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Please see Chapter 2: Grafts for more detailsIn general,
defects lead to loss of skin and thus skin graft is common
technique used to address this.
Please see the débridement and grafting section of the acute
burn chapter for acute débridement and grafting.
For reconstruction, if using split-thickness skin graft (STSG),
should use a thicker setting (0.012-0.020 in). Useful for
forehead, upper eyelids, or closure of peripheral areas.
Full-thickness skin graft (FTSG): consists of entire dermis,
therefore, less remodeling and secondary contracture.
Preferred over STSG for face, hand, and joint surfaces
DERMAL SUBSTITUTES
Used prior to skin (autograft) grafting to prepare wound bed
Cadaveric skin (homograft)
Skin substitutes derived from porcine or bovine (xenograft)
Integra (Life Sciences): collagen-glycosaminoglycan
biodegradable matrix covered by semipermeable silicone.
Secured to burn in a similar way to skin graft
*Provides temporary coverage and allows for thinner
STSG to be used (0.005-0.008 in)
May graft onto granulated surface in ~21 days if using
traditional dressing and 10 days if using a wound vac
Disadvantage: expensive
FLAPS
Local
Flaps can be utilized if there is noninjured local tissue
Groin or intercostal flaps also possible in severe hand burn
Free Flaps
Thin free flap options such as fascia only with skin graft or
fasciocutaneous free flaps
Common flaps: anterolateral thigh, scapular/parascapular,
radial forearm (see Chapter 4: Vascularized Composite
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Allotransplantation)
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TISSUE EXPANSION (SEE CHAPTER 5
FOR FURTHER DETAILS)
Produces additional tissue with similar appearance to recipient
site.
Expanded tissue has improved vascularity.
Especially helpful for burn alopecia.
Expander base dimensions should be planned preoperatively.
When first placing expander, it is important to make sure that the
expander is not folded. The pocket must not be made too large
in order to prevent unwanted changes in position of the
expander.
Create small tract distal from expander for filling port and use
remote port in a different pocket than expander.
NONSURGICAL OPTIONS
Laser therapy can improve the thickness and color of scar.
Common laser therapy used in burn care: pulsed dye (for
persistent scar erythema), fractionated CO2 (for scar thickness),
alexandrite (for hair removal from flaps and full-thickness grafts).
See Chapter 9: Lasers in Plastic Surgery for full discussion of
available laser therapies.
Continued occupational and physical therapy is essential for
reconstructive success.
CONSIDERATIONS FOR SPECIFIC
ANATOMIC AREAS
FACIAL BURNS
Ideally graft by facial subunit with use of FTSG
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If not possible, graft smaller subunits with FTSG and larger units
with thick STSG
For extensive, disfiguring burns, can also consider facial
transplantation or other complex free flap–based reconstruction
MOUTH
Reconstruction should focus on maintain oral competence and
prevent microstomia
Commissure
The commissure should form an acute angle at a vertical
line dropped from the medial limbus in repose. Burn
contractures can blunt the oral commissure.
Successful splinting may counteract, or prevent, the natural
tendency for a mild to moderate perioral burn
Commisureplasty techniques to correct microstomia
Buccal mucosal advancement flap-following burn
excision and contracture release at the oral
commissure, mucosal flaps are developed and
advanced into the defect (typically in V to Y fashion).
Myomucosal advancement flap-contracture is released
and the orbicularis oris muscle is incised and advanced
laterally toward the commissure. A vermillion flap is
additionally elevated and advanced laterally. The
mucosa of the oral vestibule is elevated and advanced
to cover remaining exposed orbicularis.
Staged lip reconstruction (Estelander, Karapandzic
flaps, see Chapter 26: Lip and Cheek
Reconstruction)
Upper Lip
Three subunits: two lateral lip elements and the philtrum.
Philtrum can be recreated using skin graft or philtral shaped
cartilage graft.
The columella can be lengthened with “fork flaps” from the
upper lip.
Important to preserve and realign white roll where possible.
May also use staged lip reconstruction techniques.
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Lower Lip
Can place scars in labiomental creases.
Maintain soft tissue of pogonion for chin prominence.
Severe neck contracture can cause lip eversion.
EYEBROW
If contralateral brow unaffected, create template from this side
May use micrografts or hair-bearing FTSG
Additionally can utilize vascularized island flap based on
superficial temporal artery
Tattoo
EYELID
Reconstructive challenges: corneal exposure, ectropion (from
internal or external contracture), and canthal contracture
Tarsorraphy may be helpful in the first few weeks to prevent
corneal exposure and keratitis
Ectropion: caused by inadequate tissue; therefore, in addition
to release, the surgeon will need to replace tissue, often with a
FTSG.
Extrinsic contracture: need to release scar and provide
additional tissue to prevent recurrence.
Release 2 mm from the ciliary margin, extending 15 mm
beyond the medial and lateral canthi.
FTSG form contralateral side for upper lid and from
retroauricular region for lower lid.
Dissect the orbicularis oculi muscle free from all scar tissue,
re-drape the muscle over the entire eyelid as a sling, and
secure it laterally to the orbital rim and medially to the nasal
sidewall.
Intrinsic Contracture
Requires addressing all lamellae
Upper lid: if ipsilateral lower lid is intact: Hughes or CutlerBeard flaps
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Lower lid: Mustarde cheek advancement with deep
anchoring. If no local tissue is available, pedicled
temporoparietal fascia flap.
Subperiosteal mid-face lift can be performed to reduce
tension of the lower eyelid
Medial: Z-plasties, V-M plasties, or double opposing Zplasties
Lateral: local transposition flap, lateral canthoplasty, or
lateral canthotomy
Middle lamella: palatal mucosal graft for support
NOSE
Layers to consider: skin, cartilage, and mucosa
Consider nine aesthetic nasal subunits: dorsum, tip, columella,
sidewalls (×2), soft triangles (×2), ala (×2)
Dermabrasion followed by STSG or FTSG in an aesthetic unit
Total or subtotal reconstruction: forehead flap
Cartilage defects: conchal or septal cartilages
EAR
Small helical rim defects: Antia-Buch advancement flap.
Larger helical rim defects: Davis conchal transposition flap
Elevation of a composite flap of skin and cartilage from the
concha, pedicled at the crus helix, is transferred to the
upper third of ear. The donor site is closed with a skin graft.
Extensive defects: a temporoparietal fascial flap is used to cover
a cartilage framework.
An osseointegrated prosthesis is an excellent option for total ear
loss with significant burn scar on surrounding tissue.
NECK AND CHIN
*Neck contractures are the most common complication of
burn injury
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Key components: range of motion and oral competence
Release scar contracture down to platysma or subplatysmal
followed by coverage with large FTSG or thick STSG followed
by aggressive range of motion 5 days after having patient in
neck brace
Can use multiple tissue expanders in infraclavicular region
Can also use thin free flaps to resurface neck contractures
Postoperative management: compression garments for 6-18
months and a neck brace to keep neck extended to prevent
recurrence
SCALP
Small defects: advancement or rotation flaps with donor site
closed or covered with skin graft
Moderate: tissue expansion with expander placed in subgaleal
plane (deep to frontalis)
Extensive: omentum or latissimus dorsi flap
BREAST
Key deformities: tight skin envelope, asymmetry, nipple-areola
complex malformations
Tissue expansion or autogenous reconstruction: TRAM or
latissimus dorsi if tissue uninjured
Can do contralateral reduction to aid in symmetry
*Prepubescent breast burns—important to release
contracture to allow for development of breast
AXILLA
Regions: anterior axillary fold, mid-axillary line, and posterior
axillary line
Common because difficult to maintain ideal position (shoulder
should be at 90°-120° abduction and 15°-20° flexion) in acute
phase of burn
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Three Grades of Axillary Contractures
Type I: both the anterior and posterior axillary folds are
involved leaving the normal skin in the hair bearing central
part. A web is formed during abduction.
Type II: the inner portion of the upper arm and the adjacent
trunk as well as one axillary fold are involved.
Type III: the upper arm and the lateral aspect of the trunk
and completely included in one mass of scar.
Types I and II: contracture sequential release and thick STSGs
or FTSGs
Type III: local and distant flaps, including parascapular and
latissimus flaps
Must pay attention to where hair-bearing regions are transposed
May need release pectoralis major or latissimus dorsi muscles
Intraoperative OT range of motion including shoulder
Postoperative OT and splinting necessary to prevent recurrence
ELBOW (TABLE 11-1)
Table 11-1 Classification of Elbow Burn Contracture Severity
and Commonly Used Reconstructive Options
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From Kung TA, Jebson PJ, Cederna PS. An individualized approach to severe
elbow burn contractures. Plast Reconstr Surg. 2012;129(4):663e–673e. doi:
10.1097/PRS.0b013e3182450c0c
Results from scarring along antecubital fossa or dorsal forearm
and upper arm
No bone exposed: FTSG or thick unmeshed STSG
May need to perform tendon lengthening of the biceps tendon
Bone exposed: local fasciocutaneous flap—reverse radial
forearm or propeller flap
Bone exposed and no local tissue available: free fascia only or
thin fasciocutaneous flap
HAND
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Prevention of hand contracture is key. Patients should be
splinted in intrinsic plus (MC flexed at 70°-90°, wrist 20°-30°, IP
joints in full extension and thumb kept abducted and slightly
opposed) in acute phase of burn.
Unchecked burn hand contracture: wrist flexion, MCP joint
hyperextension, PIP flexion, boutonniere deformities of digit,
and thumb adduction contracture
Flexion Deformities
Isolated scar bands volarly or excision of scar and FTSG
Small defects after release: local skin flaps
If joint affected: release of volar plate, joint capsule, and
collateral ligaments
Boutonniere deformity (see Chapter 38: Tendon Injuries and
Tendonitis)
MCP Hyperextension
Requires contracture release and grafting
If scar released and not sufficient gain in flexion, may need
dorsal capsulotomy
Palmar Contractures
Avoid excision of palmar skin
FTSG to resurface small defects, though may need dorsal
neurocutaneous island flap for large defects
Web Space Contractures
Postburn syndactyly is the most common secondary
deformity and usually involves dorsal skin of web space
Treatment options: Y-V advancement, Z-plasty, jumping
man
Thumb most difficult and often best treated by jumping man
Burn Syndactyly
Unlike congenital syndactyly, there is not enough laxity or
surrounding tissue for reconstruction. Usually requires
release and FTSG
Thumb reconstruction includes web space deepening,
pollicization, and toe thumb transfer
PERINEUM
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