Postburn Deformities Research Articles

Management of hand burns using tangential excision and grafting versus delayed excision and grafting

Background: A burn injury to the hand, whether in isolation or associated with a major systemic burn injury, continues to be a challenge to the treating surgeon, as correct clinical judgment and decision regarding management thereof can affect the final outcome both aesthetically and functionally.Methods: A total of 84 patients (140 hands) were covered under the study, bilateral hand involvement in 56 patients (80% of hands) and unilateral involvement in 28 patients (20% of hands). Each group had 42 patients each. All patients were admitted to the hospital within 48-96 hours of the injury and operated within 3-7 post injury day.Results: The skin graft take was much superior in the early excision group as compared to delayed excision group and hence resulted in decreased overall hospital stay. The functional and aesthetic outcomes were better achieved with less need of secondary surgical procedures. There were no major complications. Patients were followed up for a period ranging from six to twenty four months.Conclusions: The skin graft take was much superior in early excision group as compared to delayed group and hence resulted in decreased overall hospital stay. The functional and aesthetic outcomes were better achieved and the needs for secondary surgical revision were far lesser with early excision and grafting. Both early excision and grafting, and delayed excision and grafting modalities lead to post-burn deformities of hand, albeit different from each other, but more common with delayed grafting.

Inferior pole breast reconstruction by TDAP flap in post-burn breast contracture

Post-burn breast deformities are not an uncommon condition after severe second-degree or third-degree burn and present as severe asymmetry of the breast as compared to the opposite side, displacement of nipple-areola complex, obliteration of inframammary fold, and reduced breast projection. Based on deformities especially for lower pole breast contracture, we propose a new classification to describe breast contracture. There is no tailor-made approach described to deal such deformities. Various options are available ranging from skin graft to different flaps. We present reconstruction by TDAP flap after the release of breast contracture grades I and II. This study aimed to classify the lower pole breast contracture according to its severity and to evaluate the outcome of TDAP flap reconstruction and augmentation of the lower pole of the breast in terms of symmetry and aesthesis. This is a descriptive retrospective study of 10 patients with 15 post-burn contracted breast affecting the inferior pole of the breast and inframammary fold within a period of January 2012 to March 2016 in Kasralainy hospital, Cairo. All cases were evaluated according to flap vascularity, donor site morbidity, symmetry, and esthetic outcome. All flaps survived completely. Flap dimension ranged from 18 × 10 to 22 × 12 cm. The muscle sparing design had been used in three patients due to lack of reliable perforators. Patients were evaluated for their satisfaction, and all of them were satisfied. It is essential to classify the grade of post-burn lower pole breast contracture according to the proposed classification. TDAP is a valuable option in case of grade I and II deformities only. For severe grade III breast contracture, more volume restoring procedure is advisable. Level of Evidence: Level IV, therapeutic study.

Evaluation of dorsal metacarpal artery perforator flaps in the reconstruction of hand soft-tissue defects

Objective Evaluation of the dorsal metacarpal artery perforator (DMAP) flaps in the reconstruction of hand soft-tissue defects. Background The DMAP flap is a nonconventional solution for treating hand and finger defects. We present our experience in resurfacing a variety of soft-tissue defects of hand and fingers with this single-stage flap, reducing the need for other conventional flaps which may need more than one stage for reconstruction. Patients and methods This study was done on 20 patients (18–65 years) with soft-tissue defects of the hand and fingers, following trauma in 15 patients, postburn deformity reconstruction in four patients, and in one patient for post-tumor excision, presented at the Menoufia University Hospital and Kafr Al-Shaikh General Hospital over a 1-year period. Results The average flap size was 6 × 2.5 cm; raised from the dorsum of the hand as an island elliptical flap. Twelve flaps were used to resurface defects between metacarpophalangeal and proximal interphalangeal joints; three flaps were used to resurface defects between proximal and distal interphalangeal joints; one flap was used to resurface defect beyond the distal interphalangeal joint; and four flaps were used to resurface web space defects. The donor site closed primarily in all cases. Complications were distal necrosis in two flaps and congestion in two flaps. Wound dehiscence of the donor site occurred in two cases. Conclusion DMAP flap is a reliable alternative for treating defects on the hand and fingers. The flap offers the surgeon simple, single-stage, and fast procedure with minimal donor site morbidity and with preservation of functional and esthetic outcomes.

Functional and cosmetic outcomes of posterior interosseous artery flap in reconstructing hand defects

Objective The objective of this study was to evaluate the fu ncti onal and cosmetic results of reversed-flow posterior interosseous artery (PIA) flap for reconstruction of hand defects and to assess them by follow-up and physiotherapy. Background Reconstruction of soft-tissue defects in the hand needs a single-stage procedure that can provide well-vascularized graft coverage at the earliest to give the best functional result. Patients and methods This follow-up study that included 20 patients (16 male and four female) was carried out in Menoufia University, Plastic and Reconstructive Surgery Department, from March 2015 to January 2017, with assessment by a follow-up period of 12 months and physiotherapy. All our patients had PIA flap for coverage of the defects. The defects were due to post-traumatic raw areas in 15 cases, postburn deformities in two cases, postcongenital hand deformity surgeries in one case, and post-tumor ablation in two cases. The first webspace defect occurred most often and the largest flap was 10 × 12 cm2. The donor site was covered by split skin graft in 14 cases, and in six cases the donor site was directly closed. Results Regarding flap course and survival, 15 (75%) flaps passed uneventfully, four (20%) flaps suffered from venous congestion, and one (5%) flap showed ischemia. Three flaps (the ischemic flap and two congested flaps) suffered total loss. Two congested flaps survived without loss, and thus we had 17 (85%) survived flaps. All cases were satisfied with cosmetic outcome. Conclusion The reverse-flow flap based on PIA is a reliable and versatile source for coverage of complex soft-tissue defects in the hand.

Pathophysiologic Mechanisms and Current Treatments for Cutaneous Sequelae of Burn Wounds.

Burn injuries are a pervasive clinical problem. Extensive thermal trauma can be life-threatening or result in long-lasting complications, generating a significant impact on quality of life for patients as well as a cost burden to the healthcare system. The importance of addressing global or systemic issues such as resuscitation and management of inhalation injuries is not disputed but is beyond the scope of this review, which focuses on cutaneous pathophysiologic mechanisms for current treatments, both in the acute and long-term settings. Pathophysiological mechanisms of burn progression and wound healing are mediated by highly complex cascades of cellular and biochemical events, which become dysregulated in slow-healing wounds such as burns. Burns can result in fibroproliferative scarring, skin contractures, or chronic wounds that take weeks or months to heal. Burn injuries are highly individualized owing to wound-specific differences such as burn depth and surface area, in addition to patient-specific factors including genetics, immune competency, and age. Other extrinsic complications such as microbial infection can complicate wound healing, resulting in prolonged inflammation and delayed re-epithelialization. Although mortality is decreasing with advancements in burn care, morbidity from postburn deformities continues to be a challenge. Optimizing specialized acute care and late burn outcome intervention on a patient-by-patient basis is critical for successful management of burn wounds and the associated pathological scar outcome. Understanding the fundamentals of integument physiology and the cellular processes involved in wound healing is essential for designing effective treatment strategies for burn wound care as well as development of future therapies. Published 2018. Compr Physiol 8:371-405, 2018.

SURGICAL TREATMENT OF POST BURN DEFORMITIES OF ORAL COMMISSURE AND LOWER LIP

Background: The lip is affected by burn injury. The complications of post burn scarring of the lip are often resulting in aesthetic deformity and psychological troubles in patient’s particularly adult females. A burn disturbed the aesthetic features and lines of the lip. The aim of work is to choose the suitable method of treating post burn deformities of oral commissure and lower lip. .Subjects and Methods: We admitted 24 patients to our hospital from June 2007 to July 2012. They were complaining of deformity of lower lip, contracted commissure either as a single lesion or as a part of face or as a part of the body. Age of our patients ranged from 3-60 years with average age 24.38 years. The surgical methods may be full thickness skin grafts (nine cases), tissue expansion (13) cases, local flap (one case) and scar revision (one case).Results: We noticed that there were three elements that determine the surgical methods of treating deformities of lower lip: condition of the surrounding skin, extent and shape. We have already discussed and evaluated the various techniques of reconstruction. 19 out of 24 patients proved to be a success.Conclusion: full thickness skin grafts have a certain percentage of morbidity in the form of partial loss. The possibility of contamination is inevitable in some patients with bad eating habits.

Post-Burn Skin Deformities of the Face and Neck Region in Pediatric Patients: Single-Stage Treatment Using Collagen Elastin Matrix

Introduction: Treating severe post-burn deformities of face and neck region in pediatric population may become challenging because of technical difficulties (e.g. limited full thickness skin graft donor site, limited flap options, unavailability for expander placement) and increased donor site morbidity (e.g related to flap and graft donor sites) Patients and Method: In this study we present single-stage treatment of severe post-burn skin deformities of face and neck region in pediatric patients using collagen-elastin matrix (Matriderm®) combined with partial thickness skin grafts. All cases (n:8) were operated for only one region. Following release of contractures, and/or excision of wide excessive/unfavorable dermal scars, defects were reconstructed using collagen-elastin matrix (Matriderm®) combined with partial thickness skin grafts. The final functional and aesthetic results were evaluated using photography and examination. Results: Total number patients was 8 (4m, 4f). The ages were between 2 years to 11 years. The deformities were in the form of contractures and/or excessive dermal scarring. The involved regions were face (n:3) and neck (n:5), The grafts yielded favorable pilication and texture, no recurrence in excessive dermal scarring was observed. All contractures were healed unproblematically. Two patients were reoperated for regrafting caused by minor graft loss (5 % and 12 % of total area respectively). Conclusion: In this study we observed that collagen elastin matrix combined with partial thickness skin grafts provides a favorable option for treatment of pediatric late post burn complications in face and neck region with limited surgical options.

Burn injury in infants and toddlers: Risk factors, circumstances, and prevention

Aim: To study the risk factors and circumstances of burn injury in infants and toddlers. Materials and Methods: A retrospective study was conducted on children visiting the plastic surgery department with acute burns or postburn deformities in the year 2016. The children who sustained burns up to an age of 3 years were included. An analysis of data for their age, sex, type of burn injury, involved body part, seasonal variation, place of occurrence, time of the day, presence of guardians at the time of injury, and socioeconomic status was performed. Results: A total of 44 children were included in the study. Thirty-one were males and 13 were females. The majority of children (77.3%) belonged to the toddler age group (1–3 years). Scald was the most common burn injury (54.5%). The majority of burns (68.2%) were sustained in winters. Burns were most frequent in domestic settings (90.9%). 64.1% were kitchen accidents. Hands were the most commonly affected anatomical site (54%). Ninety percent of the burnt children belonged to low socioeconomic strata. Conclusion: Pediatric burns were seen more commonly among toddlers. Scalds were the most common form of burns. Male gender, domestic environment, winter season, and low socioeconomic strata were found to have an increased frequency of burns. Hands were the most commonly affected site. Focused burn prevention strategies consistent with local circumstances should be implemented for the prevention and better management of pediatric burn injuries.

Treatment of extensive post-burn deformities using extra-large sheets of full thickness skin grafts

Post burn scarring and contractures that affect function remain one of the most frustrating late complications of burn injury. Split thickness skin grafting (STSG) is still the most commonly used method for achieving skin coverage of massive raw areas. In this study, we were able to harvest 14 extra-large sheets of full thickness skin grafts (FTSGs) taken from different areas (back, abdomen and breasts after reduction mammoplasty) to treat extensive post burn contractures and scarring in 10 patients. We could cover raw areas up to 7% Of the TBSA which regained function with less morbidity and more aesthetic results than do STSGs. The results were also satisfactory in 9 patients, yet, only one patient was not satisfied with the result.

Controlled tissue expansion in reconstruction of post burn deformities of head and neck

Reconstruction of post burn scars and contractures in the region of head and neck is a difficult task. Introduction of controlled tissue expansion has provided a versatile and reliable technique in management of these cases by providing skin of excellent quality and minimal donor site deformity. A review of forty-five (45) procedures carried out for reconstruction with controlled tissue expansion, between January 1994 and December 2003 is presented. Expanders of various shapes and sizes were used to achieve a fill volume ranging from 140 c.c to 470 c.c over a period of 9 to 12 weeks. Expander was reused in eight (8) expansions and three (3) patients with large defects underwent two or more expansions of the same area to achieve desired results. In 32 cases the procedure was completed without any complications whereas in 10 cases minor or major complications hampered or delayed eventual reconstruction. Only in 4 cases (8.8%) the reconstruction was compromised as a result of early complications. Controlled tissue expansion provides a safe and predictable technique for reconstruction in the region of Head and neck with acceptable rate of complications and provides excellent results.

Treatment of post-burn secondary foot deformity

A case of simultaneous correction of severe post-burn deformity with limited movement in the ankle joint, subluxation and contractures in the metatarsophalangeal joints in a 3-year old child is presented. Excision of scar tissues, tendinous plasty, capsulotomy of involved joints were performed. To close the defect, a full-thickness skin graft was used. In two years, no signs of recurrence were observed.

Strategies for customized neck reconstruction based on the pre-expanded superficial cervical artery flap

It is still highly challenging to restore the esthetic neck contour for postburn deformities. In many patients with burns, the back skin remains intact, which is a useful donor site for extensive contracture release. As the main technique, the refinement of the pre-expanded superficial cervical artery (SCA) flaps may improve its application in diverse neck contractures. This study reviewed the cases of three types of neck contractures that were reconstructed with pre-expanded SCA flaps: (1) for unilateral neck contractures, the flaps were harvested as pedicled perforator flaps including a small amount of muscle; (2) for lateral and anterior neck contractures, vascular augmentation with circumflex scapular vessels was used to increase the flap size; (3) for contractures of the entire neck, maximal flap release with pedicle dissection toward the origin of the superficial cervical vessels allowed for reaching contralateral defects. From March 2010 to September 2012, pre-expanded SCA flaps were recommended in 15 patients with severe neck contracture. Tip necrosis occurred in one patient. The donor sites were closed primarily in all cases. One patient had donor-site wound dehiscence that healed within 2 weeks by conservative management. All patients had restored neck extension to a near-normal position without the sense of restricted neck flexion or rotation. Pre-expanded SCA flaps are practical and flexible for the reconstruction of diverse scar contractures ranging from unilateral to total neck lesions. Considering the reconstructive efficiency and the reduced donor-site morbidity, this flap may be an ideal option for the reconstruction of severe neck scar contractures.

Surgical Treatment of Post Burn Bent Contractures of the Foot in Children

The post-burn bent contracture deformity of feet in children represents a challenging and complex specific pathology of the weight bearing motor apparatus. According to the findings of burn department of RSCUMA and Inter-Regional Burn Centre of Samarkand, Uzbekistan burn contractures of the toes are observed in about 72% of patients. During the period of 1992-2007, 112 patients with post burn bent contractures of toes were treated. The patient’s ages, severity of deformity, and treatment method were followed for an average 1-5 years. Deformity was classified from I to IV degree according to the classification given by Parin BV. The choice of surgery was made on the basis of the severity and localization of the injury. The patients were followed-up during a period of one to ten years. 112 of patients were treated with surgical intervention to restore function and reduce deformity. The relative occurrence of the different types of burn contractures of the foot was as follows: mild type-21; moderate type-44; severe type-29; multilated type-18. In 79.5% of cases, contracture was removed absolutely in 14.3% there was an improvement and only in 6.3% of cases there was no improvement because of the irreversible bone-joint change.

"Hope after fire,": A free reconstructive surgery project for burn survivors: Making it possible and the lessons learned

Postburn deformities can cause loss of livelihood and a sense of self-worth. Though many can be corrected leading the patients to lead a productive life, tragically many of these patients who need help are not in the service loop. Causes may be the problems of affordability, reach or the lack of skill levels needed for difficult problems. Hope after fire, a project to offer totally free reconstructive surgery for the correction of burn deformities is a joint initiative of the Rotary Club of Coimbatore Metropolis and Ganga Hospital. In a 3-year period from 2012,304 reconstructive procedures were done in 192 patients with a project value of Rs. 1.08 crores (US $ 166,000). The project is guaranteed the continued support of the club and the community and pledges for a similar sum are available. We feel that this success is reproducible. A patient-centric attitude, the commitment of the people involved in the project to go for it irrespective what it takes to reach the goal, efforts at rehabilitation in addition to surgical efforts, and transparency and trust between partners are the key for success. These and the other factors which we feel are important for success are detailed in this article.

Strategies in the management of post-burn breast deformities

Background Burn injuries to the chest area may end up with severe breast deformity and asymmetry. They are frequently complex and unique to each case, affecting parenchymal development, breast implantation on chest wall, nipple areola complex position, infra-mammary fold definition, and skin envelope. Furthermore, contractures affecting adjacent territories may occur and add to the deformity. Surgical correction should address all the deformity components. Thus, a structured reconstructive plan that recruits different mammaplasty techniques and deals with adjacent territories is needed. This work presents different strategies used in treating severe post-burn breast deformities. Elaborate analyses of the deformities, surgical techniques, and outcomes are presented and a structured reconstructive plan is proposed.

Метод местной кожной пластики

The new local flap technique based on cutting out valve flaps combining with the principle of acute dermatension is presented in this article. The method is offered as alternative to plasty with transposed triangular flaps or Z-plasty and it allows to excise pathological scars, provides good esthetic results. On the basis of this technique some methods of eliminating post burn deformities of face, neck, mammary glands, extremities joints, hand and fingers are offered.

Unilateral Cervical Burn Scar Deformity Elimination With Contralateral Cervicothoracic Flap—A New Approach

Unilateral postburn cervical deformity is a severe cosmetic and functional defect and a challenging reconstructive problem. Many flaps have been suggested; however, after surgery, operational scars, located along the anterior neck's middle line, and the flap's skin differ from cervical healthy skin. A small flap resembles a patch. A more effective and safer technique is neck resurfacing with cervicothoracic adipocutaneous flap which had been used by the author in 32 burned patients. The flap's peculiarities are as follows: axis blood circulation via superficial cervical artery perforator; exclusion of platysma (flap is thin and elastic); and undamaged donor site. The mobilized healthy neck's skin with thin fat layer and adipocutaneous layer of the chest wall are elevated as a whole large flap. After scar excision, the cervicothoracic flap is advanced on the wound with tension. As a result of flap tension, the skin of neck's back, thoracic wall, and axilla are displaced to the anterior neck surface covering the donor wound. On an average, 6 cm of the deformed neck anterior surface was restored. No flap loss but only local superficial scar necrosis along the flap's border occurred. The cervical contracture and scar deformity (25 patients) were eliminated in all cases by a single procedure. For complete neck skin restoration, seven patients underwent staged reconstruction using the same technique. Excellent functional and good cosmetic follow-up results were achieved. The proposed technique is easy to plan and perform and yields good results; therefore, the author believes that the contralateral cervicothoracic flap's use is an exclusive option for unilateral cervical contracture and deformity elimination in adults and pediatric patients.

Reconstruction of the Achilles Tendon and Overlying Soft Tissue Using an Anteromedial Thigh Flap for a Post-Burn Pes Equinus Deformity: A Case Report

We present a 36-year-old man with a severe pes equinus deformity of the ankle and an intractable ulcer over the Achilles tendon after a 4th-degree burn. He underwent a one-stage reconstructive surgical procedure using an anteromedial thigh flap with its vascularised fascia. After lengthening of the Achilles tendon and posterior release of the ankle, the anteromedial thigh fasciocutaneous flap was transferred. The ischaemic Achilles tendon was wrapped with the vascularised femoral fascia for vascularisation and reinforcement. The skin defect was covered with the skin paddle of the combined flap. There were no postoperative complications. At the 3-year follow up, the range of movement of the ankle was almost normal. The patient was able to walk and climb stairs without support, and the ulcer was cured.

Latissimus dorsi myocutaneous flap for burned breast reconstruction

Objective Thermal burns of the anterior chest disfigure the female breast, and the postburn breast deformity is a sequela of severe scar contraction of the burned chest. For deformities that affected the mammary development, museulocutaneous flaps were used. Here we introduce our experience in using the latissimus dorsi myocutaneous island flap in burned breast reconstruction. Methods During the past 7 years, 7 female patients with such deformities required reconstruction, the expanded or unex-panded latissimus dorsi musculocutaneous island flaps were used in the partial reconstruction of burned breast. In the mild deformities group (2 cases), unexpanded latissimus dorsi musculocutaneous island flaps were used. For patients with undeveloped mammary glands (5 cases), expanded latissimus dorsi musculocutaneous island flaps were used. Results The procedure was performed in 7 patients and all the flaps were alive, with significant improvement of breast appearance. The complication rate was low. There were no deformity and dysfuction in the donor site. Conclusions The technique has many advanta-ges: beautiful contour of breast, good blood supply of the flap, no donor site morbidity. It provides the plastic surgeon with an excellent, safe and consistently successful method for burned breast reconstrue-tion. This experience has led to development of surgical principles and techniques tailored to this particu-larly difficult problem. Key words: Latissimus dorsi myocutaneous island flap; Burns; Breast; DeformityBreast reconstruction

A New Finger Fillet Design From an Index Finger With Severe Postburn Flexion Deformity

Treatment of postburn deformities of the hand is a real challenge to reconstructive surgeons. A functional reconstruction was achieved with two sensate island flaps on two discrete pedicles in a case with severe postburn deformity involving both thumb and index finger. Surgical treatment was based on amputation of the second ray and reconstruction of the thumb with the flaps derived from the discarded index finger. Two sensate island flaps on two discrete pedicles, "1st dorsal metacarpal artery based flap" from the dorsal aspect of the proximal phalanx and "palmar digital artery based fillet flap" composed of available volar skin of the index finger distal to contracture, were harvested and used for replacement of the soft tissue defect of the thumb that appeared after correction of bone and joint deformities. Both of the flaps survived and functional improvement was satisfactory at one-year follow-up. Despite the shortening of neurovascular bundles due to severe flexion deformity, a sensate thumb reconstruction with a better tissue match was achieved thanks to more beneficial design and orientation of two neorovascular island flaps from a deformed index finger. Instead of a single fillet flap design in its common use, our current approach allowed more beneficial use of a discarded index finger in severe postburn deformity involving both thumb and index finger.