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11. 8 N e c k
139
considered as the treatment of choice, especially
in children and young adults (Barrow etal. 2000).
Severe cases of complete loss of upper and
lower eyelids, especially in patients with extensive burns and no facial tissue available, require
free tissue transfer for cornea protection. The
dorsalis pedis and anterolateral thigh ap have
been used after bilateral conjunctival advancement aps and septal cartilage for structural support to cover the exposed cornea (Thai et al.
1999; Rubino etal. 2008).
Occasionally, unconscious patients lie in contact with a heat source for some time resulting in
full-thickness destruction of the eyelids and
irreparable damage to the underlying eye which
must be removed (Mustardé 1991).
Reconstruction of the facial defect requires the
use of a temporal muscle ap or a free ap. The
incidence of eyes which required enucleation has
been reported to be ca 1% (Still Jr etal. 1995),
which is considerably lower than the incidence of
eyes enucleated after ocular trauma (4.88%)
(Babar et al. 2007). Medial canthal folds (traumatic epicanthus) are best corrected with
Z-plasties when there is not a signicant tissue
deciency (Mustardé 1991).
the possibility of producing a more naturally
looking eyebrow because of the desired hair density and direction (Choi and Kim 1992). However,
the number of sessions (usually four to eight) is a
disadvantage. A good alternative reducing the
sessions to one has been described by Wang and
Fan (2004). The authors used a one- to two-hair
grafting technique. One-hair and two-hair grafts
were divided out from the superthin slices, which
resulted from dividing the harvested hair-bearing
scalp strips, and implanted in the micro holes of
the recipient site. The one-hair grafts were
arranged in the marginal region of the eyebrow
and the two-hair grafts in the central region.
Successful reconstruction was achieved in 98.1%
of the 96 patients (154 eyebrows) treated. At
6-month follow-up, 64.6% of the aesthetic results
were deemed good and 35.4% excellent (Wang
and Fan 2004). Atraumatic technique is of great
importance to ensure the best graft survival, as
the latter initially depends on the recipient site
until a permanent blood circulation is reestablished days later. Any increase of trauma during
the transplant period will negatively inuence the
nal outcome.
11.7 Eyebrows
Repair or reconstruction of the eyebrows can be
an important “nishing touch” in the reconstruction of the burned face (Motamed and Davami
2005). However, reconstruction of the eyebrows
following complete loss has been characterized
as “an unsolved” surgical problem (Donelan
2007). Generally, one of the following three
methods is used: a supercial temporal artery
island ap, a composite graft from the scalp, or
mini/micrografts from the scalp. Supercial temporal artery island aps are more suitable for
males. However, they can be bushy and conspicuous and should be used with caution, particularly
when carrying out unilateral eyebrow reconstruction (Donelan 2007). A striped scalp grafting
technique has the complication of no hair growth
because of the shortage of blood supply. A single
hair grafting or micrografting technique carries
11.8 Neck
Thirty to fty percent of severely burned patients
may present a neck burn. Inadequate treatment
occasionally leads to contractures of which the
functional, aesthetic, and psychologic sequelae
can be very severe. The skin of the anterior neck
is thin and the neck, being a highly mobile exion area, is prone to contracture, which often
extends cranially towards the chin and caudally
towards the chest. Neck contractures should be
dealt with prior to facial burn reconstruction, as
the cervical extrinsic contractile forces cause
facial deformities and can adversely affect the
maturation of scars on the face (Donelan 2007).
Preventive methods to minimize neck contractures during the acute period include aggressive
splinting, physical therapy, neck collars, and use
of special mattresses to encourage neck extension (Feldman and MacMillan 1980; Donelan
2007).
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11 Burns oftheScalp, Face, andNeck
The incidence of cervical postburn contractures (Fig. 11.14) ranges from 6% to 24%
(Elamrani et al. 2011). Severe contractures are
more common in the developing world, where
primary and secondary care is often inadequate
and options are limited for primary excision and
grafting, splinting, or physiotherapy (Antia
1985). Young patients are mostly affected. More
than one-third of patients were between 24 and
32 years of age (Rak et al. 2015), whereas in
another study, 40.8% of patients were under
20years of age (Elamrani etal. 2011). The rapid
skin regeneration, the ner and more elastic skin
of young patients compared to that of the adults
and thus more prone to contracture, could partly
explain the higher incidence of contractures in
this age group. Gender seems to be an independent risk factor for postburn pathologic scarring
with females presenting a signicantly higher
incidence than males (Gangemi et al. 2008). In
the series of Elamrani etal. (2011), 59.2% were
females and 40.8% were males. Hormonal factors could explain the above difference, as it has
been shown that regulation of certain growth factors upregulated during scarring is inuenced by
estrogens (Elamrani etal. 2011). Other authors,
however, attribute the above difference to psychosocial reasons (Adouani etal. 1997).
Anterior lateral neck contractures in the acute
period are best prevented by aggressive splinting
and incisional releases/grafting when indicated
(Cronin 1961; Serghiou et al. 2003). Adequate
airway access and minimal hypertrophic scarring
are thus ensured. Occasionally, permanent correction of neck contractures with split-thickness
skin grafting is achieved, provided that proper
splinting and pressure are applied (Donelan
2007). Further measures to minimize cervical
contractures during the acute period include
physical therapy, neck collars, and use of a threequarter mattress to encourage neck extension
(Donelan 2007).
The majority of anterior neck contractures can
be treated satisfactorily with release, tissue
expansion of adjacent healthy skin (when available), Z-plasties, or skin grafting (Fig. 11.15).
Full-thickness skin grafts can be appropriate for
focal contractures. They produce a superior outcome from both a functional and aesthetic standpoint. Extensive contractures usually require
split-thickness skin grafting. In some of these
cases, the lower face and chest are usually a combination of healed skin graft and scar (Donelan
2007). Full-thickness skin grafting was reported
to be the most adequate technique compared to
skin expansion and free ap surgery (Adant etal.
1998). Fifteen patients with severe neck burns
were reviewed. Three procedures (skin expansion, free ap surgery, full-thickness skin grafts)
were evaluated, with ve patients operated
according to each method. Follow-up was
>or=1 year. Functional and aesthetic results in
terms of morbidity, neck mobility, skin elasticity,
skin sensitivity, matching, and scar recurrence
were superior when full-thickness skin grafts
were used (Adant et al. 1998). Occasionally,
split-thickness skin grafts fail because of a recurrent contracture or an unsatisfactory aesthetic
result. In these cases, local aps (sometimes after
skin expansion) offer an excellent solution pro-
Fig. 11.14 (a and b)
Fifty two-year old male
patient with burns to the
neck, chest and arms.
The extensive post-burn
contractures are clearly
recognizable
a b
11. 8 N e c k
141
Fig. 11.15 (a–c)
Twenty three-year old
female patient with
burns to the neck and
chest. The post burn
contractures were
treated with bilateral
z-plasties and skin
grafting
a
c
Fig. 11.16 Sixty two-year old female patient with extensive neck post burn contractures. The burnt skin was
excised and replaced with a free latissimus dorsi ap. The
patient refused to undergo defatting of the ap
vided that there is available tissue. Deltopectoral
aps, extended deltopectoral aps, scapular aps,
neck shoulder aps, and latissimus dorsi aps
(Fig.11.16) have all been successfully used for
the reconstruction of anterior neck scar contrac-
b
tures in a single-stage procedure. Wang et al.
(2012) reported good results after the use of local
aps following cervical contracture release in a
series of 68 patients. In 59 cases (86.8%), the
result was deemed excellent. The follow-up
period ranged from 1 to 10years. There were no
obvious recontractures. There were no severe
donor-site complications. The extended deltopectoral ap which the authors used exceeded the
conventional deltopectoral ap with 10 cm in
length and 12cm in width (at the apex) (Wang
etal. 2012).
Skin grafts survive by neovascularization,
which always results in some degree of contraction. Local aps may lack vascularity in the most
critical region of the ap; its distal end can result
in recontracture following the reconstruction. In
order to overcome these disadvantages, free aps
have been used in selected cases. They offer supple, well-vascularized tissue which is resistant to
recurrent contracture. They can provide a good
functional result with minimal donor-site morbidity. In addition, a one-stage operation can
result in a satisfactory outcome. Microsurgical
reconstruction, however, is physically demanding and time consuming; it requires a high level
of surgical skill and a well-organized team.
Depending on the ap used, defatting procedures
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11 Burns oftheScalp, Face, andNeck
(excessive bulk) (Fig.11.16) and tattooing of the
skin island (different color) were necessary in
order to improve the aesthetic result. Recent
advances such as ap prefabrication, prelamination, pre-expansion, chimeric aps, and superthin
aps have increased the quality of free aps.
Thinner customized aps with better color,
appropriate thickness, and texture match to the
recipient sites can be used, leading to their more
frequent use in burn care (Parrett etal. 2007). In
selected cases, free aps in addition to tissue
expansion can provide excellent functional and
aesthetic results, with minimal donor-site morbidity (MacLennan etal. 2000).
Most frequently used aps are the anterolateral thigh ap (ALT), the parascapular ap, the
radial forearm ap, the latissimus dorsi ap
(Fig.11.16), the groin ap, and the lower abdominal fasciocutaneous ap. A retrospective study
of 32 patients with cervicofacial burns whose
contractures, hypertrophic scarring, or exposed
cartilage/bone were released and reconstructed
with free aps (n = 36, face = 23, neck =13)
showed that free tissue transfer is a valuable tool
in H&N burn reconstruction and that it can be
safely and effectively used with minimal morbidity in selected patients. The aps used for cervical contractures were the ALT (n = 4), the
parascapular (n= 6), the groin (n = 2), and the
lower abdominal fasciocutaneous. Forty-two percent of aps were tissue expanded before transfer, 39% were prefabricated, and one ap was
prelaminated. Two aps (6%) were lost, and two
aps with anastomosis problems were revised
successfully. Partial tip necrosis (<2cm) occurred
in six aps. Six aps were used during the initial
hospitalization (for exposed bone), and 30 were
transferred as part of late, or secondary, reconstruction. The mean time from burn to ap transfer was 4.5 years. Twenty-three aps required
future debulking or sculpting, with an average of
two debulkings each (Parrett etal. 2007). In order
to overcome the latter problem, free thin perforator aps have been used. Tsai et al. (2004)
reported on the use of free split-cutaneous perforator anterolateral thigh aps, which were thinned
after ap elevation. The aps were safely thinned
to the point where the junction between the
supercial and the deep adipose layers of the
thigh is met. This junction is usually at 0.4cm
below the skin. The motor nerve to the vastus
lateralis muscle was preserved to maintain function to the muscle. Routinely, a skin island measuring 8x40 cm was harvested based on two
perforators and split into two skin islands, with
one perforator supplying each. The two islands
were spatially placed according to the shape of
the defect. Seven patients (two with neck contractures) were successfully reconstructed using
the above method. Mun etal. (2007) used free
thin thoracodorsal artery perforator aps and cervicoplasty to achieve optimal neck appearance
after cervical burn scar release. Flaps with a mean
thickness of 5.3mm and as large as 24×12cm
were used in 12 patients with neck burns. All
aps survived without signicant complications.
Range of neck motion increased, and the cervicomandibular angle was sharpened in all patients. A
highly natural neck contour was obtained without
secondary debulking procedures (Mun et al.
2007).
The free (para-)scapular ap is another ap
which has been successfully used by various
authors. Luo et al. (2015) reconstructed severe
cervical postburn contractures in 24 patients with
a free scapular ap using a staged treatment strategy. Signicant improvement of the cervicomental angle (CM), the osseous CM angle, and the
dynamic CM angle was noticed by the third postoperative month. Pre-expanded scapular free
aps were used by Song etal. (2015) to reconstruct postburn neck deformities. In the rst
stage, skin expansion was performed with tissue
expanders ranging from 400 to 800ml according
to the neck defect size. The pre-expanded scapular ap was then harvested and transferred to the
neck defect. A total of 12 aps were successful.
The neck contour, color, and texture of the aps
matched well to the adjacent skin. The range of
motion of the neck was signicantly improved in
all cases.
The therapeutic indications depend on the
extent of the damaged skin and the availability of
local healthy skin, which can serve for the cover
of the defect after release of the contracture. A
classication system characterizing the severity,
11. 9 Scalp
143
the location, and the form of the contracture was
proposed by Onah (2005). Types 1, 2, and 3 designated mild, moderate, and severe anteriorly
located contractures, whereas posteriorly located
contractures were considered type 4. Subtypes a
through d were included to denote characteristics
affecting reconstruction (a: narrow band <2 ngers wide; b: broad band with sufcient healthy
skin to cover the defect; c: contracting segment
broad, involving most or all of the anterior part of
the neck; d: healthy skin insufcient to cover the
reconstructed defect). In type 4c, posterior contracture occurred in association with an anterior
neck contracture. In types 1 and 4a, the contracted
tissues of the anterior/posterior neck are the skin
and the subcutis. A satisfactory release can be
achieved, when the surgeon merely tackles the
above tissues. However, in type 3, the strap muscles are frequently scarred. They too have to be
addressed in order to achieve a satisfactory
release. Furthermore, distortions of the cervical
spine and tracheal alterations affecting respirations can also be present in type 3 contractures.
Based on his classication, Onah (2005) proposed a surgical reconstruction algorithm. In
types 1a, 2a, and 4a, a Z-plasty (or a modication
hereof) is suggested. In types 1b, 2b, 3a, and 4b
local aps, with or without the addition of skin
grafts can be used to cover the resulting defect.
Expanded skin aps can also be used in these
cases. In types 1c, 2c, 3b, and 4c, sheets of skin
grafts, expanded aps, and regional and distant
aps (including free aps) are to be used. Types
3b and 4c may necessitate staging of surgery in
order to achieve a satisfactory result.
Difculty with intubation can be anticipated
in a number of patients with neck contractures. In
Onah’s type 2, ber-optic-assisted intubation
may be carried out and is the recommended mode
for airway management in these patients (Han
etal. 2012; Prakash and Mullick 2015). In type 3,
where the mentosternal distance is often less than
6cm (minimum distance under which intubation
difculties can be anticipated), division of the
contracture should precede intubation. The procedure can be done under intravenous ketamine
or sedation (Al-Zacko and Al-Kazzaz 2009;
Prakash and Mullick 2015).
11.9 Scalp
Clinical studies of patients with large total body
surface burns document involvement of the head
and neck in 25–45% of cases. Flame burn has
been reported to account for the majority of cases
(53.3%, Tayyaba etal. 2015). Scald was the commonest cause (94%) for a scalp burn in a series of
107 pediatric cases (Menon et al. 2015). The
parietotemporal region is most commonly
affected (Tayyaba et al. 2015). The majority
(93.9%) appeared supercial to mid-dermal, with
an average time to complete healing of 10.3days.
The remaining cases were mid-dermal to full
thickness, with an average time to complete healing of 50.8days (Menon etal. 2015).
The long-term effect of deep burns to the scalp
is cicatricial alopecia. The management of this
problem depends on the following: the size of the
defect, the location, and the status of the remaining hair-bearing scalp. Small scalp defects can be
reconstructed with the use of excision and primary closure. Indeed, serial excision and a variety of local scalp aps are usually successful in
correcting small (<5 cm, Tayyaba et al. 2015)
alopecia defects or those covering less than 15%
of the hair-bearing scalp (Huang et al. 1977).
Hair grafting can be an option; however, it is usually difcult to achieve a natural outcome and the
poor bed (unstable scar, thin skin) often results in
no hair growth (Tayyaba etal. 2015). However, a
study by Barrera (1999) showed that the use of
micrografts (1–2 hair follicles) and minigrafts
(3–4 hair follicles) can be very successful, due to
a low metabolic rate which allows the grafts to
survive in scar tissue.
Larger defects often require more involved surgical techniques. The clinical application of tissue
expansion to the closure of large scalp defects
without excessive scarring has revolutionized the
approach to this problem. Its value is based on the
fact that the “new skin” contains hair follicles as
well as bears the same skin tone. Manders etal.
(1984) demonstrated the efcacy and safety of
soft-tissue expansion in the correction of scalp
defects in pediatric patients. Later, McCauley
etal. (1990) classied burn alopecia based on not
only the pattern of the alopecia but also the extent
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11 Burns oftheScalp, Face, andNeck
of it. Patients were classied as type I, uniform
alopecia; type II, segmental alopecia; type III,
patchy alopecia; and type IV, total alopecia.
Guidelines for the correction of the problem in
each type group were established. Type I defects
were corrected with a single sequential expansion
and type II with a single expanded ap or multiple
expanders; type III and type IV were not candidates for tissue expansion.
The rate at which expansion occurs postoperatively varies. Expansion has been recommended
anywhere from 1week to 2 ½weeks after placement. Injection fractions vary, but 10% of the
volume per week is required to complete expansion within a 3-month period. At a second stage,
the expander/s are removed and the defect is
reconstructed. The aps are planned before
removing the expander considering the size and
shape of the defect and the quality and quantity
of the expanded skin, so that unnecessary tissue
loss is avoided. The advancement aps have a
simple design, easier technique, and fewer vascularization problems and are therefore the preferred method. Major tissue loss has been
reported during ap elevation, which, however,
can be circumvented with the addition of a
Z-plasty. The latter provides better adaptation of
the expanded ap and creation of a hairline and
sideburns with proper orientation of hair follicles
without linear scar formation (Tayyaba et al.
2015). A disadvantage of it is the fact that the
amount of tissue needed to close the same size
defect is more than that for a rotation ap.
The complication rate ranges between 25% and
50% (Hudson and Grob 2005; Fochtman et al.
2013). A higher complication rate was noted in
children younger than 10 years of age and in
patients with a greater TBSA (Fochtman et al.
2013). Complications can be major or minor. Major
complications are usually dened as those which
require removal of the expander. Such complications may be secondary to infection, exposure of
the expander from traumatic extrusion, wound
dehiscence, or erosion of the envelope fold or port
through the skin (Governa et al. 1996). Implant
failure is also considered a major complication and
requires removal of the implant. Proper protocols,
patient selection, and meticulous technique have
reduced the rate of major complications from 22%
to 12% (Cherry etal. 1983). Minor complications
are dened as poor compliance, intolerance of the
injection to ll the expanders, hematoma, and
seroma. Rates of minor complications have been
reported to be between 17% and 40%, with a mean
around 20% (Neale etal. 1988).
In cases which cannot be treated by other
methods such as tissue expansion or local aps,
free aps have been used. Microvascular reconstruction of large scalp defects has been well
documented, mostly for cancer or infection and
in a few cases for burns (Ioannides etal. 1999).
The latissimus dorsi (Fig.11.17), the radial forearm, and the anterolateral thigh ap have been
successfully utilized. Yu et al. (2012) recently
reviewed eight pediatric burn patients (age
between 3.1 and 5.9 years) with large scalp
defects, which were reconstructed with an anterolateral thigh ap. Defect sites were at the parietal
region (n=6), occipital region (n=3), temporal
region (n=1), and forehead (n=1). The size of
the aps ranged from 10 to 25cm in length and
from 8 to 18cm in width. The overall ap success
rate was 100%. Satisfactory contour results were
achieved. There were no postoperative complications during the follow-up period (5.0months to
2.1 years). Despite the smaller diameter of the
vessels in children compared with those in adults,
it is conceivable that free aps can be successfully used in the pediatric burn population, especially whenever other methods have failed or are
not indicated.
Fig. 11.17 Twenty eight-year old male patient with perioral and nasal burns. Shortening of the nose with partial
loss of alar rims is noticeable
11.10 N ose
145
11.10 Nose
The nose is particularly exposed in the case of
facial burns due to its position, shape, and structure. Nasal burns result in a broad spectrum of
deformities, ranging from minor focal ones to
complete nasal amputation. The nasal mucosa
was shown to be resistant to damage when the
face is burned (Rose etal. 1996). However, when
nasal stricture caused by collapse and hypertrophic scarring is present, it can be released and
treated with full-thickness inlay grafts followed
by prolonged splinting (Bernard 2000).
Shortening of the nose with aring or partial loss
of the alar rims is common in more severe facial
burns (11.17). Local release of the alar lobules
and cover with full-thickness skin grafts are useful techniques for minor-to-moderate contractures. When the shortening is more severe,
complete excision of the scar tissue and grafting
with a full-thickness skin graft is indicated. When
the lower third of the nose has been affected by
the injury, inferiorly based turndown aps of the
dorsal nasal tissues can provide satisfactory
lengthening and improved contour to the alar lobules and tip. Taylor et al. (2009) reviewed 28
pediatric burn cases with alar shortening. An
inferiorly based nasal turndown ap was used,
which consisted of the dorsal surface of the nose
(skin graft plus scar). The ap base was the scar
transition zone between the dorsum of the nose
and the lining mucosa. This was turned over to
provide nasal length projection and to stimulate
alar lobules. The resulting defect on the nasal
dorsum was then skin grafted. If further length or
renement was required, the procedure was
repeated. The average TBSA of the 28 patients
was 46%. Adequate nasal length and projection
could be achieved in all patients. There were few
complications. All of the aps survived, although
there were 2 cases of necrosis of the distal edge
of the aps. Twelve of the 28 patients required
repeat turndown aps to achieve sufcient length
and projection. Contraction of local scar tissue
created bulk and support eliminating the need for
distant tissue transfer or cartilage grafting. The
results were durable over a follow-up period of
up to several decades (Taylor etal. 2009).
Erol (1995) described the use of a prefabricated vertical myocutaneous ap from the dorsal
nose, in order to cover lateral defects after release
of burned alar tissue and turndown of the scarred
alar skin. The dorsal scarred skin was replaced
with a skin graft in the rst stage of the reconstructive procedure, and 3 to 12months later, this
tissue was raised as a secondary columella-based
myocutaneous ap and rotated into the lateral
defect. The author postulated that the blood supply through the columella is so rich that it can
vascularize the entire dorsal skin of the nose. Six
burn patients were operated on with favorable
results.
The treatment of nostril stenosis is difcult
(Daya 2009). Facial prole and balance as well as
an adequate airway that is not prone to restenosis
should be restored. Coring out of the scar tissue
and lining of the passage with a skin graft,
increase of the nostril opening by a Z-plasty, and
creation of a nostril by a local ap are some of the
surgical methods used for release of nostril stenosis (Daya 2009). After creation of a nostril opening, use of a nasal stent serially upgraded in size
to expand the opening of the nostril and the surrounding tissue is advocated. The upgrade in the
size of the nostril is discontinued when it matches
for age or the contralateral one. However, continual use of the stent and patient compliance can
be a drawback (Daya 2009).
The forehead ap, with or without tissue
expansion, has been used for reconstruction of
the burned nose (Echinard and Dantzer 1995).
For the patients with full face burns associated
with a nasal defect and smooth atrophic scar or
grafted skin on the integrated forehead, the
expansion of the frontal area was chosen by Chen
et al. (2008) to build up a new nose. Fifty-two
patients were successfully operated on (threestage operation) with satisfactory results. The
color and texture of the reconstructed nose were
similar with the postburn face, and there was no
sign of shrinkage, attening, or collapse (Chen
etal. 2008).
When the frontal tissues have been severely
damaged (tight, adherent scar) and forehead aps
are unavailable, distant aps can be used. The
Tagliacozzi ap, a random pattern ap of upper
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arm skin, is an attractive method in patients whose
foreheads cannot be used (Miller 1985). The pedicle can be transected 9–12days after inset, thus
shortening the immobilization period. Problems
of color match can be managed by subsequent
resurfacing of the nose with a single- piece fullthickness skin graft from the supraclavicular area
(Miller 1985) or medical tattooing.
Microsurgical tissue transfer offers another
option for nasal reconstruction, when the forehead ap is unavailable. The dorsalis pedis
(Benmeir etal. 1991) and the radial forearm ap
(Watanabe et al. 1997; Sinha etal. 2008) have
both been successfully used for this purpose.
Sinha etal. (2008) used a prelaminated free radial
forearm ap, with a non-vascularized bone graft
after turning down the existing scarred skin at the
dorsum as pedicled aps for the lining. A successful total nasal reconstruction was achieved
which was aesthetically pleasing and made a tremendous impact on the patient’s quality of life.
11 Burns oftheScalp, Face, andNeck
11.11 Ears
Auricular burns occur with surprising frequency
in patients presenting to burn centers. In a recent
study from Rochester, Kraenzlin et al. (2018)
reported a prevalence of 22% (132 auricular
burns/593 facial burns). The majority of patients
healed with conservative management, but time
to reepithelialization was sometimes longer than
expected (Kraenzlin et al. 2018). Careful acute
management of these injuries can eliminate
development of otochondritis and minimize the
rate of deformity and need for reconstruction.
Otochondritis, which may occur after lesser
thermal ear injuries, is probably due to either fullthickness skin and perichondrium loss, cartilage
exposure, chondronecrosis, and subsequent infection or massive post-traumatic edema and thrombosis of small arteries typical of partial- thickness
burns (Caputo etal. 2005) (Fig. 11.18). It commonly follows a supercial partial- thickness
injury, and the incidence has been reported to be
between 10% and 25% of cases (Purdue and Hunt
1986; Caputo etal. 2005). Improved care in the
acute phase of burn injury has greatly decreased
Fig. 11.18 Auricular burn with otochondritis due to full
thickness skin and perichondrium loss and cartilage exposure of the medial aspect of the left ear
the incidence of helical chondritis and the resulting associated deformities (crumpled cartilage,
loss of cartilage). The onset is usually insidious
and occasionally delayed. Prevention is the key,
and early management should be initiated. Gentle
daily washing (once or twice) with minimal
debridement, frequent application of mafenide
acetate, and avoidance of pressure (no dressings)
on the affected ear have been effective (Purdue
and Hunt 1986; Mills 2nd et al. 1988). Caputo
etal. (2005) noticed a dramatic drop of the infection rate from 11% to disappearance with the use
of chlorhexidine as an antiseptic dressing. The
authors currently use 2% chlorhexidine gel.
Systemic antibiotic prophylaxis does not seem to
inuence the incidence of auricular chondritis
(Mills 2nd etal. 1988).
11.11 E a r s
The treatment of chondritis consists of incision and drainage, and prompt local debridement
of infected tissue following early recognition of
the process. Early diagnosis and treatment are
essential to limit progression of infection and
necrosis and to minimize deformity. The average
number of partial chondrectomies per ear was
reported by Mills 2nd et al. (1988) to be 1.85.
The frequency of repeated operation in such
patients illustrates the difculty in assessing the
adequacy of debridement. When chondrectomy
is necessary, complete removal of all nonviable
cartilage is imperative to prevent recurrence
(Mills 2nd etal. 1988). Most patients in the series
of Mills 2nd et al. (1988) had some resulting
deformity, the extent of which was proportional
to the extent of the infection and the amount of
necrotic or infected tissue excised. Ngim (1992)
presented the results of a prospective clinical
study of 100 patients with 150 ear burns.
Conservative treatment of 104 ears resulted in
complete healing except for 15 which had pigmentary and/or hypertrophic scar problems.
Surgical treatment was used in 23 ears. Three
returned to normal appearance, and eleven had
mild and four had moderate deformities. Five
ears (3% of cases) were lost. Chondritis was present in 12 ears (8% of cases), 6in deep-dermal and
6 in full-thickness burns. Seven of these ears
were successfully salvaged. The author attributed
the favorable results to the early detection of
chondritis, early surgical intervention, radical
cartilage removal, meticulous post-op care to prevent cross infection, and avoidance of pressure to
the ears.
Direct thermal injury of the ear can be sufciently severe to cause desiccation, necrosis, and
sloughing of a big part of the entire external ear.
Typically, the outer helix is lost leaving most of
the conchal bowl intact (Fig.11.19). The remaining portions of the ear are often thick and scarred
and do not easily redrape over new cartilage
frameworks. The burned auricle, whether manifesting as a partial deformity or complete loss of
the external ear, poses a signicant reconstructive
challenge. The thickened skin surrounding the
burned portion of the auricle may be delayed and
rolled to create an acceptable helix. Pearl and
147
Fig. 11.19 Postburn illustration of a 31-year old female
patient with loss of the outer helix of the right ear
Sabbagh (2011) used a two-staged technique
based on Nagata’s adaptation of Brent’s original
technique. The authors used an autologous cartilage graft (from the eighth rib for smaller helical
rim defects; from the synchondrosis of the sixth
and seventh ribs for larger defects) sculpted and
held together with ne stainless steel wire, which
was covered by either a posteriorly based skin
ap or a bipedicled or a postauricular ap. In
cases where insufcient or poor-quality skin was
present, the authors used either preoperative tissue expansion or a temporoparietal fascial ap.
Release of the ear construct from the side of the
head was performed at a second stage 3–6months
later (Pearl and Sabbagh 2011).
For more extensive loss, a range of options
exist. Surgeon preference and availability of
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11 Burns oftheScalp, Face, andNeck
local tissue are the most important variables
(Ray etal. 2010). Postauricular skin, postauricular fascia, temporoparietal fascia (pedicled or
free), and free aps have been utilized to cover
the larger costal cartilage framework (Akin S
2001; Hu etal. 2014). Park and Suk Roh (2001)
reported on 16 patients requiring total ear reconstruction, whose temporoparietal region was
devascularized due to trauma or prior surgery.
The authors used a contralateral fascial free ap
and autogenous costal cartilage. The microsurgical success rate was 87.5% (14/16 aps). On
evaluation of the nal aesthetic result, 9 out of
11 patients were graded good-to-excellent and
two fair-to-poor. Despite the comparatively low
microsurgical success rate and the long duration
of the procedure, it is an encouraging and worth
applying technique (Park and Suk Roh 2001).
Other authors preferred a free radial forearm
ap for the cover of the cartilage framework
(Akin 2011). Hu etal. (2014), in order to overcome the disadvantages of microsurgery, used
an expanded, upper arm ap, which was tubed,
transposed to the auricular region, and, consequently, re-expanded in order to cover the cartilage framework without the need of a last-stage
retroauricular skin grafting.
Burn defects of the earlobe are not uncommon, and their reconstruction can be cumbersome when the surrounding facial skin is also
burned. Preauricular (Kumar and Shah 2000) as
well as postauricular (Shen etal. 2012) aps have
been described depending on the healthy tissue
availability. Posterior ear aps have the advantage that the scar remains behind the ear and is
invisible. One- and two-stage techniques have
been used with aesthetically successful results
(Kumar and Shah 2000). Severely burned tissue
with near-total destruction of the auricle is a relative indication for osseointegrated alloplastic ear
reconstruction (Wilkes and Wolfaardt 1994).
Auricular prostheses are anchored to extraoral
(mastoid) bone-integrated implants. This technique holds several advantages: The surgical procedures can be done under local anesthesia on an
outpatient basis and are more straightforward and
of a short duration. The technique is less demanding for the surgeon and could therefore be more
widely available if there is suitable prosthetic
support. The prosthesis matches the normal ear
better (form, color, projection) than an autogenous reconstruction. If a prosthetic ear is deemed
unsatisfactory, another ear can be constructed in
order to improve the aesthetic result. This is not
the case with an autologous reconstruction.
Finally, there is no donor site necessary. Although
prosthetic reconstruction requires surgical techniques that are less demanding than autogenous
reconstruction, construction of the prostheses is a
time-consuming task requiring expertise and
experience. The other disadvantage is the fact
that foreign material and not the patient’s own
tissues have been used and there is an ongoing
commitment from both the care providers and the
patient (daily care need for replacement of the
prosthesis). Psychological problems, limitation
of body contact sports, and small risk of dislodgment of the prosthesis are further disadvantages
(Wilkes and Wolfaardt 1994). Progress in digital
technology for designing surgical guides and
progress in retention, suprastructures, and prostheses have all improved the prosthetic rehabilitation outcome. However, further improvements
are necessary to enhance longevity of prostheses
(Ariani etal. 2013).
Recent studies have shown the possibility of
cartilage bioengineering from cartilage stem/progenitor cells, which are highly chondrogenic and
may produce elastic reconstructive material with
long-term tissue restoration. An auricular shaped
construct was produced using a novel polyhedral
oligomeric polyurethane/urea scaffold for culturing bone marrow-derived mesenchymal stem
cells in chondrogenic medium (Patel etal. 2013).
Cografting of adipose-derived stem cells (ADSC)
with auricular chondrocytes (from microtia)
could efciently promote the chondrogenic differentiation and chondrogenesis of the former
(ADSC) (Cai etal. 2015). These novel techniques
in the eld of reconstructive bioengineering and
regenerative medicine are promising; however,
further research is required before they can be
clinically applied. Till then, the conventional
techniques of autologous or prosthetic auricular
reconstruction will be used, with the indication
depending on the individual patient.
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