The Art of Local Tissue Rearrangements in Burn Reconstruction: Z-Plasty and More.

In recent decades, advances in surgical anatomy, burn pathophysiology, surgical techniques, and laser therapy have led to a paradigm shift in how we approach burn scars and contractures. Scar excision and replacement with uninjured tissue, which predominated burn scar treatment for much of the 20th century, is no longer appropriate in many patients. A scar's intrinsic ability to remodel can be induced by reducing tension on the scar using various techniques for local tissue rearrangement. Often in combination with laser therapy, local flaps can optimally camouflage a burn scar with adjacent normal tissue and restore a patient more closely to their preinjury condition.

Evolution of Burn Care: Past, Present, and Future.

Burn care evolved slowly from primitive treatments depicted in cave drawings 3500 years ago to a vibrant medical specialty which has made remarkable progress over the past 200 years. This evolution involved all areas of burn care including superficial dressings, wound assessment, fluid resuscitation, infection control, pathophysiology, nutritional support, burn surgery, and inhalation injury. Major advances that contributed to current standards of care and improved outcomes are highlighted in this article. New innovations are making possible a future where severe burn injuries will require less morbid interventions for acute care and outcomes will restore patients more closely to their pre-injury condition.

Split-thickness skin graft donor-site morbidity: A systematic literature review.

The purpose of this systematic literature review is to critically evaluate split-thickness skin graft (STSG) donor-site morbidities. The search of peer-reviewed articles in three databases from January 2009 to July 2019 identified 4271 English-language publications reporting STSG donor-site clinical outcomes, complications, or quality of life. Of these studies, 77 met inclusion criteria for analysis. Mean time to donor-site epithelialization ranged from 4.7 to 35.0 days. Mean pain scores (0-10 scale) ranged from 1.24 to 6.38 on postoperative Day 3. Mean scar scores (0-13 scale) ranged from 0 to 10.9 at Year 1. One study reported 28% of patients had donor-site scar hypertrophy at 8 years. Infection rates were generally low but ranged from 0 to 56%. Less frequently reported outcomes included pruritus, wound exudation, and esthetic dissatisfaction. Donor-site wounds underwent days of wound care and were frequently associated with pain and scarring. Widespread variations were noted in STSG donor-site outcomes likely due to inconsistencies in the definition of outcomes and utilization of various assessment tools. Understanding the true burden of donor sites may drive innovative treatments that would reduce the use of STSGs and address the associated morbidities.

Five Essential Principles for First Web Space Reconstruction in the Burned Hand.

BACKGROUND: Burn injuries commonly affect the hand, and the development of adduction contractures of the first web space is frequent and deleterious, both functionally and aesthetically. Many corrective techniques and algorithmic approaches have been described to treat this problem, but there is no consensus on the optimal management. METHODS: A retrospective review at a single high-volume pediatric burn center was undertaken to evaluate the clinical course of these patients. All pediatric patients undergoing initial release of burn scar contracture of the first web space from 2005 through 2015 were included in a retrospective cohort study. RESULTS: The authors identified 40 patients with 57 burned hands. The initial approach to management was variable. Z-plasty or other local flap was the first technique used in 28 hands (49 percent), split-thickness skin graft in 19 hands (33 percent), full-thickness skin graft in seven hands (12 percent), groin flaps in two hands (4 percent), and a reverse radial forearm flap in one hand (2 percent). The mean numbers of total reconstructive procedures per hand including the initial procedure were as follows: groin flap, 4.0; full-thickness skin graft, 3.1; split-thickness skin graft, 2.1; Z-plasty, 1.4; and reverse radial forearm flap, 1.0. CONCLUSIONS: Successful reconstruction of the first web space must be addressed in the context of the entire hand. It is the authors' preference to use split-thickness skin grafting whenever a skin deficiency is present-only then should leading edge contractures be addressed with Z-plasty. Based on their experience, the authors recommend five principles that are essential to successfully treat postburn contractures of the first web space. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Triangular Fossa Graft for Philtral Reconstruction After Facial Burns: A 34-Year Experience.

BACKGROUND: Upper lip burns and skin grafts used for the resulting deformities all contract, leading to distortion of regional tissues and producing a flattened upper lip devoid of normal anatomic landmarks. Absence of the philtral contour draws attention to the upper lip and can accentuate other reconstructive inadequacies. Philtral restoration requires a 3-dimensional reconstruction capable of resisting contractile forces to restore and maintain normal relationships between the upper and lower lips. METHODS: This was a 34-year retrospective review of a single surgeon's experience using a composite triangular fossa graft from the ear for philtral reconstruction. Ten patients were identified and analyzed using records of follow-up examinations, long-term clinical evaluations, and photographic documentation. RESULTS: Five males and 5 females were identified with 2- to 34-year follow-up. Age at operation ranged from 14 to 52 years. Percent total body surface area ranged from less than 1% to greater than 90%. Previous upper lip grafts prior to the auricular graft included 5 full-thickness skin grafts and 5 split-thickness skin grafts. No significant complications were noted. All patients were satisfied with the end aesthetic result and donor site morbidity. CONCLUSIONS: A triangular fossa composite graft restores and preserves the philtral dimple and corrects the obvious visible deformity of a featureless upper lip. Addition of tissue loosens the lip transversely, and the cartilage component provides a consistent and predictable upper lip position. This results in improved projection, a concave shape to the upper lip, and a better relationship with the lower lip. Restoration of this anatomic landmark creates a more normal-appearing upper lip and helps to minimize the negative impact of other abnormalities in this vitally important area. The overall improvement in total facial appearance can be profound.

Vermillion Reconstruction With Anal Verge Transitional Epithelium: Turning Things Upside Down.

Postburn lip deformities pose a significant set of challenges to reconstructive burn surgeons because of the complex anatomy, diverse functions, and specialized nature of the lip tissues. There has been a paucity of literature on restoration of the vermillion to date. The authors report on two patients who suffered burn injuries resulting in significant lip deformities who underwent a novel method of vermillion reconstruction with a full thickness anal verge skin graft. Both patients tolerated the procedure well without complications. One patient had slight hyperpigmentation of the graft which was treated with a phenol peel to cause intentional lightening. Overall, both patients had a restored vermillion border and improved color match and contour of the lip. Histologic analysis of the anal verge demonstrates that it has a nonkeratinized, transitional epithelial architecture which is nearly identical to that of the vermillion tissue. Skin grafting remains one of the cornerstones of tissue replacement in acute burn care and burn reconstruction. The vermillion represents an area of specialized tissue that is not well reconstructed with simple skin grafts. Other methods for reconstruction involve lip switch operations or local flaps, like a ventral tongue flap. These procedures are not without limitation and can often cause microstomia among other issues. With no donor site morbidity, a full thickness anal verge skin graft represents the closest approximation of actual vermillion tissue found anywhere else in the body and should be considered a viable option in the reconstruction of these challenging patients.

Management of trauma and burn scars: the dermatologist's role in expanding patient access to care.

Recent advances in laser surgery and our understanding of wound healing have ushered in a new era of trauma and burn scar management. Traditional therapy has centered around scar excision followed by primary closure or tissue replacement with flaps and grafts. This approach represents a perpetuation of the common fallacy that extensive scar improvement requires extensive surgical intervention. Laser surgery in conjunction with pharmacotherapy and minor tissue-conserving surgery produces well-healed and remodeled existing tissue that provides the most natural appearance and function of the skin. Now, patients' hypertrophic, contracted, and disfiguring scars represent their most valuable reconstructive anatomy. With this paradigm shift, dermatologists are uniquely positioned to provide transformative and cost-effective scar therapy due to their proficiency in the necessary treatment modalities and expertise in the utilization of local anesthesia. We hope to further expand military and civilian patient access to such care in their local community through peer education and advocacy. We present a brief overview and outline of scar treatment practices that can be performed by dermatologists in office using devices and techniques they often already possess.

Laser Modulation of Hypertrophic Scars: Technique and Practice.

In this review, the authors discuss the use of laser photothermolysis and laser resurfacing in the management of hypertrophic burn scars. They provide details regarding preoperative selection, intraoperative decision making, and postoperative care.

Reconstruction of the Adult and Pediatric Burned Hand.

Thermal injuries of the hand can have a great impact on function. Initial treatment should focus on the prevention of contracture through the use of tissue-sparing techniques and optimized occupational therapy. Surgical intervention should follow the standard reconstructive ladder and can involve several techniques from simple to complex including minimally invasive techniques, such as laser and steroid injection, contracture release and skin grafting, and local tissue rearrangement and regional flaps as well as distant pedicled and free flaps. Reconstructive surgery of the hand, when performed well, can lead to meaningful functional improvement in severe burns.

Scar Management in the Pediatric and Adolescent Populations.

For most children and adolescents who have developed symptomatic scars, cosmetic concerns are only a portion of the motivation that drives them and their caregivers to obtain treatment. In addition to the potential for cosmetic disfigurement, scars may be associated with a number of physical comorbidities including hypertrichosis, dyshidrosis, tenderness/pain, pruritus, dysesthesias, and functional impairments such as contractures, all of which may be compounded by psychosocial factors. Although a plethora of options for treating scars exists, specific management guidelines for the pediatric and adolescent populations do not, and evidence must be extrapolated from adult studies. New modalities such as the scar team approach, autologous fat transfer, and ablative fractional laser resurfacing suggest a promising future for children who suffer symptomatically from their scars. In this state-of-the-art review, we summarize cutting-edge scar treatment strategies as they relate to the pediatric and adolescent populations.

Biology and principles of scar management and burn reconstruction.

Hypertrophic scarring is extremely common and is the source of most morbidity related to burns. The biology of hypertrophic healing is complex and poorly understood. Multiple host and injury factors contribute, but protracted healing of partial thickness injury is a common theme. Hypertrophic scarring and heterotopic ossification may share some basic causes involving marrow-derived cells. Several traditional clinical interventions exist to modify hypertrophic scar. All have limited efficacy. Laser interventions for scar modification show promise, but as yet do not provide a definitive solution. Their efficacy is only seen when used as part of a multimodality scar management program.

Laser treatment of traumatic scars with an emphasis on ablative fractional laser resurfacing: consensus report.

IMPORTANCE: Despite expert wound care and assiduous management with traditional therapy, poor cosmetic outcomes, restricted motion, and symptoms such as pain and itch are a pervasive problem of disfiguring and debilitating scars. The advent of ablative fractional photothermolysis within the past decade and its application to the treatment of traumatic scars represents a breakthrough in the restoration of function and cosmetic appearance for injured patients, but the procedure is not widely used. OBJECTIVE: To provide a synthesis of our current clinical experience and available literature regarding the laser treatment of traumatic scars with an emphasis on fractional resurfacing. EVIDENCE REVIEW: Eight independent, self-selected academic and military dermatology and plastic surgery physicians with extensive experience in the use of lasers for scar treatment assembled for a 2-day ad hoc meeting on January 19 and 20, 2012. Consensus was based largely on expert opinion, but relevant literature was cited where it exists. FINDINGS: After consensus was appraised, we drafted the manuscript in sections during the course of several months. The draft was then circulated among all panel members for final review and comment. Our consensus is that laser treatment, particularly ablative fractional resurfacing, deserves a prominent role in future scar treatment paradigms, with the possible inclusion of early intervention for contracture avoidance and assistance with wound healing. CONCLUSIONS AND RELEVANCE: Laser scar therapy, particularly fractional ablative laser resurfacing, represents a promising and vastly underused tool in the multidisciplinary treatment of traumatic scars. Changes to existing scar treatment paradigms should include extensive integration of fractional resurfacing and other combination therapies guided by future research.

Pediatric burn-related scalp alopecia treated with tissue expansion and the incidence of associated facial burn injuries.

In the pediatric population, cutis aplasia, scalp avulsion, and burn injuries are the leading causes of scalp alopecia that is evaluated for reconstruction by plastic surgeons. Scalp alopecia is seen in 25% of children who suffer burn injuries of the head and neck. These injuries are rarely isolated to the scalp, and the adjacent structures are often affected. This may complicate reconstruction surgery and necessitate multiple reconstructive procedures. A retrospective chart was performed of all cases of staged scalp tissue-expansion cases performed for the reconstruction of burn-related scalp alopecia by the two senior authors at the Shriner's Hospital for Children of Boston between 2003 and 2007. In each case, the incidence and severity of burn-related deformities of the nose, eyebrows, and ears as seen in clinical photographs were documented. Between 2003 and 2007, 96 scalp tissue expanders were placed in 78 patients for the treatment of scalp alopecia. Of these patients, associated adjacent burn deformities were commonly found involving the ear, nose, and eyebrow. These injuries included ear deformity (46%), nasal deformity (27%), and eyebrow deformity (46%). In planning the surgical reconstruction for pediatric scalp alopecia, it is helpful to evaluate each patient for adjacent structure burn injuries requiring reconstruction. It is our belief that the stages of tissue expansion surgery can be combined with the reconstruction of associated burn injuries sometimes using the region of expected alopecia excision.

Pulsed dye laser in burn scars: current concepts and future directions.

Hypertrophic scarring after partial-thickness burns is common, resulting in raised, erythematous, pruritic, and contracted scars. Treatment of hypertrophic scars, especially on the face, is challenging and has high failure rates. Excisional treatment has morbidity and can create iatrogenic deformities. After an extensive experience over 10 years with laser therapy for the treatment of difficult scars, the pulsed dye laser (PDL) has emerged as a successful alternative to excision in patients with hypertrophic burn scars. Multiple studies have shown its ability to decrease scar erythema and thickness while significantly decreasing pruritus and improving the cosmetic appearance of the scar. The history of laser therapy and the mechanism of action and results of the PDL in burn scars will be reviewed. The PDL should become an integral part of the management of burn scarring and will significantly decrease the need for excisional surgery.

The phrenic nerve as a motor nerve donor for facial reanimation with the free latissimus dorsi muscle.

Free functional muscle transfer for acquired facial paralysis most often involves two stages. In this report, we describe single-stage free muscle transfer using the phrenic nerve as the donor motor nerve. Six patients with unilateral facial paralysis underwent single-stage facial reanimation using a free latissimus dorsi muscle with the ipsilateral phrenic nerve as the donor nerve. These cases were retrospectively studied to review technique and to determine outcomes including time to muscle reinnervation, patient satisfaction, smile symmetry, and complications. The mean age was 33 years. Five patients had complete unilateral facial paralysis and one had incomplete. There was no flap loss. The transferred muscle demonstrated active contraction in all patients at a mean of 14 weeks postoperatively (range, 12 to 16 weeks). Good dynamic symmetry was achieved by 6 to 9 months in all patients. All patients underwent rehabilitation including nerve reeducation. No clinically significant pulmonary morbidity was observed after the unilateral transection of the phrenic nerve. Using the phrenic nerve in free muscle transfer for facial paralysis allows a single-stage procedure with no requirement for nerve grafting and a rapid reinnervation time, shortening the time required for restoring facial animation.

Nasal reconstruction after severe facial burns using a local turndown flap.

Reconstruction of the nose after severe burn injury is a challenging problem. There are usually associated facial burns, which limits the availability of local flaps. Reconstruction with unburned distant tissue is often not appropriate because of the resulting mismatch in color and texture. Successful nasal reconstruction can be accomplished in this group of challenging patients using a simple, inferiorly based flap from the nasal dorsum with subsequent skin grafting to the resulting defect. We have used an inferiorly based nasal turndown flap to reconstruct severe nasal deformities after burn injury in 28 patients. The flap tissue consists of the dorsal surface of the nose, which is usually made up of skin graft and scar. The flap base is the scar transition zone between the dorsum of the nose and the lining mucosa. This is turned over to provide nasal length, projection, and to stimulate alar lobules. The resulting defect on the dorsum of the nose is then skin grafted. If further length or refinement is required, the procedure may be repeated. The records of all patients who underwent this procedure were reviewed for demographics, age at burn, percentage of total body surface area burned (%TBSA), availability of the forehead, number of procedures, and complications. Twenty-eight patients underwent nasal reconstruction in our series using this local turndown flap. Most of these patients had severe burns, with an average %TBSA of 46%. The procedure was initially applied to patients with devastating injuries and %TBSA of 80%-95%, with extremely limited donor sites. As the success of the procedure was established, less severely burned patients were included in the series, thereby lowering the mean %TBSA. All patients had partial or complete destruction of their forehead donor site. All patients presented for multiple hospitalizations, with an average of 17 hospital admissions. Using this local turndown flap, adequate nasal length and projection could be achieved. There were few complications. All of the flaps survived, although there were 2 cases of necrosis of the distal edge of the flaps (0.7%). This resulted in decreased length and projection but this problem was successfully addressed with additional staged procedures. Contraction of local scar tissue created bulk and support, eliminating the need for distant tissue transfer or cartilage grafting. Twelve of the 28 patients required repeat turndown flaps to achieve sufficient nasal length and projection. These results were durable over a follow-up period of up to several decades. A simple, multistaged dorsal nasal flap can be used to reconstruct severe nasal deformities after facial burn injury. This can obviate the need for distant tissue transfer. Even in patients with subtotal nasal amputation and complete absence of cartilaginous support, the opportunistic use of scar tissue can restore nasal tip projection and alar lobule architecture without cartilage grafting. The resulting nasal reconstruction blends well into the surrounding facial appearance. This simple technique has been remarkably successful in this selected group of patients with challenging nasal deformities.

Pulsed dye laser therapy and z-plasty for facial burn scars: the alternative to excision.

Hypertrophic scarring after partial thickness facial burns is common when epithelialization takes longer than 3 weeks. Well-healed areas continue to mature unfavorably, resulting in raised, erythematous, and contracted scars. Excisional treatment of such scars has morbidity and can create iatrogenic deformities. The flashlamp-pumped, pulsed dye laser (PDL) in combination with z-plasty can be used as a successful alternative to excision in patients with facial hypertrophic burn scars. Fifty-seven patients with hypertrophic facial burn scars (mean age 12 years; range, 2-21 years) were treated with the PDL over the past 8 years. Thirty-four patients (60%) were also treated with z-plasties to relieve scar tension. There was one complication of postoperative blistering. Patients were divided into 3 groups based on time from burn to initial laser treatment. Group I (<1 year) had 11 patients and the laser diminished scar proliferation in these patients. Group II (1-4 years) included 24 patients and treatment resulted in reversal of hypertrophic scarring and elimination of erythema. Group III (>5 years) consisted of 22 patients. The PDL was effective in treating their stable and persistent erythema as long as 17 years after burn injury. No scars required excision in this cohort of 57 patients. The PDL should become an integral part of the management of facial burn scarring and will significantly decrease the need for excisional surgery.

Purse-string closure of scalp defects following tissue expansion: an effective aesthetic alternative.

Primary closure of scalp defects under tension can be complicated by scar widening and alopecia, and large defects usually require the use of local flaps, skin grafts or free flaps. Tissue expansion facilitates the use of local flaps to cover large defects, but multiple expanders and complex flaps with extensive incisions may cause significant scars and alopecia. We describe a purse-string closure of expanded scalp tissue following excision of a large congenital nevus sebaceous. This scalp reconstructive technique minimises iatrogenic scars and uses the predictable forces of scar contracture and skin re-draping to achieve a superior aesthetic result.