Burn Reconstruction Research Articles

Post-burn upper, mid-face and nose reconstruction using a unilateral extended superficial temporal artery-based flap

Facial burns represent between one-fourth and one-third of all burns [1]. Deformities resulting from a totally burned face present as a profound challenge to the reconstructive plastic surgeon. Burns of the head and neck present a particularlycomplex problem, as they involve critical structures, important functionally and cosmetically; they are usually extensive, involving adjacent tissues, limiting reconstructive possibilities. Whether acute facial burns should be excised and grafted is still controversial [10]. Traditionally, skin grafting has been used for resurfacing but with limited success in case of damage of the deeper facial structures. When possible, loco-regional flaps are themethod of choice. When the burns are extensive, adequate amounts of reliable regional tissue are not available. The use of tissue expanders or expanded full-thickness skin grafts is another alternative [2,11,15]. Free tissue transfers and prelaminated flaps have revolutionized burn reconstruction. Angrigiani et al. reported a novel method for total face reconstruction using the bilateral extended scapular free flaps. The donor site morbidity is, however, relatively high with a large scar extending across the entire back and, moreover the nose needs separate reconstruction [3]. Fujiwara et al. [3] used a single large free flap resulting from expansion of the back skin for reconstruction of the entire face including the nose. However, free flaps

Microvascular Reconstruction in Burn and Electrical Burn Injuries of the Severely Traumatized Upper Extremity

As the versatility and variability of free flaps have significantly increased during recent years, so have the indications for free tissue transplantation in burn reconstruction expanded. The authors report retrospectively the results of 42 free flaps for upper extremity reconstruction in 35 severely burned patients using 13 different free flaps. This experience enabled the authors to establish reconstructive principles pertinent to the type of injury (burn versus high-voltage injuries) and the timing of reconstruction procedures. In high-voltage injuries (n = 17), early free flap coverage with muscular flaps was the most frequently used type of reconstruction. The reconstruction site was predominately the forearm. In burn injuries, free flap coverage was performed during a later stage of the treatment course. Reconstruction with cutaneous or fascial flaps was the preferred method. The elbow and dorsum of the hand underwent defect coverage in most circumstances. For reconstruction of complex or large defects (n = 6), combined "chimeric" flaps were used. Overall, the flap failure rate was 12 percent (n = 5). Interestingly, there was a relationship between flap failure rate and timing of the procedure. Four of five flap failures occurred within 5 to 21 days after trauma, and all five flap failures occurred between 5 days and 6 weeks. No flap failure occurred during secondary reconstruction. The authors' data demonstrate that burn and high-voltage injuries are distinct entities, each requiring custom-tailored reconstructive solutions for limb salvage. Even if the authors' flap failures all occurred during the first 6 weeks, it should not be forgotten that this type of coverage is the only alternative to amputation in selected cases.

The Perforator Pedicled Propeller (PPP) Flap Method: A Report of Two Cases

Perforator flaps are thin free-tissue transfers consisting of skin and subcutaneous tissue which have the advantage of decreasing donor site morbidity. We have reconstructed postburn scar contractures using "propeller flaps" of the remaining healthy skin around the recipient sites. In this paper, we report on two cases and describe the concept of using "perforator flaps" and "propeller flaps" together as what are called "perforator pedicled propeller (PPP) flaps." Patient 1 was an 18-year-old man with a sacral pressure ulcer. The soft tissue defect was reconstructed with a rotated superior gluteal artery PPP flap. Patient 2 was a 53-year-old woman who presented with an open fracture of the right elbow. The skin defect over the fracture was covered with a rotated deep brachial artery PPP flap raised on the lateral upper arm. The PPP flaps are useful for burn reconstruction and repairing various types of wound. Moreover, microsurgery is unnecessary. The PPP flap may be classified into two types: the central axis type and the acentric axis type. The central axis PPP flap is significant when used as a 90-degree-rotation island flap, and the acentric axis PPP flap is significant when used as a 180-degree-rotation island flap. Both types are easy to harvest and useful for repairing various kinds of wound.

Depression in burn reconstruction patients: symptom prevalence and association with body image dissatisfaction and physical function

Objective This study investigated the prevalence and the clinical correlates of symptoms of depression among burn reconstruction patients. Method A sample of 224 burn reconstruction patients completed the Beck Depression Inventory (BDI), the SF-36 Health Survey and the Satisfaction with Appearance Scale. Results The prevalence of at least mild to moderate symptoms of depression (BDI ≥10) was 46%. Female patients were disproportionately represented in this burn reconstruction population (46%) compared to all survivors from the burn center (29%; P<.001) and compared to a national sample of burn survivors (27%; P<.001). Compared to males, female patients presented for consultation much longer after a burn injury ( P<.001), tended to have smaller burns ( P=.06) and were less likely to have facial burns ( P=.08). Depressive symptoms were largely predicted by body image dissatisfaction ( β=.58; P<.001), with additional variance predicted by physical function ( β=−.13; P=.07). The effect of patient and burn injury variables on depressive symptoms was mediated by body image dissatisfaction and physical function. Conclusion The high prevalence of significant symptoms of depression in burn reconstruction patients and their relationship with body image suggest the importance of the routine psychological screening of patients seeking reconstruction services.

Burn reconstruction in a developing country—What

Burn reconstruction in a developing country—What

Silver dressings: The need for evidence based medicine

For 2010, roughly 1446 original burn research articles were published in scientific journals using the English language. This article reviews those with the most impact on burn treatment according to the Editor of one of the major journals (Burns) and his colleagues. As in previous reviews, articles were divided into the following topic areas: epidemiology, demographics of injury, wound characterisation and treatment, critical care, inhalation injury, infection, metabolism and nutrition, psychological considerations, pain and itching management, rehabilitation and long-term outcomes, and burn reconstruction. Each paper is considered very briefly, and the reader is referred to full manuscripts for details.

Split-skin graft (SSG) adherence: Correlation with albumin levels, presence of oedema

Split-thickness skin grafting (SSG) is a technique used extensively in the care of burn patients and is fraught with suboptimal graft take when there is a less-than-ideal graft bed and/or grafting conditions. The technique of Negative Pressure Dressing (NPD), initially used for better wound healing has been tried on skin-grafts and has shown to increase the graft take rates. However, comparative studies between the conventional dressing and vacuum assisted closure on skin grafts in burn patients are unavailable. The present study was undertaken to find out if NPD improves graft take as compared to conventional dressing in burns patients.Consecutive burn patients undergoing split-skin grafting were randomized to receive either a conventional dressing consisting of Vaseline gauze and cotton pads or to have a NPD of 80 mm Hg for four days over the freshly laid SSG. The results in terms of amount of graft take, duration of dressings for the grafted area and the cost of treatment of wound were compared between the two groups.A total of 40 split-skin grafts were put on 30 patients. The grafted wounds included acute and chronic burns wounds and surgically created raw areas during burn reconstruction. Twenty-one of them received NPD and 19 served as controls. Patient profiles and average size of the grafts were comparable between the two groups. The vacuum closure assembly was well tolerated by all patients. Final graft take at nine days in the study group ranged from 90 to 100 per cent with an average of 96.7 per cent (SD: 3.55). The control group showed a graft take ranging between 70 and 100 percent with an average graft take of 87.5 percent (SD: 8.73). Mean duration of continued dressings on the grafted area was 8 days in cases (SD: 1.48) and 11 days in controls (SD: 2.2) after surgery. Each of these differences was found to be statistically significant (p < 0.001).Negative pressure dressing improves graft take in burns patients and can particularly be considered when wound bed and grafting conditions seem less-than-ideal. The negative pressure can also be effectively assembled using locally available materials thus significantly reducing the cost of treatment.

Facial burn reconstruction: A continuum between early surgery, pressure therapy and reconstructive procedures

Facial burn reconstruction: A continuum between early surgery, pressure therapy and reconstructive procedures

Microvascular free flap reconstruction in burns injuries

Comprehensive management of acute neck burns is directed towards a satisfactory aesthetic and functional result. Primary microsurgical burn reconstruction of the anterior neck may offer advantages over the traditional technique of skin grafting and delayed reconstruction. It can be indicated in selected patients, obtaining good aesthetic results, with earlier functional recovery and reducing the number of surgical procedures required.

Horseshoe expanded free flap decreases venous congestion in facial free flap burn reconstruction

Horseshoe expanded free flap decreases venous congestion in facial free flap burn reconstruction

Facial burn reconstruction: A continuum between early surgery, pressure therapy and reconstruction

Facial burn reconstruction: A continuum between early surgery, pressure therapy and reconstruction

Dual benefit procedures: Combining aesthetic surgery with burn reconstruction

Burn accounts for a significant proportion of injuries, and of these, the face, neck, and anterior torso are commonly affected. Burn scars remain a lasting reminder of the insult both for the patient and the outside world. There is little doubt that the changes in appearance, and limitations imposed by the burn scar contribute to a negative body image. We present a series of four women, who sustained full thickness burns in childhood with subsequent burn scarring and contracture. These women were noted to have poor body image in areas less affected by burn injury, notably breast ptosis, breast asymmetry and abdominal skin laxity. They were suitable candidates for planned aesthetic procedures, and the skin excised was used to effect synchronous burn reconstruction or contracture release. We believe the potential to use areas of skin excised during aesthetic procedures as possible donor sites of full thickness skin, confers the dual benefits of improved aesthetic and functional outcome, while minimising unnecessary donor site morbidity.

Erfahrungen mit der distal gestielten, dorsalen Metakarpalarterien (DMCA)-Lappenplastik und ihren Varianten in 41 Fällen

Distally based DMCA flaps are an established procedure for soft tissue reconstruction in the hand. Since the introduction of the DMCA flaps, several variants have been developed to match specific defect requirements. The aim of this retrospective study is to give an overview of the experience with the DMCA flaps based on a single center's experience. 41 distally based DMCA flaps have been performed from 2000 to 2004. Twenty-nine times a distally based DMCA flap has been performed, nine times the extended distally based DMCA flap and three times a distally based DMCA fascial flap. In summary, 34 flaps showed no complications, five had a partial necrosis, but were successfully treated with split-thickness skin graft, and two flaps were lost due to infections. The distally based DMCA flaps II to IV have proven to be reliable flaps, but nevertheless require sufficient surgical experience. They are suitable for any kind of defects, including burn reconstruction. Defects of the entire finger can be covered by the various variants of the DMCA flaps.

The use of artificial dermis for reconstruction of full thickness scalp burn involving the calvaria

The incidence of extensive full thickness scalp burn involving the calvaria is rare and can be very difficult to reconstruct, as the application of local or free tissue transfer is limited. Although wound closure can be achieved with bone debridement and immediate or delayed split-thickness autografting, the result may be problematic due to unstable skin graft surface. The use of artificial dermis that may provide stable thick coverage in the treatment scalp and skull burn has rarely been reported in literature. We encountered two patients who suffered from severe head burns involving the calvarium. Following debridement including the necrotic bone, the artificial dermis (Integra) was used for immediate wound coverage which was 15 cm × 10 cm in one case and 5 cm × 6 cm in another. Three weeks later, ultra-thin skin grafting was placed on the neodermis. Compared to split-thickness skin graft, this technique provides a thicker coverage for wound closure. Neither skin breakdown nor ulceration was noted in the 1-year follow-up. This paper reports the successful use of artificial dermis for reconstruction of severe scalp burn with calvarial bone involvement.

Surgeons and scars: Differences between patients and surgeons in the perceived requirement for reconstructive surgery following burn injury

Background Reconstruction of the burn patient presents a challenge to the burns surgeon. The variety of issues and the timing of surgery can be a daunting task. A group of 11 patients who were injured 1 year previously at the time of the Bali bomb blast were reviewed. Methods A customised assessment form was developed in order to quantify the patient's perceived need for reconstruction. Each patient was asked to prioritise, in order of preference any injured area they might consider for further surgery. These patients were then assessed independently by a consultant plastic and reconstructive surgeon and a senior trainee, using an identical form. The surgeons were asked to prioritise, in order of preference any area they might consider for further surgery and to indicate from a list the procedure they would employ. This list ranged from simple excision to free flap encompassing the entire reconstructive ladder. Results The patients all showed a strong reluctance to undergo further reconstruction. However there was a strong correlation between the surgeons, concurring on issues of function but there were discrepancies regarding “aesthetic” reconstruction. Conclusions This study highlights the absolute need for secondary burns reconstruction to be a patient driven service.

Linear Elasticity of Upper Extremity Skin in Normal Individuals: Objective Criteria for Use in Skin Grafting and Post-Operative Splinting

Skin grafting over joints in the upper extremity often leads to contractures and decreased range of motion. While this is due in part to the natural wound healing process, grafting techniques and post-operative splinting may also impact the development of contractures. The goal of skin grafting for burn reconstruction is to graft a sufficient amount of skin and to restore normal function with minimal contracture. This study was undertaken to quantify the amount of skin stretch in normal individuals across joints in various anatomic positions. There are significant differences in skin stretch across critical joints in the upper extremity when comparing neutral position, full flexion, and full extension. Anatomic landmarks were used to standardize measurements for normal subjects included in the study. The landmarks were as follows: the finger (tip of index finger to dorsal proximal wrist crease immediately distal to the Lister's tubercle), elbow (ulnar styloid to the posterior axillary fold), and shoulder (ulnar styloid to the anterior superior iliac spine) The distance of skin stretch across each joint was measured and recorded in both flexion, extension, and/or neutral position. Differences were calculated. Paired students t-tests and correlation statistics were performed to compare differences.

Regional Sensory Nerve Blocks of the Scalp Decrease the Incidence of Post-Operative Nausea and Vomiting in Reconstructive Burn Children: A Pilot Study

Regional Sensory Nerve Blocks of the Scalp Decrease the Incidence of Post-Operative Nausea and Vomiting in Reconstructive Burn Children: A Pilot Study

Late management of burns

Certain sequelae are expected after burn injury. The degree to which these sequelae affect the individual depends on the type of the injury, initial treatment and the patient. The late effects of burn injury are related to the loss of normal tissue and its replacement with scar tissue. Scars may be itchy, lumpy, discoloured and unsightly. They exert greater effect if they replace tissues with previous complex function: scars may limit movement, impair vision, make mouth opening difficult, cause pain, and otherwise prevent activity. Many patients have scars involving multiple sites, which affect many different functions, are aesthetically displeasing, and cause social embarrassment. The key to post-burn care is scar management, affecting improvement with therapy and surgery, in addition to promoting psychological acceptance and social reintegration. Burn management takes place within a multidisciplinary team (surgeon, anaesthetist, nurse, physiotherapist, occupational therapist, social worker, psychotherapist, dietitian, pharmacist, paediatrician). On completion of initial treatment, regular review is required to determine how the patient is managing the activities of daily life and to determine if he is experiencing problems. The review process assesses the function and aesthetic appearance of the burned area, assesses burn scarring and identifies areas to which treatment should be directed. The review process continues for many years. This contribution focuses on acute care, medical management of scars and burn reconstruction.

Glabrous Dermal Grafting: A 12-Year Experience with the Functional and Aesthetic Restoration of Palmar and Plantar Skin Defects

Glabrous skin on the palmar aspect of the hands and the plantar aspect of the feet has special attributes. These attributes define the skin on the palm, fingers, and sole as functionally and aesthetically different from skin on other parts of the body. When there is a glabrous skin defect, it should be replaced with similar skin to restore function and aesthetics. The authors report their 12-year experience with the technique of glabrous dermal grafting for the reconstruction of palmar and plantar skin defects. From 1992 to 2004, 13 patients with 14 defects underwent glabrous dermal grafting of either palmar or plantar defects. Defects included nine hand and five foot defects. Causes included nine acute burns, one secondary burn reconstruction, two delayed reconstructions of traumatic injuries, one congenital nevus, and one malignant melanoma. Donor sites included 12 glabrous dermal grafts from the foot and two from the hand. Follow-up ranged from 1 month to 65 months. All glabrous dermal grafts demonstrated complete epithelialization and no incidence of complete loss. There was return of sensation without hyperkeratosis or breakdown. The grafts demonstrated good color match with the surrounding skin. The donor site healed without complications, and there were no incidences of significant hypopigmentation, hyperpigmentation, or hypertrophic scarring. Glabrous dermal grafting of palmar and plantar defects is the ideal way of reconstructing glabrous skin to restore both function and aesthetics and minimize donor-site morbidity.

Outpatient Use of Integra(r) and Subatmospheric Pressure in the Management of Wound and Burn Reconstruction

DeRoberts, Dean MD; Park, Christopher A. MD; DeFranzo, Anthony J. MD; Marks, Malcolm W. MD; Molnar, Joseph A. MD, PhD