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.

Incidence

Keloid young > adult Negroes > Caucasians Female > Male
extends to surrounding uninjured skin Persists and enlarges

Extent

confined to site of injury tend to resolve after weeks or months

Result

Recurrence Some tendency to

recur after excision

High tendency to 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 2030 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 paratenon 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 Kwire 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 fullthickness 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.

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