MANAGEMENT OF POST-BURN SEQUELAE Dr. Moahmed Ahmed ELROUBY Consultant of Plastic Surgery Ain shams University - Cairo
MANAGEMENT OF
POST-BURN
SEQUELAE
Dr. Moahmed Ahmed ELROUBY Consultant of Plastic Surgery
Ain shams University - Cairo
Deep dermal or full-thickness burns
produce scarring. Scars are the
sequelae of any burn wound. The
aim of scar management is firstly
its prevention and secondary the
removal of established contractures.
Management of burn sequelae includes
the treatment of :
1- post-burn scars.
2- post-burn contractures.
Types of scars after deep burn :
a. Hypertrophic scars b. Keloids
Usually seen with deep dermal burns,
left to heal spontaneously. The burn scar
becomes raised, red and itchy within
weeks of healing. Not only these scars
are unsightly, but they contribute to joint
contracture and limitation of joint
movement when crossing them.
Both hypertrophic scar and keloid, are
included in the spectrum of
fibroproliferative disorders.
These abnormal scars result from the
loss of the control mechanisms that
normally regulate the fine balance of
tissue repair and regeneration.
Hyp. Sc. Keloid
Incidence young > adult
Negroes > Caucasians
Female > Male
Extent confined to site extends to surrounding
of injury uninjured skin
Result tend to resolve Persists and enlarges
after weeks or months
Recurrence Some tendency to High tendency to
recur after excision recur after excision
WAYS OF PREVENTION :
1- Early release of tension over flexion
creases of joints. Tension in a scar encourages
hypertrophy, so that releasing it by grafting or
local flaps may prevent its occurrence.
2- Continuous scar massage, after
application of skin emollient, can be quite
effective.
3- Pressure on maturing scar tissue, appears to
reduce the incidence of hypertrophic changes.
Such pressure is most likely maintained by
compressive garments for 24hrs./day, for at least
six to twelve months.
Mechanism of action is unknown. However,
reducing the O2 tension in the wound by occluding
small vessels, will cause reduction in tissue
metabolism with cessation in fibroblast
proliferation and collagen synthesis.
Treatment of an established keloid or
hypertrophic scar : 1- The release of the contracture by re-arranging
the tissues by local flaps (e.g.: Z- plasty) or by the
application of skin graft.
2- Intralesional steroid injection
(e.g.: triamcinolone acetonide; 1-2 cc of 40 mg./cc
at one or two weeks interval.). It inhibits collagenase
inhibitors causing degradation of collagen, thus
decreasing dermal thickening.
3- Application of silicone gel sheet as an
occlusive dressing. Ideally it should be placed
24hrs./day for about a year. Silicone does not
penetrate the skin, so its effect appear to be
secondary to occlusion and hydration.
Occlusion appears to increase the temperature
of the scar, possibly increasing the collagenase
activity. Hydration causes softening of
the scar.
4- Cryosurgery: It uses liquid N2 to cause
cell damage and to affect microvasculature
with subsequent stasis, thrombosis and
transudation of fluid resulting in cell anoxia.
The protocol is 1-3 freeze cycles lasting for
10-30 sec., with repeating therapy every 20-
30 days. Better results are obtained when
cryosurgery is combined with steroid
injection
5- Laser therapy : The advantage of laser as an
excisional tool is that it is precise, haemostatic with
minimal tissue damage thereby eliminating
inflammatory reaction. The modalities are :
- Pulse-dyed laser ----- microvascular thrombosis
- CO2 laser & Argon laser----- collagen shrinkage
through heating.
- Nd-YAG laser----- inhibits collagen metabolism
and production.
However the recurrence rate with laser therapy is
high.
6- Interferon therapy : The newest therapeutic
modality on the horizon is intralesional injection
of INF- alpha, INF- beta and INF- gamma.
They reduce fibroblast synthesis and collagen
type I, III and possibly IV and increase the
collagenase activity.
Studies show that INF- alpha 2b and INF- gamma
are most effective when injected immediately
postoperatively into the excision site.
Management of burn sequelae
in specific regions
1- Head and Neck
2- Upper extremity
3- Lower extremity
4- Trunk
Head reconstruction includes : 1- The scalp
2- The face :
a- Eye lids
b- Eye brows
c- Mouth
d- Nose
e- Ears
Scalp reconstruction: 1- Indications: The primary indication of scalp
reconstruction after burn is scar alopecia or an
unstable scar.
2- Classification:
Minor defect: up to 5% of scalp involved.
Moderate defect: from 7-70% involved.
Extensive defect: more than 70% involved.
3- Reconstruction : a- Minor defect: immediate treatment is done by
skin graft. Later on, advancement and rotation of
adjacent scalp flaps will be enough to fill the defect.
b- Moderate defect: immediate treatment is done by
skin graft. Tissue expansion is the final treatment of
choice. This allows the area to be reconstructed with
like tissue and with no donor defect.
c- Extensive defect: This is a difficult
situation. Defects in this range may be too
large to be corrected by tissue expansion. If
periosteum is intact, a skin graft is applied.
Otherwise free tissue transfer is required. The
most common flaps are the omentum and the
latissimus myocutaneous flaps.
Reconstruction of the Face: Diagnosis of the depth of burn in
the face may be difficult and early
excision is contraindicated.
It is often surprising howmuch
facial skin regenerates. Whatever
method of reconstruction is used,
the aesthetic unit of the face
should be followed.
1- The forehead : is best resurfaced with a
single sheet of split thickness skin graft.
With bony exposure or destruction, flap
reconstruction is indicated.
2- The cheeks : the best is tissue expansion
from adjacent non-injured tissue (e.g.: neck).
Thin free flaps may be considered (e.g.: radial
forearm flap). Others describe the use of a
large full-thickness graft as one aesthetic unit.
Eye lid reconstruction :
Indications : exposed cornea, contractor ectropion of upper
and/or lower eye lid and contractures at the canthi regions.
1- Total loss of eye lids : the exposed cornea can be covered
by mobilizing the conjunctiva which is covered with skin
graft. Later on the lids can be reconstructed with local flaps
(e.g.: cheek flap or
median forehead flap
with septal
mucoperichondrial graft
as lining).
2- Ectropion :
we have to distinguish between :
a- primary ectropion where the deep burn affects the eye lids
directly. The treatment is release of the contrature and
application of thick split thickness graft to the upper eye lid
and a full thickness graft to the lower eye lid.
b- secondary ectropion, due to contracture of forehead, cheek
or neck pulling on the eye lids. Treating the cause will
alleviate the condition.
3- Contracture web at the medial and/or lateral canthi are
corrected by local flaps in the form of Z- plasty or V-Y plasty.
Eye brow reconstruction :
* Loss of the hair may be compensated by
the simple simulation done by an eye
brow pencil ( specially in women ).
However surgical reconstruction of the
eye brow may be done through :
1- Hair transplantation: single hair
transplantation is better than a punch
graft.
2- Hair-bearing flap from the temporal
scalp. It is based on the superficial
temporal artery and it is an island flap.
3- Strip graft taken anywhere from the hairy scalp
with the dimension and shape of the eye brow. Care
is taken :
- not to exceed 4 mm. in width.
- not to injure the hair follicles during elevation of
the flap by the scalpel.
- the direction of the hair should be oriented from
medial to lateral.
Lip and mouth reconstruction : 1- Extensive scarring of the upper or lower lip:
excision and full thickness graft within the
aesthetic unit of the involved lip.
2- Microstomia (oral commissure contracture):
corrected by full thickness incisions at each angle
of the mouth as far as a line dropped vertically
from the pupil of the eye. Then the oral mucosa
is mobilized and everted onto the lip skin, forming
a new commissure. Some overcorrection is
generally advisable.
Nasal reconstruction : 1- Total destruction of the nose requires :
a- Flap reconstruction either
regional, like the forehead flap,
or distant by microvascular transfer.
b- Prosthetic reconstruction.
2- Unacceptable hypertrophic or hypopigmented
scars over a large surface of the nose may be
treated by dermabrasion, either mechanical or by
laser, and application of a single sheet of skin
graft within the nasal aesthetic units.
3- Alar rim reconstruction is done using a composite
graft from the ear.
4- Nostril stenosis is treated by release and skin
grafting. Splints must be worn for at least six months
after surgery to prevent recurrence.
5- Web contracture between columella and upper lip,
may be released by V-Y advancement flap.
Ear reconstruction:
- Indications: Partial or total loss of the external
ear.
- Classification: Help to determine the treatment.
Mild defect: loss of helix and upper part of the
auricle, without extensive scarring.
Moderate defect: concha nearly normal; upper half
of the ear missing; antihelix and its posterior crura
missing.
Severe defect: remnant of concha; local soft tissue
scarred; external ear orifice normal or stenosed.
Head & neck reconstruction
(Ear reconstr.)
- Treatment : 1- Total absence of the auricle : - Surgical reconstruction using a costochondral
graft, as described for microtia.
- Osteointegrated prosthesis.
2- Subtotal absence of helical rim : - The Antia procedure is effective in restoring
the helical rim.
- Local flap reconstruction is preferred.
- When the entire helix is missing, a tubed
cervical skin flap is used.
3- Ear lobe deformity:
- Adherence of the ear lobe to the neck is the main
deformity. Z-plasty or local flaps are generally
sufficient for correction.
4- Meatal stenosis :
- Splinting may be used as a preventive measure
and may eliminate the need for surgical
correction
- After release, use local flaps if available. If not
use skin graft.
- A conformer is worn by the patient for 4 - 6
months to prevent recurrence.
Neck reconstruction :
* Prevention of occurrence of contracture: 1- During the period of dressings, the neck should be fully
extended by putting pillows below the scapulae not behind the
head.
2- When the burn is dressed, a bulky foam collar may be
incorporated over the dressing to elevate the chin and keep the
neck extended.
* Treating established contractures : 1- Mild cases: mild scar bands can generally be corrected
surgically by using local flaps or Z-plasties.
2- Moderate cases: contractures involving 1/3 - 2/3 of anterior
neck, can be treated using tissue expansion. The unscarred
lateral aspects of the neck are expanded.
3- Severe cases: contractures involving more than
2/3 of the anterior neck, are better treated by
release and split thickness skin graft or distant flap
by microvascular technique. Local flaps are not
adequate.
Management of axillary contractures :
* Prevention of contracture : For burn of the axilla, the patient should be nursed
with the shoulder abducted either by splinting or
applying copious dressing paddings in the axilla.
* Treating established contractures : 1- Scar bands and minor contractures are better
treated by local flaps e.g.: Z-plasty or V-Y plasty.
They may be combined with the application of
skin graft, kept in place by tie-over dressing.
* Treating established contractures : 2- Moderate contracture may be released and the
defect filled with a latissimus dorsi fasciocutaneous
flap.
* Treating established contractures : 3- Severe contracture, producing large defect on
release, are best treated with skin graft.
Plaster of paris is applied at the
end of the operation where the
joint is kept as fully abducted
as possible.
Splintage should be maintained
for several weeks until the
patient can put the joint
through a full range of
movement.
* Prevention of contracture : During burn healing, the elbow is splinted 10 o short of
straight, but is put in a full range of movement three times
daily.
* Treatment of an established contracture: Usually follows the same principles as for the axilla. The joint
should also be splinted for several weeks.
* Prevention of contractures : 1- Frequent active and passive
movements of the wrist, M P Js
and I P Js through a full range of
motion.
2- We have to incorporate plaster
of Paris or aquaplast splint in the
bandage, so that the position
of the wrist and hand is kept as
follows :
a- The wrist is extended 20o
b- The M P Js are flexed to 90o
c- The I P Js are kept straight
3- Splintage of the hand while the patient is asleep
during night, helps to prevent contractures into a
non-functional position.
4- Early skin grafting is preferable for full-thickness
burns, to allow early movement.
* Treatment of established deformities :
1- Amputation deformity : typically they involve
the DIJs, PIJs and possibly the middle phalanges.
Toes as well as fingers are usually involved.
The most common procedure, is deepening the
web space to produce a longer finger. The thumb
amputation deformity is treated either by
pollicization or toe to finger transfer.
2- Dorsal burns :
a-Hyperextension deformity of the dorsum of the
hand, is released by a transverse incision across
the distal part of the back of the hand. The para-
tenon of the extensor tendons should be preserved
and a thick partial thickness graft applied to the
defect and maintained in place with a tie-over
dressing.
b- In severe cases of joint capsule contracture, we do
capsulotomy and the joint is immobilized by a K-wire for 3
weeks with the joints as flexed as possible.
c- The Boutonniere deformity may be corrected by releasing
the lateral slips of the extensor tendon and plicating them
onto the dorsum of the PIJ. The joint is immobilized with K-
wire for 3 weeks.
d- Arthrodeis of the PIJ, may be the only solution
for the destruction of the central extensor slip.
e- Hyperextension of the DIJ, is treated by tenotomy
of the lateral slips of the extensor tendon just
proximal to DIJ. This will allow the terminal
phalynx to drop to neutral position.
3- Palmar burns :
Mostly due to grasping electric fire
filaments. It is more common in
children.
The interphalyngeal spaces are usually
webbed (= burn syndactly).
They may be released by double
opposing Z-plasties, using full-
thickness or partial-thickness skin
grafts for the residual defects.
To facilitate dressing, the fingers and
hand are immobilized in Banjo splint.
Lower extremity reconstruction :
* Popliteal fossa : 1- Prevention of contracture:
Bulky dressing or pillows behind the knee during
the healing phase are avoided, so that the knee is
fully extended. If the patient is sitting on a chair,
legs are elevated on a footstool.
2- Treatment of established contracture :
a- Medial or lateral band contracture, are released
by local flaps.
b- More extensive scarring and contracture, are
released with the application of skin graft, or
reversed saphenous artery flap.
For all modalities of treatment, splinting and
immobilization in extention, is recommended for
1 week. Then daily stretching exercises and
splinting at night for 3-6 months.
* The ankle, dorsum of foot and toes : During the healing phase, dorsi flexion or plantar
flexion of the ankle, are prevented by applying the
appropriate splintage.
• Treatment of an established contracture:
Usually in the form of dorsiflexion of the foot and toes.
We do release till the level of the paratenon, with
application of thick partial thickness skin graft.
Tenotomy of the extensor tendons may be necessary to
alow the toes to drop into the
correct position maintained by K-wire for few weeks.
Abdomen reconstruction :
* Indication : Unstable or unattractive abdominal scar or scar
causing functional deficit or anatomic deformity.
* Treatment : 1- Small defects: managed by primary excision and
closure.
2- Moderare defects: managed with staged serial
excision. Scar bands can be released and
reconstructed by local flaps and/or skin graft.
3- Large defects:
Extensive hypertrophic scarring may need
extensive tissue expansion.
Tissue expansion provides the best approach for
like-for-like tissue.
Breast deformity management :
* Indications : - Scarring, deformity and assymetry are the major
indications for reconstruction.
- The surgeon must be extremely conservative
in debriding the nipple area. The first priority is
not to injure the breast bud.
- Follow up should continue through puberty.
After scar maturity and puberty, reconstructive
surgery can be planned.
* Treatment : 1- Restoring the breast projection:
- Surgical intervention can range from a simple
release of a contracting inframammary scar, to
extensive scar excision and skin grafting, allowing
the breast to take its shape.
- Total destruction of the breast bud will need full
breast reconstruction using TRAM- flap, lat. dorsi
muscle flap with prosthesis or tissue expansion
followed by insertion of a prosthesis.
2- Reconstruction of the N/A complex:
- A four-flap nipple procedure is done to lengthen
the nipple. A full-thickness skin graft will simulates
the areola.
- Tattoing the nipple and areola, may enhance the
result.
Management of burn deformity of the
external genitalia :
1- Scar contracture may lead to functional loss,
such as difficulty with sex or urination. Release
of the scar is by local flaps or skin graft.
2- Penile loss may be seen with electric burns.
Total penile reconstruction is performed. The
neurosensory radial forearm flap is preferred.
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