Soft Tissue Loss Research Articles

Immediate Loading of Dental Implants with Fixed Prosthodontic Constructions Advantages and Methods

“Immediate loading of implants” implies loading of implants after extraction of a tooth. The goal of our study was to observe the loss of keratinized gums and bone tissue in the region surrounding the alveolar ridge after tooth extraction, and to compare it to the immediate loading of dental implants with the same indicator. Recently, immediate implant placement after the extraction of a tooth with early loading has become more common. The advantages of this procedure include fewer surgical interventions, reduction in overall treatment time, reduced soft and hard tissue loss, and psychological satisfaction for the patient. This study shows the advantages and methods for immediate implant placement with immediate provisional restorations.

When the center cannot hold in conventional orthopedic and trauma treatments, things will not fall apart with linear rail system: A hospital based retrospective study

Background: Distraction osteogenesis is a method of producing unlimited quantities of living bone directly from a special osteotomy (cortico to my). Advances in methods of external fixation have made limb lengthening a feasible option achieved by distraction osteogenesis. Complex trauma cases such as failure of fractures to unite after several attempts, significant soft tissue infection, significant bone loss ab initio, the presence of significant soft tissue loss, or chronic osteomyelitis that may warrant significant bone resection are a nightmare to the surgeon the patient and the patients relations as well. The linear rail system and the Ilizarov device oppose other methods of bone gap management permits the realization of compression, distraction, bone-lengthening, and deformity correction, as such improving the quality of life of the patients, good fracture union with insignificant complications.Methods: A hospital based retrospective study conducted at The Potters Specialist Hospital Jos between January 2018 and December 2020. Patients were recruited following a perusal of the operation register. A proforma was filled which included the patient’s demographics, clinical characteristics. Clinical outcomes during the treatment such union at fracture site, length gained and complications during treatment were included in the proforma. Patient’s quality of life after the treatment was also assessed. Data was analyzed using SPSS version 23.Results: Thirty-six patients were enrolled into the study. Patients mean age was 39.36±10.64. Age group 31-40 accounted for 47.2% of those recruited. Males were 83.3% and complications of fracture management were noticed to account for 22 (61.1%) of the indications for surgery. Those who had two surgeries done during treatment were 27.8% with interval corticotomy counting as a separate surgery. Limb lengthening was done in 52.8% of the patients and the leg was found to be operated limb 75% of cases. Though 72.6% did not develop any problems, among those with problems, pin tract infection was noticed in 13.9%. Similarly, 88.9% had no complications but amongst complications noted limb length discrepancy in 5.6%. All of them had their fractures united and limb lengths equalized to an acceptable level. Regarding quality of life most patients (44.4%) rated it as good and the other 22.2% very good and when asked about the satisfaction their current health 50% said they were satisfied and another 19.4% were very satisfied.There was significant association noticed between quality of life and indications for surgery, between complication and aim of surgery and noticed between complication and length gained.Conclusion: The use of the linear rail system in the treatment of complex major limb fractures yielded satisfactory results with improved quality of life and less problems and complications.

Traumatic brachial artery dissection in a pediatric patient: An interdisciplinary approach to care

Severe traumatic arterial injuries are rarely seen in pediatric patients. Management decisions are often guided by anecdotal experience due to a lack of well documented evidence-based guidelines. This paper demonstrates success with multidisciplinary management and close, structured follow-up in a 5 year old boy with traumatic brachial artery dissection and extensive soft tissue loss.

SURGICAL MANIPULATION OF SOFT AND BONE TISSUE IN CONTEMPORARY DENTAL IMPLANTOLOGY

Adequate and correct manipulation of soft and bone tissues during implant therapy is extremelyimportant. Knowledge of the biological, histological and of course the surgical characteristics of the tissues canlargely be a predictor of the correct implant prosthetic rehabilitation. The main aim of this research was to describeall aspects of surgical manipulation of the soft and bone tissues during the dental implantology procedures. We havemade adequate literature research for articles relevant to our topic-surgical manipulation of the soft and hard tissuesduring the dental implantology procedures published in the last two decades (2001-2021). Kew words used for theresearch were: “surgical manipulation”, “dental implantology”, “soft tissues”, “bone tissues” and their combination.Each implantologist should take into account the biological limitations of each patient, as well as the technicallimitations that may occur during the treatment. Oral soft tissues can be affected during the various stages of theimplant treatment. During the planning of a surgical intervention such as the placement of an implant, regardless ofwhether it is an immediate or a delayed loading implant, it is necessary to have an adequate manipulation of thesurrounding soft tissue and bone structures. When designing the flap should be taken into account the degree ofaccessibility required to access the bone, as well as the final position of the flap. It is also of great importance to takeinto account the preservation of good blood supply to the flap. Based on the exposure of bone after elevation, flapscan be classified as either full-thickness or mucoperiosteal flaps and partial-thickness or mucosal flaps. Dependingon how the interdental papilla will be treated, the incisions can either divide the papilla (conventional incision) orpreserve it (papilla-preserving incision). Based on the placement of flaps after surgery, they can be classified as: 1)nondisplaced flaps, where the flap is returned and sutured to its original position, or 2) displaced flaps, which areplaced apically, coronally, or laterally from their original position. The work in bone is quite complex and requiresknowledge of its morphological and histological characteristics. When working on bone, and especially whenplacing dental implants, it is necessary to note that it is necessary to enable constant cooling. The improvement ofold techniques and the development of new technologies have created a revolution in oral implantology, and now atherapist has numerous therapeutic options that can be incorporated into daily practice to facilitate the surgicalapproach itself. Hard-tissue and soft-tissue dental lasers, which are constantly improving and have a wide range ofindications, are becoming a part of everyday dental practice and also show significant advantages compared toconventional instruments and techniques when placing dental implants. Therefore, over time they will become aninvaluable and irreplaceable tool in modern dental implantology. After the performed extensive and deductiveliterature review, it can be concluded that from particular importance is the correct manipulation of soft and bonetissues during dental implantation. After tooth extraction, the placement of dental implants is largely determined bythe integrity of existing hard and soft tissues, such as the aesthetic outcome from the prosthodontic suprastructureover dental implants. Careful assessment of soft and bone tissue loss during implantation is paramount to the successof aesthetic implant procedures

Two clinical cases of the reconstruction of distal phalanges of hand in children by combination of the regional flap and scrap bone and nailbed graft

BACKGROUND: The hand and its distal phalanges, especially in children, are among areas mostly exposed to trauma while contacting the environment. Injuries causing loss of soft tissue and bone component are both challenging and interesting. This report presents the treatment results of children with soft tissue and bone defects of distal phalanges, in which reconstructions including combination of regional flaps, bone, and nailbed grafts were performed.
 CLINICAL CASE: This report presents clinical cases of the surgical treatment of 4- and 6-year-old children with fingertip injuries who underwent reconstructions including the combination of regional flaps, bone, and nailbed grafts. A combination of the scrap graft was performed in the first case with antegrade homodigital island flap and in the second case with thenar flap. The results were assessed 6 and 7 months after surgery.
 DISCUSSION: The primary aim of the surgical treatment of children with distal phalangeal defects is coverage of those defects. The restoration of the bone component of the defect is recommended to prevent postoperative deformations of the distal phalanges. Fingertip replantation or microsurgical transplantation of vascularized tissue complexes are technically difficult and require thorough care and monitoring of the childs condition in the postoperative period as all these measures may fail.
 CONCLUSIONS: The possibility to combine the scrap bone and nailbed graft with existing reliable surgical methods open new prospects for the successful treatment of fingertip injuries.

Cervical necrotizing fasciitis complicated by sepsis case report

Cervical necrotizing fasciitis (CNF) is uncommon, difficult to diagnose, and rapidly progressive severe infection causing necrosis of subcutaneous tissue and fascial compartments, associated with high mortality; early recognition and surgical intervention are crucial. In most cases of nercrotizing fasciitis in the head and neck region the origin is odontogenic or pharyngolaryngeal; predominantly identified bacteria are Streptococci and Staphylococci. A characteristic CT finding is gas demonstration. The main complication is descending necrotizing mediastinitis (DNM), unfrequently vascular entities: internal jugular vein thrombosis, carotid sheath necrosis, carotid artery aneurysm and rupture, and other arterial hemorrhages. A fulminant CNF course requires timely implementation of appropriate treatment. Broad-spectrum antibiotic therapy and repeated surgical interventions with the removal of necrotic tissues constitute the most common treatment. Open wound treatment increases the risk of additional coinfection and sepsis; a modern approach is the use of negative pressure wound therapy or percutaneous catheter drainage. Tracheostomy may be helpful in need of further, repetitive debridement. Loss of soft tissues and skin of the neck may require reconstruction with full- or split-thickness free flap, local flap, or biodegradable dermal substitute. The authors describe the case of a patient with CNF complicated by sepsis. The necrosis resulted in a 10x20-cm defect in the front of the neck, which was covered with a split-thickness graft harvested from the anterolateral surface of the thigh. No complications occurred during the healing of the graft.

Combined Regenerative and Mucogingival Treatment of Intraosseous Defects with Buccal Gingival Recession: A Case Series

<p>Abstract: Regenerative surgery is an effective treatment of intraosseous defects, however, subject with thin gingival tissue phenotype and bone dehiscence defect tends to have more post-surgery gingival recession. The gingival recession is considered as soft tissue loss, which may affect the result of periodontal regeneration. Therefore, this case series aimed to describe a periodontal regenerative surgery combined with subepithelial connective tissue graft (SCTG) in intraosseous defects associated with buccal gingival recession would make periodontal regeneration more predictable. Materials and Methods: The case series describes a surgical approach to improve regenerative parameters in deep intraosseous defects associated with buccal gingival recession. Teeth with buccal bone dehiscence or furcation involvement were included. The surgical technique consisted of an SCTG placed on the buccal dehiscence defect or furcation area to thicken the soft tissue wall, then treated with enamel matrix derivative and biomaterials as regenerative scaffolds inside the intraosseous component of the defect. Results: In all cases, there were buccal gingival margin thickness increased, significant clinical attachment level gain, bone level gain, reduced probing pocket depth, and partial root coverage at least one year after the surgery. The radiographs demonstrated increased bone density of the deep intraosseous defects associated with buccal gingival recession in both single root and furcation-involved teeth. Conclusion: The combination of regenerative treatment and SCTG in intraosseous defects associated with buccal gingival recession in a single root or furcation-involved molar supports the stability of the gingival profile and improves root coverage outcome as well as periodontal regeneration.</p> <p> </p>

Reconstruction of large midfoot bone loss using titanium spinal mesh cage with bone graft: A case report

High energy trauma injuries in the lower extremity represent unique challenges to surgeons and often involve complex, limb threatening wounds with extensive soft tissue and bone loss. In this case report, we present a case of a 20 year old male who was presented to us with a history of 8 months old high impetus road traffic trauma which resulted in multiple open fracture of the midfoot with ipsilateral closed tibial - fibular shaft and medial malleolar fracture. Open midfoot injury with severe bone loss included complete loss of navicular, all three cuneiforms, base of 1st and 2nd metatarsals. For reconstructing this severe midfoot defect, we have utilized a titanium mesh cage which is routinely used in spinal surgeries. This innovative technique and orthoplastic approach has given the patient a stable plantigrade foot with a near normal midfoot biomechanics and ultimately, restoration of this patient's quality of life.

A Rare Case Report of Radionecrosis Mandible after Irradiation for Breast Cancer

Management of irradiated patients with cancer in the head and neck region is a challenging scenario. Radiotherapy promotes cellular and vascular insufficiency that results in a low response rate in the healing. Consequently, surgical procedures in irradiated tissues present high rates of complication. Osteoradionecrosis (ORN) is the most severe sequelae caused by radiotherapy. ORN can occur due to multiple reasons, of which periodontal disease, traumatic injury induced by ill-fitting dentures and trauma after surgery or tooth extraction are the most common. The management of this side effect is difficult and can result in bone or soft tissue loss, affecting the quality of life since majority of patients with ORN have various comorbidities associated. In this article we present a case report of osteoradionecrosis secondary to irradiation for breast cancer which is not frequently reported in literature.

Arteriovenous Malformations of the Hand: Optimizing Outcomes with Palmar Arch Reconstruction.

Arteriovenous malformations are abnormal high-flow vascular anomalies that can greatly alter the structure of surrounding tissues. Treatment of symptomatic hand arteriovenous malformations must address the functional and aesthetic considerations of the hand. Nonsurgical treatment such as embolization continues to be plagued by complications such as digital ischemia and secondary need for amputation. In this study, the authors describe their experience treating hand arteriovenous malformations with wide resection and microsurgical reconstruction of the palmar arch. This technique aims to optimize postoperative function and minimize postoperative complications and recurrence. Retrospective review identified five patients who underwent surgical excision of hand arteriovenous malformations performed by two of the senior authors (W.C.P. and M.M.) between 2002 and 2020. Four patients underwent reconstruction of the palmar arch, whereas one patient underwent ray amputation of the involved index finger only. One patient required concurrent free flap for soft-tissue coverage following resection. Mean age at the time of surgery was 34.6 years. After an average follow-up of 2.7 years, there were no postoperative complications, functional deficits, or recurrences. The patient who underwent ray amputation only was postoperatively noted to have pulsatile dorsal veins concerning for a persistent high-flow state, although no recurrent mass was seen at limited 1-year follow-up. Meticulous surgical excision with microvascular reconstruction is an acceptable technique for management of symptomatic hand arteriovenous malformations. Potential soft-tissue loss does not preclude aggressive resection. Wide excision with palmar arch reconstruction minimizes complications, optimizes functionality, and may prevent ischemia that could otherwise trigger recurrence. Therapeutic, IV.

Seasonal impact of scavenger guilds as taphonomic agents in central and northern Ontario, Canada.

The process of human decomposition is driven by biological decomposers, mainly bacteria, vertebrates, and invertebrate scavengers. When vertebrate scavengers have access to a body, they can considerably accelerate decomposition through consumption of soft tissue and dispersal of skeletal elements. Presently, there are limited data available on vertebrate scavenging activity in Canada, particularly in densely populated provinces such as Ontario. This study aimed to determine which vertebrate species belong to the scavenger guilds in central and northern Ontario, and the impact of season and habitat on these taphonomic agents. Seasonal trials were conducted in summer, fall, and spring of 2020/2021 with pig carcasses placed in open (grassland) and closed (forest) sites. Vertebrate scavenger activity was recorded continuously using cellular and non-cellular trail cameras. Photographs were analyzed to identify species, quantify feeding intensity, and document scavenging behavior. We identified four mammalian scavengers, namely coyote, red fox, fisher, and pine marten, and three avian scavengers, namely bald eagle, turkey vulture, and American crows/northern ravens (grouped as corvids) across the trials. Season impacted scavenger presence with feeding and loss of soft tissue occurring more quickly in the summer, followed by spring and fall. None of the scavengers demonstrated a clear preference for the open versus closed sites. Our findings have identified the most prevalent vertebrate scavengers in central and northern Ontario and their taphonomic impact on soft and hard tissues. It is important to consider these agents and their ability to degrade and disperse remains during the search and recovery of human remains.

FK506 increases susceptibility to musculoskeletal infection in a rodent model

BackgroundDelayed fracture healing caused by soft tissue loss can be resolved by the administration of a Th1 immunosuppressant, such as FK506. Additionally, open fractures are at high risk for infection. We hypothesized that the inclusion of an immunosuppressant to a subject at risk for a musculoskeletal infection will increase the likelihood of infection.MethodsA rat model of musculoskeletal infection was used. Sprague Dawley rats received a stabilized femur defect and were inoculated with 104 CFU Staphylococcus aureus via a collagen matrix. Six hours after inoculation, the wounds were debrided of collagen and devitalized tissue and irrigated with sterile saline. The animals were randomized into two groups: carrier control and FK506, which were administered daily for 14 days and were euthanized and the tissues harvested to measure local bioburden.ResultsThe dosing regimen of FK506 that restored bone healing increased the bioburden in the bone and on the fixation implant compared to the carrier control animals. As expected, the administration of FK506 decreased circulating white blood cells, lymphocytes, neutrophils, and monocytes. Additionally, the red blood cell count, hematocrit, and body weight were lower in those animals that received FK506 compared to carrier control.ConclusionsFK506 administration decreased the systemic immune cell counts and increased the bacterial bioburden within a model of musculoskeletal infection. Collectively, these outcomes could be attributed to the overall T cell suppression by FK506 and the altered antimicrobial activity of innate cells, thereby allowing S. aureus to thrive and subsequently leading to infection of severe, musculoskeletal injuries. These observations reveal the crucial continued investigation for the clinical use of FK506, and other immunosuppressant compounds, in trauma patients who are at increased risk of developing infections.

Observation of role of orthofix limb reconstruction system in with non-union with major soft tissue defect

Soft tissue loss with multiple sinuses, osteomyelitis, osteoporosis, complex deformities with limb length inequality, stiffness of the adjacent joints and multi drug resistant infection all complicate treatment and recovery. Aim of the study is to observe the role of Orthofix limb reconstruction system as a treatment in non-union with bone loss and major soft tissue defect due to fresh fractures. The method of treatment of infected non-union by the Limb Reconstruction System with a predictable healing of nonunion and control of infection is well shown in this study.

Medial plantar artery perforator (MPAP) flap is an ideal option for reconstruction of complex soft tissue defect in the finger: Clinical experience from 11 cases.

IntroductionSoft tissue defects of fingers are common in reconstructive plastic surgery, and reconstruction of the defects remains challenging for plastic surgeons. In our study, we reported our experience in finger reconstruction with a medial plantar artery perforator (MPAP) flap, especially using a lobulated MPAP flap for the complex multifinger soft defect.Patients and methodsFrom the period April 2012 to October 2018, 11 patients (9 males and 2 females) with an average age of 44 years old (ranging from 11 to 58) received finger reconstruction with a free MPAP flap. In total, 11 flaps (8 single-lobulated flaps and 3 two-lobulated flaps) were raised from the ipsilateral or contralateral instep area. Trauma and scar contracture caused hand soft tissue loss in all cases.ResultsThe sizes of the flaps ranged from 2×3 to 5×7.5 cm2. All flaps survived intact with no complications. One donor site was closed primarily, and other donor sites were covered with a full-thickness skin graft. The mean follow-up time was 6 months (ranging from 3 to 8 months). During the follow-up period, the patients were satisfied with their appearance without any traces of flap plastic surgery.ConclusionThe MPAP flap is a reliable and acceptable option for the reconstruction of complex soft tissue defects in the finger. Depending on the two branches of the medial plantar artery, the use of the lobulated MPAP flap holds promise in the treatment of multifinger soft tissue defects.

792 Complete wound healing utilizing procine urinary bladder matrix in a serise of traumatic wounds with significant soft tissue loss

PUBM is a non-synthetic, completely resorbable xenograft product with a myriad of uses including management of burns, acute and chronic wounds, soft tissue reinforcement, and hernia repair. The material is available in both powder and sheet form allowing for excellent coverage of irregularly shaped wounds. We present three patients with significant soft tissue loss that underwent xenograft implantation utilizing PUBM. Despite challenging locations and severity of wounds, 100% healing and wound closure with excellent cosmetic results was achieved.

Levator Palpebrae Superioris With Inferior Oblique Muscle Flaps for Total Ocular Surface Reconstruction.

A healthy middle-aged man sustained extensive burns after a motor vehicle accident, including fourth-degree burns to the ocular adnexa. He had bilateral eyelid necrosis with complete tissue loss to the orbital rim. Progressive corneal thinning occurred bilaterally despite frequent lubrication, weekly amniotic membrane placement, and a Gunderson flap, ultimately requiring evisceration of his OS. In accordance with family wishes to perform all interventions for the OD, he underwent ocular surface reconstruction with levator palpebrae superioris (LPS) and inferior oblique (IO) muscle flaps, supplemented with an orbital fat transfer and bucket-handle muscle flap. These flaps were covered with porcine urinary bladder matrix and remained viable with complete globe coverage postoperatively. Although local eyelid flaps traditionally involve tissue supplied by branches of the external carotid artery, this case suggests that orbital-internal carotid artery based flaps utilizing the LPS and IO muscles may achieve ocular surface coverage after complete periocular and facial soft tissue loss.

Stabilization and enhancement of soft and hard tissues around dental implants: a surgical perspective

This article discusses the surgical considerations for stabilizing and enhancing soft and hard tissues around dental implants. Recession is one of the recognized complications around dental implants, especially in the aesthetic zone. The novelty of computed dental implantology has widened the practice of dental implants with increased predictability and better safety margins. However, case selection is paramount to fulfil patients' functional and aesthetic expectations in the short and long term. 3D surgical planning for dental implant placement is key to ensure maximum stability of the soft and hard tissues around dental implants and reduce the risks of biological and mechanical complications. Holistic treatment planning needs to be formulated to achieve the expected aesthetic and functional treatment outcomes and ensure that there is no soft tissue or bone loss.CPD/Clinical Relevance: Knowledge of the surgical considerations in placing dental implants is essential for achieving a good aesthetic and functional outcome.

Algorithmic Approach to Reconstruct Major Implant and Dental Complications

Patients with failing implants or teeth may require multiple procedures to correct their problems. The purpose of this article was to describe an algorithmic approach for clinicians to use to simplify the restoration of the patient. The topics for this article were used to search for references using PubMed. Topics included the effect of thickening thin gingiva to promote stable soft tissue margins, the use of different bone graft materials for sockets and for ridge augmentation, and methods to use digital technology for efficient planning. Other sources were book chapters, which had an extensive reference section including multiple case series and clinical trial results. Based on the search results, references were chosen that would verify the techniques suggested to be used for these problems. For this narrative, diagnostic information is described using virtual digital methods rather than analog methods to develop the final prosthetic plan, which guides the surgical procedures. The surgical phases are described in detail. The gingiva needs to be healthy and thick to support a hard tissue graft. The timing of procedures begins with assessment of the quality of the soft tissue and the loss of both soft and hard tissues. The operative procedures should be based on the final prosthetic plan, created digitally, to provide information that is required to properly position soft and hard tissue grafts and the implants. This organized, algorithmic approach can be used for many situations that clinicians are seeing in their daily practice due to complications that can occur.

Tubed-Groin Flap for Coverage of Deep Burn Injuries in Two Adjacent Fingers: A Case Report

The reconstruction of two adjacent fingers is challenging for reconstructive surgeons, especially if there is a circumferential skin and soft-tissue loss along with bone exposure. Herein, we present the case of a 22-year-old male with a circumferential defect in two adjacent fingers due to an electrical burn. The patient had a circumferential soft-tissue defect with middle phalangeal bone exposure in the left index and middle fingers, revealed after serial debridement and ostectomy. After failure of free flap reconstruction, other options were considered, and the defects were repaired using a newly designed tubed-groin flap. Afterwards, flap detachment was performed on postoperative day 21 and provisional syndactyly separation without a skin graft was performed 2 weeks after flap detachment surgery. The patient was satisfied with the well-reconstructed fingers, which demonstrated adequate length and function. A full range of motion of the metacarpophalangeal joint was restored. The newly designed tubed-groin flap can be an efficient method to easily and effectively reconstruct a circumferential defect in two adjacent fingers.

QS59. Pulsed-release Dexamethasone-loaded Microspheres Mitigate Scar Contracture and Adhesions in Composite Tissue Burn Reconstruction

Purpose: Soft-tissue loss after complex burns is devastating to quality of life, ability to work, and psychosocial well-being. These are disfiguring injuries requiring surgical management and are almost universally limited by contracture, adhesion, and soft-tissue deficit. We have previously described a fat-first, delayed-skin approach to complex burn reconstruction to treat the hypodermal deficit and improve soft tissue-mobility and deficits. Here we describe the use of timed- and pulse-release dexamethasone to augment this approach and mitigate contracture during skin-graft delay. Methods: Yorkshire swine received 16, 4x4 cm full-thickness burns. After 48 hours, eschar was removed to fascia. Wounds were stratified across untreated pigs to receive A) No Reconstruction, B) Skin-Only, C) Fat-Only, D) Immediate-Skin, Delayed-Fat, or E) Immediate-Fat, Delayed-Skin. Treatment pigs with Group E wounds then received either 1) Empty Microspheres or Dexamethasone as follows 2) Continuous/Sustained, 3) Immediate-Pulsed, 4) Delayed-Pulsed, or 5) Bimodal-Pulsed. At 8 weeks post-engraftment animals were sacrificed and all wounds were collected for photography, ultrasound, histology and serum studies. Results: Fat-first reconstruction minimizes adhesions soft-tissue deficits, however, is limited by rapid early contracture which was mitigated by the skin-first approach. Early dexamethasone blocks contracture, however, sustained dosing limited skin graft take. Pulsed-dosing was permissive of skin grafts in the drug elution nadir. Combination fat-first with pulsed-dexamethasone resulted in significant reduction in adhesion, soft-tissue deficit, and contracture vs. skin-first approaches. Conclusion: Here we demonstrate augmentation of a fat-first approach by timed-release dexamethasone to safely mitigate contracture, adhesion, and soft-tissue deficits vs. current reconstructive standards for complex burn wounds.