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Ростовский Государственный Медицинский Университет

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Медицина общая

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CHAPTER28 Burns scar management

Common types ofburn scars and interventions

For almost all burns scars, avoidance of exposure to sunlight, high factor sun screen for at least 2years, and massage with suitable moisturizer is generally recommended.

Hypertrophic and keloid scars

Hypertrophic scars are erythematous, raised, and itchy. Keloid scars tend to be of a greater order of severity and extend beyond the boundaries of the original scar/ injury.

Interventions

• Pressure therapy (pressure garments or masks)

• Silicone therapy

• Massage

• Intralesional corticosteroids

• Laser treatment (see Chapter44)

• Moisturizers including medicated ones to help with itch and hydration

Keloids only:also

• Intralesional 5- uorouracil

• Intralesional cryotherapy

• Brachytherapy and radiotherapy

• Surgery (last resort due to high recurrence, and often combined with

other modalities)

Intralesional corticosteroids such as triamcinolone are one of the most successful and safe interventions for those that respond. In general, most other interventions tend to be for ‘steroid non- responsive’ cases.

Scar contractures (see also Chapter30)

• Surgical scar release:skin grafts, reconstructive aps, dermal substitutes

(see Chapter25)

• Laser treatment (mild)

• Splintage (prevention is better than cure)

Common scar interventions such as corticosteroid injections have limited success in mature scar contractures which do not have a hypertrophic element.

Mature scars

These are non- hypertrophic scars which will neither improve nor worsen spontaneously.

They will be of cosmetic concern and often cause functional limitation.

• Cosmetic camouage

• Massage including interventions such as vacuum massage systems

• Laser (colour, contour, camouage ability)

• Surgery and other interventions for functional and/ or cosmetic

limitations

Common scar interventions such as corticosteroid injections have limited success in mature scars.

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COMMON TYPES OFBURN SCARS AND INTERVENTIONS

Hyperpigmented scars

These scars show discolouration which is dierent from erythema (both may co- exist).

• Laser

• Dermabrasion

• Cosmetic camouage

• Hydroquinone- based topical treatments (limited success)

Hypopigmented scars

• Cosmetic camouage is the mainstay of treatment as reintroducing

pigmentation is challenging and has highly variable and inconsistent results from most modalities available including:

• Laser or dermabrasion with or without autologous cell transfer (eg. Re- Cell)

• Micropigmentation and tattooing

Iatrogenic and surgical scars

Iatrogenic scars in burns are usually donor sites from split thickness skin grafts (STSGs) and full thickness skin grafts (FTSGs).

These scars may be amenable to a range of interventions to improve them as described before depending on the problems (eg. vascular laser for erythema, silicone and pressure for early hypertrophic scars).

Other iatrogenic changes are most frequently from corticosteroid injections, causing erythema, telangiectasia, and atrophy. Combined vascular (pulsed dye and/ or Nd:YAG) is the mainstay of treatment for this problem.

Novel interventions forburn scars

• Platelet- rich plasma

• Autologous fat grafting

• Photodynamic therapy

• Tissue mechano- stimulation (LPG- Endermologie/ ‘vacuum massage’)

The holistic management of scars including psychological support is paramount.

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CHAPTER28 Burns scar management

Further reading

Alser OH, Goutos I. The evidence behind the use of platelet- rich plasma (PRP) in scar manage-

ment:a literature review. Scars, Burns & Healing 2018;4:2059513118808773.

Goutos I, Ogawa R. Brachytherapy in the adjuvant management of keloid scars:literature review.

Scars, Burns & Healing 2017;3:2059513117735483.

Riyat H, Touil L, Briggs M, Shokrollahi K. Autologous fat grafting for scars, healing and pain:a review.

Scars, Burns & Healing 2017;3:2059513117728200. Shokrollahi K (ed.). Laser management of scars. Springer- Nature, 2019. Shokrollahi K, Whitaker IS, Nahai F. Flaps:practical reconstructive surgery. Stuttgart:Thieme, 2017. Yeates R, Rospigliosi E, Thompson AR. A mixed methods evaluation of medical tattooing for people

who have experienced a burn injury. Scars, Burns & Healing 2018;4:2059513118784721.

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Chapter29

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Principles ofburn reconstruction

Key principles 236 Assessment 238 Timing 240 Further reading 240

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CHAPTER29 Principles ofburn reconstruction

Key principles

Burn reconstruction starts with the initial surgery and continues until either the maximal functional and aesthetic outcome has been achieved, or the patient and/ or surgeon feel that no further intervention is warranted. Communication and understanding of the limitations of surgery are essential to ensure that the appropriate approach is taken. While reconstruction is considered to be surgical, it is important not to forget the other contributing modalities that are essential to address the specic needs of the postburn patient, such as splinting, physiotherapy, camouage, laser, and scar management. In the ideal situation there should be a specialist, integrated team able to assess and plan a treatment programme dependent on the needs and wishes of the patient and the expertise and skills of the burn reconstruction team. Successful burn reconstruction owes much to eective early burn care and the prevention of complex scar contracture sequelae. Early excision and grafting of deep burns, coupled with carefully constructed regimes of splinting, scar therapy, and mobilization, has done much to reduce post- burn contractures and hypertrophic scarring, but there is still the need for surgical reconstructive procedures (both simple and complex) in certain cases. In countries where there are delays in initial treatment, minimal excision and grafting, and a lack or total absence of rehabilitation, the needs for functional surgical reconstruction are much higher.

Principles of reconstruction can be considered in terms of assessment and timing.

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KEY PRINCIPLES

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CHAPTER29 Principles ofburn reconstruction

Assessment

Consider the5 Ps

Problems

• Physical

• Consider:Where are the scars, are they limiting function, are they clearly visible, are they painful, do they itch, are there areas of breakdown, what is it that bothers the patient etc.?

• Psychological

• Consider:Is the problem more of perception, are there underlying social and psychological or relationship issues etc.?

Priorities

The priorities need to be considered from both the surgeon’s point of view and the patient’s as these are not necessarily the same, in which case the issues need to be carefully explored and discussed. From the surgical perspective, the priorities can be classied as urgent or non- urgent. Urgent indications would include severe ectropion leading to corneal exposure, severe microstomia, neck synechia limiting ventilation, and areas of unhealed or ulcerating scar (especially if long term where there is a risk of SCC formation). Non- urgent procedures still need to be prioritized and this depends on each individual patient. Sometimes it is better to do a small simple procedure rst, other times it is better to address a more major contracture, but in general functional improvement takes priority over purely aesthetic improvement.

Possibilities

When considering the possibilities, it is important to think of both surgical and non- surgical options. Within surgical options, all the possibilities should be considered and rather than progressing stepwise using the ‘reconstructive ladder’ (starting with the most simple technique and moving up to the most advanced), the most appropriate should be chosen. It is not about what ‘could’ be done, but what ‘should’ be done. Within the surgical toolbox there are many dierent options and the rst decision with respect to scar contractures is whether to do an incisional or excisional release (ie. whether to cut through the scar or cut out the scar). Then all the options for providing skin ± soft tissue cover need to be considered and this will include direct closure, local aps, split and full thickness skin grafts, composite grafts, tissue expansion, free tissue transfer, and use of dermal templates.

Patient perceptions

It is critical that the patient has a realistic understanding of what can be achieved and what cannot be achieved. Good, clear communication is essential and the length of surgery, likely hospital stay, time o work, postoperative physiotherapy, splinting, scar management, etc., need to be understood by the patient as the rehabilitation investment can be quite considerable and this needs to be weighed against the likely improvement achieved.

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Plan ofaction

Once the above process has been gone through, the nal stage is for the burn reconstruction team and the patient to agree a plan of action. This may be simple and involve one minor procedure, or highly complex involving staged procedures over a considerable period of time.

ASSESSMENT

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CHAPTER29 Principles ofburn reconstruction

Timing

Most reconstruction will be delayed until scars have fully matured (72years) and eects of scar management have declared themselves, unless early intervention is warranted due to severe functional impediment or deformity. Correct surgical timing is pivotal:operating too early may worsen eventual outcome. As children are growing, the timing of surgical interventions is particularly important, too early and it might be necessary to repeat a procedure, too late and there might be permanent eects on movement due to secondary joint tightness.