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Perineal webs result from burn to genitalia and perineum and
deep burns to proximal thigh, interfering with hygiene and
ambulation
Early scar release and grafting important in severe deformities
Labia and scrotum: release of webbing and skin grafting
Complete reconstruction utilizes the techniques of genderaffirming surgery
FOOT
Based on the complexity, depth, and severity of the contracture,
a classification system was developed to describe each toe burn
scar contracture as mild, moderate, or severe (Table 11-2).
TABLE 11-2 Decision Tree for Foot Burns
Mild: superficial tissues only. Treatment: scar excision or
rearranging the local tissue, that is, with a Z-plasty burn scar
release.
Moderate: soft tissue deficits. Treatment: scar excision and
resurfacing with skin grafts. Sometimes require ancillary
procedures, such as closed capsulotomy of the metatarsal
phalangeal or interphalangeal joints.
Severe: involvement of deeper structures, including tendons,
ligaments, and joint capsules. Treatment: multiple procedures,
including skin grafting, possible free flaps for adequate soft
tissue coverage, tendon lengthening, open capsulotomy,
tenotomy, and pin fixation.
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HETEROTOPIC OSSIFICATION
Formation of extraskeletal bone.
Risk of heterotopic ossification increases with percent body
surface area burned and more common in blast injuries.
Thought to be caused by trauma-induced activation of local
mesenchymal cells or endothelial to mesenchymal transition of
local endothelial cells.
Current diagnosis strategies inadequate and include X-ray and
CT.
Possible prophylaxis includes NSAIDs, specifically
indomethacin.
Treatment includes radical resection of osseous tissue and
contracture release.
PEARLS
1. Acute burn care plays a critical role in decreasing secondary
burn reconstruction needs.
2. Adequate splinting in the acute setting as well as following
elective burn reconstruction is critical to reconstructive success.
3. Full-thickness skin grafts are preferred in the face and hands.
4. Burned lid ectropion should to address the internal, middle, and
outer lamella.
5. Burn scar finger syndactyly often has a greater tissue deficit
than congenital syndactyly and almost always requires a skin
graft.
6. Burned breast reconstruction in children requires release of the
cutaneous scar restricting the breast bud to allow breast growth.
QUESTIONS YOU WILL BE ASKED
1. What angle should you set up the limbs of a Z-plasty?
In general, between 60° and 70°.
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1.
2.
3.
4.
5.
6.
7.
2. What are you gaining by doing a Z-plasty?
Gaining length at the expense of width.
3. What flap is ideal to improve a web space contracture of the
thumb?
Jumping man flap.
4. What is heterotopic ossification?
Formation of extraskeletal bone. It is most common in large total
surface area burns and blast injuries.
THINGS TO DRAW
1. Z-plasty and serial Z-plasty including where to place and how it
rearranges tissues
2. Jumping man flap
Recommended Readings
Klein MB. Burn reconstruction. Phys Med Rehabil Clin N Am. 2011;22(2):311‐
325. vi–vii
Klein MB, Donelan MB, Spence RJ. Reconstructive surgery. J Burn Care Res.
2007;28(4):602‐606.
Klein MB, Moore ML, Costa B, Engrav LH. Primer on the management of face
burns at the University of Washington. J Burn Care Rehabil. 2005;26(1):2‐6.
Orgill DP, Ogawa R. Current methods of burn reconstruction. Plastic and
Reconstructive Surgery. 2013;131(5):827e‐836e.
Parsel S, Winters R. Commissuroplasty. Operative Techniques in
Otolaryngology. 2020;33:33‐37.
Ranganathan K, Wong VC, Krebsbach PH, Wang SC, Cederna PS, Levi B. Fat
grafting for thermal injury: current state and future directions. J Burn Care Res.
2013;34(2):219‐226.
Wainwright DJ. Burn reconstruction: the problems, the techniques, and the
applications. Clin Plast Surg. 2009;36(4):687‐700.
*
Denotes common in-service examination topics.
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12
Preoperative Cardiopulmonary
Risk Stratification and
Prophylaxis
Kory LaPree
PULMONARY
AIRWAY
Mallampati Scores (Fig. 12-1): a high Mallampati score (either
3 or 4) is associated with more difficult mask ventilation and
intubation.
Figure 12-1 Mallampati classification.
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Class I: full visibility of tonsils, uvula, and soft palate.
Class II: visibility of hard and soft palates, upper portions of
tonsils, and uvula.
Class III: soft and hard palates, as well as base of uvula,
are visible.
Class IV: hard palate is the only visible structure.
The LEMON method of airway assessment is a useful
screening tool. Patients who meet multiple LEMON criteria
should be referred for preoperative anesthesia consultation.
L = Look externally (for beard/mustache, facial trauma,
macroglossia, micrognathia)
E = Evaluate the 3-3-2 rule
Mouth opening <3 finger breadths (the patient’s
fingers) with normal dentition quality
Hyoid-mentum distance <3 finger breadths
Thyroid cartilage-hyoid bone <2 finger breadths
M = Mallampati score of 3 or 4
O = Obstruction (from large tonsils, peritonsillar abscess,
trauma, macroglossia)
N = Neck mobility (cervical extension and flexion)
Other patients to refer to preoperative anesthesia for airway
issues include
Patients with a history of difficult airway.
Patients with other barriers to intubation (such as a halo).
Consider patients with known obstructive sleep apnea or
supermorbid obesity if in combination with any LEMON
criteria from above.
CARDIOVASCULAR
RISK STRATIFICATION AND
PROPHYLAXIS FOR ENDOCARDITIS
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In general, invasive procedures performed through surgically
scrubbed skin are not likely to produce clinically relevant
bacteremia.
Patients that require prophylactic antimicrobial therapy based on
2017 AHA/ACC guidelines (high risk only).
Dental procedure that involves the manipulation of gingival
tissue, periapical region of teeth, or perforation of the oral
mucosa.
Urologic surgery if the urinary mucosa is pierced in the
setting of active urinary tract infection or colonization.
High-Risk Categories
Prosthetic cardiac valves
Patients with implanted prosthetic material, such as
annuloplasty rings and artificial chordae tendineae
Patients with a history of infectious endocarditis
Patients with a history of unrepaired cyanotic congenital
heart disease, including patients with a repair, but with a
residual shunt or valvular regurgitation
Patients with a history of cardiac transplantation who have
a regurgitant valvular lesion due to a structurally abnormal
valve
AMERICAN HEART ASSOCIATION
GUIDELINES FOR PERIOPERATIVE ΒBLOCKADE
Revised Cardiac Risk Index (RCRI): tool used by AHA/ACC to
estimate patient’s risk for perioperative cardiac complications (2
or more = high-risk patient)
Creatinine >2.0 mg/dL
Heart failure
Insulin-dependent diabetes mellitus
Intrathoracic, intra-abdominal, or suprainguinal vascular
surgery
History of CVA or TIA
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Ischemic heart disease
Preoperative Evaluation
*If the patient is already on a b-blocker for a
cardiovascular indication (angina, arrhythmia,
hypertension), plan to continue this medication in the
perioperative period.
Consider starting higher risk patients on β-blockade at least
1 week prior to surgery or refer them back to their primary
care provider to address this issue.
The initiation of beta-adrenergic blockade within 1 day of
elective noncardiac surgery has been associated with a
decreased risk of myocardial infarction. Although NOT
recommended because of the elevated risks of clinically
significant hypotension, bradycardia, stroke, and death
based on POISE trial of 2008.
Higher-risk patients also include
Vascular surgery patients with coronary artery disease
Vascular surgery patients with multiple cardiac risk
factors listed above in the RCRI
Patients with cardiac ischemia present on preoperative
testing
Patients having high-risk procedures such as
intrathoracic, aortic, or major transplant (heart, lung, or
liver) for cardiac events
The utility of β-blockade is unknown for lower-risk patients,
including
Patients undergoing low- or intermediate-risk surgery
Vascular surgery patients without known coronary
artery disease
Electrocardiogram Preoperative
According to the 2014 guidelines, it is reasonable to
perform a preoperative ECG in patients with coronary heart
disease, significant arrhythmia, peripheral arterial disease,
cerebrovascular disease, or other significant structural heart
disease who are undergoing elevated-risk surgery.
Postoperative Management
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Continue β-blockers in patients receiving them
preoperatively for cardiovascular indications.
Watch for hypotension and bradycardia.
VENOUS THROMBOEMBOLISM
Venous thromboembolism (VTE) includes deep venous
thrombosis and pulmonary embolism
Major source of morbidity and mortality among hospitalized
patients.
Considered potentially preventable through use of
sequential compression devices (SCDs) and, in some
cases, chemoprophylaxis like heparin or low molecular
weight heparin.
VTE risk stratification and prophylaxis for inpatient surgery
2005 Caprini Risk Assessment Model (Table 12-1) has
been validated to predict 60-day VTE risk in plastic surgery
patients.
TABLE 12-1 The 2005 Caprini Risk Assessment Model
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From Pannucci CJ, Dreszer G, Wachtman CF, et al. Postoperative
enoxaparin prevents symptomatic venous thromboembolism in high-risk
plastic surgery patients. Plast Reconstr Surg. 2011;128(5):1093-1103.
PMID: 22030491.
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If NO chemoprophylaxis is given, expected 60-day VTE
rates include
Caprini scores of 3-4 = 0.6%
Caprini scores of 5-6 = 1.3%
Caprini scores of 7-8= 2.7%
Caprini scores of >8 = 11.3%
For inpatients with Caprini scores of >7, weight-based
prophylactic dose enoxaparin given during the inpatient
stay can decrease observed 60-day VTE rate by 50%.
When started 6-8 hours after surgery, a 0.7%
increased rate of reoperative hematoma can be
expected.
This can be balanced against the risk reduction for
potentially fatal VTE events.
Unless a contraindication is present, all patients should
have SCDs while in the hospital.
VTE risk stratification and prophylaxis for outpatient
surgery (Table 12-2)
TABLE 12-2 Weighted Risk Stratification Tool for 30-Day VTE
Events After Outpatient Surgery
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