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12.3 Pathologic Responses toWound Healing
169
Fig. 12.12 (a)
Depressed scar of the
right mandibular area.
(b) Orthopantomogram
(OPG) showing
pseudarthrosis of the
right mandibular angle.
(c) Postoperative OPG
after surgical
debridement, bone
grafting, and rigid
mandibular xation. (d)
Postoperative clinical
picture
a
c d
mismatch after ap transposition (Furnas and
Farzadmehr 2001).
Unstable Scars
Scars which do not heal properly and tend to
break down over and over again are termed unstable scars. They are usually caused by repeated
chronic stress or injury of vulnerable wounds
resulting in a repeating cycle of healed wound–
open wound–healed wound. Post-burned lesions,
especially deep burns which healed by secondary
intention or never healed completely, that frequently ulcerate on trivial traumatic insults of
daily life often end up in an unstable scar (Saaiq
and Ashraf 2014
). Common sites are weightbearing surfaces, areas of poor circulation, or
unpadded convexities (knee or elbow). If ulceration persists for many years (>2–3 decades),
metaplasia and nally a squamous cell carcinoma
may occur. Malignant degeneration of skin scars,
particularly the post-burned scars, has been
called a Marjolin’s ulcer (MU). The head and
neck was reported to be the second most frequent
site of occurrence after the lower limbs (Saaiq
and Ashraf 2014). Primary prevention is ensured
b
by provision of proper surgical care in the acute
phase of burn injury management. Early excision
of deep burns and grafting or use of a ap for
adequate cover prevents the formation of an
unstable scar and averts the factors that would
predispose to malignant transformation. In cases
of an initial mismanagement, secondary prevention can be instituted before a Marjolin’s ulcer
has established, provided that the patient seeks
medical advice. Prevention is the key to successful eradication of Marjolin’s ulcers. If a MU is
diagnosed, surgery is the mainstay of treatment
(Saaiq and Ashraf 2014). Adjuvant radiotherapy
and chemotherapy have an important role in
managing these malignancies. Marjolin’s ulcer
tends to behave more aggressively compared
with other skin cancers of similar histotypes
(Copcu 2009).
Collagen Defects
Patients with genetic defects in collagen metabolism and synthesis (Ehlers-Danlos syndrome,
protein deciency, systemic steroid treatment,
etc.) can present healing problems. Abnormal
scars may result even when the patients have
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12 Wound Healing Disturbances: TheUnfavorable Result
been treated by competent plastic surgeons.
Currently, there are no methods available to diagnose or treat these defects.
One more cause leading to poor outcomes is a
“factitious” wound. Common presentation includes
persistent soft-tissue wounds, often infected, which
are treated by plastic surgeons. Poor outcomes may
focus the patients’ underlying psychological problems on the surgeon and initiate litigation
(Eisendrath and Telischak 2008). It is cumbersome
to tackle such a “self- injurious behavior” from the
surgeon’s point of view. The doctor-patient relationship should not be endangered in cases of suspicion, and interdisciplinary management will
probably result in a more effective nal outcome.
12.4 Complications ofSpecic
Anatomical Areas
12.4.1 Scalp
The main complication of scalp burns is alopecia (hair loss). It is also seen after extensive lacerations. It seems to occur in all grafted sites of
the scalp, as well as in some patients (4%)
treated conservatively (Menon et al. 2015).
Methods which have been used for reconstruction of burn alopecia include hair grafting
(small, good- quality burn alopecia of the frontal
or parietal area), scalp reduction (in small or
medium burn alopecia with good/moderate scar
quality), scalp extension (especially in the vertex region), and nally scalp expansion (for
large, poor-quality alopecia) (Jeong etal. 2010).
Scalp extension was rst described by Frechet
(1993), and it employs a thin sheet of bioplastic
(an extender) stretched and attached with hooks
to the galea after a scalp reduction. During the
few weeks that the extender is implanted, the
constant tension it exerts on the galea causes a
progressive stretching of the scalp. Advantages
of this method are the shorter total treatment
time, the absence of major side effects, and the
absence of any deformation of the scalp (unlike
scalp expansion). Tissue expansion has been
used for many years in reconstructive head and
neck surgery. The best aesthetic results, espe-
cially, in children, have been achieved in the
scalp (Hudson and Grobbelaar 1995). Patients
require careful selection in order to achieve
optimal results.
Lichen planopilaris, a type of primary scarring
alopecia which is characterized by perifollicular
lymphocytic inammation and brosis, has been
associated with scalp trauma (Montpellier and
Donovan 2014). Dissecting cellulitis (DSC) is
another uncommon type of suppurative scarring
alopecia. It presents with painful scalp nodules
and sinus tracts and can develop at trauma sites
especially in patients receiving interferon beta-1a
(Donovan 2015).
12.4.2 Eyebrow
Malalignment of the wound edges leads to a trapdoor deformity and disgurement of the eyebrow.
The scar should be reopened and the edges properly aligned and resutured in order to correct the
deformity.
Muscular trauma (e.g., corrugator) can result
in functional brow asymmetry. Nerve problems
such as frontal nerve injury causing unilateral
frontalis dysfunction can cause brow asymmetry. The latter can also be related to the “spasticfrontalis syndrome,” a functional derangement
of the eyelid and eyebrow related to eyelid ptosis (Ramirez 1994). Extensive scarring in and
around the eyelid and its adnexae following burn
injuries may also lead to eyebrow malposition
and lagophthalmos. Finally, eyebrow asymmetry
can preexist (congenital causes), and childhood
photographs of the patient should be examined if
other reasons for the asymmetry cannot be found
(Ramirez and Pozner 1997). Correction of posttraumatic asymmetric eyebrows depends primarily on ascertaining the cause of the asymmetry.
The nature of the injury, the position of the scar,
and the eyebrow position in repose and animation should be evaluated in order to dene the
cause. In cases of muscular trauma, severing of
the contralateral musculature matches the injured
site and adequately restores brow symmetry. In
cases of a well-healed scar of good quality, the
procedure can be done endoscopically, (Ramirez
12.4 Complications ofSpecic Anatomical Areas
171
and Pozner 1997). Endoscopic correction of
post- traumatic eyebrow malposition using a
somewhat different technique was described in a
more recent report from Taiwan (Tu etal. 2004).
The authors conducted an endoscopic subpericranial dissection freeing the entire scalp as a unit
by separating the pericranium from the skull.
When the eyebrows were too high, the scalp was
moved forward. When the eyebrow was too low,
the subpericranial dissection was limited to the
forehead area and the forehead skin was moved
backward (cranially) to elevate the eyebrow. The
pericranium was anchored in the new position
by mini screws, which were removed 3weeks
postoperatively.
Correction of the malpositioned eyebrow does
not only improve the aesthetic appearance of the
patient. In cases of lagophthalmos, it restores
eyelid competency. Although eyebrow malposition is an uncommon sequel after facial trauma,
when present it ought to be addressed.
Endoscopically assisted techniques have gained
popularity over the classical hemi- or bicoronal
approach because of the disadvantages of the latter (sensory changes, alopecia).
Severe burns cause alopecia of the eyebrow
and are usually repaired with a hair-bearing island
temporoparietal ap. The results are not always
successful. Omranifard and Doosti (2010)
reported better results after use of a subcutaneous
pedicle island ap. Hair grafting with one- or two-
hair grafts using a dense-packing technique has
achieved satisfactory results with a very natural
appearance (Wang and Fan 2004). Women, not
wishing to undergo surgery, occasionally, camouage the defect with cosmetics or tattooing.
12.4.3 Eyelids
Poor surgery or late surgery of eyelid injuries
may give rise to disguring scars. Lacerations
parallel to the lid margin usually cause disguring puckering. Injuries which run at right angles
to the margin give rise to ectropion or entropion.
Distortion in the anterior lamella and eversion
(ectropion) (Figs.12.8, 12.13, and 12.14) or distortion in the posterior lamella and inversion
(entropion) are likely to result after partialthickness lacerations, whereas in full-thickness
injuries, contraction of both the deep and the
supercial layers tends more often to give rise to
notching of the lid margin (Fig.12.1). Minor vertical scars in the pretarsal or preseptal zones of
the lower eyelid may give rise to a degree of eversion which, if it involves the punctum, greatly
increases the epiphora usually present and due to
the exposure of conjunctiva. It should be noted,
however, that distortion of the lower eyelid may
often be present without any serious consequences, while even moderate-degree notching
or ectropion of the upper eyelid can, by causing
Fig. 12.13 (a, b)
Traumatic ectropion of
the left eye
ab
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12 Wound Healing Disturbances: TheUnfavorable Result
Fig. 12.14 (a, b)
Traumatic ectropion of
the left eye. (c) The
resulting lagophthalmos,
when the patient closes
the eyelids, is clearly
seen
a
b
c
the cornea to be even slightly exposed during
sleep, give rise to desiccation and ulceration of
this delicate structure, with serious consequences
to vision (Mustardé 1991).
When a lid position abnormality exists, the
surgeon ought to analyze the position of the lower
orbital rim, the position of the canthi, and the
location and severity of brosis within the lid
(anterior or posterior lamella) (Manson 2001).
The lid should be able to be elevated over the
superior margin of the pupil, when grasped.
When this is not feasible, brosis and contracture
have restricted the lamella, and these structures
need to be released.
The timing of repair of secondary contractures
will be determined by the risk to the underlying
eye. Issues such as appearance and discomfort
from epiphora (watering eye) are less important
at initial examination. Whenever possible, scars
should be observed for roughly 6months before
any secondary surgery is carried out. In this way,
broblast activity can settle, the initial scar can
reach a mature non-active state and the risk of
hypertrophic new scar or keloid formation can be
kept to a minimum.
Minor scars, even the ones involving the orbicularis, can be corrected by scar tissue excision
and meticulous reapproximation (Fig. 12.15).
The wound is closed in layers; skin is sutured as
a separate layer with 6.0 interrupted Prolene
sutures. When the scarring is more marked, excision of all obvious scar tissue may leave a degree
12.4 Complications ofSpecic Anatomical Areas
173
Fig. 12.15 (a, b) Minor
scar of the left upper
eyelid. (c) The scar has
been corrected by scar
tissue excision and
meticulous
reapproximation
a
c
of shortness in the scar line. In such cases, the
line of the excised scar will need lengthening by
means of a Z-plasty. With long scars crossing
normal crease lines, multiple Z-plasties may be
required. When the scar affects the orbicularis,
the Z-plasty must be carried out using aps of
skin and orbicularis. This results in areas of muscle lying at an angle to the normal muscle line,
which is not a problem in the pretarsal, canthal,
and orbital areas; however, in the area of the
upper eyelid skin fold, it can result in some deformity of the fold which is difcult to correct
(Mustardé 1991). In full-thickness scars, the
Z-plasty aps will contain skin, orbicularis, and
tarsal plate/conjunctiva.
When initial surgical repair has resulted in
faulty orientation of tissues, meticulous excision
of all scars should allow them to be correctly oriented, before the original injury is dealt with, as
if primary closure was being carried out.
Small “pin cushion” scars are closed directly
after excision of scar tissue. Large ones need to
be broken up by a Z-plasty.
Placement of spacers or grafts (thin nasal cartilage, palatal or buccal mucosa) into a contrac-
b
ture of the posterior lamella has been advocated
by some authors (Bartley and Kay 1989).
Furthermore, if there is not adequate skin in the
anterior lamella, a skin graft may need to be used.
The decision about grafting is made after brosis
and contractures are released.
Upper eyelid entropion can successfully be
managed by either anterior lamellar repositioning
or a terminal tarsal rotation. Complete success,
which is dened where no eyelashes touch the
globe, can reach 85% (Ross etal. 2011). Anterior
lamellar recession with buccal mucous membrane grafting has also been used with a somewhat lower success rate (66%; Koreen et al.
2009).
More extensive scarring with much loss of
subcutaneous tissue as well as skin necessitates
the introduction of aps, comprising skin and
underlying fat from the periorbital areas
(Mustardé 1991).
Ectropion due to a burn injury is managed by
excision of burned scar tissue and skin grafting. In
the lower eyelid, a full-thickness skin graft (retroauricular area) should be used. Upper eyelids
require a much suppler graft, which should be a
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12 Wound Healing Disturbances: TheUnfavorable Result
medium-thickness split skin graft, which will
impart mobility to the lid. Because the thinner
graft will contract more, about twice as much skin
(in vertical direction) ought to be used. In severe
burns, the underlying brosis may cause more
contraction than anticipated. A second and sometimes a third graft may be required, each on the
marginal side of the last (lower lid) or above the
original (upper lid) (Mustardé 1991). Each subsequent dissection further damages the remains of
the orbicularis causing stiffness of the lid. In the
case of the lower lid, this is of no great importance; however, if a degree of xity of the upper
lid exists, then the lid must be long enough to
allow the cornea to roll under it during sleep and
be completely covered. Sight is enabled, provided
that there is a gap between the eyelids, by adjusting head movement, rolling eyes down, and looking out from below the xed lid (Mustardé 1991).
Other methods which have been used for correction of cicatricial ectropion are local aps, fascia slings, palmaris longus tendon, and fat
grafting (Qian etal. 2006; Caviggioli etal. 2008;
Song etal. 2014). The reports are anecdotal, and
the experience is limited.
canthopexy (Merkx et al. 1995). In secondary
surgery, canthi can be freely repositioned only
following wide subperiosteal dissection, which
releases brosis and abnormal attachments.
Occasionally, the periosteum may have to be
resected in order to increase soft-tissue exibility
and achieve a more effective repositioning. In the
case of the lateral canthus, a small transverse
local incision is usually sufcient to isolate the
canthus and reposition it in its correct position
(Fig. 12.16). The medial canthus can be either
vertically or horizontally displaced (Fig.12.5a, b).
In cases of a vertical canthal dystopia, the canthus is repositioned using a local incision and a
Z-plasty deals with the skin.
In lateral shifts, removal of soft tissue and
bone contouring may permit better reinsertion of
the medial canthal tendon. A procedure like the
four-ap technique described by Mustardé for
correction of epicanthus can be used for the skin
(Mustardé 1991). The canthal tendon can be stabilized either with the standard transnasal canthopexy or with miniplates, where poor bony
support for transnasal wires is evident (Shore
etal. 1992) (Fig. 5.15).
12.4.4 Canthus
Malposition of the canthi is, like malposition of
the eyelids, one of the most distressing postinjury complications. Furthermore, it is one of
the post-traumatic facial deformities most refractory to secondary correction (Imola etal. 2008).
It can involve either the medial or the lateral canthus, and it is due to unrepaired primary canthal
displacement or a recurrence of primary canthal
surgery. Primary direct canthopexy was reported
to have a smaller relapse than primary indirect
Fig. 12.16 (a)
Traumatic dystopia of
the left lateral canthus.
(b) After surgical
correction
ab
12.4.5 The Lacrimal System
In the presence of a normal tear production, posttraumatic obstruction of the tear drainage passages
leads to the troublesome symptom of epiphora.
This, however, is not the only symptom caused by
lacrimal obstruction. Severe pain and swelling
accompany dacryocystitis. Swelling is caused by
accumulation of mucus within an obstructed lacrimal sac and was reported to occur in 50% of
patients (Ali etal. 2012). Epiphora is uncommon,
unless there is an obstruction of both canaliculi
12.4 Complications ofSpecic Anatomical Areas
175
(upper and lower), the common canaliculus or
beyond the interval opening of the latter.
Before examining the lacrimal system, a thorough examination of the eyelids has to be made.
Neither canaliculus will drain if the position of
the lid margin precludes entry of tears into the
punctum. Stenosis of the punctum due to scarring
may be relieved by a one-snip or three-snip procedure or by the use of a specially designed
punch to remove the posterior margin of the
punctum (Mustardé 1991). Assessment of the
membranous tear passages is done by insertion of
a cannula into the lower canaliculus and irrigation of the passages. If uid reuxes from the
opposite punctum, this conrms canalicular
patency, at least as far as the common canaliculus. Reux of mucus usually implies an obstruction within the sac. There is no doubt that
additional information can be obtained from
properly executed contrast studies (dacryocystography) (Fig.12.17). The latter (with or without subtraction) and more recently CT
dacryocystography (Bonnet etal. 2009) and MR
dacryocystography (Manfré etal. 2000) are routinely used for the diagnosis of obstruction of the
lacrimal system. In patients with epiphora with
no demonstrable anatomic abnormality on dacryocystography, nuclear scintigraphy (dacryoscintigraphy) can be helpful (Weber etal. 1996).
Relief of symptoms due to lacrimal obstruction is almost always possible surgically. When
the canaliculi are obstructed, it may be possible
to create a functional, mucosa-lined passage by
anastomosing any patent canalicular tissue to the
nose using the lacrimal sac mucosa as a bridge. If
the canalicular function has been lost, the only
way of effecting tear passage is by the insertion
of a bypass tube (Mustardé 1991). Eyes with a
lower canaliculus injury which water can often
be rendered symptom free by carrying out a dacryocystorhinostomy, which enhances ow along
the upper canaliculus (Mustardé 1991). Any case
of lacrimal obstruction located beyond the internal opening of the common canaliculus is managed with a dacryocystorhinostomy. The main
principle of this surgical procedure is to make the
part of the lacrimal sac that harbors the interval
opening of the common canaliculus an integral
part of the lateral wall of the nose. Mukherjee and
Dhobekar (2013) reported a 96% success rate (28
patients with traumatic nasolacrimal duct
obstruction) using an external dacryocystorhinostomy and after a mean follow-up period of
7.7months (range: 3months to 6years).
An acceptable alternative to the traditional
external dacryocystorhinostomy is endonasal
endoscopic dacryocystorhinostomy. Hartikainen
et al. (1998) compared the two methods and
found a higher success rate with external dacryocystorhinostomy (91% vs. 75%) after primary
surgery. The success rate after secondary surgery
(follow-up 1year) was the same in both groups.
Endonasal endoscopic dacryocystorhinostomy is
more rapid than the traditional approach
(Hartikainen et al. 1998; Dolman 2003) and
seems to be preferred by patients who had alternative techniques performed on opposite sites
(Dolman 2003). Furthermore, it has the advantages of no scar and a lack of damage to the pump
mechanism that often occurs with external dacryocystorhinostomy. Recent evidence has
indicated that the success rate of both methods is
indeed comparable (Marcet etal. 2014).
12.4.6 Nose
Nasal trauma often involves the nasal septum. A
nasal septal hematoma can occur even after minor
trauma. It is more common in children (Alshaikh
and Lo 2011) because their septal cartilage is
softer than that of adults (Sanyaolu etal. 2014).
Fig. 12.17 (a, b)
Dacryocystographies
showing an obstruction
at different levels of the
lacrimal system
a b
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12 Wound Healing Disturbances: TheUnfavorable Result
External injury might not be obvious, and symptoms can be nonspecic, particularly in children;
therefore, a high index of suspicion is necessary
in any patient presenting with a history of nasal
injury, however innocuous it might seem. Nasal
septal trauma is often neglected and frequently
goes undiagnosed until complications ensue. It
has been reported that a considerable proportion
of patients with nasal injuries seen in emergency
departments have no documented evidence of a
septal examination and assessment of the presence of a hematoma (Agrawal and Brayley 2007).
Untreated septal hematoma can lead to irreversible septal necrosis within 72–96 h (Sanyaolu
et al. 2014). This, in turn, leads to severe cosmetic distortion of the nose (external) and considerable functional (nasal perforations,
respiratory difculty) abnormalities. If a nasal
hematoma is infected, a nasal septal abscess is
formed. The latter is a serious medical condition
and requires urgent surgical management because
it can result in substantial morbidity and mortality (intracranial complications, facial deformity,
and delayed facial growth in children; see also
section on “Septal hematoma”).
Prompt diagnosis of nasal septal hematomas,
incision/drainage, and intravenous antibiotics are
mandatory in order to prevent nasal deformity
and serious infective complications. The immediate management of nasal septal abscess is incision, drainage, and antibiotic therapy. Recent
studies suggest early septal reconstruction in
children in order to prevent immediate and late
facial deformity due to necrosis of the, e.g., quadrangular nasal cartilage and collapse of the nasal
dorsum, and nasal dysfunction. Autologous cartilage is the implant material of choice (Alshaikh
and Lo 2011).
Another, rare, sequel of a nasal septal abscess
is septal perforation (Jalaludin 1993; Moon etal.
2011). Nasal obstruction, whistling, crust, and
epistaxis are common symptoms presented by
patients with a septal perforation (Lanier et al.
2007; Moon etal. 2011). An extensive range of
methods have been used for surgical closure of
septal perforations. Mucosal aps, mucosal aps,
and interpositional grafts, even free aps, have
been reported with rarely statistically signicant
results. Studies utilizing interpositional grafts
generally produced higher closure rates (Goh and
Hussain 2007). However, it seems that each technique has its own advantages and drawbacks.
Nasal burns result in a wide range of deformities which are the cause of functional as well as
aesthetic problems (Fig.12.18). Minor contractures can be released with Z-plasties or releases
in combination with full skin grafting. Stenosis
of the nasal vestibule may require cartilage grafting (batten graft or spreader) in order to restore
the strength of the ala (Daines etal. 2010). Scar
tissue is excised (eventually at a second stage,
Daines et al. 2010), followed by full-thickness
skin grafting. Subsequent use of a nasal stent
which is serially upgraded in size to expand the
opening of the nostril and the surrounding tissue
maintains the size of the nostril in most patients.
However, continuous use of the stent and patient
compliance can be a drawback (Daya 2009).
Shortening of the nose can be dealt with by dor-
Fig. 12.18 Severely burned, and scarred, nose and lower
face, which caused functional as well as aesthetic
problems
12.4 Complications ofSpecic Anatomical Areas
177
sal scar excision after alar lobule release and fullthickness skin grafting. Excision of the whole
aesthetic unit and skin grafting is required in
cases of more severe shortening. Large defects
are reconstructed with dorsal turndown aps, cartilage grafts, when necessary, and aps (forehead
ap when available, otherwise an upper inner
arm ap or free microsurgically anastomosed
aps, e.g., radial/ulnar forearm, anterolateral
thigh or thoracodorsal artery perforator ap).
The opportunistic use of scar tissue in turndown aps and subsequent skin grafting can
restore nasal tip projection and alar lobule architecture without cartilage grafting. Repeat turndown aps may be required to achieve sufcient
nasal length and projection (Taylor etal. 2009).
Prousskaia etal. (2015) reviewed 150 cases of
nasal burns. Twenty of those were treated surgically. Five patients required secondary reconstruction. Lack of volume of nasal tip after
primary skin grafting or resurfacing with a fascia
lata plus Integra® was the indication in four
patients. In the fth patient, who had been treated
conservatively, the collapsed external nasal valve
was reconstructed with spreader grafts. The
authors concluded that secondary nasal reconstruction after a nasal burn is based on an assessment of the residual functional and cosmetic
problems of the patient. When the face requires
ap resurfacing, then a nasal reconstruction with
ap tissue is the best option. If the face is composed of burn scar, a distant (free) ap reconstruction has the disadvantage of appearing to be
“stuck on” and stand out in the midst of the otherwise mosaic appearance of the face.
12.4.7 Lips
Perioral burns (thermal, electrical, or chemical)
may result in contracture of the tissues causing
microstomia (limited oral access), which compromises aesthetics, speech, food intake, etc.
Various appliances have been designed and used
by dentists and hospital burn centers in order to
prevent microstomia. Understanding of different
treatment concerns, ease of fabrication, age
appropriateness, and cost-effectiveness aid the
clinician in selecting or developing the best
appliance for each burn patient. In general, the
devices can be classied as intraoral or extraoral;
they deliver a stretch either horizontally, vertically, or circumorally. Extensive reviews of oral
appliances used to prevent and/or manage microstomia have been published by Taylor and
Walker (1997), Dougherty and Warden (2003),
and Sofos etal. (2015). The benet of oral splints
has already been established since the early
1990s. Barone et al. (1994) retrospectively
reviewed 29 patients with perioral burns. Patients
in group 2 (nonsurgical management with splint
appliance) had a less noticeable scar and more
normal lip parameters. Patients in group 1 (no
surgery and no splint) and patients in group 3
(commissuroplasty) had similar percent of scar
involvement and overall poor subjective scores.
Patients with a commissuroplasty fared better
compared with no surgery and no splint. The
authors concluded that the application of a splint
yielded the best results. Use of microstomia prevention devices seems to be particularly important in cases of oral electrical burns in children.
Without their aid, the resultant contracture and
associated functional decits are difcult to
release and reconstruct (Yeroshalmi etal. 2011).
Patient compliance of a pediatric population,
however, can be questionable.
When conservative means have failed, surgical reconstruction of burn microstomia, macrostomia, or lip defects is undertaken. Various
locoregional and free aps have been used for
this purpose. Some have been highlighted in
Chaps. 8 and 10.
Static reconstruction of subtotal or total
defects in cases of absence of a functional
orbicularis muscle results in oral incompetence
and lower lip drooping. Dynamic lower lip suspension with bilateral temporalis muscle aps
and fascia lata grafts has been suggested by Chan
et al. (2012). Lower lip function and long-term
dynamic oral competence can thus be achieved.
Rehabilitation of swallowing (transition from
nonoral to oral intake) and speech (improvement
of articulation and speech intelligibility) is essential after postburn reconstructive procedures of
the lips (Clayton etal. 2009).
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12 Wound Healing Disturbances: TheUnfavorable Result
Deformities of the lower lip often occur in
combination with deformities of the chin. Inferior
dislocation and eversion of the lower lip as well
as compression of the chin contour is the result of
the resultant contracting forces. Release at the
vermillion scar junction is indicated in such cases
so that the lower lip can be unfurled. Iatrogenic
injury to the orbicularis oris muscle should be
avoided. Full-thickness skin grafts are used for
the resurfacing of the defect. A genioplasty can
improve the chin contour.
Severe burns can result in shortening and
retrusion of the upper lip. Releasing and skin
grafting improve the functional and aesthetic
defect. Care should be taken not to overcorrect
and lengthen the lip. The philtrum is best reconstructed, when indicated, with a composite graft
from the triangular fossa (Schmid technique).
12.4.8 Neck
The distribution and depth of the burn predict the
patterns of deformity and neck contractures. The
more extensive the burn, the greater the rehabilitation challenge. Immediate and aggressive initiation of patient-specic rehabilitation programs
is common practice. The neck is positioned in a
neutral position or in slight extension (15°).
Positioning is facilitated with a foam cushion
behind the upper back at the level of the scapular
line. A soft neck collar or a custom-made thermoplastic collar may be fabricated in cases of anterior neck burns. In cases of a lateral neck
contracture (torticollis), a lateral neck splint is
fabricated to counteract the lateral neck contractile forces. However, scar contractures are still a
common complication. Schouten et al. (2012)
found no strong evidence for the effectiveness of
static splinting therapy in preventing scar contracture, whereas in vitro and animal studies
demonstrated that mechanical tension will stimulate the myobroblast activity, resulting in new
extracellular matrix and maintenance of their
contractile activity.
Neck contractures after burns result in
restricted mobility and aesthetically unacceptable results. Surgical treatment is often indicated for those scar contractures. Small and
linear scars can be corrected with release,
Z-plasties (Fig.12.19), or skin grafting, as has
been earlier outlined (Chap. 11). In cases of
broader, diffuse contractures, a different surgical approach is required. Regional tissue or
preferably free tissue transfer is often indicated.
Use of a number of free aps has been highlighted in Chap. 11. Recently, the use of perforator aps has gained popularity. Stekelenburg
et al. (2017a) reported the results of a multicenter randomized controlled trial which compared the effectiveness of perforator-based
interposition aps and full- thickness skin grafts
after release of burn scars. Interposition aps
showed superior results compared with skin
grafts regarding mean surface area (at 3 and
12 months), scar assessment, and color. The
same group (Stekelenburg et al. 2017b) conducted a review of the relevant literature in order
to evaluate the long-term outcome of perforatorbased aps for the treatment of burn scar contractures. Three papers regarding neck
contractures were included. The authors could
not reach denitive conclusions regarding the
true clinical signicance, due to paucity and low
Fig. 12.19 (a) Linear
scar of the right
forehead, partly
corrected with a
Z-plasty. An effort has
been made to place the
horizontal limb of the
Z-plasty in a skin crease.
(b) The same patient
6months
postoperatively
ab
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