behaves as a continuum rather
than as an endpoint. There are factors at play that constantly
alter the scar biology. Fibroblasts and growth factors like
transforming growth factor (TGF)-beta are responsible for
the changes in scar morphology, altering the rate and type of
collagen synthesis leading to hypertrophic scar formation.
As described in the previous segment a post-burn scar
requires a lot of early rehabilitative measures like pressure
therapy and scar massage, which are now accepted as the
standard of care. When an attempt at scar amelioration
Special subsets of patients are the ones who suffer a serious
injury like a high-voltage electric injury. This may lead to
exposure of the calvarium. It may even cause a necrosis of the
outer table of the skull vault. Simple exposure of the calvarium
can be managed by drilling holes through or burring the outer
table of the skull and allowing granulation tissue to develop.
Following this, the defect can be covered by autograft or
Integra. However, a necrotic bone may require removal fol­
lowed by formal coverage of the defect with a flap. If neigh­
boring tissue is uninjured, a rotation or transposition scalp
flap may be performed. For larger injuries, coverage of the
exposed structures may necessitate use of microsurgical free
tissue transfers of large flaps like anterolateral thigh flap or
latissimus dorsi flap.
Neck burns
The neck is another important contiguous area that, when
burnt and if neglected, can lead to development of disastrous
secondary deformities. Posturing an acute burn patient can
go a long way in preventing neck contractures if treated by a
conservative method. The patient is made to lie with a bolster
support behind the upper back and using a very thin or no
pillow support for the head. This automatically converts the
posture of the neck into one of that of extension during the
healing phase. When posturing is coupled with the use of
thermoplastic splints or neck collars, neck contractures can be
effectively prevented. If excision is opted for it is carried out
like elsewhere on the face or body, taking care of splintage
and posturing in the postoperative period also.
Surgical management of the facial
burn wound – delayed surgery
Early excision and wound cover has become the standard of
care for acute burns. This ideal line of management may not
be feasible in certain facilities and countries due to a lack of
infrastructure and lack of high-dependency intensive care
facilities. Despite these drawbacks, the best possible care in
the form of a regimen of topical antimicrobial treatment, moist
wound dressings, and regular cleaning of necrotic tissue and
wound debris can be followed. Once the eschar of deeper
burn separates, it is replaced by healthy granulation tissue
over a period of about 3 weeks. By this time the patient has
stabilized hemodynamically and nutrition is at the optimum.
The patient can be taken up for wound debridement and
coverage with split-thickness autografts. It is preferable to
assess the wound microflora by sending regular wound swabs
or, more reliably, wound biopsies before taking up the patient
for surgery. Adequate blood products should be available
before surgery, and intraoperative hemostasis is further aided
by the infiltration of the granulated areas with 1 in 1 000 000
saline adrenaline solution. In the event of paucity of donor
areas, various techniques are available to optimize the quan­
tity, such as increasing the meshing ratio, sandwich technique
of using widely meshed autografts with homografts, and
meek micrografting method.
Aftercare and early scar management
Once the early management is concluded and the wounds are
closed, it is now time for the most aggressive phase of facial

452.e1
Management of facial post-burn deformities
A
Fig. 20.6  (A,B) Thermoplastic splints for
microstomia.
B
Moisturization using a lubricant serves to make the scar or
grafted skin more pliable, soft, and prevents ulcerations and
scar breakdown. The scar massage done at the time of mois­
turizing helps in the scar maturation and fading. The theory
suggested for this effect is massage maintaining the unifor­
mity of orientation of collagen bundles. Hypertrophic scars
typically show a disorganized arrangement of these bundles.
However, the volume of scientific evidence showing large
benefits with massage is lacking. There is better evidence to
show benefits of scar massage in postoperative scars rather
than burn scars.30
Silicone sheets have been used to soften scars, increase their
pliability, and reduce contracture formation. The silicone
sheet by the property of occlusion improves the hydration of
the stratum corneum layer, regulates fibroblast production,
and reduces excessive collagen synthesis, thus altering many
scar properties like color, texture, and thickness.34
Pressure therapy, i.e., use of pressure garments, has been
widely described and used in post-burn scars. It has come to
be accepted as the standard of care for post-burn scar manage­
ment. However, there are not many studies that have docu­
mented the optimal pressure to be used and the exact regimen
or duration of use. Most regimens remain empiric and based
on directives created by experienced surgeons rather than on
hard evidence. How compression leads to scar modulation
and its effect on maturation may be explained by the follow­
ing two theories:
i) compression reduces the blood flow to the scar
ii) constant pressure inhibits hypertrophic scar formation.
By limiting blood supply, nutrients, and oxygen to the scar,
collagen synthesis is inhibited reducing the scar redness and
edema formation. Thus blanching of the scar is used as an
indicator of adequacy of pressure exerted by the garment.
The pressure recommended is about 15–20 mmHg. Higher
pressures of 20–30 mmHg have also been said to give benefit,
but these are already exceeding capillary pressures; any
higher pressures would jeopardize the limb circulation and
give rise to paresthesia and ischemia. The patient is instructed
to wear the garment, which is custom fit, for 23 hours a day
and for at least 6–12 months. The pressure is claimed to
improve thinning and pliability by 60 to 85%. However, pres­
sure garment use has its own disadvantage. They are cumber­
some and unattractive, and their costs are often prohibitive.
They are known to cause morbidities like itching, scar break­
down, and even known to affect bone growth when used in
children. Their use in the tropics, where it is humid, leads to
problems of compliance.31–33

453
Presentation to the surgeon
work together towards a common goal, i.e., good functionality
with an adequate but realistic aim of aesthetics.
Planning
The final appearance of the patient is only as good as the
overall plan. The patient may present with multiple contrac­
tures or scarring in many parts of the body. An overall plan
has to be made keeping the entire body in perspective. When
we see the patient as a whole, a note can be made of the
available donor areas for skin grafts, flaps, or sites for tissue
expander placement.
The sequence of correction of the deformities with the
interval between each procedure should be penned down
after discussing with the patient. This is especially true for
patients who present with multiple contractures. For a patient
who presents with bilateral hand, elbow, axillary as well as
neck contractures, the sequence can be as follows:
■ 1st stage – Release of neck contracture with dominant
hand and elbow release
■ 2nd stage – Opposite axilla + hand release
■ 3rd stage – Elbow of non dominant side
■ 4th stage – Axilla of dominant side
These decisions are based on many factors like present func­
tion of each hand, handedness, occupation, patient desires,
etc. The fact that it is paramount to release the neck contrac­
ture first is not debatable.
Photography during planning
Planning is helped considerably by photography. A set of
photographs of the patient from as many angles as possible
showing the contractures (in their extreme ranges of motion)
as well as available normal tissue should be taken (Fig. 20.8).
After making a tentative plan in the preliminary consulta­
tion, the surgeon can go over the photographs at a more lei­
surely pace and revisit the plan. Often an unhurried study of
the photographs occasionally lends a new dimension of
thought and a better plan as compared to the one made in the
rush hour of a busy outpatient clinic. The new plan can be
discussed with the patient in the next consultation.
General principles of facial reconstruction
1. Wait for scar maturation and softening before the first
surgery, as well as in between sessions. Waiting for scars to
soften and mature will go a long way in reducing the
amount of skin and scar that may need excision. Every
scar does not need to be excised. An effort should be
made to relieve tension in the scar. This relief of tension
itself helps to settle the scar better.
2. Blush areas, if available, to be reserved for facial resurfacing.
Areas on the face, postauricular regions, neck,
supraclavicular regions, and even the upper arms have
a high cutaneous vasculature. Donor skin from these
areas are preferable for the face as there is good color
and texture match.
3. Combine complimentary surgical procedures in one sitting.
This helps keep the overall time to full reconstruction
down and also saves the patient from multiple
postoperative recovery periods. Waiting between stages
is occasionally excruciating for patients as they are very
through these efforts cannot be made due to patient factors
or poor follow-up by the burn unit, the incidence of scar
morbidity in the form of hypertrophic scarring, keloid for­
mation, and contractures rises. However, the tendency to
excessive scarring may also depend on a number of other
factors. These include:
1. Age
2. Sex
3. Race/color of skin
4. Depth of burn and time to healing
5. Method of management of acute injury
6. Management after healing.
Presentation to the surgeon
A patient may present to us for facial burn reconstruction with
any or all of the following:
1. Scarring with issues of pigmentation (aesthetic
component)
2. Hypertrophic scars (aesthetic component)
3. Tight scarring of the face leading to adynamic face
(aesthetic component with expressive component)
4. Scarring with contractures, but no functional problems
5. Scarring with contractures leading to functional
problems.
The consultation
Facial burn survivors deserve a higher level of empathy from
the surgeon compared to those who have body burns alone,
sparing the face. The approach to these patients who come
with expectations like “can these scars be removed?” has to
be a realistic one. It has to be made clear right at the first
consultation that skin once scarred cannot be made unblem­
ished again despite the array of procedures at our disposal.
An explanation of the process of healing and scar formation,
if given to the patient and caregivers, makes them realize that
it is impossible to regain the preburn facial appearance.
Restoration of function and esthetic appearance in facial
burns may require a number of procedures. The surgeon needs
to be able to play out mentally the whole process towards the
final outcome. The plan needs to be made after detailed discus­
sion with the patient so that they have a shared vision of the
final outcome. During the preliminary consultation, a detailed
history should be elicited from the patient. All details of the
earlier management should be asked for, like details of early or
delayed surgery, donor site usage, early rehabilitation in terms
of use of pressure garments, splints, positioning, and silicone
sheets. Non-compliance to ancillary measures helps to red flag
the patient as one who would need special counseling and
repeated reiteration of the benefits of these measures. Often in
a busy outpatient clinic, the author has found it worthwhile
introducing one patient to another showing how the other
patient has benefited from being compliant to the post-healing
care regimes. It is also beneficial to have photographs of
patients (taken with informed consent) who have undergone
reconstructive procedures, which may help illustrate some
points to the new patient who may be unable to visualize how
a flap or graft may appear. The consultation is concluded in a
positive spirit, reiterating that the surgeon and patient would

453.e1
Presentation to the surgeon
Factors affecting post-burn scarring
Age
As compared to adults, the skin of a child has a greater density
of dermal appendages. This helps wound healing and leads
to faster re-epithelization. But, it can also lead to devastating
hypertrophic scarring in some children due to the overcom­
pensation of the cellular mechanism.36
In the elderly, the skin is atrophic, loose, and less elastic
due to reduction in the dermal layer as well as loss of the
elastic fibers.
Sex
Females of all comparative age groups have a tendency to scar
better compared to their male counterparts.
Race/color of skin/ethnicity
The colored races scar much more than Caucasians.
Depth of burn/severity of burn
Scarring after wound healing corresponds directly to the
depth of the wound. The deeper the burn, the higher the
chances of scarring. Burn wounds that heal within 10 days
usually leave no scars. Burn wounds that take between 10 and
20 days to heal do scar and are at risk of forming permanent
scars. However, they do not hypertrophy if good aftercare is
taken. Burn wounds that take longer than 21 days to heal or
those that need closure by grafting have a higher chance of
hypertrophy or contracture formation (see Fig. 20.4).
Method of management of acute injury
Due to the contours of the face, patients treated at the best of
centers with standard of care (early excision and cover) also
do develop facial scarring and deformities, but these are much
lesser than those patients who have undergone conservative
management for deep burns. In burn centers in the develop­
ing world, often skin banks are not available and facilities for
early excision are either suboptimal or not available (either
due lack of equipment or lack of man power). In these situa­
tions, the burn patients are managed conservatively, that is
the burn wound is allowed to granulate, then finally it is
resurfaced with autografts after a period of three to four
weeks. During this waiting period some wounds may heal
spontaneously at three to four weeks. This prolonged healing
by secondary intention leads to poor aesthetic outcomes and
hypertrophic scars with a tendency to develop contractures.
There is a third set of patients – those who have not been
treated at burn centers or those who were left to fend for
themselves after burns (Fig. 20.7). These patients have sur­
vived the trauma of burns but have had the misfortune of
suffering the morbidity of contractures to the extreme. These
patients present to us with avoidable contractures sometimes
affecting every component of the face.
Management after healing
The use of pressure garments, splints, silicone gel sheets,
massage, and moisturization of scar goes a long way in “set­
tling” of scars. If this standard of care has not been advised
in the first instance or has not been followed by the patient,
the scarring and deformity will be much more.

453.e2
SECTION III
CHAPTER 20 • Management of the burned face
A
B
C
Fig. 20.7  (A) Old unattended facial burns with raw areas
and contractures. (B) Neglected burn presented to us
about two weeks after burn, anterior view. (C) Lateral
view. (D) 6 months after grafting showing deformity of
the left side of face. (E) Lateral view.
D
E

454
SECTION III
CHAPTER 20 • Management of the burned face
6. In case tissue expanders are to be used, exclude endogenous
sources of infection. An implant is a foreign body whose
presence attracts infection. It is always better to ensure
the absence of any source of infection in the body.
7. Sequence of surgery should be formalized after full discussion
with patient. Patients and their caregivers not only need
to accept the sequence but also understand the
reasoning. This helps in compliance to the supportive
scar management techniques to be used by the patient
in the waiting periods. Sequence of surgery should be
revisited after each step. (Be flexible in approach.)
8. Share sequence of surgery with all team members. Burn
reconstruction is all about teamwork, involving the
other burn surgeons in the unit, skilled nurse, and the
therapist. Having discussions with the team and getting
the sequence counterchecked by others ensures that
everyone is on the same page and overlooked points
may be picked up.
9. Provide splints to all areas of contractures in the waiting
period. The use of splintage in the waiting period during
staged management of contractures cannot be
overemphasized. It will help stop the progression of
contractures, reduce the amount of release and donor
skin required, and also improve compliance.
eager to move ahead to the next surgery, waiting for the
final expected end result. This may occasionally lead to
non-compliance or interruption in the treatment flow if
the patient decides to default. The knowledge that many
procedures are being done in a sitting is very reassuring
to the patient.
4. Be flexible in your approach. Postoperative outcomes and
scar behavior may not often fall in line with the
surgeons expectations. The surgeon must have the
vision to predict adverse outcomes and have secondary
contingency plans ready that may not conform to earlier
decisions. All changes in plans have to be discussed in
detail with the patient, explaining the reasons for doing
so. A rigid surgeon may often have to be satisfied with a
similar scar.
5. If tissue expander placement is planned, explain the sequence
and temporary change in appearance. It is important for the
patient to understand and accept this, especially in case
of facial burns as the donor areas are adjacent and
cannot be hidden under camouflage clothing. If the
patients travel considerable distances for weekly
expansions, they would have to make arrangements for
safe travel and avoid crowded surroundings due to
possibility of trauma.
A
B
Fig. 20.8  Severe neck contracture. (A) Anterior view. (B) Left oblique view.
(C) Right oblique view.
C

455
Presentation to the surgeon
split-thickness one. In the face it is always preferable to
use a full-thickness graft as compared to split-thickness;
if for some reason a split-thickness graft is used, a thick
split-thickness graft is to be preferred.
16. Keep threshold for use of flaps in facial burn reconstruction
very high. Flaps tend to bring in too much adynamic
tissue which may mask facial expression and emotion. If
their use is inevitable, locoregional flaps like cervico-
humeral flaps or expanded cervical flaps are to be
preferred over distant flaps.
17. Multiple modalities of treatment can be used concurrently as
required to treat any one area to be able to obtain the best
possible outcome. For example, Z-plasty to relieve tension,
later use of silicone gel sheets, as well as laser therapy
to reduce the scar hypertrophy.
18. Release of tension in scars/linear contractures reduces
hypertrophic scars and stimulates pigmentation.
Reorientation of the scar to lie along the relaxed skin
tension lines will often produce dramatic changes in
appearance due to release of tension.
19. Take photographs after each stage. Not only does this help
the surgeon in planning further, it is also reinforcement
to the patient that improvements have occurred due to
the earlier surgery. It helps in patient counseling and
revisiting the next planned step (Figs. 20.9–20.14
).
Figs. 20.9–20.13 appear online only.
20. The final aim is to provide a face that is balanced, pleasing,
symmetric, and dynamic.
Timing of surgery
The timing of surgery obeys the usual laws of scar matu­
ration. However, there are exceptional conditions which
demand early intervention. These areas, having skin
laxity, are the periorbital or perioral regions where the
mildest contractures can cause deviation of structures and
distortion of anatomy. Splintage of these areas is not easily
10. Give a trial of “serial splintage” to all contractures. As
waiting lists for surgery in busy public hospitals in
LMICs run quite long, the method of serially splinting
the contractures has positively shown improvement in
the contracture angles and reduction in requirement of
grafts at the time of surgery. In minor contractures it
may even help obviate the need for the surgery, and
major contractures may be converted to those of
intermediate severity.37
11. Recognize intrinsic and extrinsic contractures and treat the
intrinsic first. The extrinsic will be relieved or severely
diminished once the causative intrinsic contracture is
released.
12. Aesthetic units and subunits should to be kept in mind when
resurfacing the face. The face was divided into convenient
aesthetic subunits by Gonzales and Ulloa.38 While
treating a scar in a particular aesthetic subunit, it is
better to treat the unit as a whole to optimize outcome.
13. Planning incisions in the form of “Z”s instead of straight
incisions helps keep the requirement of skin graft down and
also helps recruit normal skin from the surrounding areas.
Occasionally there may be an excess bulging of skin on
the sides of a linear contracture due to ballooning or
trap-door effect of scars that can thus get utilized. This
is especially true of linear neck contractures.
14. Calculation of the “true defect”. Especially in the case of
severe contractures it is imperative to calculate the true
defect as this can appear deceptively less. This is done
by comparing or marking out the defect that will be
created post-release by utilizing the opposite normal
side for planning. Contracture dimensions marked on
the normal side with measurements taken from fixed
bony landmarks on the affected side will give the size of
the true defect that will be produced on release.
15. Decision regarding the use of split-/full-thickness graft. A
full-thickness graft has less long-term secondary
contraction and pigmentary changes compared to a
Fig. 20.14  Two years after full-thickness grafts to resurface the cheek and chin scars and 13 years since first presentation. (A) Anterior view. (B) Left oblique view.
(C) Right oblique view.
A
B
C

455.e1
Presentation to the surgeon
A
B
Fig. 20.9  Eight months after release and split skin graft. (A) Anterior view. (B) Left
oblique view. (C) Right oblique view.
C
Fig. 20.10  (A–C) Eight years after neck release, patient presented for an improved look.
A
B
C

455.e2
SECTION III
CHAPTER 20 • Management of the burned face
Fig. 20.11  (A–C) One month after full-thickness graft.
A
B
C
Fig. 20.12  (A–C) Eight months after full-thickness graft.
A
B
C

455.e3
Presentation to the surgeon
Fig. 20.13  (A–C) One and a half years after full-thickness graft.
A
B
C

456
SECTION III
CHAPTER 20 • Management of the burned face
can be provided by a blister graft or ultra-thin split-thickness
skin graft. This has to be preceded by some technique to
create a raw surface, which can be achieved by dermabra­
sion or by using CO2 ablative lasers. These techniques have
been most commonly described and used in the treatment of
vitiligo.40
Flaps
Flaps are an important addition to the reconstructive arma­
mentarium. Flaps are tissues that are transferred from the
donor to the recipient area maintaining its source blood
supply. This obviates the need for a healthy blood supply in
the recipient bed as the flaps bring with them their own
nourishment. In the face, the most commonly used flaps are
local flaps from unburnt tissues. Local flaps include local
transposition and rotation flaps from adjacent areas. The
donor site is managed by a primary closure. This local adjust­
ment of available skin avoids color and contour mismatches
that might otherwise occur with flaps transferred from distant
areas. Flaps are better suited for reconstruction of the wider
flat peripheral part of the face. Flaps occasionally tend to be
bulky and are at risk of masking expressions and emotions.
Advancements in flap harvests make it possible to obtain thin
and super thin flaps, thus giving a good contour and aesthetic
appearance.
Z-plasty
This is one of the reliable techniques of scar revision. It can
help to lengthen a scar, change the direction of a scar to lie
along the relaxed skin tension lines. It can help in interrupting
the scar line and camouflaging the scar. The surgical technique
should be fine and meticulous, and use of magnification is
recommended.41
Tissue expansion and flap advancement
Despite the availability of skin grafts, local flaps, and free
flaps, the burn surgeon still desires more in terms of aes­
thetic capability. This involves attempting to replace like
with like and if possible give a good color, texture, and sen­
sation match. Each of the above described modalities of
reconstruction has some shortcoming when compared to the
ideal. Tissue expansion attempts to achieve most of the
goals. It utilizes tissues that are a good color and texture
match, and the skin flap is well vascularized and sensate.
There is minimal to no donor morbidity (Fig. 20.16
). Tech­
nical factors that need to be considered include site of the
incision, port placement, and whether internal or external
port is to be used.42 During surgery, once the intended
amount of expansion has been carried out, the expander is
removed and the flap is advanced into the recipient area.
What is of essence is thorough asepsis, use of powder-free,
lint-free techniques, and meticulous hemostasis. Use of
expanded skin for resurfacing lower cheek and chin contrac­
tures has the added disadvantage of gravity pulling down
on the flap after advancement. It is liable to cause ectropion
of the lip or loss of cervicomental angle due to the pull. The
benefits of use of tissue expanders have to be weighed
against the cons like cost factors, risk of infection and expo­
sure, and requirement of high motivation and compliance on
the part of the patient.
Fig. 20.16 appears online only.
accomplished, so the splint and wait policy cannot be adopted
either.
Reconstructive options
A barrage of reconstructive options is available if the surgeon
decides to proceed with his or her operative reconstructive
plan. But it must be borne in mind that only certain tools are
ideal in each circumstance, and the surgeon must choose his
weapon judiciously, weighing factors like site, size, color, and
texture required.
Skin grafts
A skin graft is the most easily and abundantly available
replacement for excised scar tissue. As mentioned earlier,
grafts for the face are taken from the “blush” areas for color
match. Grafts vary depending on the thickness of their harvest.
Split-thickness grafts
Split-thickness grafts have a greater degree of secondary
contraction (due to the presence of lesser dermis in the graft,
which is the main component to ensure elasticity) and hence
contract more. These grafts have a slightly shiny appearance
lifelong.39 Split-thickness grafts may also be used in the more
peripheral areas of the face as well as after the release of upper
lid ectropion.39
Full-thickness grafts
Full-thickness grafts contract less, have a natural appearance,
are aesthetically reliable, and are the first choice for facial
burn reconstruction (Figs. 20.14 & 20.15
). Full-thickness
grafts can be taken after expanding the donor area skin so
that a primary closure of the donor site is feasible. It pro­
vides soft mobile skin in the long run. There are some basic
principles to be followed while placing a full-thickness
skin graft for reconstruction. Accurate defect measurement
should be made in its largest dimensions, and preferably a
larger full-thickness graft should be marked out on the
donor area. Infection should be excluded before proceeding
with the grafting. After the graft is obtained, it is the authors’
practice to totally defat the undersurface to expose the
dermis. This is most essential to ensure a good take. The
defatting is done by spreading the graft epidermal surface
down over a bowl and held at the edges with sutures or
hemostats for stretching it or, in case of smaller grafts, over
the gloved index finger of the non-dominant hand. The fat is
then carefully pared away from the undersurface exposing
the white dermis using a sharp iris scissor, taking care not to
buttonhole the graft. The graft has to be sutured meticu­
lously to the defect with edge to edge approximation using
fine (5-0) nylon or prolene sutures. Hemostasis has to be
perfect in the wound bed before the graft is sutured on to it.
A pressure dressing is the norm to maintain good graft–
wound bed cohesion. This can be achieved with tie-over
sutures placed over a bolster dressing. Dressing change is
done directly on day 10 post-grafting.
Fig. 20.15 appears online only.
Blister grafting/super thin grafts
If there are no contractures and the scars are hypo- or hyper­
pigmented, all that is deficient is the pigment-producing
cells. An epidermal transfer will suffice in such cases. This

456.e1
Presentation to the surgeon
A
Fig. 20.15  (A) Minor deformity and scarring of the lower lip and chin complex.
(B) Pleasing appearance after resurfacing with full-thickness graft and repositioning
of the lip.
B
A
Fig. 20.16  (A) Scar over the left forehead and eyebrow. (B) Resurfaced with
expanded skin.
B

457
Reconstruction of specific areas
may be tried, followed by pulsed dye laser therapy and finally
surgical excision if nothing else helps.45 Surgery for keloids
has to be preceded by counseling the patient regarding high
chances of recurrence (Fig. 20.17). In selected patients radio­
therapy after surgery is a viable option. Intralesional 5-FU has
shown good results according to evidence. Added to surgery,
antimitotic agents like bleomycin and mitomycin C, as well
as immunomodulators like 5% imiquimod cream, have been
considered for refractory keloids.46
Reconstruction of specific areas
Scalp
The scalp and the hairline add a framework to the face and
complement youth and identity. Involvement of scalp in
burns can lead to a range of problems from minor alopecia
to exposure of calvarium in cases of devastating electric
burns. The scalp is involved in almost 25% of facial burns. In
the scalp, alopecia is the morbidity of a burn injury. The
Dermabrasion with thin autografting
Depigmentation often develops after healing of partial-
thickness and full-thickness burn injuries that are allowed to
heal by secondary intention. This hypopigmentation is a
serious aesthetic complication especially in the dark-skinned
individual. The pathophysiology of this depigmentation is
poorly understood, but it is thought that scar tissue prevents
melanocyte migration and melanin transfer.43 Dermabrasion
is accomplished by scraping away the surface epidermal
layer of the scar with the use of tools like a dermaroller,
which has microneedles on its surface. A smooth rotating
burr with tiny abrasive particles on its surface has been seen
to produce satisfactory dermabrasion. Dermabrasion is
usually followed by any of the standard melanin transfer
methods like blister grafting, ultra-thin autograft, etc. The
newest tool to achieve dermabrasion is the laser. A carbon
dioxide ablative laser has been shown to achieve uniform
results in creating a raw surface, which is then covered with
thin autografts.43
Serial excision
This is one of the time honored and traditional methods of
scar revision. This entails removal of the scar in multiple
sessions, always excising an ellipse of scar from the middle
so that the resultant suture line is contained within the
original scar.
Hair transplantation
The technique of microfollicular hair transplantation has
evolved to a unique degree of art and expertise. Post-burn
alopecia scar is no barrier anymore to attempting a transplant
in expert hands.
Fat grafting beneath scars
Regenerative medicine is a rapidly evolving field, with
adipose-derived stem cells the foremost tool. Studies have
shown that autologous fat transfers in the form of small
parcels are able to vascularize and survive in the toughest of
environments. Burn scars that are adherent and tough were
seen to respond well to the injection of fat cells beneath them.
Both aesthetic and functional improvements in scar character­
istics were observed. Scars became less pigmented and supple,
increasing the skin elasticity and reducing movement
limitation.44
Tattooing
Camouflage tattooing for medical conditions has gained
increasing popularity over time. It has a wide range
of applications from tattooing hypopigmented lesions
and burn scars to areola pigmentation after breast
reconstruction.
Management of keloids
The first line of management when the keloids are minor is to
pursue the scar management program more vigorously with
methods like silicone gel sheeting, etc. Intralesional injection
of triamcinolone has been proven to show efficacy in minor
keloids. If there is no improvement in 8–12 weeks of treat­
ment, then 5-FU in combination with intralesional steroids
A
Fig. 20.17  (A) Large ear keloids. (B) After surgical intralesional excision, result at
one year.
B

458
SECTION III
CHAPTER 20 • Management of the burned face
local flaps move with difficulty. Orticochea flaps can be used
for defects that are less than 50 cm2 in the occipital region
where mobility of the scalp is only moderate.49 The Orticochea
flaps can close scalp defects greater than 15% of the hair-
bearing scalp.50
Hair transplantation
Hair transplantation is a very good option for post-burn
alopecia, but it can be done only if the scar is supple, there is
intact deep tissue below the cicatricial alopecia, and the
occipital donor site is available. In these cases grafting by
follicular unit transfer (FUT; strip method) or follicular unit
extraction (FUE) can be done.51–53
Tissue expansion
Scalp expansion allows redistribution of the scalp tissue
without creating new hair follicles. Interfollicular distance can
increase up to twofold without noticeable thinning of the
hair.54 More than 30 years ago, Manders et al. reconstructed
almost half the scalp with tissue expansion.54 It continues to
be the commonest method for hair restoration for post-burn
scalp alopecia42,55–58 (Fig. 20.18
). Pressure on the suture line
in the early healing phase could lead to exposure.
Fig. 20.18 appears online only.
Microvascular free tissue transfer
In cases of devastating injury to the scalp as occurs in high
voltage electrical burn with exposure of deeper structures like
the calvarium, use of the aforementioned techniques is pre­
cluded. This requires special measures like bringing in distant
tissue with its vascularity to provide the necessary cover.
Flaps like free anterolateral thigh flap and latissimus dorsi
flap can cover large areas of the scalp using the superficial
temporal vessels as recipient vessels for the anastomosis
(Fig. 20.19
).
Fig. 20.19A & C appear online only.
primary goal of reconstruction here is to create a natural
looking hair-bearing scalp with hair growing in the correct
direction while having a good hairline. McCauley et al. clas­
sified scalp defects suggesting reconstructive options for
each described type.42 Serbulent Guzey et al. classified lateral
scalp burn alopecia into 3 groups – type 1 (total lateral), type
2 (temporal and side burn), and type 3 (sideburn). This
classification helped them in planning tissue expander
placement.47
Classification of scalp defects
Depending on the size and location of scar, suppleness of
scar, quality of surrounding scalp tissue, presence or absence
of hair on it, and location of hair line, one can choose a recon­
structive option. Many reconstructive options have been
described – reduction techniques, serial excisions, scalp flaps,
hair grafting, and expanders.
Reduction techniques
Serial excision
To remove alopecia of up to 15% of the hair-bearing scalp,
serial scar excision was a very viable option. Huang et al. in a
large series of 117 patients with post-burn alopecia described
serial excision as one of the management modalities.48 This is
a preferred approach even now if complete excision of the scar
can be done in two to three sittings. It has the advantage of
lesser morbidity and a short recovery period.
Local flaps
If the defect is anterior, the primary goal is to achieve a good
hairline. Hence, while planning local flaps and scars of exci­
sion this has to be kept in mind. If the alopecia is in the
parietal region, defects smaller than 25 cm2 can be managed
with direct closure or use of Limberg flap or rotation flap, as
the surrounding parietal scalp is more mobile. It is to be
remembered that tissue mobility in the vertex is limited, hence
Fig. 20.19  (B) On removal of the eschar, slough was seen in the craniotomy burr holes. (D) One year postoperative, after resurfacing with ALT flap.
B
D

458.e1
Reconstruction of specific areas
A classification system was devised by McCauley et al. to help
in planning (reconstruction as well as expander choice and
placement) and description. Pattern of alopecia was classified
as type 1 to 4 and subtypes A to D. Type 1 is uniform, type 2
is segmental, type 3 is patchy, and type 4 is total with extent
defined in the subtypes as A = 25%, B = 25–50%, C = 50–75%,
and D = >75% loss of hair. McCauley suggested that patients
A
C
(A) Full-thickness electric injury with eschar on scalp. He had a subdural hematoma that was evacuated by craniotomy at another hospital, and 10 days later
the patient was sent to us for the dead necrotic skin and management of burns. (C) The craniotomy bone was picked up, and the slough over the dura was debrided. Seen
here is the exposed dura after debridement of dead tissue.
Fig. 20.19 
with type 1A or 1B burn alopecia could be corrected with
a single expansion, albeit occasionally with overinflation.
Patients of type 1C and 1D burn alopecia would need multiple
expanders either together and/or sequentially; patients with
type IIA or IIB alopecia may also be corrected with single
expansion. However, patients with type IIC and IID would
require flaps.42
Fig. 20.18  (A) Alopecia of left temporal and parietal region. (B) With expander in situ. The nose has been reconstructed with radial artery forearm flap.
(C) Post-resurfacing.
A
B
C

459
Reconstruction of specific areas
3. Cryptotia of the ear due to adhesion between the auricle
and the postauricular skin and mastoid region. The
commonest sites involved in this manner are over the
helix/antihelix81
4. Contracted external ear, due to crumpling of the
cartilage or occasionally upper third contracture or ear
lobe contracture due to folding on itself
5. Partial loss of different components of the external ear
6. Complete loss of the external ear.
Thermal injury to the ear will cause deformities due to direct
damage to skin and cartilage or due to suppurative chondritis
due to secondary infection. In deep burns the cartilage may
get exposed and undergo focal necrosis, if uninfected it will
heal with scarring as the eschar separates.82 Some surgeons
have described reconstruction of the external ear during the
acute setting by using turnover flaps of temporoparietal
fascia, platysma flap, and mastoid flaps.83,84
Suppurative chondritis, which is due to secondary
infection, can develop even 3–5 weeks after the burn.80
Avoidance of pressure and good topical treatment goes a
long way in reducing chondritis and hence its associated
deformities.85 Many devices have been described for pre­
venting pressure.86–88
Different classifications have been proposed for ear defor­
mities aimed towards decision-making for reconstruction.
K’ung’s classification, which divided ear deformities into 3
types, is half a century old.89 Bhandari in 1998 presented his
classification of 5 groups depending on availability of skin
around the ear.90
The reconstruction of post-burn ear deformities uses the
same principles and surgical techniques as those used for
congenital deformities. The difference here is that the quality
of surrounding skin available for reconstruction is dubious
and quantity insufficient. Minor deformities of the burnt ear
can be tackled by Z-plasty releases or local adjustment of
tissues. Local cutaneous flaps with or without cartilage grafts
are used for the reconstruction of helical rim defects.82,91–94
Innovative techniques have been described for upper95–97 and
middle third98–100 defect reconstructions. For lobe reconstruc­
tion again local skin flaps are used.98,101,102
Options for individual areas
For badly scarred ears and loss of large component
parts or total loss, Brent advocated excising the auricular
scarred skin and replacing it with carved costochondral
cartilage graft and covering it immediately with temporopa­
rietal fascial flap.103–106 Nagata presented ten principles of
post-burn reconstruction more than two decades back, which
continue to be followed for post-burn ear reconstructions to
date.107,108
Silicone and polyethylene frameworks have also been
described and used with varying results in place of carved
costal cartilage. But the complication rate and problems of
extrusion are much higher in these cases.109–111 Use of osseoin­
tegrated implants to achieve better cosmesis have been
described over the years and require good cortical bone and
pliable soft tissue.112 However, despite the prosthetic ear’s
excellent color and anatomic contour match, reconstructions
of the ear (staged or single) continue to be the method of
choice for post-burn ear reconstruction (Fig. 20.20
).
Fig. 20.20A & B appear online only.
Scalp skin used as donor area to resurface facial burn
wounds had shown alopecia as a side effect according to
studies.59
Forehead
The contour of the forehead is defined by the underlying bony
structure while the surface appearance is due to the skin and
facial muscles beneath.60 Forehead skin is some of the thickest
in the face, with it being thickest in the supra-brow region and
progressively decreasing towards the hairline. In 71% of facial
burns the forehead is involved.61
The aim of the forehead reconstruction is to produce a skin
coverage that is uniform and capable of dynamic facial
expression.62 A stuck-on appearance of a graft should be
avoided as it erases all the creases of the forehead. Connell
and Marten in their paper on forehead-plasty emphasize the
importance of reconstructing creases as they convey strength,
power, and wisdom.63
Choice and sequence of reconstruction will depend on the
size and location of the scar and the condition of the bordering
structures such as the eyebrows and the hairline. Reconstruc­
tive options include excision in an elliptical manner and
primary closure occasionally with intraoperative expansion
using Foley’s catheter,64 serial excision, local flaps, advance­
ment flaps,65,66 bilateral rotation flaps,67 FTG, SSG,68–71 and
tissue expansion.72–75
Eyebrows
Loss of an eyebrow or eyebrows creates a dramatic change in
the facial countenance of an individual, thus demanding a fair
share of importance in secondary reconstruction. In cases of
extrinsic pull distorting the eyebrow, release of the offending
tight scar tissue and replacement with supple tissue will help
reposition the eyebrow. Occasionally the eyebrow can be
repositioned using Z-plasty.
In cases of loss of eyebrows, reconstruction will be accord­
ing to amount of tissue loss. Either one of the following
methods can be used for reconstruction – superficial temporal
artery island flap; subcutaneous island pedicle flap from
scalp,76 composite grafts from scalp, or hair grafting.
Hair grafting: Other than the scalp a reasonable potential
donor site is nasal vibrissae.77 Also, Baretto mentions that
eyebrow hair has more similarities to eyelashes than scalp
hair as far as texture, speed, and length of growth (8–12 mm)
is concerned, so when a small area is to be filled in, it is a most
favorable donor site.51
Eyebrow repositioning, repair or reconstruction can be an
important “finishing touch” in the overall reconstruction of a
burned face.78
Ears
Though isolated burns of the ear are rare, in most facial burns
the ear is involved. Tolleth mentions that the ear is involved
in 90% of facial burns.79 Mills et al. mention that 52.7% of all
the patients of burns surveyed over a 7-year period had ear
burns.80 Ear deformities due to burns may range from mild
discoloration of skin to complete loss of the external ears. A
burnt ear may have the following deformities:
1. Mixed pigmentation scars without contour deformities
2. Hypertrophic scars and keloids

459.e1
Reconstruction of specific areas
A thin tube pedicle is best suited to reconstruct a pure helical
rim defect. This tube can be constructed from the postauricular
skin. Care should be taken to defatten it well so that it does
not become floppy.91 More often than not, it needs more stages
than planned, as even after inset into the defect step deformi­
ties of the edges may need correction. If postauricular skin in
not available, suprascapular skin can be used for the same.82,92
Partial helical rim defects could also be managed by the
chondrocutaneous advancement flap as described by Antia
and Buch,93 composite graft from the opposite ear, or advance­
ment flap from the retroauricular region preferably with a
strut of cartilage inside it.94
Upper third defects can be reconstructed by helical advance­
ment technique banner flap,95 contralateral conchal cartilage
graft,96 or a conchal flap.97
Middle third defects are best repaired by the tunnel technique
of Converse or by a cartilage graft and adjacent skin
flap.98–100
Ear lobe reconstruction is best done using the postauricular
skin. Soft and supple skin, even if scarred, can be used. If the
skin is scarred, a delay may be done to increase the vascular
safety of the flap. The undersurface of the flap may be covered
by a skin graft or it can be folded on itself or a turnover flap
from the anterior ear can be used to cover it.98,101,102

460
SECTION III
CHAPTER 20 • Management of the burned face
its concomitant problems of excessive tearing, exposure kera­
titis, and corneal ulceration.
Some salient principles that must be followed for release of
lid ectropion are as follows:
1. Recognize whether it is an intrinsic or extrinsic contracture.
It is very important to know whether the ectropion is
intrinsic or extrinsic. The eyelid being a mobile structure
with a free border is very easily pulled by the
surrounding tissues as they are healing and may easily
develop an ectropion or scleral show due to the tight
scar above or below it.121,122 In extrinsic contractures,
excision of the offending scar will reposition the eyelid.
In intrinsic contractures, it is usually the skin and
orbicularis that is involved and the deeper tissues are
Eyelids/periorbital region
Though the eyelids and periorbital region are injured often
in burns, globe injury is not as common due to the blink
reflex as well as the reflex protective mechanisms of the
body to save the face and eyes. More often than not eyelids
are injured due to exposure to the dry heat of fire and not
due to direct contact with fire.82 Ophthalmic injury with
facial burns has been reported ranging from 4% to 36% of
facial burns with 13% having direct corneal injury.113–115
Corneal injuries have been reported to occur more often
with chemical burns and in some other reports due to flame
burns.113–117
Smith et al. reported that short-term ophthalmologic com­
plications after burns included eyelid burns, corneal abrasions,
vision loss, high intraocular pressure, and surface discomfort.
Long-term complications included eyelid retraction, lagoph­
thalmos, trichiasis, ectropion, vision loss on follow-up, and
need for surgery, and its risk factors were wound infection
with Pseudomonas or Acinetobacter, third-degree burn, hours
to ophthalmology evaluation, time on mechanical ventilation,
and need for split-thickness skin graft.118
Eyelid deformities due to burns may range from mild
discoloration of skin to complete loss of the eyelids (Fig.
20.21). The severity and extent of the eyelid scarring or defor­
mity will depend on the nature, intensity, and duration of the
exposure to the heat source.82 A burnt eye and periorbital
region may have the following deformities:
1. Mixed pigmentation scars without deformity
2. Hypertrophic scars and keloids
3. Ectropion, lid retraction
4. Canthal deformities
5. Symblepharon, entropion, blepharostenosis, canalicular
stenosis
6. Partial loss of the eyelid
7. Complete loss of the eyelids.
Eyelid retraction and ectropion are the commonest sequelae
of periorbital region burns.119,120 Depending on the severity of
the deformity, the ectropion or eyelid retraction will lead to
eversion of the eyelid with exposure of the conjunctiva and
Fig. 20.20  (C) More than half ear deformity.
(D) Reconstruction with postauricular skin and
costal cartilage graft.
C
D
Fig. 20.21  Right upper and lower eyelid contracture with corneal opacity.

460.e1
Reconstruction of specific areas
A
B
(A) Upper third ear deformity. (B) Reconstruction
with postauricular skin and costal cartilage graft.
Fig. 20.20

461
Reconstruction of specific areas
incision on the upper lid should be a few millimeters from the
lid margin. It should extend medially beyond the medial
canthus onto the nose and laterally beyond the lateral canthus,
at all times staying above the canthal line. The straight line is
opened up like a “Y” on both ends of the incision. Fishtailing
of the incision at both ends helps to avoid a re-contracture as
well as break any vertical scar bands, which are often present
along the lateral or the medial canthus region. The incision
should be deepened to full thickness of the scar tissue such
that a complete release is obtained. Occasionally one may
have to cut through the fibers of the orbicularis. Skin above
and below the incision is dissected allowing it to slide back
such that there is overcorrection. Excision of the folded and
bunched-up scarred skin along the edges of the incision and
in continuity with it as much as required is performed. Gentle
traction on the stay sutures will help facilitate a complete
release. Waiting adequate time after infiltration with tumes­
cence solution helps keep the field clean and relatively blood­
less. Hemostasis should be achieved using a bipolar cautery
and gentle pressure. Though there are many surgeons who
prefer to use split-thickness skin grafts for the upper eyelids,
the authors’ choice is to use a thin, hairless full-thickness graft
either from the postauricular region or the supraclavicular
region. If these are not available, then one can opt to resurface
with a split medium-thickness graft from the blush areas or
scalp or a full-thickness graft from any other donor site.
Lower lid release
The lower lid release is similar to the upper lid release in most
aspects of surgery. The incision should be a gentle C-shaped
one such that it parallels the line of the lid margin. The lateral
end of the incision should extend downwards into an imagi­
nary crow’s feet line. The release and scar excision should be
such that the graft is placed from the lid margin to the infra­
orbital margin. Again, overcorrection is the key to avoiding a
re-contracture. Even after all efforts at overcorrection, the
re-contracture rates of eyelid ectropions are high. After release,
ideally the defect should be covered with a very thin flap so
as to avoid re-contracture. As the adjacent areas are also often
scarred and unavailable, skin grafts are the usual mode of
cover. A full-thickness graft from the opposite eyelid, postau­
ricular region, or the supraclavicular region is the graft of
choice. If these are not available, then one can opt to resurface
with a full thickness graft from any other available area of the
body. An effort should be made to color match the graft of the
lower lid to the cheek skin.
Calculation of graft requirement
A template of the required full-thickness graft is made after
traction on the lid suture such that the defect is maximized.
This template is used to mark the required graft area on the
donor site. Suturing is done edge to edge with 6-0 prolene
suture in a continuous manner so that there are no free tips
of the cut sutures that may injure the cornea. In case addi­
tional interrupted sutures are required, the ends are kept
long and taped down till removal. At the end of suturing the
graft bed is flushed out with normal saline to confirm that
there is no hematoma beneath. Dressing is done using a
medicated tulle grass dressing, 1 cm thick foam, and a thin
pliable stainless steel mesh, all cut to the size of the template.
After the tulle grass is placed on the graft, the foam and the
usually not violated. Direct thermal injury to the levator
or the tarsus is very rare and such severe full-thickness
lid injuries can occur in case the person falls
unconscious over the heat source.82
2. If both lids are involved, do not treat both lids
simultaneously. One can opt to do the more severe
contracture first. When in doubt (or in case the cornea is
exposed), it is more prudent to release the upper lid
contracture first. It is the author’s preference to do the
second release after about 12 weeks to give adequate
time for the graft to settle and remain in good stretch in
the early phase. The chances of re-contracture will be
much lesser if the new graft can be splinted for a period
of at least 2 to 3 months before embarking upon the
other lid.
3. If both sides are involved, operate on one side at a time. As
the dressing involves closing the eye completely,
operating on both sides would mean that the patient
would be temporarily blinded due to the dressings, and
this can be very incapacitating for an adult.
4. Keep a low threshold for release. If possible, in immature
minor contractures, release should be delayed till the
scar matures. Aggressive scar massage and eye exercises
should be begun to help in scar stretching. But one
should keep a low threshold for scar release, as
occasionally even if the patient can close the eye
actively; it tends to open up while sleeping. Taping the
eyelids may help along with the trial of conservative
management. It needs to be kept in mind that when
operating on an immature scar, the chances of
re-contracture are very high
5. Full esthetic subunit of the eyelid should be covered with a
graft.
6. The release incision should extend all the way from the medial
to the lateral canthus. Fishtailing or making darts at the
extremities of the incision helps to release any medial or
lateral bands.
7. Always overcorrect to avoid a re-contracture.
8. Ideal qualities the graft should possess – thin, hairless,
full-thickness graft. Though the ideal graft will be from
the other lid, postauricular skin or graft from the
supraclavicular area are the next best choice. If these are
not available, then it would be better to use a split
medium-thickness graft from the blush areas or scalp
instead of a thick split-thickness graft.82
9. Color match the lower lid to the cheek. Given a choice, if
there is inadequate graft available of blush areas, it
would be better to use the matching graft for the lower
lid as any color mismatch is more obviously seen in the
lower than the upper lid.
10. Save the best for the last. Do not use the best grafts from
the blush regions if they are limited if re-contracture is
expected or inevitable. Save them for the last surgery.
Technical pointers for ectropion release
Upper lid release
Infiltrate large amounts of tumescence solution into the scar
and wait for a minimum of 10 min before making the incision.
Two or three temporary lid margin stitches are taken and the
suture threads kept long for traction during surgery. The

462
SECTION III
CHAPTER 20 • Management of the burned face
Flaps
For lower lid defects, if the surrounding skin is available, one
could proceed with any of the locally available flaps according
to the surgeon’s choice and familiarity. Superiorly based naso­
labial flaps, inferiorly based temporal flaps, medial, lateral
or bipedicled orbicularis oculi myocutaneous flaps, Tripier
flaps, lateral orbital flaps, etc., have been described.82,123–126
Occasionally one may have to delay these flaps, especially if
they are being raised from scarred skin.
Facial suspension can be a good ancillary tool for lower lid
extrinsic ectropion to correct any residual drooping. An endo­
scopic technique of suspension has been described with low
morbidity and good results.127 The same principles were used
as for aesthetic facial suspension with good results.
Partial or complete loss of the eyelids
The reconstruction of a lid loss is dependent on the available
tissues in the other lid and the surrounding area. If local
tissues are available, then the usual techniques of lid recon­
struction can be followed, as done for trauma or oncologic
reconstruction. In case there is no local tissue available and
there is full-thickness lid loss, distant flaps lined with cartilage
and mucosa need to be brought in to reconstruct the eyelids.
The authors’ preference is for a free radial artery forearm flap,
which is a good option because of its thin, pliable nature. Even
so, flap thinning is almost always required at a later date. As
a second stage the palpebral fissure is created. If contracted
and rolled up conjunctiva is present, it can be opened up and
used to avoid a mucosal graft. Chen Jiaqi et al. used acellular
dermal allograft instead of cartilage as a tarsus substitute and
covered it with orbicularis muscle. They concluded that the
allograft appeared to be biocompatible and does not aggravate
the inflammation in the injured eyelid.128 For completely
destroyed eyelids in the acute setting, Kai Liu et al. have
described suturing the conjunctiva and resurfacing with skin
grafts to save vision.129
The final goal in eyelid reconstruction is to provide a
mobile, supple and esthetic lid that can fulfill its protective
function.
Nose
The nose is not only central on the face but also has projection.
Owing to these properties it tends to be involved in a large
percentage of facial burns. Nasal distortions cannot be cam­
ouflaged as easily as the ear, which can be hidden with long
hair. Also, post-burn deformities of the nose cause not just
aesthetic problems but they may also cause functional prob­
lems like difficulty in breathing due to nostril stenosis.
The post-burn sequelae of the nose could be anyone or all
the following82:
1. Altered surface texture or discoloration
2. Elevated nasal tip and alar margins (ectropion)
3. Scarred and shortened columella
4. Full-thickness loss of parts of the nose (most often nasal
base, tip, and/or ala)
5. Nostril stenosis or a complete block of passage.
Achauer classified burned nasal deformity into five types130:
without major tissue loss (cutaneous issues only); ectropion
(elevated nasal tip and alar margins); subtotal tissue loss
mesh are sutured into the margins of the defect. The foam
gives gentle constant pressure, and the stainless steel mesh
provides splintage and immobility to the grafted area (Fig.
20.22B). First graft dressing is done on day 10 directly, by
which time the graft has usually taken well and is stable.
The graft can then be lubricated with liquid paraffin and
covered for another week to 10 days so that it is kept in a
maximally stretched position. Further to this period, the
patient is asked to gently massage the graft in the direction
opposite to that of the contracture (downwards for upper lid
contractures and upwards for lower lid contractures). Exer­
cises to open and close the lid tight are also explained to
keep the graft and the lid supple. Direct sun exposure is to
be avoided for about 3 to 6 months to avoid pigmentary
complications. This is important more so in the darker-
skinned races. Custom-made devices to keep the lid in
stretch with padded thermoplastic material can be used at
night along with taping of the lid for 6 months.
A
Fig. 20.22  (A) Full-thickness graft sutured in place. (B) Dressing using foam and
mesh.
B

462.e1
Reconstruction of specific areas
Canthal deformities
Both the canthi often develop scar bands and folds. Medial
epicanthal folds can be released by the Mustarde “jumping
man” flap. Canthal folds and bands can also be released by
the single, multiple, or double opposing Z-plasty. In the lateral
canthal region local flaps can be done after release. If the scar
is very tight and contracted, occasionally full release may not
be obtained with the Z-plasty. In this situation, the Z flaps can
be sutured in place as far as they reach and full-thickness
grafts should be inserted into the residual raw areas created.
For medial canthal region scars, silicone gel sheets may be
glued to spectacle nose pads to keep them in place. The
spectacles can also be provided with an elastic band on the
back to tighten it to give pressure on the medial scars.
Symblepharon, entropion, blepharostenosis, and
canalicular stenosis
These deformities are not seen commonly post-burn. They
may occur in cases of chemical burns if the blink response has
been slow or large amounts of chemical has been thrown on
the face as occurs in survivors of homicidal acid burn. Sym­
blepharon can be managed by Z-plasties or release and
mucosal grafting according to its severity. In cases of entro­
pion, the cause should be looked for and conjunctival contrac­
ture released or repositioning of the eyelid margin done. If no
conjunctival contracture is appreciable, the offending eye­
lashes can be ablated by electrolysis. Blepharostenosis can be
managed by separating the two lids with a horizontal incision
and suturing the skin and mucosa with 5-0 vicryl. The length
of the stitches should be kept long so that they can be taped
down to the skin until removal or else they may abrade the
cornea. Depending on the severity of the burn injury to the
canalicular system and the presence or absence of epiphora,
these injuries can be managed by dilatation of the canaliculus,
temporary stenting, or dacryocystorhinostomy.

463
Reconstruction of specific areas
before the advent for microvascular surgery. Some innova­
tive distant pedicled flaps have also been described for nasal
reconstruction in the absence of forehead skin.137
Figs. 20.18 & 20.24C appear online only.
Skeletal support: Cartilage or bony support is rarely needed
for post-burn sequelae. If required, costochondral cartilage
grafts, stacked septal cartilage grafts, split rib grafts, split
calvarial grafts, or iliac crest grafts can all be used. It is prefer­
able to use autogenous material as compared to substitutes
like silicone implants or porous polyethylene implants as they
can erode through tissues and get exposed. When skeletal
support is being provided, it is essential to make sure that
there is adequate soft-tissue cover over the bone or cartilage.
Nostril stenosis or complete block: Loss of cartilaginous
support and inadequate care in the healing phase can lead to
a complete nostril block. The block is very rarely deep and,
after scar excision, one usually finds the nasal mucosa about
5–10 mm from the nostril rim (Fig. 20.25). Overcorrection
should be attempted as the grafts tend to contract and the
nostril opening reduces to a certain extent. After creating the
nostril opening, the raw area on the undersurface should be
grafted with a thick split-thickness graft or a full-thickness
graft. One way to do this is to drape the graft on a mold and
pack it into the newly opened up nostril. Graft dressing
should be done early if the mold blocks the nostril completely.
The authors create a mold of dental stent material with a red
rubber catheter in the middle so that the patient can breathe
through it and secretions can drain. In this situation, the dress­
ing can be done on the 7th postoperative day. Postoperatively,
it is imperative for the patient to wear a nasal stent for at least
6 months.
The goal of nasal reconstruction is to create a nose that is
aesthetically pleasing, has projection, and does its functional
job of breathing.
Cheeks
The preeminence and large proportion of the face the cheeks
occupy define its unique characteristics as an anatomic unit.
(more than the nasal tip but not whole nose); extensive tissue
loss; and nostril stenosis.
Just as in the ear, avoidance of pressure, topical treatment,
and use of splints go a long way in the reduction of nasal
deformities.
As the nose has many components, deformity of one will
affect the other. Hence, it is very important to evaluate what
could be the cause of the deformity; for example, is it a tight
scar that is causing the nostril show or is it actual tissue loss
of the alar rim or is it a tight scarred deformed lining.
Reconstruction of the post-burn nose follows the same
principles as those of reconstruction of the nose due to trauma
or oncologic defects. An evaluation of whether the nose needs skin
cover, lining, and or skeletal support is the first step in planning
reconstruction. This will help one choose the reconstructive
option. The availability of supple forehead skin is a boon in
nasal reconstruction.
Altered surface texture or discoloration: Lasers or other
methods of dermabrasion can be used for ablation, and resur­
facing can be done with super-thin graft.
Elevated nasal tip and alar margins (Fig. 20.23): Everted nos­
trils have been corrected with circumferential release of the
tissues around the nostril rims, turndown of the resulting
vestibular flaps, and grafting of the tip defect.131 This principle
has been effectively demonstrated by Helena et al. in their
2009 paper in which they conclude that the efficacy of the
nasal turndown flap is twofold – that it provides substantial
bulk for nasal tip projection as well as tip and lobule recon­
struction without the need for cartilage grafting even in severe
ectropions and that it may be repeated with the passage of
time and growth of the patient.132 After a turndown, the defect
can also be reconstructed with nasolabial flaps to receive like
tissue.133 A composite graft from the helical rim is also an
option to add tissue in a case of nostril ectropion release. Skin
grafts used on the nasal dorsum should be thick split-thickness
grafts or full-thickness grafts from the postauricular, supra­
clavicular, or medial arm region.
Scarred and shortened columella: The nasolabial flap can be
used to reconstruct the columella. Even if it is scarred, this
tissue would be the best match. A forehead flap can also be
used for columella reconstruction.
Full-thickness loss of parts of the nose (usually nasal base, tip,
and or ala): If there is a composite defect, then graft is not an
option.
Cover: For smaller defects local flaps like the Banner flap,
bilobed flap, dorsal nasal flap, or nasolabial flaps may be
utilized. A galea frontalis myofascial flap has been described
by Sharma and Sohi for the cover of nasal bones.134
For larger defects, the median or paramedian forehead
flap is the best choice. Forehead flaps are the flap of choice
for all nose reconstructions as they can reach all the way to
the columella, are reliable flaps, and have an ease of dissec­
tion. If the forehead is scarred but supple, it can be used for
reconstruction. If the tissue of the forehead is inadequate, it
can safely be expanded and used for nasal reconstruction
(Fig. 20.24
).135 If midline and paramedian forehead is not
available, the scalping flap can be done if lateral forehead skin
is available. If forehead skin is not available, then free flaps
like the radial artery forearm flap (see Fig. 20.18) or fascial
flaps with skin graft can be used for nasal reconstruction.136
The Tagliacozzi flap is a distant pedicled flap from the medial
arm that was used extensively earlier for nose reconstruction
Fig. 20.23  Elevated nasal tip and alar margins.