Burn Reconstruction Research Articles

Splints And Accessories Following Burn Reconstruction

Splints, exercise, traction, and compression garments are commonly accepted methods to minimize disabling scar formation. Although burn rehabilitation treatment has improved over the past 10 years, there is still no overnight cure for scars and contracture. The extent and depth of the burn injury, emotional strength and patience of the burn victim, and support systems available play an important role in scar treatment. Scar contracture is a frustrating complication for the recovering patient and burn team. Surgical reconstruction to correct functional impairment is often needed before wound maturation is complete. Splints are usually part of the postoperative treatment plan. When this is the case, patient understanding, compliance, motivation, and comfort are important to assure splint effectiveness. The treatments reviewed are specific for scar contracture limiting function of the upper body. Although they were presented as treatment of neck, mouth, axilla, and hand contractures, many of the principles and materials can be used after burn reconstruction of the lower extremities. Regardless of the area treated, assessment of patients is important to determine their specific needs in splint design.

Reconstructive Goals for Children with Burns: Are Our Goals the Same?

It is often difficult if not impossible to include a pediatric patient in the planning of burn reconstruction. To give the patient greater input into his or her reconstructive plan, we developed a survey tool to evaluate the different reconstructive goals of the patient, the parent, and the physician. Each patient, parent, and physician were requested to complete a separate goal form. Each form consisted of a simple line drawing of a child that shows both anterior and posterior views. The patient, the parent, and the physician were each asked to circle the desired reconstruction site or sites. The responses were collated and compared by sex, age, size of burn, and evaluator (patient, parent, or physician). Patients indicated fewer and different desired reconstruction sites than the physicians or the parents. Before reconstruction is planned, the patient should be consulted. The desires of the parents and the physician may differ significantly from those of the patient.

Applications and complications of tissue expansion in pediatric patients

We have reviewed our experience with 61 tissue expansions in 49 pediatric patients. Indications for expansion included traumatic alopecia or soft tissue loss, myelomeningocele, congenital hairy nevi, burn scars, and other less common defects. The complication rate, necessitating interruption of expansion, was 25%. This occurred more frequently with scalp and burn reconstruction. Nevertheless, 86% of patients ultimately achieved good to excellent results.

Guo En-tan et al. The evaluation on late reconstruction of electrical burn of the forearm. (Chinese) Chin. J. Plast. Surg. Burns 2

Guo En-tan et al. The evaluation on late reconstruction of electrical burn of the forearm. (Chinese) Chin. J. Plast. Surg. Burns 2

Reconstruction of burned lower extremities by free flaps

Three latissimus dorsi muscle flaps with skin grafts, one latissimus dorsi myocutaneous flap, and one scapular flap were used in reconstruction of deep burns of the heels and calf caused by various agents. The follow-up period was 11 to 46 months. Of the five patients treated, two sustained electrical injuries, two had contact burns and one suffered a degloving injury with a contact burn resulting from a car accident. The latissimus dorsi muscle flaps with skin grafts gave excellent results in reconstruction of the calf and ankle areas due to their large caliber vessels and versatility. The latissimus dorsi myocutaneous flap was indicated in a case with extensive soft tissue loss on the sole of the foot with stiffness of the ankle joint in plantar flexion. A non-sensory scapular flap was satisfactory for reconstruction of the medial half of the heel since the remaining lateral half of the heel provided adequate sensation for weight-bearing and protection. Early reconstruction of the burned lower part of the leg with free flaps shortens hospitalization and prevents further extension of the injury. Reconstruction of a burned distal lower extremity provides a challenge for the reconstructive surgeon due to limited availability of local tissue; there is durable soft tissue in the weight-bearing area and a relatively poor blood supply compared to other areas of the body. The basic requirement in the treatment of a full thickness burn is early debridement and immediate coverage of the defect with a skin graft or a well vascularized flap. Even though multiple local flaps, such as axial [7, 17], muscle [1], musculocutaneous [5], fasciocutaneous [11], and island flaps [4], have been described. These flaps are useful in relatively small wounds with undamaged sourrounding tissues. Electrical injuries are manifested in a variety of clinical and pathologic ways with early, as well as delayed, tissue damage complicating reconstruction. With the advent and refinement of microvascular techniques, it has become possible to reconstruct extensive defects of the distal lower extremity with either free muscle flaps with skin grafts [8], myocutaneous free flaps [10], or axial free flaps [18]. This paper relates our experience in reconstruction of extensive defects of the lower extremities caused by various burning agents.

Fasciocutaneous flaps for burn reconstruction: a report of 57 flaps

We have used 57 fasciocutaneous flaps in 24 patients to correct burn contractures. There were six complications, four of which healed with dressings alone. The flaps were used either locally (22 patients) or as a cross-leg flap (2 patients). The local flaps have clearly shown that grafted areas can be raised as flaps provided that the fascia is included in the flap, and that the flap can also be based distally. Fasciocutaneous flaps have several advantages over the technique of cross-cutting the contracture, followed by split skin grafting. Firstly, there is no skin graft, which may result in further contracture. Secondly, if a patient does not have a skin graft on the secondary defect (83% in this series), the patient has the advantage of a shorter hospital stay. The techniques of the design and raising of fasciocutaneous flaps for burn reconstruction are discussed.

Island flaps in the primary reconstruction of electrical burns

This paper presents a preliminary study of the successful use of island flaps in the primary treatment of electrical burns.

The use of tissue expansion in burn scar reconstruction.

The use of tissue expansion is described in patients with burn-scarred skin. Twenty-six tissue expanders were inserted into seven selected patients undergoing burn reconstruction. Expansion usually was completed rapidly, with injections generally done every two to three days over a three-to five-week period. In only one case did use of an expander fail to result in adequate tissue expansion. Complications included implant exposure (6/26 cases), injection port exposure (1/26), infection (2/26), and transient nerve palsy (1/26). Implant exposure did not preclude continued tissue expansion and ultimate reconstruction. In selected patients, expansion of burn-scarred skin has a definite role in burn scar reconstruction.

Face burn reconstruction—does early excision and autografting improve aesthetic appearance?

Despite improvements in functional rehabilitation secondary to better control of scar and contractures, aesthetic rehabilitation of the extensively burned face has remained a difficult problem. This study was undertaken to evaluate both technique and aesthetic results of early excision and split thickness autografting (STAG) of full skin thickness face burns. Twenty-five patients with full skin thickness face burns were operated on between days 4 and 14 post-burn. Thirteen patients had excision and STAG in one stage. Twelve patients had a two-stage procedure-excision and coverage with a biological dressing followed 24–72 h later by STAG. Seven of these patients had a pressure dressing in the form of a silicone face mask applied at the second stage. Early cosmetic results were encouraging in all patients. Twenty-five per cent of patients later required either contracture release or skin resurfacing. Preliminary results are encouraging and warrant evaluation by surgeons at other centres. When early excision of full skin thickness face burns is undertaken, cautious optimism as to the ultimate aesthetic result, both by the surgeon and the patient, is advisable.

The radial forearm flap in burn reconstruction.

The radial forearm flap in burn reconstruction.

Reconstruction Following Head and Neck Burns

Burn reconstruction of the head and neck must first start with special care to this anatomic area in the early acute phase, with appropriate early débridement and coverage with sheet grafts of medium thickness into unit facial orientation. Postoperative garment and mask splinting, will help lessen the hypertrophic scar formation that frequently follows facial burns and skin coverage. Carefully planned reconstruction of these areas is indicated, with priority given first to the neck, then to the periorbital area, and then to perioral areas. Principles of scalp, ear, nasal, and cheek reconstruction following burns of the face are carefully outlined. The unit concept of burn scar resurfacing of the face has been the mainstay of our treatment. We have emphasized skin coverage of the face from similar donor site areas. The emotional and psychological effects of facial scarring secondary to severe burns are crippling to patients. Although numerous reconstructive surgical procedures may lessen the deformity, ultimately burn patients realize that their burn scars are permanent and no surgeon can give them back their original facial appearance. These patients need strong and continued support and reassurance from their physicians and nursing professional staff to maintain their self-identity and confidence.

The early treatment and reconstruction of eyelid burns.

Eyelid burns occurred in 67% of the 210 patients with facial burns admitted to the San Diego Regional Burn Center between 1 December 1977 and 30 June 1982. Evaluation of 48 surviving patients with significant eyelid injury demonstrated the safety and effectiveness of early excision and grafting of eyelid burns. Tarsorrhaphies were found not to be useful in preventing ectropion and resulted in deformity of the lid margins. Our technique employing early excision and grafting and reconstruction of eyelid burns is illustrated.