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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_537_Библиотеки_им_академика_М_И_Перельмана
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Efforts to maintain the integrity of viable tissues include avoiding tight
dressings, use of antimicrobial cream, and keeping the wound bed moist.
Separate strips of non-adherent moist dressings can be wrapped around the
burned areas to avoid circulatory impairment, reduce bacterial growth, and
maintain wound bed moisture (avoid scabbing) until patients can be
surgically treated [100–102]. These treatments are meant to support
debridement and surgical removal, which should be prioritized for most
patients. In cases where early excision cannot be performed (e.g., lack of
resources), dressings are placed until eschar separation is initiated. While
this open technique is still used today in developing countries when no
other resources are available, it is not supported in the literature and has
been criticized for over 50years [103, 104].
Table 2 summarizes the relative indications for initial excision of dead
tissues in burn injury. Additional considerations for eschar removal and
grafting of severe facial burn injuries are listed below [105]:
Larger, diffuse areas of dead tissue have been sufficiently treated with
debridement/excision
Stable patients with confirmed diagnosis of deep facial burns
Presence of useable donor skin for grafting
Patient is clear of severe infections
Table 2 Treatment indications for various burn injuries
Technique Timing
(days after
injury)
Indications/contraindications
Immediate or early excision Immediate:<1Immediate excision: optimal results for
relatively healthy younger individuals
Removal of burn eschar (necrotic tissue)
prior to invasive infection and/or sloughing
Early: 2–10Early excision: excision is performed
after patient is stabilized (adequate
volume restoration, inhalation injury),
staged burn repair
Delayed excision After 10
but before
21
Facial burns with unconfirmed depth
Removal of burn eschar (necrotic tissue)
prior to invasive infection and/or sloughing
and after secondary intention healing has
initiated
Resource-limited center
Tangential Excision Variable Standard method
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Technique Timing
(days after
injury)
Indications/contraindications
Removal of damaged tissues in thin layers
using a dermatome to allow for preservation
of deeper layers
Fascial excision Variable Deep burns
Removal of fascia and all overlying
superficial tissues
High-voltage electrical burns
After eschar removal, grafts can then be placed (either concurrently or
delayed) to cover the exposed tissue [105].
4.3 Non-melanoma Skin Cancer (NMSC)
The presentation of nonmelanoma skin cancer (NMSC) varies depending on
the epidermal layer from which the neoplasm originates. As shown in Fig.
10, squamous cell carcinoma (SCC) can develop in any layer of the
epidermis superficial to the basal cells. Basal cell carcinoma (BCC)
develops from basal cells at the epidermal-dermal junction. Patients
generally complain of recently developed or altered superficial skin lesions,
which should trigger a thorough full-body skin examination [106, 107].
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Fig. 10 SCC and BCC are shown in a cross-section of the skin at their site of origin [108]
There are several BCC variants, including superficial, morphea-like,
and nodular, the latter of which is most common. Of these variants,
morphea-like BCC is more likely to incur extensive destruction of the
underlying and adjacent tissues [109–112].
Figures 11, 12 and 13 show common variants of BCC, highlighting the
differences between nodular, superficial, and morpheaform subtypes.
Squamous cell carcinomas (SCCs) are usually detected upon observation of
expanding crust forming or keratinized (scaly) lesions that do not heal over
time. These lesions can take on a varied appearance, which is shown in the
images of documented SCC cases (Figs. 14, 15 and 16) [114–116].
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Fig. 11 Nodular BCC [113]
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Fig. 12 Superficial BCC [113]
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Fig. 13 Morpheaform BCC [113]
Fig. 14 SCC lesion with well-identified borders [113]
Fig. 15 SCC lesion with ill-defined borders [113]
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Fig. 16 Keratocanthoma [113]
Lesion borders may be well determined (Fig. 14) or hard to differentiate
from the surrounding skin (Fig. 15). Keratoacanthomas are an easily
identified variant of SCCs, marked by their domed nodular shape and
central zone of hyperkeratosis (Fig. 16).
Any suspicious lesions should be further assessed with detailed imaging
and/or biopsy sampling, usually performed by a dermatologist.
Dermatoscopes are handheld tools which illuminate and magnify observed
skin and are well utilized in the hands of trained providers to assess the
surface and sub-surface structures. Classification of lesions is improved
with use of dermoscopy, allowing for improved risk stratification and
targeted treatment indications. Biopsy is performed to assess the histologic
subtype and provide additional confirmation for the diagnosis [117].
There are various factors which determine the relative risk of metastasis
and reoccurrence for NMSCs. Increased risk has been indicated in
neoplasms which originate on the “H zone,” defined by Swanson as the
region of the face containing the scalp, forehead, periocular area, auricular
area, cheek, nose, and upper lip [118]. Lesions with a diameter greater than
2 cm has been associated with increased reoccurrence and risk of metastasis
[119]. Additional factors to consider include tumor thickness,
differentiation, histologic subtype, lymphovascular/perineural invasion, and
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integrity of the patient’s immune system, which are well detailed by Akcam
et. al. [120].
Extensive invasion of NMSCs has been studied by Batra and Kelley
[121], who summarize the risk factors of these neoplasms based on a study
of previous cases. The predicted subclinical spread indicates the surgical
excision approach. Generally, invasive NMSCs tend to follow the patterns
listed as follows [122]:
Preoperative size <10 mm
Male patients: recurrent BCC and/or neck location
Basosquamous, nodular, morpheaform, or recurrent subtypes originating
on the nose
Morpheaform BCC originating on the cheek
Neoplasms originating on the eyelid, helix (ear), or temple
For the purposes of this section, the techniques are listed in Table 3 with
their relative indications and timing of reconstruction [120].
Table 3 Excision techniques for removal of skin cancer [120]
Technique Indications Timing of reconstruction
Surgical
excision
with
standard
margin
Well-defined margins, low-risk
neoplasms
Simultaneous, limited to uncomplicated
reconstructions
Surgical
excision
with frozen
section
Poorly defined margins, recurrent
lesions, locations more greatly impaired
aesthetically with tissue removal,
infiltrative growth
Simultaneous, allows for complicated
reconstruction
Surgical
excision
with delayed
repair
Maintenance of maximal healthy tissue
indicated for aesthetic/functional
purposes
Reconstruction with flaps/grafts
performed after tumor-free margins are
confirmed with histology, best for
complicated reconstruction
Mohs
micrographic
technique
High-risk NMSC, immunosuppressed
patients
Simultaneous, best for complicated
reconstruction
5 Application of Surgical Techniques
5.1 Surgical Planning
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Craniofacial reconstruction may be relatively straightforward, such as in the
cases of isolated uncomplicated fracture or deep wounds, although there are
more complex cases which require additional planning. Three-dimensional
reconstructions of CT imaging can be helpful in surgical planning, notably
with free osseous tissue transfers, design of implants or plates, and creation
of preoperative cutting guides. When patients present with orbital or
periorbital fractures, real-time image-guided surgery using intraoperative
CT can help to confirm structural integrity and avoid severe complications
[123, 124].
Due to the high vascularity of the face and neck region, microvascular
free tissue transfers have a very high survival rate and are well utilized in
repair of soft tissue deformity or loss. As a result of this high success rate,
the lower minimal approaches on the reconstructive ladder may be
bypassed with soft-tissue facial reconstruction. Patients with severe facial
injury may require multiple free tissue transfers, which can be performed in
a single operation or completed with subsequent surgical reconstruction
[125].
After adequate imaging has been obtained, including angiography
(suspected vascular damage) and MRI (detection of ocular injury or foreign
bodies), the surgical planning will proceed with the most urgent conditions
treated first. As previously stated in Sect. 3.1, any patients with lifethreatening injuries that are not a direct result of facial fractures should be
stabilized prior to craniofacial reconstruction.
5.2 Soft Tissue Reconstruction
Techniques used to reconstruct the soft tissues of the face vary based on the
facial subunits damaged by the injury. Various reparative strategies will be
further discussed specific to each respective facial component.
The repair technique of soft tissue injuries on the scalp and/or forehead
is determined by the depth of injury and estimated tissue loss. Fullthickness wounds less than 2–3 cm in diameter are indicated for primary
layered closure with galeal, subcutaneous, and cutaneous sutures. When
necessary, galeal scoring and undermining with blunt dissection can
improve coverage [Cite chapter “Aesthetic Surgery of the Upper Face and
Cheeks”, Sect. 2].
Patients who present with tissue loss with an area less than 25 cm2 on
the scalp or forehead may undergo repair with a pinwheel flap, which
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involves the creation of 2–4 full-thickness axial rotation flaps that are
repositioned to close the defect. In some cases, tissue loss in the forehead
region is better repaired with an island pedicle flap transferred from the
occipital region or medially transposed bilateral advancement flaps to allow
for eyebrow continuity after reconstruction. Large tissue losses from the
scalp (>25 cm2) may also be repaired using full-thickness axial rotation or
advancement flaps containing hair-bearing tissue. Tissue expansion is an
additional technique which stretches nearby cutaneous tissues using airfilled subcutaneous expanders [126–128].
Midfacial lacerations are considerably more complex, as they tend to
involve structures such as the eyelids or nose. Changes to the appearance of
these structures can have a large impact on the overall facial aesthetics. The
repair of these lacerations has been tailored to these areas, and various
reparative strategies are detailed in Table 4 (Fig. 17).
Table 4 Wound closure techniques for midfacial lacerations [128, 130–132]
Eyelids Full-thickness
defect <33% of
horizontal distance
Primary layered closure with conjunctival, tarsal plate, and cutaneous
sutures; marginal wounds closed with eversion of wound edges
Full-thickness
defect
Local or composite flap repair, with harvested auricular cartilage
grafts for tarsus reconstruction and mucosal grafts for conjunctival
reconstruction
33–66% of
horizontal distance
Hughes flap or Cutler-Beard flap: Multi-stage repair using harvested
flap from uninjured eyelid
Full-thickness
defect
Cutler-Beard flap: repair of upper central eyelid
>66% of
horizontal distance
Composite graft and/or cheek rotation flap: repair of lower eyelid
Paramedian forehead flap or free tissue transfer for double eyelid
repair
Full-thickness
defect on eyelid
margin
Eversion of wound edges prior to layered closure with vertical
mattress sutures
Medial canthus: Assess for lacrimal injury before flap closure, silicone stent placement used for
soft tissue coverage when lacrimal repair is indicated
Cheek Minimal defects Primary repair, healing by secondary intention
Extensive defects Local repair with transposition, advancement, or rotation flaps
Cervicofacial or cervicopectoral rotation flaps
Free tissue transfer
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