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CHAPTER43 Hair restoration
Fig.43.3 Factors to consider when planning hair restoration in burn scars.
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OPTIONS FORMANAGEMENT
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CHAPTER43 Hair restoration
Conclusion
Hair restoration in burn scars is a specialized eld with a number of options
that may not all be available locally within the burns centre. It is important
for the multidisciplinary team to be aware of the possible therapeutic modalities and to develop established links with practitioners who oer those
services that are not available locally. Consultations should be co- ordinated
and streamlined so that the treatment options are discussed with the patients prior to their making an informed decision on management of post
burn alopecia.
Further reading
Farjo B, Farjo N, Williams G. Hair transplantation in burn scar alopecia. Scars, Burns & Healing
2015;12059513115607764.
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Chapter44
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Laser management ofscars
Introduction to laser management of scars 376
Potential therapeutic interventions with lasers for scars 377
Post- procedural considerations 378
Summary 378
Further reading 378
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CHAPTER44 Laser management ofscars
Introduction tolaser management
ofscars
There is increasing interest and evidence that laser therapy can help in the
management of scars. Owing to accessibility, variations in education and
training, cost of lasers, and disparate nature of scars there is still much work
to be done in relation to indications and outcomes.
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THERAPEUTIC INTERVENTIONS WITH LASERS FOR SCARS
Potential therapeutic interventions
withlasers forscars
Erythema
The pulsed dye laser at 585– 595nm has potentially the greatest evidence
base for scar treatment, especially in hypertrophic scars. It is the most effective laser for reducing erythema. Some reports of success with deeper
vascularity with Nd:YAG laser have been published.
Hair bearing skin
Depending on skin type, the alexandrite or Nd:YAG lasers and some diode
lasers are the most useful for depilation in the context of burn- related
folliculitis.
Pigmentation
Q- switched Nd:YAG and ablative lasers, such as the carbon dioxide laser,
can help with areas of hyperpigmentation. Patient selection based on skin
type is important to avoid complications such as worsening the problem
or hypopigmentation. Some benet has also been reported from intense
pulsed light (IPL).
Hypopigmentation
Hypopigmentation may occur in all skin types following thermal injury, but
is more prevalent in the higher Fitzpatrick scale skin types. This is a very
dicult problem to treat and the role of lasers remains unclear, but there is
potential promise in laser resurfacing combined with autologous keratinocytes, although this remains a matter for further research.
Hypertrophic and keloid scarring
Hypertrophic and keloid scarring responds to vascular lasers such as pulsed
dye laser (PDL) or long pulsed Nd:Yag laser with variable but often good
results. It may be benecial to concurrently treat established keloid scarring
with intralesional steroid injections and persisting with less invasive treatments such as pressure garments. It is well established that PDL treatment
in keloid scarring can lead to improved density and texture as well as reduced irritation and pruritus in addition to reducing overall scar volume.
Fractional or totally ablative laser resurfacing with the CO2 laser can be of
considerable benet, but results can be unpredictable and treatment should
be undertaken in the context of multimodal therapy.
Inconsistencies intexture
Scar resurfacing, following grafting or aberrant natural healing processes,
may be achieved with fractionated carbon dioxide laser. All ablative treatments must take into consideration the thickness and quality of the skin
being treated and the density of pilo- sebaceous units:skin grafts will respond dierently to native skin. Some benet has also been achieved with
erbium:YAG fractional resurfacing.
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CHAPTER44 Laser management ofscars
Post- procedural considerations
Re- epithelialization after laser treatment relies upon the mobilization of epidermal cells from the pilosebaceous units; areas that have fewer units or
where the units are signicantly damaged may be slower to heal. Patients
with higher Fitzpatrick scale skin type scores will be more susceptible to
side eects of laser treatment and may therefore require longer treatment
courses at a lower uence. Arisk– benet analysis should be undertaken in
every case, bearing the side eect prole, Fitzpatrick skin type, and predictability of response in mind.
Potential side eects ofablative laser therapy
• Immediate skin whitening
• Pain
• Infection
• Erythema, purpura
• Oedema
• Blistering, serous discharge
• Delayed wound healing
• Discolouration
• Textural change
• Hyperpigmentation
While non- ablative therapies are not without risk, the chances of side effects are greatly reduced. Atest patch should be undertaken before laser
treatment to minimize risk and maximize benet.
Summary
Laser treatment is gradually establishing a rm footing as mainstream in the
battle against scars. Atailored treatment programme and clear communication are of utmost importance in delivering a high- quality laser service. In
order to oer a comprehensive laser scar service, a variety of ablative and
non- ablative laser modalities with highly trained sta is required, preferably incorporated within a multi- modality multidisciplinary team oering a
wide spectrum of scar interventions and psychological input. Owing to the
expense of lasers and the high level of experience and training required,
treatment is best delivered in centres of focused expertise in association
with a burns unit.
Further reading
Shokrollahi K (ed.). Laser management of scars. Springer- Nature. 2019.
McGoldrick RB, Sawyer A, Davis CR, etal. Lasers and ancillary treatment for scar management:per-
sona experience over two decades and contextual review of the literature. Part1: Burn scars.
Scars, Burns & Healing 2:2059513116642090.
McGoldrick, RB, Theodorakopoulou, E, Azzopardi, E. Lasers and ancillary treatments for scar
management Part 2: Keloid, hypertrophic, pigmented and acne scars. Scars, Burns & Healing
2017;3:205951311689805.
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Chapter45
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Face transplantation
Introduction to face transplantation 380
History of face transplantation 380
Patient indications for face transplantation 380
Patient selection 381
Outcomes of facial composite tissue allotransplantation 381
Summary 382
Further reading 382
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CHAPTER45 Face transplantation
Introduction toface transplantation
Facial composite tissue allotransplantation (CTA) refers to the en bloc
transplantation of hard and soft facial tissue between two non- related persons. In severe cases of facial disgurement, as may occur following burn
injury, facial CTA has the potential to restore aesthetic and functional derangements beyond that which conventional reconstructive options currently allow. This benet must be weighed against the need for lifelong
immunosuppression and risk of rejection. In the properly selected patient,
however, facial CTA can be a transformative operation.
History offace transplantation
• First face transplant performed in 2005 in Amiens, France
• Total of 22 partial or full facial transplantations have been performed
worldwide to date
• Five of these patients have medium- term follow- up
• All have experienced acute rejection episodes; no reported
commensurate loss of transplant
• One patient died of unclear cause, another died secondary to severe
infection (face and hand transplantation)
Patient indications forface
transplantation
Patients recovering from burn injuries in the face may have signicant aesthetic and functional concerns secondary to excessive facial scarring and
contracture. Indications for facial transplantation in the burn patient are
similar to those having suered major facial trauma and include:
• Severe disgurement, usually encompassing soft tissue loss more than
25% of facial surface area
• Loss of multiple facial units considered dicult to reconstruct, including
nose, eyelids, and lips
• Loss of multiple facial functions, including eating, drinking, speaking,
breathing through the nose, and the ability for facial expression
• Multiple reconstructive facial operations performed without satisfactory
aesthetic or functional outcome
• Indications for the procedure are ever changing and contingent upon
advancements in immunosuppressive medication, synthetic materials,
and expanding reconstructive options
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OUTCOMES OFFACIAL TISSUE ALLOTRANSPLANTATION
Patient selection
Following facial CTA, patients engage actively in rehabilitation during the rst
few years postoperatively to assist in the process of regaining facial function. Furthermore, patients must remain accessible, as their care requires
frequent and involved medical surveillance, including scheduled biopsies and
laboratory tests and urgent assessments of potential episodes of rejection
or opportunistic infection. Therefore, patients must be otherwise physically
and mentally healthy to participate in and gain benet from the procedure.
• Patients must not have a recent history of malignancies, chronic
infections which may be potentiated by immunosuppression, or other
signicant chronic diseases which may be life- threatening or limiting
• Psychiatrist screening necessary to diagnose existing psychological disorders
• Must assess history of alcohol and substance abuse, as well as social
support
• Determine and plan for logistical issues in maintaining frequent follow- up
• Use of human allograft skin and blood transfusion during the acute burn
care seems to lead to high level of pre- sensitization; possibly limiting
donor selection
Outcomes offacial composite tissue
allotransplantation
Medical outcomes
• Complications reported in the acute postoperative phase include
infections, hematoma, and lymphadenopathy
• Patients enrolled in our immunosuppression protocol have suered, at
most, one episode of acute rejection
• Opportunistic infections have occurred in three patients
• Metabolic and haematologic complications include new onset diabetes,
steroid- induced confusion, haemolytic anaemia, hypertension, and acute
renal failure
• No evidence for new neoplastic growth
Functional outcomes
• All patients demonstrate progressively improving 2- point discrimination
• Return of sensation to transplanted segment in 3– 6months, slower
return of facial expression
• Facial expression slower to return than sensory and varies in degree of
success. There may be asymmetry between each side of the face
• All patients able to achieve some level of autonomous oral feeding
within rst 2 weeks
• Normal food bolus mobilization slower to return
• Speech correlates with success of facial reanimation
Social outcomes
• All patients self- report dramatic improvement in post- transplantation
appearance
• All report increase in self- esteem and self- appearance
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