MANAGEMENT OF

POST-BURN

SEQUELAE

Dr. Moahmed Ahmed ELROUBY Consultant of Plastic Surgery

Ain shams University - Cairo

Deep dermal or full-thickness burns

produce scarring. Scars are the

sequelae of any burn wound. The

aim of scar management is firstly

its prevention and secondary the

removal of established contractures.

Management of burn sequelae includes

the treatment of :

1- post-burn scars.

2- post-burn contractures.

Types of scars after deep burn :

a. Hypertrophic scars b. Keloids

Usually seen with deep dermal burns,

left to heal spontaneously. The burn scar

becomes raised, red and itchy within

weeks of healing. Not only these scars

are unsightly, but they contribute to joint

contracture and limitation of joint

movement when crossing them.

Both hypertrophic scar and keloid, are

included in the spectrum of

fibroproliferative disorders.

These abnormal scars result from the

loss of the control mechanisms that

normally regulate the fine balance of

tissue repair and regeneration.

Hyp. Sc. Keloid

Incidence young > adult

Negroes > Caucasians

Female > Male

Extent confined to site extends to surrounding

of injury uninjured skin

Result tend to resolve Persists and enlarges

after weeks or months

Recurrence Some tendency to High tendency to

recur after excision recur after excision

WAYS OF PREVENTION :

1- Early release of tension over flexion

creases of joints. Tension in a scar encourages

hypertrophy, so that releasing it by grafting or

local flaps may prevent its occurrence.

2- Continuous scar massage, after

application of skin emollient, can be quite

effective.

3- Pressure on maturing scar tissue, appears to

reduce the incidence of hypertrophic changes.

Such pressure is most likely maintained by

compressive garments for 24hrs./day, for at least

six to twelve months.

Mechanism of action is unknown. However,

reducing the O2 tension in the wound by occluding

small vessels, will cause reduction in tissue

metabolism with cessation in fibroblast

proliferation and collagen synthesis.

Treatment of an established keloid or

hypertrophic scar : 1- The release of the contracture by re-arranging

the tissues by local flaps (e.g.: Z- plasty) or by the

application of skin graft.

2- Intralesional steroid injection

(e.g.: triamcinolone acetonide; 1-2 cc of 40 mg./cc

at one or two weeks interval.). It inhibits collagenase

inhibitors causing degradation of collagen, thus

decreasing dermal thickening.

3- Application of silicone gel sheet as an

occlusive dressing. Ideally it should be placed

24hrs./day for about a year. Silicone does not

penetrate the skin, so its effect appear to be

secondary to occlusion and hydration.

Occlusion appears to increase the temperature

of the scar, possibly increasing the collagenase

activity. Hydration causes softening of

the scar.

4- Cryosurgery: It uses liquid N2 to cause

cell damage and to affect microvasculature

with subsequent stasis, thrombosis and

transudation of fluid resulting in cell anoxia.

The protocol is 1-3 freeze cycles lasting for

10-30 sec., with repeating therapy every 20-

30 days. Better results are obtained when

cryosurgery is combined with steroid

injection

5- Laser therapy : The advantage of laser as an

excisional tool is that it is precise, haemostatic with

minimal tissue damage thereby eliminating

inflammatory reaction. The modalities are :

- Pulse-dyed laser ----- microvascular thrombosis

- CO2 laser & Argon laser----- collagen shrinkage

through heating.

- Nd-YAG laser----- inhibits collagen metabolism

and production.

However the recurrence rate with laser therapy is

high.

6- Interferon therapy : The newest therapeutic

modality on the horizon is intralesional injection

of INF- alpha, INF- beta and INF- gamma.

They reduce fibroblast synthesis and collagen

type I, III and possibly IV and increase the

collagenase activity.

Studies show that INF- alpha 2b and INF- gamma

are most effective when injected immediately

postoperatively into the excision site.

Management of burn sequelae

in specific regions

1- Head and Neck

2- Upper extremity

3- Lower extremity

4- Trunk

Head reconstruction includes : 1- The scalp

2- The face :

a- Eye lids

b- Eye brows

c- Mouth

d- Nose

e- Ears

Scalp reconstruction: 1- Indications: The primary indication of scalp

reconstruction after burn is scar alopecia or an

unstable scar.

2- Classification:

Minor defect: up to 5% of scalp involved.

Moderate defect: from 7-70% involved.

Extensive defect: more than 70% involved.

3- Reconstruction : a- Minor defect: immediate treatment is done by

skin graft. Later on, advancement and rotation of

adjacent scalp flaps will be enough to fill the defect.

b- Moderate defect: immediate treatment is done by

skin graft. Tissue expansion is the final treatment of

choice. This allows the area to be reconstructed with

like tissue and with no donor defect.

c- Extensive defect: This is a difficult

situation. Defects in this range may be too

large to be corrected by tissue expansion. If

periosteum is intact, a skin graft is applied.

Otherwise free tissue transfer is required. The

most common flaps are the omentum and the

latissimus myocutaneous flaps.

Reconstruction of the Face: Diagnosis of the depth of burn in

the face may be difficult and early

excision is contraindicated.

It is often surprising howmuch

facial skin regenerates. Whatever

method of reconstruction is used,

the aesthetic unit of the face

should be followed.

1- The forehead : is best resurfaced with a

single sheet of split thickness skin graft.

With bony exposure or destruction, flap

reconstruction is indicated.

2- The cheeks : the best is tissue expansion

from adjacent non-injured tissue (e.g.: neck).

Thin free flaps may be considered (e.g.: radial

forearm flap). Others describe the use of a

large full-thickness graft as one aesthetic unit.

Eye lid reconstruction :

Indications : exposed cornea, contractor ectropion of upper

and/or lower eye lid and contractures at the canthi regions.

1- Total loss of eye lids : the exposed cornea can be covered

by mobilizing the conjunctiva which is covered with skin

graft. Later on the lids can be reconstructed with local flaps

(e.g.: cheek flap or

median forehead flap

with septal

mucoperichondrial graft

as lining).

2- Ectropion :

we have to distinguish between :

a- primary ectropion where the deep burn affects the eye lids

directly. The treatment is release of the contrature and

application of thick split thickness graft to the upper eye lid

and a full thickness graft to the lower eye lid.

b- secondary ectropion, due to contracture of forehead, cheek

or neck pulling on the eye lids. Treating the cause will

alleviate the condition.

3- Contracture web at the medial and/or lateral canthi are

corrected by local flaps in the form of Z- plasty or V-Y plasty.

Eye brow reconstruction :

* Loss of the hair may be compensated by

the simple simulation done by an eye

brow pencil ( specially in women ).

However surgical reconstruction of the

eye brow may be done through :

1- Hair transplantation: single hair

transplantation is better than a punch

graft.

2- Hair-bearing flap from the temporal

scalp. It is based on the superficial

temporal artery and it is an island flap.

3- Strip graft taken anywhere from the hairy scalp

with the dimension and shape of the eye brow. Care

is taken :

- not to exceed 4 mm. in width.

- not to injure the hair follicles during elevation of

the flap by the scalpel.

- the direction of the hair should be oriented from

medial to lateral.

Lip and mouth reconstruction : 1- Extensive scarring of the upper or lower lip:

excision and full thickness graft within the

aesthetic unit of the involved lip.

2- Microstomia (oral commissure contracture):

corrected by full thickness incisions at each angle

of the mouth as far as a line dropped vertically

from the pupil of the eye. Then the oral mucosa

is mobilized and everted onto the lip skin, forming

a new commissure. Some overcorrection is

generally advisable.

Nasal reconstruction : 1- Total destruction of the nose requires :

a- Flap reconstruction either

regional, like the forehead flap,

or distant by microvascular transfer.

b- Prosthetic reconstruction.

2- Unacceptable hypertrophic or hypopigmented

scars over a large surface of the nose may be

treated by dermabrasion, either mechanical or by

laser, and application of a single sheet of skin

graft within the nasal aesthetic units.

3- Alar rim reconstruction is done using a composite

graft from the ear.

4- Nostril stenosis is treated by release and skin

grafting. Splints must be worn for at least six months

after surgery to prevent recurrence.

5- Web contracture between columella and upper lip,

may be released by V-Y advancement flap.

Ear reconstruction:

- Indications: Partial or total loss of the external

ear.

- Classification: Help to determine the treatment.

Mild defect: loss of helix and upper part of the

auricle, without extensive scarring.

Moderate defect: concha nearly normal; upper half

of the ear missing; antihelix and its posterior crura

missing.

Severe defect: remnant of concha; local soft tissue

scarred; external ear orifice normal or stenosed.

Head & neck reconstruction

(Ear reconstr.)

- Treatment : 1- Total absence of the auricle : - Surgical reconstruction using a costochondral

graft, as described for microtia.

- Osteointegrated prosthesis.

2- Subtotal absence of helical rim : - The Antia procedure is effective in restoring

the helical rim.

- Local flap reconstruction is preferred.

- When the entire helix is missing, a tubed

cervical skin flap is used.

3- Ear lobe deformity:

- Adherence of the ear lobe to the neck is the main

deformity. Z-plasty or local flaps are generally

sufficient for correction.

4- Meatal stenosis :

- Splinting may be used as a preventive measure

and may eliminate the need for surgical

correction

- After release, use local flaps if available. If not

use skin graft.

- A conformer is worn by the patient for 4 - 6

months to prevent recurrence.

Neck reconstruction :

* Prevention of occurrence of contracture: 1- During the period of dressings, the neck should be fully

extended by putting pillows below the scapulae not behind the

head.

2- When the burn is dressed, a bulky foam collar may be

incorporated over the dressing to elevate the chin and keep the

neck extended.

* Treating established contractures : 1- Mild cases: mild scar bands can generally be corrected

surgically by using local flaps or Z-plasties.

2- Moderate cases: contractures involving 1/3 - 2/3 of anterior

neck, can be treated using tissue expansion. The unscarred

lateral aspects of the neck are expanded.

3- Severe cases: contractures involving more than

2/3 of the anterior neck, are better treated by

release and split thickness skin graft or distant flap

by microvascular technique. Local flaps are not

adequate.

Management of axillary contractures :

* Prevention of contracture : For burn of the axilla, the patient should be nursed

with the shoulder abducted either by splinting or

applying copious dressing paddings in the axilla.

* Treating established contractures : 1- Scar bands and minor contractures are better

treated by local flaps e.g.: Z-plasty or V-Y plasty.

They may be combined with the application of

skin graft, kept in place by tie-over dressing.

* Treating established contractures : 2- Moderate contracture may be released and the

defect filled with a latissimus dorsi fasciocutaneous

flap.

* Treating established contractures : 3- Severe contracture, producing large defect on

release, are best treated with skin graft.

Plaster of paris is applied at the

end of the operation where the

joint is kept as fully abducted

as possible.

Splintage should be maintained

for several weeks until the

patient can put the joint

through a full range of

movement.

* Prevention of contracture : During burn healing, the elbow is splinted 10 o short of

straight, but is put in a full range of movement three times

daily.

* Treatment of an established contracture: Usually follows the same principles as for the axilla. The joint

should also be splinted for several weeks.

* Prevention of contractures : 1- Frequent active and passive

movements of the wrist, M P Js

and I P Js through a full range of

motion.

2- We have to incorporate plaster

of Paris or aquaplast splint in the

bandage, so that the position

of the wrist and hand is kept as

follows :

a- The wrist is extended 20o

b- The M P Js are flexed to 90o

c- The I P Js are kept straight

3- Splintage of the hand while the patient is asleep

during night, helps to prevent contractures into a

non-functional position.

4- Early skin grafting is preferable for full-thickness

burns, to allow early movement.

* Treatment of established deformities :

1- Amputation deformity : typically they involve

the DIJs, PIJs and possibly the middle phalanges.

Toes as well as fingers are usually involved.

The most common procedure, is deepening the

web space to produce a longer finger. The thumb

amputation deformity is treated either by

pollicization or toe to finger transfer.

2- Dorsal burns :

a-Hyperextension deformity of the dorsum of the

hand, is released by a transverse incision across

the distal part of the back of the hand. The para-

tenon of the extensor tendons should be preserved

and a thick partial thickness graft applied to the

defect and maintained in place with a tie-over

dressing.

b- In severe cases of joint capsule contracture, we do

capsulotomy and the joint is immobilized by a K-wire for 3

weeks with the joints as flexed as possible.

c- The Boutonniere deformity may be corrected by releasing

the lateral slips of the extensor tendon and plicating them

onto the dorsum of the PIJ. The joint is immobilized with K-

wire for 3 weeks.

d- Arthrodeis of the PIJ, may be the only solution

for the destruction of the central extensor slip.

e- Hyperextension of the DIJ, is treated by tenotomy

of the lateral slips of the extensor tendon just

proximal to DIJ. This will allow the terminal

phalynx to drop to neutral position.

3- Palmar burns :

Mostly due to grasping electric fire

filaments. It is more common in

children.

The interphalyngeal spaces are usually

webbed (= burn syndactly).

They may be released by double

opposing Z-plasties, using full-

thickness or partial-thickness skin

grafts for the residual defects.

To facilitate dressing, the fingers and

hand are immobilized in Banjo splint.

Lower extremity reconstruction :

* Popliteal fossa : 1- Prevention of contracture:

Bulky dressing or pillows behind the knee during

the healing phase are avoided, so that the knee is

fully extended. If the patient is sitting on a chair,

legs are elevated on a footstool.

2- Treatment of established contracture :

a- Medial or lateral band contracture, are released

by local flaps.

b- More extensive scarring and contracture, are

released with the application of skin graft, or

reversed saphenous artery flap.

For all modalities of treatment, splinting and

immobilization in extention, is recommended for

1 week. Then daily stretching exercises and

splinting at night for 3-6 months.

* The ankle, dorsum of foot and toes : During the healing phase, dorsi flexion or plantar

flexion of the ankle, are prevented by applying the

appropriate splintage.

• Treatment of an established contracture:

Usually in the form of dorsiflexion of the foot and toes.

We do release till the level of the paratenon, with

application of thick partial thickness skin graft.

Tenotomy of the extensor tendons may be necessary to

alow the toes to drop into the

correct position maintained by K-wire for few weeks.

Abdomen reconstruction :

* Indication : Unstable or unattractive abdominal scar or scar

causing functional deficit or anatomic deformity.

* Treatment : 1- Small defects: managed by primary excision and

closure.

2- Moderare defects: managed with staged serial

excision. Scar bands can be released and

reconstructed by local flaps and/or skin graft.

3- Large defects:

Extensive hypertrophic scarring may need

extensive tissue expansion.

Tissue expansion provides the best approach for

like-for-like tissue.

Breast deformity management :

* Indications : - Scarring, deformity and assymetry are the major

indications for reconstruction.

- The surgeon must be extremely conservative

in debriding the nipple area. The first priority is

not to injure the breast bud.

- Follow up should continue through puberty.

After scar maturity and puberty, reconstructive

surgery can be planned.

* Treatment : 1- Restoring the breast projection:

- Surgical intervention can range from a simple

release of a contracting inframammary scar, to

extensive scar excision and skin grafting, allowing

the breast to take its shape.

- Total destruction of the breast bud will need full

breast reconstruction using TRAM- flap, lat. dorsi

muscle flap with prosthesis or tissue expansion

followed by insertion of a prosthesis.

2- Reconstruction of the N/A complex:

- A four-flap nipple procedure is done to lengthen

the nipple. A full-thickness skin graft will simulates

the areola.

- Tattoing the nipple and areola, may enhance the

result.

Management of burn deformity of the

external genitalia :

1- Scar contracture may lead to functional loss,

such as difficulty with sex or urination. Release

of the scar is by local flaps or skin graft.

2- Penile loss may be seen with electric burns.

Total penile reconstruction is performed. The

neurosensory radial forearm flap is preferred.

THANK YOU