Color Atlas of Burn Reconstructive Surgery

Color Atlas of Burn Reconstructive Surgery Hiko Hyakusoku · Dennis P. Orgill Luc Téot · Julian J. Pribaz Rei Ogawa (E...

Author: Hiko Hyakusoku | Dennis P. Orgill | Luc Teot | Julian J. Pribaz | Rei Ogawa

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Color Atlas of Burn Reconstructive Surgery

Hiko Hyakusoku · Dennis P. Orgill Luc Téot · Julian J. Pribaz Rei Ogawa (Eds.)

Color Atlas of Burn Reconstructive Surgery

Hiko Hyakusoku, MD, PhD Professor Nippon Medical School Hospital Department of Plastic and Reconstructive Surgery 1-1-5 Sendagi Bunkyo-ku Tokyo 113-8603 Japan [email protected] Dennis P. Orgill, MD, PhD Professor of Surgery Harvard Medical School Brigham and Women’s Hospital Division of Plastic Surgery 75 Francis Street Boston, MA 02115 USA [email protected] Luc Téot, MD, PhD Professor CHU de Montpellier Service de Chirurgie Plastique et Reconstructrice 34295 Montpellier France [email protected]

Julian J. Pribaz, MD Professor of Surgery Program Director, Combined Residency in Plastic Surgery Harvard Medical School Brigham and Women’s Hospital Division of Plastic Surgery 75 Francis Street Boston, MA 02115 USA [email protected] Rei Ogawa, MD, PhD Associate Professor Nippon Medical School Hospital Department of Plastic and Reconstructive Surgery 1-1-5 Sendagi Bunkyo-ku Tokyo 113-8603 Japan [email protected]

ISBN: 978-3-642-05069-5 e-ISBN: 978-3-642-05070-1 DOI: 10.1007/978-3-642-05070-1 Springer Heidelberg Dordrecht London New York Library of Congress Control Number: 2009943441 © Springer-Verlag Berlin Heidelberg 2010 This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilm or in any other way, and storage in data banks. Duplication of this publication or parts thereof is permitted only under the provisions of the German Copyright Law of September 9, 1965, in its current version, and permission for use must always be obtained from Springer. Violations are liable to prosecution under the German Copyright Law. The use of general descriptive names, registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. Product liability: The publishers cannot guarantee the accuracy of any information about dosage and application contained in this book. In every individual case the user must check such information by consulting the relevant literature. Cover design: eStudio Calamar, Figueres/Berlin Printed on acid-free paper Springer is part of Springer Science+Business Media (www.springer.com)

Prefaces

Reconstructive surgery of burns, especially of extensive burns, is a topic that requires the ideas and inspiration of plastic surgeons. Traditionally, it is considered that almost all burn wounds can be reconstructed using simple skin grafting. However, sophisticated reconstructive surgery based on knowledge of various surgical methods is needed to accomplish both functionally and cosmetically acceptable long-term results. The contents of this book represent ideal guidelines for burn reconstructive surgery and were provided by authors from 14 different countries. In other words, this book is the grand sum of the newest surgical technologies and strategies proposed by plastic surgeons. I have been involved in reconstruction surgery for extensive burns since I became a plastic surgeon. I have developed many reconstructive procedures and have been able to apply these methods clinically. Burn reconstruction has brought many thoughts to develop flap surgical methods to me. Moreover, I have realized that burn reconstruction should be accomplished via an all-out mobilization of knowledge on flap surgery and that this is an area that requires continual development of surgical methods. However, I have met many plastic surgeons who are performing novel and innovative methods. This book is a collection of these worldwide experiences. I hope that this book will provide great benefits for burn patients worldwide. Tokyo, Japan

Hiko Hyakusoku, MD, PhD

v

vi

Prefaces

Damage to skin from thermal, electrical or chemical injury has devastating effects on aesthetic and functional outcomes of burn victims. The stigmata of burn patients remains one of the most devastating injuries that man can survive. Fortunately, over the last 30 years, there have been simultaneous advances in scar biology, materials science and knowledge of microanatomy, surgical techniques, transplantation and cell culture. As a result there are now many treatment options available that give greater hope to our patients restoring function and improving their societal interactions. In this atlas, Dr. Ogawa has brought together the world’s experts to review the important topics of super-thin flaps, pre-fabricated flaps, dermal and epidermal replacements as well as vacuum-assisted closure technologies. This atlas will be an important resource for practicing plastic surgeons as well as students and residents in training. Examples in the atlas will also be valuable for patient education of these varied techniques. Boston, MA, USA

Julian J. Pribaz, MD Dennis P. Orgill, MD, PhD

Prefaces

vii

Burns represent a pathology remaining among the hardest to heal wounds. Even if important progresses in rescucitation allowed life-threatening body surfaces to regress during the last 50 years, force is to recognize that restoring the original function after extensive and deep burns requires a long period of fight against contractures, hypertrophy and tissue shortening. A multi-disciplinarity approach is mandatory to obtain a return to the social and working life, but skin has changed for the rest of the life of the patient. The development of microsurgery in the 80s, followed by an intense activity in anatomical studies could evidence the angiosomes and the skin, muscle, tendon and bone vascular cartographies. From this era, all types of flaps were proposed, including pre-fabricated and perforator flaps, a founding melting pot and a source of intense activity for the new plastic and reconstructive surgery. This atlas details how to use them in burn reconstructive surgery. During the last decade, the surgical possibilities of dermal replacement becomes more and more efficient. The recent development of tissue engineering, leading to added biological similarities with the normal skin, opens a new space for reflexion and trials, based on cell–extracellular matrix interactions via cytokines and growth factors. The need for repairing the cosmetic outcome of facial burns remains a social challenge and will certainly be a long-term contract for the new generation of burns specialists and plastic surgeons. Montpellier, France

Luc Téot, MD, PhD

viii

Prefaces

Every reconstructive surgeon thinks that evidence-based burn reconstruction is an ideal method; however, it is yet to be established. The reason for this may be that every single wound or scar is unique. Moreover, the color, texture, thickness and hardness of the skin vary according to human race, age, sex and body site. Thus, we are forced to select treatment methods on a case-by-case basis according to the limited experience of each surgeon. Meanwhile, during the finishing stage of reconstruction, large parts of the surgical procedure should include elements of aesthetic surgery. In this stage, it may not be an exaggeration to state that evidence-based surgery is not beneficial. Treatment methods should be selected and performed based on the aesthetic sense and cultivated sensitivity of each surgeon. Evidence-based surgery and artistic reconstruction represent a big dilemma that is posed to every burn reconstructive surgeon. I believe this book, which is entitled Color Atlas of Burn Reconstructive Surgery provides an answer for this particular dilemma. This answer may be the fusion of evidence-based surgery and artistic reconstruction. After reading this book, the surgeon will recognize what part of the reconstruction should be carried out using evidence-based surgery and what part should be performed artistically. We should not give up on the generation of evidence-based standardized protocols for patient safety or on the education of younger-generation surgeons. In addition, we should not neglect artistic reconstruction at any time. In this book, international authors who have wide perspectives in burn reconstructive surgery shared their own valuable experiences and concepts about the characteristics and indications of their methods. The contents include wound management, classification and evaluation of wounds/scars, various artistic and geometric methods and future treatment strategies from a “regenerative medicine” standpoint. I hope that this book will enhance the work of burn reconstructive surgeons and confer tremendous benefits to burn patients. Finally, I thank all authors and coeditors who have taken time from their busy schedules to assemble this book. In addition, I appreciate the tremendous help of Ms. Ellen Blasig at Springer in Germany. Her contribution was essential for the accomp lishment of this project. Moreover, I thank the illustrator Mr. Kazuyuki Sugiu from Studio Sugi’s for preparing the figures. Tokyo, Japan

Rei Ogawa, MD, PhD

Contents

Part I

Primary Burn Wound Management................................................

1

1 Primary Wound Management: Assessment of Acute Burns................... Luc Téot

2

2 Primary Wound Management: Strategy Concerning Local Treatment.......................................................................................... Luc Téot

6

3 Debridement of the Burn Wound.............................................................. 10 Hans-Oliver Rennekampff and Mayer Tenenhaus 4 Application of VAC Therapy in Burn Injury........................................... 16 Joseph A. Molnar 5 Use of Vacuum-Assisted Closure (V.A.C.)® and Integra® in Reconstructive Burn Surgery......................................... 22 Joseph A. Molnar 6 ReCell........................................................................................................... 26 Fiona M. Wood 7 Strategies for Skin Regeneration in Burn Patients.................................. 38 Victor W. Wong and Geoffrey C. Gurtner Part II

Burn Scar Management.................................................................... 43

8 Diagnosis, Assessment, and Classification of Scar Contractures........... 44 Rei Ogawa and Julian J. Pribaz 9 Prevention of Scar Using bFGF................................................................. 62 Sadanori Akita 10 Medical Needling......................................................................................... 72 Hans-Oliver Rennekampff, Matthias Aust, and Peter M. Vogt

ix

x

11 Treatments for Post-Burn Hypertrophic Scars........................................ 76 Rei Ogawa, Satoshi Akaishi, and Kouji Kinoshita 12 Make-Up Therapy for Burn Scar Patients............................................... 82 Ritsu Aoki and Reiko Kazki

Part III Dermal substitutes/Skin Graft......................................................... 89 13 Dermal Substitutes...................................................................................... 90 Luc Téot, Sami Otman, and Pascal Granier 14 Acellular Allogeneic Dermal Matrix......................................................... 100 Yoshihiro Takami, Shimpei Ono, and Rei Ogawa 15 Application of Integra® in Pediatric Burns............................................... 108 Paul M. Glat, John F. Hsu, Wade Kubat, and Anahita Azharian 16 Pediatric Burn Reconstruction.................................................................. 118 Paul M. Glat, Anahita Azharian, and John F. Hsu 17 Skin Grafting............................................................................................... 132 Matthew Klein 18 Skin Graft for Burned Hand...................................................................... 140 Wassim Raffoul and Daniel Vincent Egloff 19 Tips for Skin Grafting................................................................................ 146 Masahiro Murakami, Rei Ogawa, and Hiko Hyakusoku

Part IV Local flap method............................................................................ 159 20 Z-Plasties and V-Y Flaps............................................................................ 160 Shigehiko Suzuki, Katsuya Kawai, and Naoki Morimoto 21 Use of Z-Plasty in Burn Reconstruction................................................... 172 Rodney K. Chan and Matthias B. Donelan 22 Local Flaps for Burned Face...................................................................... 178 Allen Liu and Julian Pribaz 23 The Square Flap Method............................................................................ 186 Hiko Hyakusoku and Masataka Akimoto 24 Propeller Flap and Central Axis Flap Methods....................................... 198 Hiko Hyakusoku and Masahiro Murakami

Contents

Contents

xi

25 Facial Reconstruction................................................................................. 208 Pejman Aflaki and Bohdan Pomahac Part V

Expanded flap, Prefabricated flap and Secondary vescularized flap............................................................ 219

26 The Expanded Transposition Flap for Face and Neck Reconstruction........................................................................... 220 Robert J. Spence 27 Expanded Thin Flap................................................................................... 230 Chunmei Wang, Junyi Zhang, and Qian Luo 28 Tissue Expansion for Burn Reconstruction.............................................. 240 Huseyin Borman and A. Cagri Uysal 29 Scalp Alopecia Reconstruction.................................................................. 250 Jincai Fan, Liqiang Liu, and Jia Tian 30 Nasal Reconstruction.................................................................................. 260 Jincai Fan, Liqiang Liu, and Cheng Gan 31 Ear Reconstruction..................................................................................... 270 Chul Park 32 Reconstruction in Pediatric Burns............................................................ 276 Jui-Yung Yang and Fu-Chan Wei 33 Secondary Vascularized Flap..................................................................... 288 Hiko Hyakusoku and Hiroshi Mizuno 34 Prefabricated and Prelaminated Flaps..................................................... 300 Brian M. Parrett and Julian J. Pribaz 35 Prefabricated Facial Flaps......................................................................... 310 Luc Téot Part VI Regional Flap and Thin Flap............................................................ 319 36 Scarred Flap................................................................................................ 320 Hiko Hyakusoku 37 Use of Previously Burnt Skin in Local Fasciocutaneous Flaps............... 330 Rodney Chan and Julian Pribaz 38 Supraclavicular Flap.................................................................................. 338 Vu Quang Vinh and Tran Van Anh

xii

39 Superficial Cervical Artery Perforator (SCAP) Flap.............................. 344 Rei Ogawa, Shimpei Ono, and Hiko Hyakusoku 40 Super-Thin Flap.......................................................................................... 356 Hiko Hyakusoku, Rei Ogawa, and Hiroshi Mizuno 41 Super-Thin Flaps......................................................................................... 368 Jianhua Gao and Feng Lu Part VII Free flap and Perforator flap......................................................... 377 42 Anterolateral Thigh Flap for Reconstruction of Soft-Tissue Defects.................................................................................. 378 Jianhua Gao and Feng Lu 43 Free Muscle Flaps for Lower Extremity Burn Reconstruction................................................................................... 388 Huseyin Borman and A. Cagri Uysal 44 Prepatterned, Sculpted Free Flaps for Facial Burns............................... 398 Elliott H. Rose 45 The Deltopectoral Free Skin Flap: Refinement in Flap Thinning, Pedicle Lengthening, and Donor Closure............................... 408 Kenji Sasaki, Motohiro Nozaki, and Ted T. Huang 46 Shape-Modified Radial Artery Perforator (SM-RAP) Flap for Burned Hand Reconstruction..................................................... 416 Musa A. Mateev and Rei Ogawa 47 The Radial Artery Perforator-Based Adipofascial Flap for Coverage of the Dorsal Hand...................................................... 428 Isao Koshima, Mitsunaga Narushima, and Makoto Mihara 48 Microdissected Thin Flaps in Burn Reconstruction................................ 434 Naohiro Kimura 49 Perforator Pedicled Propeller Flaps.......................................................... 442 Hiko Hyakusoku, Musa A. Mateev, and T. C. Teo 50 Perforator Supercharged Super-Thin Flap.............................................. 452 Hiko Hyakusoku and Rei Ogawa 51 Perforator Supercharged Super-Thin Flap.............................................. 462 Vu Quang Vinh 52 Extended Scapular Free Flap for Anterior Neck Reconstruction.......... 470 Claudio Angrigiani, Joaquin Pefaure, and Marcelo Mackfarlane References............................................................................................................ 478 Index .................................................................................................................... 495

Contents

2

Primary Wound Management: Assessment of Acute Burns

CHAPTER 1

luc tÉot

Introduction

Estimation of Burn Depth

The burn is depicted as a traumatic lesion provoked by several possible agents (thermal, chemical, mechanical, or electrical) involving different skin layers to a certain degree. Assessment of the clinical situation is based on (1) evaluation of the total body surface of the burns, and (2) estimation of burn depth. Visual assessment and vascular evaluation of the wound are crucial [1, 2].

Burn depth is traditionally defined in three degrees, and clinical observation remains the main source of information for the clinician, even though some complementary examinations can be useful to determine the exact extent of deep burns. In the majority of cases, the surgical indication for excision and grafting depends upon the visual evaluation of the wound. This part of burn assessment remains difficult and cannot be done with precision, even with experience, before the third day post injury. In second degree burns, the first assessment has been estimated to be accurate in less than 70% of cases.

Evaluation of the Total Body Surface of the Burns Rule of 9 Anatomical area

Head

Upper limb

Lower limb

Ant body (chest + abdomen)

Post body (thorax + back)

Genital area

Estimated % of surface

9

9

9

2 × 9

2 × 9

1

TBSA Following Age Anatomical area

Adult TBSA (% for each side of the structure)

Fifteen year TBSA (% for each side of the structure)

Ten year TBSA (% for each side of the structure)

Head

3.5

4.5

5.5

Neck

1

1

1

Trunk

13

13

13

Arm

2

2

2

Forearm

1.5

1.5

1.5

Hand

1.25

1.25

1.25

Genital area

1

1

1

Buttock

2.5

2.5

2.5

Thigh

4.75

4.5

4.25

Leg

3.5

3.25

3

Foot

1.75

1.75

1.75

L. Téot, MD, PhD Montpellier University, France e-mail: [email protected]

H. Hyakusoku et al. (eds.), Color Atlas of Burn Reconstructive Surgery, DOI: 10.1007/978-3-642-05070-1_1, © Springer-Verlag Berlin Heidelberg 2010


CHAPTER 1

Clinical Evaluation First Degree The first degree corresponds to a shallow wound. The aspect is red, and the area is extremely painful, as the sensory endings remain intact. A typical example of this is sunburn. Only the superficial layer of the epidermis is involved. When the total body surface is important, complications like cerebral edema can be encountered, but the wound remains easy to heal.

Superficial Second Degree Superficial second degree burns usually present as blisters, appearing some hours after the accident. Once the blister is removed, the wound can be observed. Redness is uniform and pain is extreme, rarely allowing the physician to touch the lesion. Healing time is short, usually within the first 2 weeks, without aesthetic sequellae. The superficial dermis is exposed, without involving the basal membrane, which guarantees a quick healing in the superficial aspect of the skin (Figs. 1.1–1.5).

⊡ Fig. 1.1 Early assessment of second degree burns over the dorsum of the hand. Blister has just been removed. Diff icult to evaluate if deep. Reevaluate the next day and the day after

⊡ Fig. 1.2 Palmar aspect of the same hand. Same difficulty, but the fact that both aspects of the hand are involved is worse than when only one is involved

⊡ Fig. 1.3 Sand burns of the palmar aspect of the feet after walking over a long distance on a hot beach. Second degree, superficial

3

CHAPTER 1

4


endings. Blanching of the skin under digital pressure cannot be obtained. These burns have a tendency to heal spontaneously, except in critical general conditions or if TBS burnt is extensive. The wound will stay unhealed or deteriorate and transform into a third degree burn. Usually, healing can be observed within 2–3 weeks, but as the deep dermis is exposed, a permanent scar will remain. These wounds can sometimes require an excision and a skin graft (Fig. 1.6).

Third Degree

⊡ Fig. 1.4 Fresh scald burns (second degree). Blister appearing progressively. Reevaluate after some hours before establishing a prognosis

Third degree burns are deep burns involving the subdermal structures. Extent in depth can be important, reaching aponeurosis or even bones. Lesions are sometimes circular on the limbs, a source of ischemia for the distal segments, necessitating emergency surgical procedures of discharge incisions to reestablish a normal distal blood flow. Lesions present with a white color and the tissues are hard. A black eschar will be observed after carbonization (Figs. 1.7 and 1.8). Establishing the risk of vital issue is an important step, most of the time to be realized in emergency. Factors like surface, location of deep burns around the orifices and

⊡ Fig. 1.5 Fresh burns of the face. Ophtalmologic assessment. Removal of blisters is necessary before a proper assessment of the burns

Deep Second Degree Deep second degree burns also present blisters, but after removal, the aspect is white or similar to patchwork. Sensibility to touch is not as important as in more superficial lesions, due to a partial destruction of sensory

⊡ Fig. 1.6 Deep grill burns of the plantar aspect of the foot on a diabetic patient. Excision and grafting


⊡ Fig. 1.7 Electric burns of the scalp: third degree with possible cortical bone involvement. Deep excision and preoperative assessment of the bone. If necrosed, removal of the outer cortex. The use of NPT may then be necessary before skin grafting

CHAPTER 1

5

⊡ Fig. 1.8 Deep necrotic burns of the hand after digital amputation. Exposed tendons can be covered with negative pressure therapy, with serial excisions of still necrosed structures before skin grafting

Degrees of burns

First

Second superficial

Second deep

Third

Anatomical structure involved

Epidermis

Dermis above basal membrane

Dermis below basal membrane

Whole skin

Color

Red

Red below the blister

Red–white below the blister

White or black

Skin hardness and vascular density

Supple

Humid

Medium hard

Hard thick dry

Bleeding at contact

No bleeding

High

Moderate

No

Pain

Painful

Extremely painful

Painful

No pain

Time for closure

No wound

Less than 2 weeks

Within three to four weeks. Sometimes, needs skin graft

Needs skin replacement (graft, VAC, flap)

Scar formation

No scar

No scar

Notable scar formation and contractures

Notable scar formation and contractures

prevention of infection have to be determined urgently. Above a surface of >10% TBSA in adults and >5% TBSA in children, burns are considered serious. In over 30% of surface in adult and 10% in children, life-threatening difficulties can be encountered. It is important to check the face, nostrils, and hair, to assess the risk of tracheal and pulmonary burns (an endoscopy is often needed for diagnosis when in doubt). The risk of burns infection is higher when initial management is delayed (septicemia).

Conclusion Establishing the risk of functional issue is focused on reestablishing the limb vascularization and the need for discharge incisions when third degree burns are circumferential. Other functional issues are linked to possible exposure of joints. Immobilization of interphalangeal joints on the hands or ankle must be realized as soon as possible.

6

CHAPTER 2

Primary Wound Management: Strategy Concerning Local Treatment luc téot

Introduction Primary wound burn strategy depends on burn wound assessment. Deep second degree and third degree burns are candidates for surgery such as excision and grafting, while superficial burns can be treated using topical antimicrobials. In superficial burns, emergency management is based on cooling using water at a mild temperature. Burns are irrigated with water for a period of 5–10 min. Essentially, the aim of cooling is to remove pain. Antiseptics are applied to the wound, soaked with sterile water and dried using gauzes.

Blister Management Blisters are encountered both in superficial and deep second degree burns. A blister is an obstacle for the assessment of burns and should be removed. The top of the blister is gently cut with a sharp scalpel, allowing the liquid to leak out and then the whole non-adherent epidermis is excised, while trying to prevent painful contact with the base of the wound (Fig. 2.1).

When to Operate Assessment is determinant for strategy, but cannot be conclusive during the first examination. Surgical excision and grafting in deep second degree burn wounds will be decided after a period of 2–3 days, as the evolution of the burn wound can be positive. Diagnosis of burn depth is difficult during the first days. Thirty percent of burn experts cannot determine the exact wound depth when analyzing the burns at the first assessment. On the contrary, observation of a frank third degree

L. Téot, MD, PhD Montpellier University, France e-mail: [email protected]

⊡ Fig. 2.1 Blister is removed on the fourth finger, and not removed on the third finger. Debridement of blister allows a right assessment of the burn wound

burn will necessitate a surgical decision of immediate excision followed by a skin graft (Figs. 2.2–2.3).

Local Dressings Silversulfadiazine cream is the most commonly used local treatment, worldwide. This drug is a combination of sulfamides and silver, with a low risk of resistance and allergy, proposed in various situations. The cream modifies the local ground and can be applied over a period of 3 weeks. The need for a persistent antimicrobial dressing during the whole evolution of superficial burns has to be revisited (Demling). Most of the authors propose the use of non-antimicrobial dressings as soon as the diagnosis of superficiality is complete. Dressings formed by hydrofiber, a texturized carboxymethylcellulose frame including and delivering silver have been successfully proposed in the local management of second degree burn wounds. Silicone coated dressings (safetac technology), aiming at reducing pain during dressing changes, are often used in superficial burns (Heymans).


Primary Wound Management

CHAPTER 2

7

Indication for use

Acute second degree (1–3 days)

Clear superficial second degree

Clear deep second degree

Third degree

Silversulfadiazine

++

±

++

±

Modern dressing (foam, silicone)

±

++

±

±

Flammacerium

−

−

−

+ (waiting solution before grafting)

Excision skin grafting

−

−

+

++

Negative pressure after excision

−

−

−

++ if noble tissue is exposed

tools for pain are numerous and should be selected depending on the condition of the patient. The visual assessment scale is the most common mode of quantifying pain when the patient can communicate. Other scales may be suggested when the patient is under general anaesthesia. Pain is more pronounced when the burns are superficial, granulation tissue is present, and repetitive dressings are done. Pain at dressing change is a specific issue, more easily managed when using adapted modern dressings.

⊡ Fig. 2.2 Before, during and after the debridement of deep electrical burns wound using high power hydrojet

Surgery The aim of surgery is to remove potentially infected materials from the wound, cover the exposed tissues using skin grafting and reduce the length of stay in the hospital. This coverage can be done using either splitthickness skin graft, full-thickness skin graft or step by step reconstruction of the skin using bioengineered tissues like artificial dermis (Fig. 2.4).

Dermis and/or Skin Substitutes

⊡ Fig. 2.3 Before, during and after the debridement of deep electrical burns wound using high power hydrojet

Pain Management Pain should be correctly managed during the first hours after accident, then regularly reassessed. Assessment

Early excision and skin grafting is the most traditional method, where a skin graft is harvested on different possible areas (skull, thigh, legs, back, abdomen). Depending on the extent of surfaces to cover, the skin graft may be amplified using mesh grafts (×1.5, 2, 4, 6). The uniformity and regularity of the scar obtained with these methods mostly varies with the possibility to use unmeshed skin grafts. In moderate surfaces, the colour matching of the skin graft is also an issue and is better matched when harvested close to the recipient zone. When using a skin graft coming from further away, such

8

CHAPTER 2


⊡ Fig. 2.5 Mesh grafting (×2) over the lower limb burns

⊡ Fig. 2.4 Non-cellularized dermal substitute before skin grafting after deep burns of the lower limb. Revascularization can be sped up by the use of negative pressure therapy

as thigh skin to resurface a cheek, the risk of having a bad colour match is higher, leading to a permanent hyperchromia of the transferred skin. The use of dermal substitutes will be dealt with in Chap. 13. Scar improvement was observed when using double layer dermal substitutes (Integra, Purdue, Heimbach, Renoskin, Hyalomatrix Pelnac), and more recently with single layer dermal substitutes (Matriderm™) being immediately covered using thin skin grafts (Van Zuijlen). Cadaver skin can safely be used, especially to cover temporarily deep burns wound (Sheridan). The use of these materials is dependent on the availability, which is an issue linked to tissue banks which are necessary to store them under adapted freezing conditions. Allografts can be used as a sandwich technique when autograft donor sites are limited (extensive TBSA) or when the

patient is in poor general health, thereby limiting the possibility of general anaesthesia. Autografts can be extensively meshed (×6) and covered using ×2 meshed allografts (Fig. 2.5). Keratinocyte Autologous Cell cultures provide hope for the future, if a functional dermis has been obtained (Rheinwald, Compton, Boyce). The use of xenograft has also been proposed, either to replace dermal components or to secure skin grafts. Early skin grafting may be contraindicated, due to various situations such as contraindications for surgery, exposure of joints, tendons or vascular bundles. Flammacerium (silver sulfadiazine plus 2% cerium nitrate) was proposed in the 90s, and was mainly used over extensive surfaces of third degree burns where surgery cannot be performed on a single occasion. Flammacerium presents the unique possibility of combining with necrotic tissue, transforming it into a calcified tissue strongly adhering to the wound edges for a very long period of time. This powerful antimicrobial agent should be used only over limited surfaces (no more than 30% TBSA), the risk of inducing methemoglobinaemia being a real and lifethreatening complication (Fig. 2.6) (Wassermann).


CHAPTER 2

Negative pressure therapy is not the treatment of choice for burns, but presents some interesting capacities to promote granulation tissue over noble exposed tissues like joints, tendons or vascular pedicles, after complete surgical excision of the burnt tissues. This technique has indications when doubts persist on the vitality of the exposed tissues before skin grafts.

Conclusion

⊡ Fig. 2.6 Late result of skin grafting of the plantar aspect of the skin. Elasticity is required and the use of dermal substitute may help

Burns management is mainly based on excision and grafting techniques, in deep burns with the recent introduction of the use of dermal substitutes and on the use of antimicrobials in superficial burns, with the recent use of modern dressings.

9

10

CHAPTER 3

Debridement of the Burn Wound hans-oliver rennekampff and mayer tenenhaus

Rationale for Debridement At first glance, the rational for debriding a wound, a burn wound for example, seems evident. Nonviable, necrotic cells and tissue debris should be removed, and a clean, viable, and well-vascularized wound bed be established allowing for subsequent wound closure; and yet, what concrete evidence do we have to justify this approach? Steed et al. [1] analyzed wound healing rates in diabetic patients. In this study, he was able to demonstrate that when compared to conservative management, radical surgical debridement led to improved rates of healing. In the case of burn wounds, biochemical changes in the wound affect not only the rate of wound healing, but may pose systemic risk to the patient. Several experimental burn wound models have clearly demonstrated that toxic products are released from burned skin, and that these substances manifest a negative and potentially lethal systemic effect. A lipoprotein complex with high toxicity has subsequently been isolated from the thermally injured skin, and neutrophils derived from the burn wound have been shown to produce Leukotoxins which have been associated with both morbidity and mortality in the burn patient. Hansbrough et al. were able to show that the presence of thermally injured skin has a systemic immunosuppressive effect on the individual [2]. Necrotic, nonperfused tissue may serve as a nidus for bacteria and fungi, and as such, debridement of such tissue can potentially reduce the incidence of wound infection. While topical antimicrobial ointments may penetrate into the nonviable burned skin, systemic H.-O. Rennekampff, MD, PhD (*) Klinik für Plastische, Hand- und Wiederherstellungchirurgie, Medizinische Hochschule Hannover, Carl Neubergstraße 1, 30625 Hannover, Germany e-mail: [email protected] M. Tenenhaus, MD Division of Plastic Surgery, Medical Center, University of California San Diego, USA

antibiotics may not reach the nonperfused tissues. Local bioburden does not only pose a risk for delayed wound healing and further tissue loss but may also systemically compromise the patient when sepsis occurs. A bioburden of more than 105 bacteria/gram of tissue is considered to be an invasive infection, which impairs wound healing, leads to graft loss, and may similarly impair the successful application of temporary wound dressings. The successful reduction of bioburden below concentrations of 105 bacteria/gram of tissue is a key element of surgical wound debridement [3]. The effects of burn tissue on both local complication and generalized outcome were analyzed by Davis et al. and Deitch et al. [4, 5]. In their review, they were able to demonstrate that a burn wound which took longer than 21 days to heal posed a hypertrophic scar development risk of nearly 80%. Furthermore, they were able to show that early skin grafting could reduce the incidence of hypertrophic scaring as compared to late grafting of the debrided wound.

Debridement of Blisters The management of burn blisters has been a source of ongoing debate for many years [6]. While others have suggested that intact burn blisters may act as biologic bandages, keeping the underlying tissues safe from further trauma and desiccation, numerous researchers and clinicians have shown that blister fluid derived from the burn wound setting, in contradistinction to dermatologic and immunologically induced blisters, contains products which are inflammatory and vasoconstrictive in nature. In vitro testing has similarly shown inhibition of various key cellular elements involved in the epithelialization process. These findings have generally promoted the trend toward early debridement and cytoprotective strategies. This affords a proactive approach to the evaluation of depth of injury, while promoting standard wound healing strategies. This is particularly true of cases in which the mechanism of injury is known to have been


Debridement of the Burn Wound

deep in nature, i.e., contact burns in aesthetically and functionally critical areas or when presented with large and fragile blisters as well as blisters which have broken.

Timing of Debridement Is there an optimal time for debridement? Groundbreaking work by Janzekovic [7] demonstrated the clinical advantage of early debridement (3–5 days postinjury) and grafting vs. conservative management with 2–3 weeks of autolytic debridement, antimicrobial dressings and finally skin grafting. In a number of subsequent studies [8, 9], early debridement was shown to reduce length of stay; however, no difference in mortality was found as compared to late debridement. In contrast to these studies, Herndon et al. [10] could demonstrate that in the group age 17–30, without inhalation injury, an early intervention (5 Months

4 Months

Stratum Corneum Epidermal Stratification Basement Membrane

Papillary & Reticular Dermis

Appendage Development

Skin Glands

⊡ Fig. 7.2 Attempts to understand skin regeneration begin with embryologic skin morphogenesis. Following gastrulation, the embryo surface is covered with a single layer of ectoderm and periderm. In the second month, ectoderm develops into epidermis that thickens and mesoderm develops into connective

tissue and blood vessels. Around the fourth month, periderm regresses, epidermis undergoes stratification and basement membrane formation, and early dermal appendages form. After the fifth month, a protective keratinized layer forms, dermis further matures, and rudimentary skin glands form

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40

Despite these studies, skin regeneration remains a complex process that is poorly understood. Epithelialmesenchymal interactions play an important role in hypertrophic scarring [18] and fibroblasts harvested from different dermal regions exhibit a fibrotic potential that positively correlates with depth [19], demonstrating spatial determinants in scarring. Furthermore, genetic and microarray studies on wound repair and genetically-modified mice models have revealed developmental profiles that underscore the complexity of wound repair [20–22]. The discovery of multipotent human epidermal stem cells (Fig. 7.3), which are critical to both normal skin homeostasis and wound repair, promises to expand on progenitor cell-based therapies for burn treatment [23, 24]. Thus, human skin displays remarkable plasticity which we are only starting to understand.

Epithelium

Hair Shaft

Strategies for Skin Regeneration in Burn Patients

Current Research and Strategies for Skin Regeneration Inflammation has long been an obvious target for anti fibrotic therapy but to limited clinical success. Based on fetal wound healing studies, attempts have been made to recapitulate the in utero cytokine environment using transforming growth factor b isotypes [25]. Recently, our laboratory has shown that wound mechanical forces can modulate fibrosis in a small [26] and large animal model and attenuation of intrinsic skin stresses recapitulated a regenerative stress state with minimal scarring (being prepared for submission). Matrix components such as hyaluronic acid [27] and fibromodulin [28] have been explored as structural factors potentially critical for skin regeneration. Additionally, enhancement of neovascularization in wound healing via gene delivery [29] and growth factor-seeded scaffolds [30] has yielded positive results. Current cell-based therapies like cultured epithelial autografts have proven useful when donor site availability is limited but clinical results have been suboptimal considering the resources needed for processing and maintenance [31, 32]. The future of skin regeneration Native Sources: Skin “Stem Cells”

Outer Root Sheath

Sebaceous Gland

Adipose Tissue

Bulge Stem Cells

Putative Progenitor Types: Bone Marrow

Inner Root Sheath

• Epithelial Stem Cells • Endothelial Progenitor Cells • Hematopoietic Stem Cells • Mesenchymal Stem Cells • Adipose-derived Stem Cells

Dermal Papilla

⊡ Fig. 7.3 Epidermal stem cells are found in the hair bulge region and migrate to defined skin microenvironments. Selfrenewing bulge stem cells can migrate to the sebaceous gland, epidermis, and dermal papilla both to maintain normal skin homeostasis and in response to injury

Other

⊡ Fig. 7.4 In addition to epidermal stem cells, progenitor populations used experimentally in burn treatment include bone marrow-derived and adipose tissue-derived progenitor populations. Stem cells from other sources, including umbilical cord blood and embryonic lineages, may also play an important role in the future of burn therapy

Strategies for Skin Regeneration in Burn Patients

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⊡ Fig. 7.5 The future of regenerative burn therapy will require multifaceted approaches utilizing control release growth factor gradients, tissue-engineered matrix scaffolds,

and exogenous pluripotent stem cells to recapitulate a regenerative wound environment

will undoubtedly involve progenitor cells both within the skin and from distant sites (Fig. 7.4) [33, 34]. There are multiple stem cell populations that can be derived from various sources, and they have been utilized to accelerate acute and chronic wound healing [35]. Embryonic stem cells are the most pluripotent cell type but ethical issues have impeded their use. Adult progenitor cells are readily available and include epidermal stem cells, a diverse population of skin progenitors critically involved in skin homeostasis and wound repair [36, 37]. Bone marrow-derived mesenchymal stem cells (MSCs) have also been implicated in skin repair [38] and a recent study utilized MSC-seeded dermal scaffolds to improve burn wound healing [33]. Hematopoietic stem cells are readily harvested from human umbilical cord blood and display the potential to regenerate skin [39], and endothelial progenitor cells are known to regulate vasculogenesis following hypoxic injury [40]. Finally, adipose-derived stem cells have been shown to improve wound healing via dermal matrix delivery [41] and have even been used to fabricate new skin [42]. These studies highlight the tremendous potential of progenitor-based therapies, providing

novel paradigms for both tissue engineering and regenerative medicine.

Future of Regenerative Medicine in Burn Therapy As researchers continue to elucidate the molecular mechanisms underlying wound repair and tissue engineers further develop regenerative biomaterials, the biological secrets of scarless wound repair will continue to be revealed. As such, the future of burn treatment demands a multifaceted approach exploiting these diverse technologies (Fig. 7.5). Ideally, temporal and spatial biomimetic cues are replicated with control release of cytokines and patterned matrix components. These signals (“soil”) then direct implanted progenitor and/or resident cell (“seed”) differentiation toward a regenerative profile with scarless repair. It is the hope that these promising laboratory discoveries make their way bedside and to the operating room, so that burn patients and physicians can expect a complete functional and aesthetic recovery.

41

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Diagnosis, Assessment, and Classification of Scar Contractures rei ogawa and julian j. pribaz

Diagnosis of Postburn Scar Contractures Differential diagnosis of ankylosis or contracture is important (Fig. 8.1). Ankylosis is a stiffness of a joint, and can vary from moderate to severe. Ankylosis may involve the deeper tissues, including bone, cartilage, and joint capsule and may require orthopedic surgical release. In soft tissue contractures, myogenic and neurogenic contractures should be excluded for surgical reconstruction. In connective tissue contracture, differential diagnosis by anatomical structures should be

performed before the planning of surgical methods. Connective tissue contractures can be classified by affected tissues (Fig. 8.1); (a) Cutaneous, subcutaneous or fascial contracture, (b) Tendon contracture, (c) Ligament contracture and (d) Muscle contracture. Many of burn scar contractures are classified into cutaneous/ subcutaneous contracture. If tendon, ligament, and muscle contracture were diagnosed, these replacement/ reconstruction methods should be considered in addition to releasing scar contractures.

1. Distinguish between soft tissue contractures and joint anchylovsis

2. Distinguish between connective tissue contracture and myogenic/neurogenic contracture

3. Differential diagnosis of contractures by anatomical structures a. Cutaneous , subcutaneous, or fascial contracture Scar contracture b. Tendon contracture c. Ligament contracture d. Muscle contracture

4. Assessment and classification of scar contractures to decide treatment methods

5. Functional and aesthetic evaluation of joints/tissues on both pre-and post-treatment

⊡ Fig. 8.1 Differential and exclusive diagnosis of post-burn scar contractures R. Ogawa, MD, PhD (*) Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School Hospital, Tokyo, Japan e-mail: [email protected] J. J. Primbaz, MD Department of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, USA H. Hyakusoku et al. (eds.), Color Atlas of Burn Reconstructive Surgery, DOI: 10.1007/978-3-642-05070-1_8, © Springer-Verlag Berlin Heidelberg 2010

Diagnosis, Assessment, and Classification of Scar Contractures

Assessment and Classification of Postburn Contractures “Scar contractures” are diagnosed by abnormal resting position of anatomical structures or movement disturbance of joints and other tissues. To decide the treatment

CHAPTER 8

of scar contractures, careful assessment and classification of contractures by site are needed (Fig. 8.2). Shape and depth of scars should be diagnosed pre- and/or intraoperatively. Postoperative assessment is also important to evaluate the selected methods.

1. Periorbital region 2. Perioral region 3. Neck 4. Digital joints (DIPj ,PIPj, MCPj) 5. Digital web 6. Wrist joint 7. Cubital joint 8. Axilla 9. Anterior Chest 10. Lumbar region 11. Inguinal region 12. Knee joint 13. Ankle joint 14. Toe joints (DIPj ,PIPj, MTPj) 15. Toe web 16. Other special regions (Nose, Ear, Palmar, Plantar, Genital region, etc. )

⊡ Fig. 8.2 Therapeutic-objective sites of post-burn scar contractures

45

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46

Periorbital Region (Fig. 8.3) If the contracture is associated with mild dysfunction of eye closure over 3 months after burn injury (type I), minimal incision for releasing contracture and wound closure with local flaps can be performed. If conjunctiva and middle lamella are intact but if there is severe dysfunction of eye closure (type II), skin grafting should be used. Local flaps are also available for partial contracture


(type IIa). With respect to skin grafting, split thickness skin grafts (STSG) for the mobile upper eyelids and full thickness skin grafts (FTSG) for the lower lids have been routinely used [1]. Complete eyelid loss from burn is rare; however, sometimes conjunctiva and/or middle lamella is damaged (type III). In this case, skin grafting, local or free flaps should be selected on a case-by-case basis according to the necessity of appropriate material transfer such as cartilage and fascia.

* Upper eyelid and lower eyelid should be evaluated separately I Contractures with mild dysfunction of eye closure II Contractures with severe dysfunction of eye closure (with normal conjunctiva and middle lamella)

Lower eyelid Type IIa

IIa Partial contractures IIb Extensive contractures

III Contractures with severe dysfunction of eye closure (with contracture of conjunctiva and/or middle lamella)

IV Unclassified

Lower eyelid Type IIb

⊡ Fig. 8.3 Periorbital region


Perioral Region (Fig. 8.4) Contracture with mild dysfunction of mouth movements should be reconstructed with minimal scar release and reconstructed with FTSG or local flaps (type I). Contracture with severe dysfunction without commissure contracture should be reconstructed with FTSG according to the aesthetic units/subunits theory [2–5] (type II). If contractures are partial but the commissure is

CHAPTER 8

contractured, not only FTSG but also local flaps should be used for complete releasing of contracture and reconstruction of commissure (type IIIa). If the contracture is extensive and commissure is also contractured (type IIIb), extensive releasing and reconstruction with flaps such as pedicled regional flap, free flap, and prefabricated flap should be selected on a case-by-case basis. In the case of male patients, beard and mustache reconstruction can be considered by flaps harvested from beard region [6].

* Upper lip and lower lip should be evaluated separately

I Contractures with mild dysfunction of mouth movements II Contractures with severe dysfunction of mouth movements (with normal commisure) Lower lip Type IIb

III Contractures with severe dysfunction of mouth movements (with contractures of commisure) IIIa Partial contracture IIIb Extensive contracture

IV Unclassified

Uper / Lower lip Type IIIb

⊡ Fig. 8.4 Perioral region

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48

Chin and Anterior Neck (Fig. 8.5) Short linear contractures can be released using single z-plasty or small local flap (type I). However, long linear contracture extended to next unit should be reconstructed by multiple z-plasties, local flaps, or skin grafting (type II). With respect to the skin grafting, FTSG should be selected to prevent recontracture. Broadband contracture should be released completely and reconstructed by


FTSG or thin flaps. If the wounds, after removal of scar tissues, have platysma at the base, FTSG can be selected (type IIIa). However, if the platysma is missing, thin flaps should be used (type IIIb). “Super-thin flaps” [7] harvested from chest or dorsal region, perforator flaps, supraclavicular flaps [8] may be used. Broadband contracture extended to the next units should be reconstructed by a sheet of large and thin flaps such as perforator-supercharged “Super-thin flaps” (type IV).

* Mental-submental, anterior neck, and lateral neck on both sides should be evaluated separately

I Short linear contracture within the unit II Long linear contracture extended to next unit III Broadband contracture within the unit IIIa not including platysma IIIb including platysma IV Broadband contracture extended to next units V Unclassified Anterior neck Type I

⊡ Fig. 8.5 Chin and Anterior Neck

Mental-submental/Anterior neck Type IV


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49

Digital Joints (DIP, PIP, MCP) (Fig. 8.6)

Digital Web (Fig. 8.7)

Short linear contracture can be released by a small rotation or transposition local flap designed next to the contracture (type I); however, long linear contracture should be reconstructed by skin grafting (type II). Broadband contracture should be reconstructed by skin grafting (type III), but a contracture less than a quarter of circumferences can be reconstructed by local flaps designed on the digit adjacent to the contracture (type IIIa). In this case, flaps such as a digital artery flap and metacarpal artery flap may be used. Contracture of entire circumferences can be treated by not only skin grafting but also distant abdominal or groin flaps [9] (type V).

Single web contracture should be reconstructed by a local flap such as a square flap 10 based on the web and a five flap z-plasty designed on the intact side (type I). Contractures on both the palmar and dorsal regions should be reconstructed by skin grafting or digital artery flap (type II). If web contracture is severely affecting adjacent digits, complete releasing of contracture and reconstruction using skin grafting should be performed (type III).

* DIPj, PIPj and MCPj should be evaluated separately I Short linear contracture on one of joints II Long linear contracture extended to next joint III Broadband contracture IIIa less than a quarter of circumferences IIIb over a quarter of circumferences

⊡ Fig. 8.6 Digital joints (DIPj, PIPj, MCPj) contracture

IV Contractures of entire circumferences MCPj Type I

DIPj / PIPj Type II

V Unclassified

I Single web contractures Ia palmar side contracture Ib dorsal side contracture II Double web contractures (contractrures on both palmer and dorsal sides) III Web contractures severely affecting adjacent digits IV Unclassified

⊡ Fig. 8.7 Digital web

Type Ib

Type III

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50

Wrist Joint (Fig. 8.8) Linear contracture should be excised completely and can be closed primarily with z-plasties, w-plasty, or small-wave incision to release tension (type I). Broadband contracture on one surface should be reconstructed by skin grafting (type II), but extensive


contractures extending to subsequent surfaces should be reconstructed by skin grafting or local flaps designed on intact surfaces (type III). In the case of contracture of the entire circumferences, not only skin grafting but also flaps designed from the proximal forearm, distant abdominal or groin flap, or free flaps (type IV) can be used.

I Linear contracture involving palmar, dorsal, radial or ulner surface

II Broadband contracture involving palmar, dorsal, radial or ulner surface III Broadband contracture extended to next surfaces IV Contractures of entire circumfrences

V Unclassified Type Ia

⊡ Fig. 8.8 Wrist joint

Type III


Cubital Fossa/Elbow Joint (Fig. 8.9) Linear contracture should be excised completely and can be closed primarily with z-plasties, w-plasty, or smallwave incision to release tension (type I). In the case where the patient has linear scar contractures on both radial and ulnar surfaces, contractures can be released by propeller flaps designed on the cubital fossa (type Ib). Broadband contracture on one surface should be reconstructed by skin grafting or local flaps designed on

CHAPTER 8

the intact surface (type IIa), but for broadband contractures on both radial and ulnar surface, propeller flap [11] designed on the cubital fossa can be used (type IIb). Broadband contractures extended to next surfaces sometimes need vascular pedicled relatively large flaps harvested from upper arm or forearm (type III). In the case of contracture of the entire circumferences, flaps such as vascular pedicled flaps or free flaps are useful to prevent recontracture (type IV).

I Linear contracture of the cubital joint Ia flexor, radial, ulnar or dorsal surface Ib radial and ulnar surface Type Ia II Broadband contracture of the cubital joint IIa flexor, radial, ulnar or dorsal surface IIb radial and ulnar surface

III Broadband contracture extended to next surfaces

IV Contractures of entire circumfrences

V Others Type III

⊡ Fig. 8.9 Cubital joint

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52

Axilla (Fig. 8.10) Minor area of contracture within the axillary area can be reconstructed by skin grafting (type I). Single linear contracture can be released by a large z-plasty, multiple z-plasties, or other local flaps, but sometimes hair bearing regions must be divided. Square flap [10] is a good choice for these cases (type II). Square flap should be designed on the intact surface. Double linear contracture


exists on both anterior and posterior axillary line, propeller flaps designed on the center of axilla and contractures can be released at the same time (type IIIa). If a contracture is found between linear contractures, all of the contractured area should be excised and reconstructed by local or regional flaps from the chest or dorsal region (type IIIb). Broadband contracture over the axillary area should also be reconstructed by regional flaps or free flaps (type IV and V).

I Minor area of contracture within the axillary area II Single linear contractures Type IIa

IIa anterior axillary line IIb posterior axillary line III Double linear contractures IIIa Both anterior and posterior line with normal tissues between the lines IIIb Both anterior and posterior line with contractures between the lines IV Broadband contracture over the axillary area

Type IIb

IVa The contractures extended to the chest IVb The contractures extended to the back IVc The contractures extended to the upper arm V Broadband contractures surrounded with scars VI Others

Type IIIa

⊡ Fig. 8.10 Axilla


Anterior Chest (Fig. 8.11) Anterior chest contractures should be reconstructed by skin grafting. In the case of a hemilateral contracture, displacement of nipple after skin grafting should be avoided

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(type Ib and IIb). In the case of contractures with displacement of the nipple, contracture should be released completely and reconstructed by adequate size and thickness of FTSG to prevent recontracture. Very severe cases should be reconstructed by STSG (type III and IV).

I Contractures with no displacement of the nipple Ia Central contracture Ib Hemilateral contracture Ic Bilateral contracture

II Contractures with displacement of the nipple IIa Central contracture Type Ia

Type IIa

IIb Hemilateral contracture IIc Bilateral contracture

III Entire chest contractures with normal breathing

IV Entire chest contractures with breathing difficulty

V Unclassified

Type IIb

⊡ Fig. 8.11 Anterior chest

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54

Lumbar Region (Fig. 8.12) Linear contracture can be excised completely and closed primarily with z-plasties, w-plasty, or small-wave incision to release tension (type I). However, broadband


contractures should be reconstructed by skin grafting or local flaps harvested from abdomen or dorsal area (type II). If lateral curvature exists, complete resection of scars and reconstruction using a sufficiently large STSG is necessary (type III).

* Right and left lumbar regions should be evaluated separately I Linear contractures Type I II Broadband contractures without lateral curvature IIa Minor boradband contractures within the luber region IIb Major broadband contractures extended to other regions with no lateral curvature III Broadband contractures with lateral curvature IV Unclassified

Type III

⊡ Fig. 8.12 Lumber region


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Inguinal Region (Fig. 8.13) Linear contracture can be excised completely and closed primarily with z-plasties, w-plasty, or small-wave incision to release tension (type I). However, broadband

contractures where anterior thigh extension is compromised should be reconstructed by skin grafting or local flaps harvested from abdomen or anterior thigh (type II). Broadband contracture surrounded by scars should be reconstructed by STSG (type III).

* Left side and right side should be evaluated separately

I Minor contractures with the normal anterior thigh extension

Type I

II Broadband contractures with difficulty of the anterior thigh extension

III Broadband contractures surrounded with scars IV Unclassified

Type III

⊡ Fig. 8.13 Inguinal region

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56

Knee Joint (Fig. 8.14) Linear contracture should be excised completely and can be closed primarily with z-plasties, w-plasty, or small-wave incision [12] to release tension (type Ia). In the case that has linear scar contractures on both tibial and peroneal surface, contractures can be released by propeller flaps [11] designed on the center of posterior knee (type Ib). Broadband contracture on one surface should be reconstructed by skin grafting or local flaps


designed on the intact surface (type IIa), but for broadband contractures on both tibial and peroneal surface, propeller flap designed on the popliteal fossa can be used. (type IIb). Broadband contractures extending to adjacent surfaces sometimes need vascular pedicled relatively large flaps harvested from thigh or lower leg (type III). In the case of contracture of the entire circumferences, flaps such as vascular pedicled flaps or free flaps are useful to prevent recontracture (type IV).

I Linear contracture on the knee joint Ia anterior, posterior, tibial or peroneal surface Ib tibial and peroneal surface II Broadband contracture on the knee joint IIa anterior, posterior, tibial or peroneal surface IIb tibial and peroneal surface III Broadband contracture extended to next surfaces IV Broadband contracture of entire circumfrences Type Ia

⊡ Fig. 8.14 Knee joint

Type Ib

Type III

V Others


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Ankle Joint (Fig. 8.15) Linear contracture should be excised completely and can be closed primarily with z-plasties, w-plasty, or smallwave incision [12] to release tension (type I). Broadband contracture on one surface should be reconstructed by

skin grafting (type II), but extensive contractures extending to adjacent surfaces should be reconstructed by skin grafting or local flaps designed on intact surfaces (type III). In the case of contracture of the entire circumferences, not only skin grafting but also flaps designed on the lower leg or free flaps (type IV) can be used.

I Linear contracture involving plantar, dorsal, tibial or peroneal surface II Broadband contracture involving plantar, dorsal, tibial or peroneal surface Type Ia

III Broadband contractures extended to next surfaces IV Broadband contractures of entire circumfrences V Unclassified

Type II

⊡ Fig. 8.15 Ankle joint

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58

Toe Joints (DIP, PIP, MTP) (Fig. 8.16) Short linear contracture can be released by a small rotation or transposition local flap designed next to the contracture (type I); however, long linear contracture should be reconstructed by skin grafting (type II). Broadband


contracture should be reconstructed by skin grafting (type III), but a contracture less than a quarter of the circumferences can be reconstructed by local flaps designed next to the surface of digit (type IIIa). Contracture of the entire circumferences should be treated by skin grafting (type V).

* DIPj, PIPj and MTPj should be evaluated separately I Short linear contracture on one of joints II Long linear contracture extended to next joints Type I

III Broad band contracture extended to next joints IIIa less than a quarter of entire circumflerences IIIb over a quarter of entire circumflerences V Major contractures of entire circumfrences

VI Unclassified

Type IIIb

⊡ Fig. 8.16 Toe joints (DIP, PIP, MTP)


Toe Web (Fig. 8.17) Single web contracture should be reconstructed by a local flap such as a square flap and five z-plasty flap that are designed on the intact side (type I). Contractures on

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both plantar and dorsal regions should be reconstructed by skin grafting (type II). If web contracture is severely affecting adjacent digits, complete releasing of contracture and reconstruction using skin grafting should be performed (type III).

I Single web contractures Ia plantar side contracture Ib dorsal side contracture

II Double web contractures Type Ib

(contractrures on both planter and dorsal sides)

III Web contractures severely involved with next toes

IV Unclassified

Type III

⊡ Fig. 8.17 Toe web

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Other Special Regions (Nose, Ear, Genital Regions, etc.) (Fig. 8.18) Other regions should be evaluated by degree of cosmetic and functional dysfunction, and the size of tissue defects.

I Cosmetic dysfunction with no major tissue defects II Cosmetic dysfunction with major tissue defects III Cosmetic and functional abnormality with no major tissue defects IV Cosmetic and functional abnormality with major tissue defects V Unclassified

⊡ Fig. 8.18 Other special regions (nose, ear, palmer, plantar, genital region, etc.)


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CHAPTER 9

Prevention of Scar Using bFGF sadanori akita

Background of the Method Hypertrophic scars or keloid scars caused by burns are sometimes problematic when functional regions such as articular joints or conspicuous areas on the face or extremities are involved [1]. Massive burn wound scars have a tendency to develop progressive hypertrophic scars, and earlier skin grafting may improve the overall skin quality as well as shorten the hospital stay [2]. Humoral and cellular mediators have been considered for the pathogenesis of burn wound-induced hypertrophic scars. One possible role of the growth factors or cytokines in wound healing is to promote high cellular proliferation, differentiation, and migration of keratinocytes of the epidermis and the recruitment of inflammatory cells [3]. A basic fibroblast growth factor (bFGF) may play a pivotal role in cutaneous wound healing by activating local macrophages, with the effects continuing up to the remodeling stage, several weeks after the initial injury. Burn wound fluids or skin graft wound fluids limited to the dermis contain lower concentrations of bFGF compared to surgical wounds, which is deeper than the dermis with subsequently lower endothelial cell proliferative and chemotactic activities [4]. The bFGF is increased by silicone gel application in normal and fetal fibroblast cultures and may result in the prevention of hypertrophic scars. The healing of burn wounds is more complicated than acute wound healing. Sustained burn wounds are more susceptible to bacterial contamination and bring about unfavorable results, particularly in children [7]. Faster wound healing is highly expected to prevent severe systemic damage or sequelae such as invasive wound infection and sepsis. The bFGF was effective for second-degree burn wound healing in a randomized control trial although bovine

S. Akita, MD, PhD Nagasaki University, Japan e-mail: [email protected]

recombinant bFGF was employed [5]. The bFGF was regulated in spatial and temporal expression in accordance with the recruitment of inflammatory cells and interaction with keratinocytes [3] and was lower in second-degree burn wound fluid, therefore decreasing endothelial cell proliferative and chemotactic activity [4]. Wounds treated with bFGF produced scars that were significantly less hard 1 year after final wound closure [6]. Pediatric burn wounds can be problematic since accurate evaluation is difficult due to anatomically immature vasculature or immobilization failure, especially in second-degree burns, and the burn surface areas and the burn depth tend to worsen over time. Delayed wound healing results in unsightly scarring, such as hypertrophic scars, which are problematic both esthetically and functionally. Among cytokines and growth factors, bFGF is clinically proven, having demonstrated accelerated acute and chronic wound healing. Accelerated wound healing may lead to improved scarring. To elucidate the effects of bFGF on second-degree pediatric burn wounds, a comparative study was performed. bFGF-treated pediatric burn wounds demonstrated better scarring and well-organized stratum corneum after healing both clinically and by moisture meter analysis [7]. The bFGF demonstrated endogenous immunolocalization in the human dermis in partial-thickness burns from day 4 to day 11. The bFGF participates in cutaneous wound healing by activating local macrophages up to the remodeling phase, which occurs several weeks after injury. The bFGF in burn wounds may be a presynthesized mediator that is released locally from injury sites, and thus may play an important role in early wound healing [8]. In adult second-degree burns, the topical application of bFGF within 5 days postinjury demonstrated significantly better regeneration of granulation tissues and newly formed capillaries in a randomizedcontrol clinical trial. Our therapeutic regimens of bFGF treatment for the second-degree burns in this investigation started as early


Prevention of Scar Using bFGF

as on arrival day of postburn, and burn wound healing was completed at 12 days for the bFGF-treated group; this may be compatible with the endogenous bFGF expressions observed during day 4 to day 11 as observed in rat immunohistochemically [9]. Reconstruction of the lower extremities can be a concern. After extensive soft tissue defects due to metabolic changes such as diabetes, atherosclerosis and subsequent osteomyelitis as well as local infection, contusion, traffic accident or tumor resection, it is more difficult to resurface the skin if the raw surface consists of bone and tendon tissues. The combination of an artificial dermis with the topical administration of bFGF is the only angiogenic cytokine currently available in Japan. The bFGF also demonstrated acceleration and improvement in burn wounds in terms of the healing rate and hardness of the postskin grafting. Staged lower extremity reconstruction with daily bFGF-treated artificial dermis and subsequently thinner split-thickness skin grafting was beneficial for the quality of reconstructed skin in comparison with the artificial dermis and split-thickness skin grafting alone in terms of hardness and moisture parameters such as transepidermal water loss (TEWL), water content and thickness. The bFGF-treated reconstruction demonstrated almost equal values in water content and thickness, consistent with the softer and thus better nature of the reconstructed lower extremity. The advantage of using an artificial dermis includes immediate coverage for deeper tissue exposure such as tendon and bone, protecting from fluid, protein, and electrolyte loss, from microorganism invasion, and reducing secondary donor-site morbidity as only thinner skin grafting is required. Also, the combination of artificial dermis with bFGF demonstrated the reconstruction of deep diabetic soft tissue loss, diabetic pressure ulcer healing in a mouse model and intractable fingertip ulcers caused by burn injury [10].

CHAPTER 9

Characterization and Indication of the Method Genetically recombinant basic human fibroblast growth factor (bFGF) is used for spraying: the recombinant human bFGF with 154/153 aa residues (E.Coli). The molecular weight of the recombinant human bFGF is 17 kDa. The isoelectric point is 10.1., basic, and nonglycosylated single chain peptide. The beginning of bFGF use varied from 2 to 4 days postburn injury. The concentration of bFGF is 30 mg of bFGF per 30 cm2 area as 100 mg of freeze-dried bFGF dissolved in 1 mL of benzalkonium chloride solution, with 300 mL sprayed over a 30 cm2 area from 5 cm distance, and 0.3 mL of such concentration solution is applied by this method. Ointmentimpregnated gauze is applied to wounds treated with bFGF after waiting for 30 s. The bFGF administration continues until the wound had healed. For comparison, the non-bFGF treatment group receives only ointment-impregnated gauze without bFGF spraying. Standard procedures for stabilizing the burn wounds are applied for all the cases. For application with artificial dermis, the bFGF containing solution, which is reconstituted in the same way as the spray form, at a concentration of 1 mg/cm2 is delivered to the undersurface of the artificial dermis.

Specific Points of the Method 1. The reconstituted bFGF solution, either spray form or solution form, should be stored at 4° until use and each vial should be used up within 2 weeks period. 2. Major foreign body or large necrotized tissues should be debrided off before applying bFGF. 3. The principle is once per day application. Even another dressing change is required within 24 h. 4. Prevent the eyes from contacting bFGF directly.

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64


Clinical Cases + Case 1

9

A 78-year-old woman living alone in a remote hilly house. The fire from a candle spread over her clothes and she fell down on the floor. The bilateral buttocks and posterior thighs and part of leg developed totally 12% surface area burns. Eight percentage of TBSA was third degree and required debridement and split-thickness skin grafting. This patient was also suffering from dementia she thus had little understanding of the burn was so little. In 5 days, after she was found and brought to us by ambulance, the first debridement and skin grafting was performed. In third degree burn areas in posterior thighs, debridement was performed up to the fat tissues and sheet grafts were placed over bilateral ischiums and majority of wound was covered with mesh or patched grafts. In 18 months, the left buttock with bFGF spray demonstrated softness and more durability to trauma compared to the right buttock (control). The histology in both the buttocks showed quite different findings. The bFGF-treated wound demonstrated stratified epithelia and matured collagen fiber in the transverse direction; on the other hand, the control histology demonstrated thinner epithelia and loss of rete ridges, along with the deranged dermis and partly hyalinized collagens, which was consistent with the durometer readings (Fig. 9.1a–d).


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a c

b

d

⊡ Fig. 9.1 78-year-old woman demonstrated total 12% BSA IIIrd-degree flame burn (a). Immediately after debridement (b). Histology of the control scar in 18 months. There is ran-

domized array of the collagen fibers (×100) (c). Histology of the bFGF-treated scar in 18 months. There is organized array and the rete ridges are obtained (×100) (d)

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+ Case 2

9

A 2 and a half year-old girl mistakenly spilt hot water over her forearm and upper arm. In the forearm (left of the Fig. 9.2a), the bFGF spray as well as the ointment-impregnated gauze was applied and the arm side (right of the Fig. 9.2a) was treated with the ointment-impregnated gauze daily. The depth of the burn wounds in both upper arm and forearm seems comparable and indistinguishable between superficial dermal burn (SDB) and deep dermal burn (DDB) initially. In 1 year after complete healing, the appearance of the scar was much better in the bFGF-treated wounds in terms of color, hardness and height (Fig. 9.2a–b).


CHAPTER 9

a

⊡ Fig. 9.2 2.5-year-old girl with scald burn. Let (forearm) was treated with the bFGF and right was the control (a). One year after complete wound healing. The bFGF-treated scare is much flatter, softer and well-matched in color with surrounding tissue (b)

67

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68


+ Case 3 An 80-year-old woman who developed sudden onset infection in the left lower extremity. The severe cellulitis after minor burn wound and partial infection to the bones and some tendons were exposed.

9

In 5 days after she was referred to our hospital, the secondary debridement, bFGF spray for wound bed and the artificial dermis were applied. The bFGF injection was continued at 30 mg up to the secondary spit-thickness skin grafting. After the continuation of 14-day bFGF from the side of the artificial dermis, 10/1,000 inch-split-thickness skin grafting was performed over the bFGFtreated wound bed. In 3 years after skin grafting, the wound healed uneventfully with softer and much normalized appearances (Fig. 9.3a–e).


a

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b

c d

e

⊡ Fig. 9.3 80-year-old woman developed the severe cellulitis of sudden onset in the left calf (a). After thorough debridement, the bFGF was sprayed over the wound and covered with the artificial dermis (b). With 14-day continuous injection of the bFGF from the side of the artificial

dermis, the would bed was optimally ready for secondary skin grafting (c). Right after 10/1,000 inch-split-thickness skin grafting was applied (d). In three years after the final surgery, the scar is softer and demonstrated normal appearance (e)

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70


+ Case 4 An 82 year-old man who mistakenly spilt the flamed kerosene over his upper back, posterior neck, and arms. There was a DDB area in the upper left back. Daily bFGF spraying along with the ointment-impregnated gauze dressing up to 14 days when all the wounds completely healed. In 1 year after healing, the scar is pliable and color-match favorably with the adjacent intact skin (Fig. 9.4a–b).

9


a

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b

⊡ Fig. 9.4 82-year-old man spilt the flamed kerosene over his back, neck and arms (a). With 14-day continuous spraying of the bFGF until wound healing, it is pliable, color-matched scars in one year (b)

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C H A P T E R 10

Medical Needling hans-oliver rennekampff, matthias aust, and peter m. vogt

Background of the Technique Patients with post-burn scarring frequently request help in improving the aesthetic appearance of their residual cicatricial deformity. It is their hope to eradicate the physical evidence of a scar and to re-establish a normal appearance and texture to the site of injury. This quest has led to the application of many different topical therapies which have included carbon dioxide (CO2) laser resurfacing, dermabrasion and deep chemical peels. All these modalities share a similar mechanism of action, topically ablating the skin in an attempt to yield a more homogenous surface. This therapeutic injury destroys the epidermis and the basement membrane. Ablating the epidermis of already scarred skin with subsequent protracted re-epithelialization may render the skin more sensitive to photodamage and dyschromia and may possibly cause additional dermal fibrosis by initiating a prolonged inflammatory response. Rejuvenation of scarred skin and re-establishment of a more normal appearance require the maintenance or establishment of a normal epidermis with normal colour and a normal dermis with natural dermal papillae, good hydration, and normal resilience. New therapeutic interventions have attempted to preserve the epidermis either completely as in radiofrequency tissue heating or partially as effected by fractionated laser ablation. Initiating a wounding stimulus in the dermis and causing necrosis of dermal cells create a stimulus for fibrosis, inducing new collagen and elastin synthesis by fibroblasts, resulting in skin tightening. H. Rennekampff, MD, PhD (*) Klinik für Plastische, Hand- und Wiederherstellungchirurgie, Medizinische Hochschule Hannover, Carl Neubergstrasse 1, 30625 Hannover, Germany e-mail: [email protected] M. Aust, MD and P. M. Vogt MD, PhD Klinik für Plastische, Hand- und Wiederherstellungchirurgie, Medizinische Hochschule Hannover, Carl Neubergstrasse 1, 30625 Hannover, Germany

Orentreich and Orentreich [1] and Fernandes [2] independently described “subcision” as a way of building up collagen beneath retracted scars and wrinkles by separating the tethered and depressed surface tissue from the underlying deeper scar tissue. Camirand and Doucet [3] treated scars using a tattoo gun to “needle abrade” them, and although this technique can be used on extensive areas, it is laboriously slow. The holes created in the epidermis by a tattoo gun are generally felt to be too close and too shallow to effect optimal improvement. Severing old, short and vertically oriented collagen strands which tether the bed of the scar to the most superficial layer of the dermis, promotes the removal of damaged collagen, and inducing new collagen formation immediately below the epidermis. Ideally, one would prefer to effect the reticular dermis, stimulating the production of collagen and elastin fibres while avoiding excessive bleeding under the skin and scar. Percutaneous collagen induction by medical needling results from the natural response to wounding the skin. This can be initiated through even minute injuries [4, 5]. A single needle prick created through the skin would generally cause an invisible response. A completely different picture emerges when multiple fine wounds are placed close to each other. Building upon these principles and experiences, a specialized tool was designed by Fernandes [1] employing rows of needles which range in length between 1 and 3 mm to achieve percutaneous collagen induction by medical needling.

Topical Adjuncts Vitamin A, as retinoic acid, is an essential vitamin, actually a hormone, for skin that expresses its influence on approximately 400–1,000 skin cell related genes. Vitamin A is thought to be essential for maintaining the normal physiologic processes of the skin, for preserving collagen content and ensuring quality wound healing. It controls proliferation and differentiation of all the major cells of the epidermis and dermis and is felt to be


Medical Needling

essential for rapid healing of the skin [6, 7]. Vitamin A has been shown to facilitate collagen and glycosaminoglycans production by fibroblasts and appears to control the release of transforming growth factor (TGF) b3 in preference to TGF-b1 and -b2 favouring the development of a lattice-patterned collagen network as opposed to the more visible and contracted appearing-scar pattern of parallel collagen deposition . Retinyl esters are the main form of vitamin A in the skin, and only tiny fractions of vitamin A are found as retinoic acid [8–10]. Fortunately, retinyl esters are easily and rapidly converted into retinoic acid at physiologic doses. As opposed to the retinoic acid formulations, retinyl esters are not considered cellular irritants and as such are generally well tolerated when applied topically. It is for that reason that we have elected to utilize products with high levels of retinyl esters when treating problem scars. Vitamin C is a potent reducing agent and is critical for the formation of normal collagen [11]. It is poorly absorbed through the skin and can be quite irritating when applied topically. Ascorbyl tetraisopalmitate has been shown to be an efficient topical form of vitamin C, easily penetrating the skin and incorporated into skin cells. Once inside the cell, it is de-esterified and becomes bioavailable as ascorbic acid.

Needle Depth When performing 3-mm Roll-Cit needling, needles penetrate 3 mm into the dermis and initiate a complex chemical cascade. Platelets instigate the release of various growth factors e.g. PDGF [12]. Fibroblasts migrate into the micro wound sites, and this surge of activity inevitably leads to the production of more collagen and more elastin . Keratinocytes migrate rapidly across the minute epidermal defects and then proliferate establishing a thickened epidermis. If the 1-mm Roll-Cit device is used for micro needling, the bleeding is microscopic and occurs entirely within the papillary and upper reticular dermis as the needles penetrate only to a depth of approximately 0.75–1 mm. Because the epidermis is, on average, 0.2 mm, one can be certain that the injury will be limited to the upper layers of the dermis. It is hypothesized that micro needling excites a smaller inflammatory response, yet the cascade of growth factors still gets initiated by the release of platelets through the puncturing of small vessels by micro needling. The possibility that with micro needling, one gets a purer stimulus for collagen synthesis without the

CHAPTER 10

heavy inflammatory reaction, exists because subdermal fat is certainly not damaged at the same time. It is believed that because the epidermis remains intact, this might favour predominantly TGF-b3 rather than TGF-b1 and -b2, which are associated with scar collagen deposition. TGF-b3 is implicated in scarless healing and normal lattice weave collagen deposition. Percutaneous collagen induction seems to induce normal lattice weave collagen rather than scar collagen [2]; so, theoretically, TGF-b3 may play an important part in this very early phase [13–15].

Characteristics and Indication of the Method The first step is to topically address deficiencies as well as supply the antioxidant vitamins C and E and vitamin A. Medical-needling is done with a roller that is filled with numerous tiny needles that penetrate the skin by 3 mm. Medical needling uses 3-mm needles to penetrate deeper into the skin, and this does cause bruising and swelling. On the other hand, micro needling uses needles that only penetrate to a maximum of 1 mm, and this causes virtually no bruising and minimal swelling. With micro needling you can return to work the day after the treatment without any signs except some pink skin, as though you have been exposed to the sun. The number of treatments required will depend on how each individual responds to the treatments, and the extent of damage at the beginning (Fig. 10.4). Most patients will begin to see results after the very first appointment (Fig. 10.5). Depending on the degree of improvement that is required a series of needling sessions can be necessary.

Indications for Medical Needling Post-Burn Using the 1-mm Roller 1. As an alternative to dermabrasion for mild to moderate scarring. 2. Scars can be made less obvious by 1-mm needling, and if the scars are depigmented, one can achieve a better colour match with the surrounding skin.

Indications for Medical Needling Post-Burn Using the 3-mm Roller 1. Burn scars (Fig. 10.4)

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Medical Needling

Advantages of Medical Needling 1. Percutaneous collagen induction does not ablate the epidermis. 2. Any part of the body may be treated. 3. Skin becomes thicker. 4. The healing phase is short. 5. The skin does not become sun sensitive. 6. Telangiectasias may disappear. 7. Hyperpigmentation has not yet been described.

Disadvantages of Medical Needling

⊡ Fig. 10.1 Medical needling roller

1. Exposure to blood and a sharp instrument. 2. Although we cannot achieve as intense a deposition of collagen as in CO2 laser resurfacing, treatment can be repeated with possibly better results. 3. There is a need for anaesthesia of the skin when doing 3-mm needling. 4. It takes a longer time to see the result than with laser resurfacing. 5. There is unsightly swelling and bruising for the first 4 days when 3-mm needling has been done. 6. At present no keloids have been described after medical needling, but caution should be taken in patients prone to keloid formation.

Specific Skills of the Method 1. The scarred skin is evaluated and photographs should be taken pre-treatment. 2. The skin is prepared with topical vitamins A and C and antioxidants for at least 3 weeks, but preferably for 3 months. 3. Under topical, local or general anaesthesia, the skin is closely punctured with the special medical needling tool (Fig. 10.1), consisting of a rolling barrel with needles at regular intervals. It comes in a sterile plastic container and is mounted on a handle at the time of use. Two different needle lengths are available, that is, 1 and 3 mm. By rolling backward and forward with some pressure in various directions, one can achieve an even distribution of the holes (Fig. 10.2). The needles penetrate through the epidermis but do not ablate it, and because the epidermis is only punctured, it will heal rapidly. The skin bleeds for a short while and develops multiple microbruises in the dermis. We use wet gauze swabs to soak up any ooze of serum

⊡ Fig. 10.2 Medical needling performed with a 3-mm roller on a post-burn scar

when 3-mm needles have been used. Once the serous ooze has stopped, the skin is washed thoroughly and then covered with a special vitamin A, C, and E oil. If the skin has been needled with the 1-mm roller, the bleeding under the skin is microscopic, and one does not get serious ooze post-operatively. If 1-mm needling has been done, the patient will only experience a flushed appearance of the skin and will not develop bruises or swelling. 4. If 3-mm needling has been done, the patient should be instructed that he/she will look bruised and become quite swollen (Fig. 10.3). The patient is encouraged to shower within a few hours of the procedure, and that by day 4–5, the skin will develop a moderate pink flush that can be concealed with makeup. Some residual bruising may still be present at this time.

Medical Needling

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⊡ Fig. 10.5 Three months after 3-mm medical needling of the same area. The patient was very satisfied with the outcome

⊡ Fig. 10.3 View of the skin immediately after medical needling with a 3-mm roller; notice bruised appearance

⊡ Fig. 10.4 Post-burn scarring after partial thickness burn to the lower face

5. Post-treatment, the patient is encouraged to use topical vitamin A and vitamin C cream or oils to promote better healing and greater production of collagen. The addition of peptides such as palmitoyl pentapeptide could possibly ensure even better results. Iontophoresis also tends to reduce the swelling of the skin. Low-frequency sonophoresis can be used to enhance penetration of palmitoyl pentapeptide or other peptides.

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C H A P T E R 11

Treatments for Post-Burn Hypertrophic Scars rei ogawa, satoshi akaishi, and kouji kinoshita

Treatment Strategy of Post-Burn Hypertrophic Scars

Partial/Complete Surgical Contracture Releasing (Fig. 11.1 (A))

Hypertrophic scars (HSs) occur within weeks after burns, rapidly increase in size for 3–6 months, and then, after a static phase, begin to regress. The full maturation process may take up to 2–5 years. In the treatment of post-burn HSs, indication of treatment methods should be decided based on whether scar contracture is associated with HSs (Figs. 11.1 and 11.2) [1], because, surgery should be selected for HSs cases with scar contracture, to avoid functional dysfunction. Releasing scar contractures improves joint function, and even if it is partial releasing of contractures, it accelerates maturation of surrounding immature scars and HSs (Fig. 11.1 (A)). However, small and linear HSs with mild scar contractures can be treated with complete surgical resection radically (Fig. 11.1 (B)) or with non-surgical multi-modal therapy (Fig. 11.1 (C)). Intractable recurring HSs can be treated according to the algorithms of keloid treatment [1], among which the combination of surgery and adjuvant therapy (e.g. radiation or corticosteroid injection) is the treatment of choice (Fig. 11.1 (D)). After these treatments, longterm follow-up and conservative therapies are needed for complete functional and cosmetic recovery (Figs. 11.1 (E)).

For type 1 and 2a cases of HSs (Figs. 11.1 and 11.2), partial release of scar contractures (sometimes can be treated radically by complete resection of contractures) should be considered. Flaps are more effective than skin grafting from the aspect of the prevention of re-contracture. Even if it is a partial contracture-releasing and a small-resection of scars, transferred flap (interposed flap between scars) can be expanded gradually, and that accelerates maturation of surrounding immature scars and HSs (Fig. 11.3; Case 1). Skin grafting is also useful for the total replacement of scars on contour sensitive areas such as the dorsal hand (Fig. 11.4; Case 2).

Complete Surgical Resection (Fig. 11.1 (B)) Small or linear HSs with mild contracture (Fig. 11.1; type 2b) can be treated with complete surgical resection. At that time, a type of tension-releasing technique, which includes as z-plasty, w-plasty and small wave incision, should be applied to prevent recurrence of HSs.

Non-Surgical Multi-Modal Therapy (Fig. 11.1 (C))

R. Ogawa, MD, PhD (*) Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School Hospital, Tokyo, Japan e-mail: [email protected] S. Akaishi, MD, PhD Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School Hospital, Tokyo, Japan K. Kinoshita, MD Department of Plastic and Reconstructive Surgery, School of Medicine, Fukuoka University, Fukuoka, Japan

HSs without scar contractures (Fig. 11.1; type 3) naturally improve during the process of scar maturation; thus non-surgical therapy should be tried. Various kinds of non-surgical therapies can accelerate the maturation process and improve subjective symptoms, which include irritation, pain, and itch, as well as objective symptoms, which include redness and scar elevation; thus, multiple non-surgical therapies should be employed to their full extent, but non-invasive therapies, which include compression therapy and gel sheeting (Fig. 11.5; Case 3), should be prioritized (Fig. 11.1 (C)).


Treatments for Post-Burn Hypertrophic Scars

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77

Post-Burn Hypertrophic Scars (HSs)

(Type 1) HSs With severe scar contractures

(Type 2)

(Type 3)

HSs With mild scar contractures

HSs Without scar contractures

(Type 2a)

(Type 2b)

Large /Wide HSs

(A) partial / complete surgical contracture releasing

Small / Linear HSs

(B)

(C)

Complete surgical resection

Non-surgical multimodal therapy

a. Skin grafting

a. Compression therapy

b. Flap transfer

b. Gel sheest

Recurrencce

Effective

c. Corticosteroid injection Satisfactory improvement

d. Laser

Unsatisfactory results

(D)

Repeat

(C)


e. External agents

Surgery + adjuvant therapy

f. Internal agents g. Make-up / camouflage therapy

a. Surgery + radiation b. Surgery + corticosteroid injection

h. Others

(E) Long-term follow-up + conservative therapices

Effective

Recurrence

Satisfactory improvement

Unsatisfactory results

a. Gel sheets b. Taping fixation c. Compression therapy d. External agents e. Internal agents

(C)

Repeat


f. Make-up / camouflage therapy

⊡ Fig. 11.1 Algorithm of post-burn hypertrophic scars (HSs)

Compression therapy has been widely studied [2, 3], but the number of high level studies is still small. Further analysis of the mechanisms of acceleration of scar maturation is needed, but the application of appropriate pressure on HSs should be considered.

however, it seems that there are “resting and fixation effects” that protect wounds from extraneous stimulus, and “tensile reduction effect” [5]. There are some reports that the materials of gel sheets may not be vital (Fig. 11.5; Case 3: a case treated by polyethylene gel sheets) and that, instead, education of patients may be the most important factor in the treatment of HSs with gel sheets [6].

Gel Sheeting

Corticosteroid Injection

According to a recent meta analysis [4], there is weak evidence of benefit in using silicon gel sheeting;

The effect of corticosteroid injection is rapid, but injections must be limited to small areas, because of severe

Compression Therapy

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⊡ Fig. 11.2 Types of post-burn HSs. Type 1: contractured areas are large, so partial contracture releasing should be considered. Type 2a: contractures are not so severe, but a part of scars caused contractures, and that results in dysfunction; thus partial con-


tracture releasing should be considered. Type 2b: contractures are mild, and entire scars can be resected radically, or non-surgical therapy can be used. Type 3: there are no contractures, and non-surgical multi-modal therapy should be used


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79

b

a

⊡ Fig. 11.3 (a) Six months after burn injury. (b) Postoperative view. (c) Six months after contracture releasing. A 39-year-old male suffered from extensive burn in the lower extremities. Motion of sitting was painful according to the contracture associated with HSs on the left thigh. A 11 × 3 cm of small local flap was interposed on the upper region of the

a

b

d

c

scars and 5 × 2 cm of another local flap was also interposed in the lower region. Three months after the operation, flap widths were clearly expanded to 5 cm (167%) and 3.5 cm (175%), respectively. Moreover, redness and elevation of surrounding HSs were reduced significantly

c

e

⊡ Fig. 11.4 (a) Two years after burn. (b) Total scar resection. (c) Sheets of skin graft were transplanted from the right inguinal region. (d) Taping and bandage fixation. (e) One year after the operation. A 56-year-old female suffered from post-burn HSs with mild contracture on the hand. Total

removal of scars and skin grafting were performed. A sheet of skin grafting was used and small drainage holes were made on the grafts using “Kenzan”, a Japanese flower holder. Taping and bandage fixation were performed and the post-operative course was uneventful

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a

b

c

d

e

f

g

h

⊡ Fig. 11.5 (a) One week before starting polyethylene gel sheeting. (b) Post 1 month. (d) Post 2 months. (e) Post 3 months. (f) Post 1 year. (g) Post 18 months. (h) Post 28 months. A 1-year-old female suffered from scald burn on her chest. It was a superficial dermal burn (SDB) and a deep dermal burn

a

(DDB), which were epithelialized after 5 weeks of conservative treatments. Polyethylene gel sheeting has been applied since then. It was effective to protect the scars from extraneous stimuli, and the maturation course was uneventful. Anterior chest contracture was not observed after the treatment

c

b

⊡ Fig. 11.6 (a) Six months after burn. (b) One year after treatment. (c) Two years after treatment. Post-burn HSs on the right thigh of a 39-year-old male. Those with a diameter of 15 cm and were treated by Nd: YAG laser with non-contact mode every 3–4 weeks from 9 to 13 month. The laser swung

from right to left about 2 or 3 cm above the scars with a spot size diameter of 5 mm, an energy density of 14 J/cm2, an exposure time per pulse of 0.3 ms, and a repetition rate of 10 Hz, 500–1,000 pulses/cm2. After 13 months, the scars were treated every 3–4 months. Elevation and redness were improved

pain associated with their injection, and the local side effects that include thinning and atrophy of the skin, and subcutaneous tissues, steroid acne, capillary dilatation, hypopigmentation will be a problem. These complications sometimes hamper combination treatments; thus, careful planning with patients is necessary.

Laser Pulsed dye laser (PDL) [7,8] or Nd: YAG laser (Fig. 11.6; Case 4: a case treated by Nd: YAG laser) are suggested as effective for the treatment of post-burn HSs. However, laser alone may not be the ideal method to treat HSs, but


it may provide significant benefits when used as part of a multi-modal therapy. For example, it is beneficial to use laser before injecting steroids.

CHAPTER 11

to a reduction in symptoms of HSs. Anti-inflammatory drugs and anti-allergic drugs can be used for strong subjective symptoms.

Make-Up Therapy/Camouflage Therapy External Agents Corticosteroid ointments, tape, and non-steroidal antiinflammatory drugs (NSAIDs) are effective in reducing symptoms. Moreover, onion extract gels and mugwort lotion [9] have also been suggested for the treatment of scars, but large-scale RCT studies are required to confirm their beneficial effects.

Internal Agents The oral administration of the anti-allergic drug tranilast [10] has been used to treat HSs, and it reportedly led

Make-up therapy or camouflage therapy [11] should also be considered in the management of psychological stress of patients, as these therapies improve not only the cosmetic appearance of scars but also reportedly promote physiological changes; however, this contention warrants scientific confirmation.

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C H A P T E R 12

Make-Up Therapy for Burn Scar Patients ritsu aoki and reiko kazki

Background The advances in the burn medicine have brought an increase in the survival rate of extensive burn patients. However, unfortunately, the increase in survival from severe burn is not directly connected with the happiness of the patients. According to our data, only 25% of the patients whose BSA was more than 30% could recover their original position after the discharge from plastic surgical ward [1]. Most of them had to live on social welfare because they could not obtain jobs due to their appearance. Plastic and reconstructive surgery could help mainly functionally. For those who had injured extensively, as the donor site for skin grafting or flaps were very limited, the aesthetic results were not satisfactory. So we introduced the make-up therapy combined with plastic and reconstructive surgical treatments. The history of make-up therapy for the camouflage of the scar can be traced back to 1940s. The British redcross nurses started to hide the scars of the soldiers who were injured in the World War II [2]. They have proved that even nonmedical procedures such as make-up could ease the pain of the patients. Recently, camouflage makeup is recognized as a good method of scar management and is utilized and researched widely [3, 4].We have been utilizing the make-up therapy combined with plastic surgical services since 2000 to find that this method is pretty effective for the improvement of the quality of life of the patients, especially those with extensive burn scars [5]. However, when we give make-up therapy, we always have to remember the patients’ favor and their social or cultural background. They may not become happier or even become less happy when unfavorable make-up is R. Aoki, MD (*) Nippon Medical School, Greenwood Skin Clinic Tachikawa, Tokyo, Japan e-mail: [email protected] R. Kazki, MD Nippon Medical School, Reiko Kazki co ltd, Tokyo, Japan

applied. Improving their figure is more difficult than functional improvement. Since 2000, we have treated more than 350 patients with make-up therapy.

The Method of the Make-Up Massage Patients of burn scars may sometimes have edemas. Even if not so, facial massage is effective for the improvement of skin texture and color. Massage should start with lower eyelid laterally to medially (Fig. 12.1). Then upper eyelid massage in the opposite direction should be followed. Next sides of the face are massaged from top down. This massage is performed consecutively with a sponge moistened by squalan oil or face lotion.

Foundation The choice of foundation should be made considering the patient’s skin condition, age, social status, and patient’s make-up ability. There are various types of cosmetic foundations, such as lotion type, cream type, hard type, mixing type, and covering type. The cosmetic foundation is made in three layers: total face basement, total face upper, and local top (scar part). If the patients require quick make-up, lotion type would be selected as the basement. If there is unevenness of color, yellow foundation of hard type or covering type foundation should be selected. The yellow color is good for erasing the erythema (redness) due to burn scar. For total face upper foundation, hard type and cream type foundation are used for standard patients. If patients require light cosmetic, cream type and mixing type should be chosen, and if strong coverage is required, cream type or mixing type and covering foundation should be used. If there are some scars which need to be


Make-Up Therapy for Burn Scar Patients

CHAPTER 12

covered more, covering foundation is used partially in some cases.

Make-Up When the scar is covered by foundation, the scar becomes less visible; however, the appearance of surrounding areas is also important for patients’ satisfaction. Shaving and drawing eyebrows, eye make-up, cheek make-up, and other make-up procedures are made. At first, our make-up therapists explain the application of make-up, but the goal of make-up therapy is for the patient to independently apply make-up. Therefore, we have to consider whether the patient can apply make-up by herself if she has injured her hands. In such a case, glasses, a hat, or a scarf can help to cover the scar.

⊡ Fig. 12.1 Massage should be performed before make-up. It starts from lower eyelid to upper eyelid drawing a clockwise circle, then from temple to check

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12

A 55-year-old female who had attempted suicide had extensive burn on her face, upper arms, and trunk. She underwent operations more than 10 times including the total nasal reconstruction with a distant flap. As her eyebrows were burnt out, only drawing eyebrows in a good shape helped her to change her impression. Also making up her eyelids can make her eyes look larger.


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86


+ Case 2 A 52-year-old female was found with 55% BSA. Her mentum was reconstructed with a free flap of which the skin, color, and texture are far different from the surrounding skin. Even after make-up, the shape of her chin could not be changed, and so a scarf was used to cover it. After make-up therapy, she was able to go outside to shop by herself which she had not been able to do.

12


CHAPTER 12

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88

Meaning of Make-Up Therapy The application of make-up to cover the scar does not simply mean the treatment of the patients’ injured mind, because make-up is not the method to erase the scars completely. Once the patient removes the make-up, the scar appears again. Therefore, the better the scar can be hidden, the more the patient becomes uneasy when it is removed. When the patient decides to marry or begin a job, he or she distresses over when to confess that he or she has a scar. The important thing in doing make-up therapy is not to cover and hide the scar completely, but to encourage the patients to mix with society. Most of the patients wonder whether their scar may make others uncomfortable. If the scars become less visible, it would not annoy the patients as well as the neighbors. For that purpose, Ms. Kazki who is in charge of our make-up clinic, named her method of make-up as “Rehabilitation Make-up” which emphasizes the improvement of the patients’ quality of life [5]. In rehabilitation make-up, the patients are always made-up not only on the scar, but the whole face, because the key is not only to diminish the scar, but also to make the patient more beautiful. The rehabilitation make-up always starts with facial massage to accelerate the venous return which results in the deflation of the face and the improvement of facial skin color. This step also makes it easier to apply foundation


powder evenly to the scar, which is too smooth for normal foundation powder to stay on. Shaving and drawing eye brows are also important for the change of the impression of the patient. According to the survey of patients who had self-injured scars on their forearms, even though they don’t have any scarring on the face, if make-up is performed on their face at the same time as the make-ups over the arm scars, their scores assessed by the satisfaction of their appearance by VAS (visual analog scale) improves significantly [6]. The benefits of make-up therapy are 1. Noninvasive. Even those who are suffering from internal organ dysfunction or disorder can have this therapy. 2. Reasonable cost. No special equipment or material is required. Only standard cosmetics are necessary. No specific license is essential even though the staff should be trained in make-up therapy. 3. Reversible. If the patient doesn’t like the appearance after make-up therapy, the patient can wash the face to recover. Accordingly, make-up therapy is a good option for the treatment of burn scars, especially for the patients who almost finish the surgical operations. Make-up therapy is not an enemy of medical profession, and can benefit both the patient and the medical staff.

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C H A P T E R 13

Dermal Substitutes luc téot, sami otman, and pascal granier

Background of the Technique Dermal substitutes have been developed during recent decades. Integra, a substitute for dermis, was initially developed by Burke and Yannas. This device is derived from bovine collagen and contains glycosaminoglycannes. Safety issues (prions) have been solved. The device was initially proposed for burns coverage, and although randomized studies have determined the efficacy of the technique, no statistical difference has been observed in terms of scar characteristics of the obtained skin tissue. Alternative collagen or noncollagen products of different thicknesses were more recently developed, with or without silicone covering films. These products can be derived from porcine, bovine, or human origin. We may now divide dermal substitutes into two categories, double layer DS and single layer DS.

Double Layer Dermal Substitutes Integra is composed of bovine collagen and glycosaminiglycannes. Initially indicated in acute burns for scar pliability improvement, this DS has demonstrated its capacities to be used over extensive burns after a sharp early excision. In a pivotal study on burns, Heimbach et al. showed the interest of using Integra to restore skin suppleness and prevent skin graft adherence to the depth of the exposed structures. Other authors, using Integra in reconstructive surgery, concluded that the product could be used in traumas, skin excision after skin cancer removal, and other types of L. Téot, MD, PhD (*) Burns and Plastic Surgery Unit, Montpellier University Hospital, France e-mail: [email protected] S. Otman, MD and P. Granier, MD Burns and Plastic Surgery Unit, Montpellier University Hospital, France

skin replacement. The product seems particularly indicated over exposed tendons or bones in thin skin reconstruction, for example, in hand and feet skin reconstruction. Integra may be used as originally described, with a period of revascularization and neoangiogenesis lasting 3 weeks. After this period, the silicone film is removed, and a thin skin graft is applied over the collagen. It is also possible to reduce the length of revascularization by applying negative pressure therapy over the silicone layer, thereby saving a week. When using VAC™, a skin graft can be applied after a period of 10 days (Jeschko). Rehabilitation should start early in order to prevent skin adherences, especially when applied over mobile structures. Transient inflammation and redness of the skin can be observed for a period of 1 year. Renoskin™ is a double layer DS, with the same composition as Integra. This product is indicated in acute burns (Braye). Pelnac™ is comparable to the previously described DS, presenting a capacity of dermal regeneration within a period of 3 weeks (Akita). Hyalomatrix 3D™ is based on the principle of bringing hyaluraonic acid inside the neodermis. Clinical series describing good results were recently proposed, especially in acute burns. The product allows an intense and rapid granulation tissue formation and needs a secondary skin graft (Scalise). Matriderm™ thick layer has been recently proposed by Middlekoop et al. (Van Zuijlen). The promotion of angiogenesis in the DS, using Negative Pressure Therapy in conjunction with the application of DS, has been proposed (Jeschke et al.). When negative pressure is permanently applied over the dermal substitute, this significantly shortens the delay before it is possible to apply a skin graft. Within a period of 10 days, the collagen can be revascularized. A decrease in the infection rate has also been observed, certainly due to the isolation of the treated area from external contamination. VAC therapy is applied with moderate negative pressure (50 mmHg) in order not to harm the collagen matrix.


Dermal Substitutes

Single Layer Dermal Substitutes A new generation of DS has recently been proposed. Some of them are based on the same collagen composition, while others present different properties. Reduction in the thickness of these DS and the absence of a covering silicone layer make them possible to perform an immediate skin graft during the same surgical procedure. Matriderm™ is composed of collagen mixed with elastin fibers. This product has been proposed as a single layer matrix in burns and reconstructive surgery. The product presents interesting capacities of hemostasis. Elasticity of the structure helps when the device is applied over irregular surfaces. The product is more suited to extensive well-vascularized structures, particularly over the face or the skull. Integra™ thin layer is identical in structure to Integra, without a silicone film covering. The product is under clinical evaluation.

CHAPTER 13

Alloderm™, Strattice, and Permaform are derived from porcine dermis. These products may be used as solid thick structures. Their capacity of being penetrated by vessels is lower than the previous ones. Used in dura matrix replacement, they can be proposed as fixation devices for abdominal wall reconstruction or internal brass in mammary ptosis or after reduction. Gliaderm™ has recently been proposed by the Dutch skin bank. Clinical indications include burns coverage and trauma. The device is immediately covered using skin grafts during the same surgical procedure or some days after. Gammagraft™ has been proposed and used in Germany. The combination to NPT is also possible, in order to reduce the length of take of the compound skin graftdermal substitute.

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Dermal Substitutes


13

A 12-year-old boy sustained flame burns over about 36% of TBSA. He was intubated and maintained under artificial respiration for rescusitation needs (a–c). After stabilizing his general condition, his face and hands were operated on. A tangential excision was performed, followed by an immediate application of Matriderm™ and then a thin split skin graft. The result was good as per healing was concerned, as the epidermis was stable after 5–7 days. A transient hyperchromic pigmentation and a retraction in the fingers were noted as minor complications. The situation of both hands and the color of the face improved after 6 months (d). No retraction was noted at this time.

Dermal Substitutes

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c

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b

d

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Dermal Substitutes

+ Case 2

13

A 14-year-old boy presented with large scar areas over the neck and the lower part of the face after extensive burns sustained at a young age (a). He was operated on for scar correction. After removal of scar contractures, a skin defect (60 cm long 45 cm wide) was immediately covered using Integra double layer (b). The revascularization process took 3 weeks. The silicone film was then removed and the area covered using a split-thickness skin graft harvested on the skull. Results were good, with no seroma or hematoma observed, and no infection. Rehabilitation could be started after 3 weeks (c).

Dermal Substitutes

a

c

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b

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Dermal Substitutes

+ Case 3 A depressed 40-year-old, was severely burnt by the autoprojection of boiling liquid (oil). She was deeply burnt over 10% of TBSA, mainly on the head, neck, and over both hands. She was intubated and artificially ventilated.

13

Several days later, a pan facial excision was achieved. As the cranial cortical bone was involved, an excision of the outer portion of the bone was carried out, exposing an area 30 cm long and 25 cm wide. A dermal substitute (Matriderm™) was applied over the whole defect, and immediately covered using a split skin graft. The skull was used as donor site area (a–c). Final results concerning healing, color, smoothness, hand and digit mobility, facial expressions, and periorificial muscles functions were good (d).

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a

b

c

d

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Discussion Dermal substitutes, used as temporary or permanent devices, have been developed over the previous decade. Their use is in rapid progression in reconstructive surgery, some of them replacing flaps when contraindicated or when not possible, especially in extensive burns. The purpose of the use of these techniques is to improve the quality of scar and increase suppleness of the final coverage by increasing elasticity of the dermal part of the skin. The use of negative pressure therapy contemporary to the postoperative period, which is limited in time and in level of pressure (50 mmHg for 5 days), has been used in some cases. This technique may decrease the rate of postoperative infections. The use of dermal substitutes looks better than using a simple skin graft, especially when applied over a bone structure. Adherence to the depth is minimized when

Dermal Substitutes

compared to split skin grafts applied over the same anatomical area. Functional results of Matriderm™ can be considered as good. The skin may transitorily be hyperchromic, especially in acute burns, a return to a normal color having been observed in one patient after a period of 8 months. Scar retractions were not observed in this series. The tendency of the scar to hypertrophy after Matriderm™ was only noted once on a facial scar reconstruction. Limiting the number of surgical procedures has to be evaluated in terms of cost efficacy, but reducing the number of anesthetics can also be considered a positive aspect of the use of single layer dermal substitutes that are immediately covered with a split skin graft. This has to be compared with the two-step procedures necessary until now in the use of dermal substitutes like Integra.

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C H A P T E R 14

Acellular Allogeneic Dermal Matrix yoshihiro takami, shinpei ono, and rei ogawa

Available donor skin is so limited in extensive burns that thin meshed split-thickness skin grafts (STSG) or cultured epidermal autografts are commonly used to close the wounds. However, a lack of sufficient dermal beds results in poor cosmetic appearance with thin meshed STSG and poor graft survival with cultured epidermal autografts. In order to resolve these problems, a number of dermal substitutes have been produced. Among them, acellular allogeneic dermal matrix (ADM), which is produced by decellularizing allogeneic cadaver skin, has physiological properties closest to those of normal human dermis [1, 2]. We attempted to use ADM for two different purposes in burn surgery. One is simultaneous skin graft overlay with ADM transplantation on excised full-thickness burn wounds [3]. The other is the use of an ADM as a scaffold of a tissue-engineered autologous skin equivalent (TESE) [4, 5].

3 h at 37°C to remove the epidermal cells and then washed in a mixed solution of 0.25% tritonX-100 and 0.125% trypsin to remove all the cellular components of the dermis for 4 h at 37°C. The decellularized dermis (trypsintreated ADM) was stored at 4°C. These procedures remove the basement membrane structure from the skin. The other method was to create an ADM suitable for tissue-engineered skin equivalents. Pieces of split-thickness skin from the same source above were incubated with 1 M sodium chloride at 37°C for 12 h to separate the epidermis from the dermis. Then, the separated dermis was incubated in PBS with continuous agitation at room temperature for 7–10 days to remove all the cellular components, and then stored at 4°C. The decellularized dermis (sodium chloride-treated ADM) with this method retains intact basement membrane structure. All procedures for the preparation and clinical application of ADMs were performed under the approval of the ethics committee of Kyorin University, Tokyo, Japan.

Preparation of Acellular Allogeneic Dermal Matrix (ADM)

ADM Transplantation with Simultaneous Skin Graft Overlay

Introduction

ADM (Fig. 14.1) was prepared by the following two methods. The first method was to create an ADM suitable for simultaneous skin graft overlay. Pieces of split-thickness (0.015 inch-thick) cryopreserved cadaver skin obtained from the official skin bank of Japan were rapidly thawed at 37°C in phosphate-buffered saline (PBS). The skin was treated with 0.25% of trypsin/1 mM EDTA solution for Y. Takami, MD, PhD (*) Plastic Surgery, Seibu General Hospital, Saitama, Japan Burn Center, Kyorin University Hospital, Tokyo, Japan e-mail: [email protected] S. Ono, MD, PhD Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School Hospital, Tokyo, Japan R. Ogawa, MD, PhD Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School Hospital, Tokyo, Japan e-mail: [email protected]

Clinical Results Trypsin-treated ADMs were used for the following clinical application. ADM was transplanted on excised full-thickness burn wounds with simultaneous STSG overlay (six wounds of five cases). All the transplanted ADMs and the overlaid thin (less than 0.010 inch-thick) STSGs (three meshed STSGs: and three sheet grafts) survived completely. The interstitial scar formation of overlaid meshed STSG was inhibited by ADM transplantation (Fig. 14.2). Histologically, the transplanted ADM was fully vascularized and remained as a stable dermal matrix in the wound (Fig. 14.3).

Discussion and Conclusion Dermal component was added and regenerated by ADM transplantation in full-thickness burn wounds. It is


Acellular Allogeneic Dermal Matrix

a

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b

⊡ Fig. 14.1 Histological appearance of acellular allogeneic dermal matrix (ADM). (a) Cryopreserved allogeneic skin. (b) ADM after decellularization of the allogeneic skin. H&E, original magnification, ×40

suggested that ADM transplantation may be a useful method to improve the conspicuous scar after thin meshed STSG in beep burn wounds.

Tissue-Engineered Autologous Skin Equivalent (TESE) Based on ADM as the Scaffold Preparation of TESE (Figs. 14.4 and 14.5) Sodium chloride-treated ADMs were used for the scaffolds of TESE. To prepare autologous keratinocytes, small samples of healthy skin (about 2 cm2) were obtained from four patients with extensive burns. The epidermis and dermis were separated by incubation with Dispase (Godo Shusei Co. Ltd., Tokyo, Japan) for 3 h at 37°C. The epidermis was treated with 0.25% trypsin/1 mM EDTA for 15 min at 37°C to disaggregate keratinocytes. The keratinocytes were collected, centrifuged, and resuspended in a keratinocyte growth medium (KGM; defined Keratinocyte-SFM, Gibco). The separated dermis was

cut into small pieces and placed in culture dishes to produce a culture of dermal fibroblasts. After the pieces of dermis had become attached to the culture dishes, 10% fetal calf serum (FCS)/Dulbecco’s modified Eagle’s medium was added to the dishes, which were then incubated at 37°C in 5% CO2/air. To create the TESE, the subcultivated autologous fibroblasts were seeded on the reticular side of the ADM with 2% FCS and KGM. Two days later, subcultivated keratinocytes were seeded on the basement-membrane side of the ADM. After 2 or 3 days of culture, the medium was changed to 10% FCS/KGM to induce keratinocyte differentiation. After an additional day of culture, the cultured TASE was transferred to an air–liquid interface to promote stratification. The resulting TESEs were washed thoroughly with Hanks balanced salt solution, then transplanted to patients. The average time required to create a TESE from the biopsied skin was 21 days. Histologically, TESE showed a well-developed epidermal layer, rete ridges, and normal dermal structures (Fig. 14.5c).

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a

b


c

e

⊡ Fig. 14.2 Appearance of ADM transplantation with simultaneous meshed split-thickness skin grafts (STSG) overlay. Case: a 38-year-old, female. A deep burn wound of the right thigh was excised. Wound before ADM transplantation (a) and the transplanted ADM with meshed STSG overlay (b). On the area below the black line, 5 × 7 cm of an ADM was placed and overlaid with

a 0.008 inch-thick, meshed STSG (c–e). On the area above the black line, only meshed STSG was placed. (c) Appearance at 7 days after the transplantation. (d) Appearance at 14 days after the transplantation. (e) Appearance at 21 days after the transplantation. The meshed scar formation was inhibited in the area with ADM transplantation (below the line)

Clinical Application

third-degree burn wound of the right thigh (Fig. 14.8). Case 4 was a 63-year-old man with second and thirddegree burns to 60% of the body surface. Seven sheets of TESE (four sheets of 5 × 5 cm-sized TESE and three smaller sized TESEs) were transplanted to the excised third-degree burn wound of the abdomen (Fig. 14.9).

Case 1 was a 29-year-old woman with second and thirddegree burns to 75% of the body surface. One sheet of TESE (5 × 2.5 cm) was transplanted to the excised thirddegree burn wound of the right thigh (Fig. 14.6). Case 2 was a 41-year-old woman with second and third-degree burns to 98% of the body surface. Four sheets of TESE (mean size: 5 × 5 cm) were transplanted to the excised third-degree burn wound of the abdomen (Fig. 14.7). Case 3 was a 36-year-old woman with third-degree burns to 46% of the body surface. Four sheets of TESE (mean size: 5 × 5 cm) were transplanted to the excised

Clinical Results (Figs. 14.6–14.9) Graft survival was evaluated 14 days after transplantation. The survival rate was 100% for case 1, 96% for case 2, 93% for case 3, and 90% for case 4. By 28 days after


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103

⊡ Fig. 14.4 Appearance of tissue-engineered autologous skin equivalent (TESE). A 5 × 5-cm-sized TESE in a Petridish is ready for the clinical transplantation

⊡ Fig. 14.3 Histology of transplanted ADM and overlaid STSG, 14 days after the transplantation. H&E, original magnification, ×40. S indicates area of the STSG. A indicates the area of transplanted ADM

a

b

⊡ Fig. 14.5 Production of TESE. (a) Cryopreserved allogeneic skin. (b) ADM after decellularization of the allogeneic skin. (c) Produced TESE. Keratinocytes and fibroblasts from

c

iopsied patient’s skin were seeded and cultivated in the b ADM. H&E, original magnification, ×40

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a

b

c

d

⊡ Fig. 14.6 Appearance of transplanted TESE. Case 1, a 29-year-old, female, right thigh. Wound before TESE transplantation (a), the transplanted TESE (5 × 2.5 cm) (b), 7 days after (c), and 42 days after (d). The TASE survived completely

a

b

c

⊡ Fig. 14.7 Appearance of transplanted TESE. Case 2, a 41-year-old, female, abdomen. Wound before TESE transplantation (a), the transplanted TESE (four sheets of TESEs,

mean size: 5 × 5 cm) (b), and 42 days after (c). The TASE survived well. Arrow indicates an ulcer due to biopsy for the histological examination


CHAPTER 14

a

b

c

d

⊡ Fig. 14.8 Appearance of transplanted TESE. Case 3, a 36-year-old, female, right thigh. Wound before TESE transplantation (a), the transplanted TESE (four sheets of TESEs,

mean size: 5 × 5 cm) (b), 14 days after (c), and 9 months after (d). The TASE survived well

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a

b

c

d

⊡ Fig. 14.9 Appearance of transplanted TESE. Case 4, a 63-year-old, male, abdomen. Wound before TESE transplantation (a), the transplanted TESE (four sheets of 5 × 5 cm-sized TESEs and three smaller sized TESEs) (b), 14 days after (c),

and 60 days after (d). Partial graft loss due to bacterial infection was observed, but the wound was healed with additional TASE transplantation

surgery, the areas to which TESEs had been transplanted had become completely epithelialized. There was no delayed graft loss, or graft fragility during the observation period (42–270 days). Abnormal pigmentation on the transplanted site was seen in all cases. Only case 4 suffered partial graft loss due to bacterial infection, but the wound was healed with additional TESE transplantation. Cases 1 and 2 died of multiple organ failure some 50 days after TESE transplantation. However, no evidence suggests that transplantation contributed to their deaths. Cases 3 and 4 were discharged to go home.

and epidermal structure with positive staining of antitype IV collagen (Figs. 14.10a and 14.11b). Transplanted ADM as the scaffold of TESE remained as a stable dermal matrix in the regenerated skin (Fig. 14.10b).

Histological Examination (Case 1) The TESE had become keratinized with a fully stratified epidermis and normal polarity of differentiation (Fig. 14.10a). The epidermis was firmly attached to the remaining basement membrane of the ADM (Fig. 14.11a). Transplanted TESE showed stable dermal

Discussion and Conclusion Although several types of ADM-based cultured skin have been introduced previously, results of the clinical trials have been far from satisfactory [6, 7]. In order to improve the clinical results, we have prepared ADMs without protease, surfactants, and further sterilizing procedures, which have been commonly used to prepare ADMs [6, 7]. It is suggested that our method of ADMpreparation retained more natural dermal structures, and thus, improved the property of ADMs as a scaffold of a tissue-engineered skin [4, 5]. We have concluded that TESEs based on ADM as a scaffold may be a useful tool for permanent repair of full-thickness burn wounds.


a

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b

⊡ Fig. 14.10 Histological appearance of TESE (case 1). Before transplantation (a), and 42 days after the transplantation (b). Arrow indicates the part of acellular ADM. H&E, original magnification, ×40

a

b

⊡ Fig. 14.11 Immunohistochemical staining of anti-type IV collagen to TESE (case 1). Before transplantation (a), and 42 days after the transplantation (b). Original magnification, ×100

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Application of Integra® in Pediatric Burns paul m. glat, john f. hsu, wade kubat, and anahita azharian

Background Treatment of burn wounds has always proved challenging in the pediatric population. When treating large surface area or complex burn wounds, pediatric patients frequently have limited area of graft donor sites [1]. Infants often have skin too thin to be harvested for skin grafting and to provide adequate coverage for reconstruction. Burn scars repeatedly become hypertrophic and are hard to treat. When they are treated successfully, recurrence rates are high. In the traditional surgical reconstructive ladder, various methods are available for the treatment of simple to complex wounds [1–3]. Simple wounds can be treated with primary or secondary closures and various graft materials. Complex wounds are often closed with tissue expansion and a variety of musculocutaneous or fasciocutaneous flaps. The development of Integra® has dramatically changed the treatment of burn wound by providing an additional option to the armamentarium of the reconstructive burn surgeon [1–3].

Integra® Integra® (Integra LifeSciences, Plainsboro, NJ) is a biosynthetic, implantable, bi-layered membrane system for skin

P. M. Glat, MD (*) Department of Plastic and Reconstructive Surgery, St. Christopher’s Hospital for Children, Philadelphia, PA 19134, USA e-mail: [email protected] J. F. Hsu, DO, MPA W. Kubat, DO A. Azaharian, DO, MPH Department of Plastic and Reconstructive Surgery, St. Christopher’s Hospital for Children, Philadelphia, PA 19134, USA

replacement [1, 4, 5]. It contains a dermal regeneration layer and a temporary epidermal layer. The temporary epidermal layer is composed of synthetic polysiloxane polymer (silicone) [4, 5]. This layer enables immediate wound closure and provides a mechanical barrier against bacterial invasion. It also functions similar to normal skin by retaining moisture while allowing water vapor transmission [1, 6]. The dermal regeneration layer is composed of a three-dimensional porous matrix of cross-linked bovine collagen and glycosaminoglycans (chondroitin-6-sulfate) [4, 5]. This layer functions by promoting cellular growth and collagen synthesis. Biodegradation is defined while the layer is being replaced by autologous dermal tissue. Integra® application begins with complete excision of the full-thickness wound or scar contracture down to viable tissue [1, 6]. Once a viable tissue bed is achieved, meticulous hemostasis is important to prevent postoperative hematoma and complications. A sheet of Integra® is then applied to the wound bed with the silicone layer remaining intact. When multiple sheets are applied, they should abut each other to prevent dense granulation formation which later results in scar [1]. Integra® should adhere to the tissue bed and wound edges to promote neovascularization into the matrix (Fig. 15.1).

Neodermis Generation The neodermis generates in the dermal layer over the next 21 days. The integration and replacement can be divided into four phases: imbibition, cellular migration, neovascularization, and remodeling and maturation [1, 7]. During imbibition, red blood cells and fibrin assist in adhering the matrix to the wound. In the second phase (~day 7), fibroblasts migrate into the matrix and begin to produce collagen [1, 7]. Neovascularization begins when endothelial cells migrate in and carry with them blood and nutrients (~day 14) [1, 7]. Remodeling and maturation occurs in the last stage similar to normal wound healing. The


Application of Integra® in Pediatric Burns

CHAPTER 15

⊡ Fig. 15.1 Integra® application begins with complete excision of full-thickness wound. This is followed by meticulous hemostasis. A sheet of Integra® is then applied to the wound bed with the silicone layer remaining intact

neodermis gradually changes color during the process from red to peach colored to yellow (Fig. 15.2). The neodermis formation is completed around day 21. The silicone layer is removed in the operating room immediately prior to autografting. Due to the neodermis generated from Integra®, only a thin epidermal autograft is needed for the final stage of the surgery [1, 6] (Fig. 15.3).

This results in faster donor site healing with minimal scarring while providing opportunities for earlier donor graft reharvesting (Fig. 15.4). This also provides the equivalent of a full-thickness skin graft with only the donor site of a split-thickness graft. The aesthetic appearance of the graft is also generally improved when compared to standard split-thickness autograft (Fig. 15.5).

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Day 0

Day 7

Day 14

Day 21

⊡ Fig. 15.2 The integration and replacement can be divided into four phases: imbibition (day 0), cellular migration (day 7), neovascularization (day 14) and remodeling and maturation (day 21)

Advantages and Disadvantages Some of the clinical advantages of Integra® are listed below:

• • • • • •

Minimize size/number of reconstructive procedures Immediate physiologic wound closure No temporary coverings No risk of rejection Potential for early ambulation/rehabilitation Delay in the need to create donor site wounds

However, the clinical disadvantages should also be noted and include:

• Requirement of multiple operations (minimum two) • Requirement of rigorous surgical technique and monitoring • Labor intensive postoperatively • Cost With Integra®, the advantages far outweigh the disadvantages. The single greatest benefit of Integra® is its versatility in the treatment of pediatric wound care. Integra® can be applied in every level of the traditional reconstructive ladder (Fig. 15.6). Several representative cases are provided below as examples of the excellent results obtainable with the use of Integra® (Figs. 15.7–15.9).


CHAPTER 15

⊡ Fig. 15.3 Due to the neodermis generated from Integra®, only a thin epidermal autograft is needed for the final stage of the surgery

⊡ Fig. 15.4 Integra® result in faster donor site healing with minimal scarring while providing opportunities for earlier donor graft reharvesting

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Split-Thickness Autograft Integra® Template Site Split-Thickness Autograft Integra® Template Site

⊡ Fig. 15.5 The aesthetic appearance of the graft is also generally improved when compared to standard split-thickness autograft


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113

The Reconstructive Ladder Bone, Tendons, etc ...

Complicated

Skin Expansion Single Sequential

INTEGRA template (could be an alternative)

Flaps Free Flaps Penninsular Island Local Distant Random Cutaneous pattern Myocutaneous Axial Arterial

{

INTEGRA template (could be an alternative)

{

Grafts Split-thickness Full-thickness Autografts, Allografts, Xenografts

INTEGRA template (could be an alternative) INTEGRA template (if donor sites could be a problem)

Wound Closure Primary: Direct approximation: (z-plasty) Secondary: Spontaneous healing: (granulation) Tertiary: Delayed wound closure: (infected)

Simple

⊡ Fig. 15.6 The reconstructive ladder

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114


a

b

c

d

⊡ Fig. 15.7 Seven-year-old boy, 2 years status post third degree scald burn to left chest and upper extremity with split-thickness skin graft. (a) Hypertrophic scars of left chest and upper extremity. (b) Mature Integra® in place 2 weeks

after excision of scar. (c) Thin autograft applied to neodermis in the operating room. (d) Well-healed Integra® with thin autograft 8 years post operation


CHAPTER 15

a

b

c

d

⊡ Fig. 15.8 Eighteen-year-old boy 1 year status post third degree burn to head and neck. (a) Hypertrophic right cheek scar at the time of excision in operating room. (b) Mature Integra® in place 2 weeks after placement. (c) Thin autograft

applied onto neodermis in the operating room. (d) Wellhealed wound with Integra® 1 year post operation. Note the good aesthetic result despite crossing aesthetic units

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a

b

c

d

e

f

⊡ Fig. 15.9 Case of necrotizing fasciitis of left hand dorsal surface. (a) Open wound on the dorsum of left hand after debridement. (b) Integra® in place 2 weeks after placement.

(c) Mature neodermis prior to autograft. (d) Well-healed autograft. (e, f) Excellent range of motion after Integra® with thin autograft

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Pediatric Burn Reconstruction paul m. glat, anahita azharian, and john f. hsu

Background In the past, pediatric burn injuries were devastating and often fatal. With improved burn resuscitation techniques in children, multidisciplinary approach to burn management and early excision and grafting, survival has become the norm. Now, with better survival, burn reconstruction has taken on a major role in the management of these patients. The basic concerns in pediatric burn reconstruction are function, comfort, and appearance. Normal and hypertrophic scarring, scar contractures, loss of anatomic structures, loss of function, and changes in color and texture of injured skin are common concerns among all burn patients and yet unique to each [7, 8]. To understand burn reconstruction, one must have a good understanding of wound healing and scar maturation in order to plan for adequate timing and reconstructive technique. The reconstructive ladder principle of starting simple when possible and progressing to more complex techniques is the basis for pediatric burn reconstruction.

Selection of Methods In all instances, the burn injury is assessed for the deficiency of tissue and distortion of anatomy. Traditionally, if there is no deficiency and local tissues are easily

P. M. Glat, MD (*) Department of Plastic and Reconstructive Surgery, St. Christopher’s Hospital for Children, Philadelphia, PA 19134, USA e-mail: [email protected] A. Azharian, DO, MPH J. F. Hsu DO, MPA Department of Plastic and Reconstructive Surgery, St. Christopher’s Hospital for Children, Philadelphia, PA 19134, USA

mobilized, excision and direct closure or Z-plasties can be performed. However, if there is deficiency in tissue, the need for skin replacement becomes critical. With advances in burn reconstruction, tissue expanders have become a great option not only for improved cosmetic results, but also for decrease in donor site morbidity. Tissue expanders are useful, particularly in the head and neck, especially in correction of burn-associated alopecia. This, however, involves multiple visits for expansion and a final surgery, weeks to months later for the reconstructive phase. Tissue expanders also have a high incidence of complications, including infection, tissue ischemia, and even extrusion of the expander, requiring removal and restarting the reconstructive process. Like tissue expanders, regional and even free flaps offer an important option in selected difficult wounds, such as those associated with high voltage injury and extensive soft tissue loss of the distal lower extremity [8]. For example, fasciocutaneous flaps can be raised on the chest wall to cover small full-thickness burns of the hands in selected cases. The flap is then usually divided in 3 weeks from its donor site to provide coverage [8]. Another example is a latissimus dorsi microvascular free flap being used to cover a large scalp defect with exposed calvarium after a high voltage electrical injury. These flaps not only provide excellent quality tissue replacement, but also have potential complications such as ischemia, flap loss, and high rates of donor site morbidity. Cultured epidermal autograft is another approach for skin coverage of the excised burn wound. These grafts are grown in the laboratory from a biopsy of the patient’s own skin. Several weeks after the biopsy, the grafts are applied to the wound bed. These grafts are particularly useful in very large surface area burns where there is minimal to no donor site availability for autologous grafts [1, 3]. However, the healed grafts are extremely fragile and susceptible to infection, shear, and dressing changes. In addition, the cost to produce these grafts is high.


Pediatric Burn Reconstruction

Further Advancements In the last decade there have been further advances in the world of pediatric burn reconstruction such as the use of dermal replacement matrices such as cadaveric acellular dermal grafts or Integra® dermal regeneration template. These dermal matrices allow for a better quality graft with a much thinner autograft harvest, which in turn improves functional outcome (decreased scarring

CHAPTER 16

and contractures) and decreases donor site morbidity [4]. This may also result in improved cosmesis of the grafting procedure by reducing hyperpigmentation, hypopigmentation, and mesh pattern seen in the recipient graft site as well as improved cosmesis in the thin donor site area [2, 5]. Several representative cases are provided below as examples for some of the above mentioned reconstructive techniques.

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Clinical Cases + Case 1 Two-year-old female with full thickness cigarette burns to the lateral aspect of the right eye (a). Intraoperative markings of myocutaneous rotational flap reconstruction (b). Myocutaneous rotational flap from upper eyelid to the lower eyelid (c). Six month follow-up status-post flap reconstruction (d).

16


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a

b

c

d

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+ Case 2 One-year-old male with full thickness burns on the palm of the hand (a). Reconstruction with cadaveric acellular dermal grafts, split-thickness and fullthickness skin grafts. Six month follow-up status-post reconstruction (b).

16


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b

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+ Case 3 Comparison of recipient sites from traditional split-thickness skin graft vs. STSG and Integra® (a, b). Decreased donor site morbidity and improved cosmesis with thinner split-thickness skin graft harvest when used in conjunction with Integra® (c). Increased donor site morbidity and scarring with traditional split-thickness skin graft harvest site (d, e).

16


a

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b

c

d

e

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+ Case 4 Eight-year-old female with full-thickness burns to left flank (a, b). Intraoperative application of Integra® (c). Three weeks status-post Integra® application with thinner split-thickness skin graft reconstruction (d). Eight year follow-up visit. Donor site at 8 year follow-up (e).

16


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a

b

c

e

d

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+ Case 5 Eight-year-old male with full-thickness burns to right axilla with grafting. Patient developed contracture with decreased range of motion of right upper extremity (a). Intraoperative markings for scar excision (b). Wound defect after scar excision (c). Single stage application of Integra® and split-thickness skin graft (d). Three month follow-up with full range of motion of the right upper extremity (e).

16


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a

b

c

d

e

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+ Case 6 Two-year-old male with 87% total body surface area full-thickness flame burns. Patient status-post burn excision and Integra® application (a). Three weeks after excision and Integra® application, cultured epidermal autograft was applied (b). Four weeks after the application of cultured epidermal autograft and newly regenerated skin (c).

16


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Skin Grafting matthew klein

Introduction and Historical Perspective Timely burn wound excision and skin grafting form the cornerstone of acute burn surgical management. In addition, skin grafting remains one of the most useful tools in the burn reconstruction armamentarium. Grafts are often the first choice to fill defects created from scar contracture release and from excision of large areas of hypertrophic scar. The first known report of skin grafting comes from the Sushruta Samhita, an ancient Indian surgical text that may date as far back as the seventh century, bc. This text described the use of both skin grafts and flaps for a variety of facial reconstructive procedures. The Indian method of grafting was first introduced to Western medicine by English surgeons in the eighteenth century. It was not until 1804 that successful transplantation of free skin grafts was reported by Baronio of Milan, who successfully grafted large pieces of autogenous skin onto different sites on sheep [1]. Several decades later, in 1869, Guyon and Jacques Reverdin described the use of a small epidermal graft, which became known as the pinch graft, in a report to the Societe Imperiale de Chirurgie [1]. However, this technique did not gain wide recognition until 1870, when successful experiments in skin grafting for the treatment of burn patients were performed by George David Pollock [2]. In 1872, Ollier described the use of both full-thickness and split-thickness skin grafts, and realized the possibility of covering large areas with such grafts if a satisfactory method of cutting them could be devised [1]. It was not until the description of grafting techniques by Blair and Brown that skin grafting gained wide acceptance. They distinguished between

M. Klein, MD University of Washington Burn Center, USA e-mail: [email protected]

epidermal, partial thickness, and full-thickness grafts and, importantly, demonstrated reliable healing of donor sites if a portion of the dermis was not harvested [3, 4]. Over the past several decades, there have been a number of advances in the tools available for skin graft harvest, as well as graft meshing. The decision to use skin grafts rather than local flaps or tissue rearrangement should be based on the availability of local tissue (i.e., if there is significant scarring in tissue adjacent to the area requiring coverage) and the amount of tissue deficiency. Areas with scar contracture typically have a significant amount of tissue deficiency that cannot be adequately addressed with a Z-plasty, V-Y plasty, or Y-V plasty. However, there are many potential challenges to skin grafting for burn reconstruction primarily related to donor site deficiency. Patients who have sustained extensive burns have few areas of skin that were either unburned or not previously used as donor sites to achieve initial wound closure.

Classification of Skin Grafts Skin grafts can be classified by both their thickness and whether or not they are meshed following harvest.

Split-Thickness and Full-Thickness Grafts Skin grafts can be classified by their thickness – as either split-thickness skin grafts (STSG) or full-thickness skin grafts (FTSG). This classification is based on the amount of dermis included in the graft – with FTSGs including the entire thickness of the dermis and STSGs including a portion of the thickness of dermis. STSGs can be further classified as thin or thick, again depending on the depth of dermal harvest. The thinner the skin graft, the greater the degree of contraction that is likely to occur at the recipient site. This is an important consideration


Skin Grafting

CHAPTER 17

a

b

c

d

⊡ Fig. 17.1 (a–d) Technical aspects of skin grafting. (a) Templates using glove wrapper can be used to ensure an appropriate area of skin graft is harvested. (b) Split-thickness skin grafts (STSG) are used when larger areas of coverage are needed. In order to facilitate harvest, particularly over areas of bony prominence or lax tissue, tumescing the donor site with isotonic solution can be used. In the scalp, epinephrine

(1:500,000) can be used to assist in hemostasis. (c–d) In order to minimize graft sheer and ensure adequate contact between the wound bed and graft, particularly in areas of concavity, bolster dressings or the vacuum-assisted closure as shown here over a neck graft (c) can be used. For extremity grafts, an Unna’s boot (d) can provide vascular support and minimize shearing

when skin grafts are applied across mobile joint surfaces. Split-thickness grafts are commonly used to cover larger defects such as following an axillary contracture or the following excision of a large area of hypertrophic scar (Figs. 17.1–17.3). FTSG are particularly useful for reconstructing defects of the hand and the face. For example, moderate to severe web-space contractures in the hand are often managed with full-thickness grafts, particularly when there is a significant amount of tissue deficiency that cannot be adequately addressed using a Z-plasty. Fullthickness grafts are commonly harvested from the inguinal region, flank, or from postauricular area. These donor sites can be closed primarily and care should be taken to select a harvest site that does not contain hair. Larger full-thickness grafts can be harvested following tissue expansion [5] (Figs. 17.4–17.6).

Meshed vs. Sheet Grafts Skin grafts can be further classified as meshed or unmeshed (sheet) grafts. Sheet grafts are applied without altering following harvest, whereas meshed grafts are passed through a machine that produces fenestrations in the graft. Grafts can be meshed at ratios of 1:1– 4:1. Meshing allows the egress of serum and blood from wounds, thereby minimizing the risk of the formation of hematomas or seromas that could compromise graft survival. In addition, meshed grafts can be expanded or stretched to cover larger surface areas. When grafts are meshed at ratios of 3:1 or higher, allograft skin or another biologic dressing can be applied over them to prevent the interstices from becoming desiccated before they close. Because of the lack of dermis in the interstices, widely expanded mesh always scars, takes a long time to

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a

b

c

d

⊡ Fig. 17.2 (a–d) Full-thickness skin grafts (FTSG) for digit contractures. FTSG are commonly used following release of contractures in the hand and face. This is a 16-yearold male who sustained a hand burn as a child and developed flexion contractures of his two to five digits (a). Following

a

scar release, k-wires were placed to maintain the digits in extension (b) and the soft-tissue defects were filled with FTSG harvested from the inguinal region. Three months following surgery, the grafts are well healed and the patient has full extension (c, d)

b

c

⊡ Fig. 17.3 (a–c) Full-thickness skin grafting for ectropion repair. This is a 25-year-old male who sustained full thickness burns to his face. He developed severe cicatricial ectropion (a). Following scar release, the skin defects were closed using FTSG from the flank (b). Traction sutures were used to

facilitate ectropion release and were kept in place for 1 week postoperatively. A bolster of cotton rolls was used to secure the graft and minimize fluid accumulation and sheer. Graft healing and lid position are shown at 3 months postoperatively in (c) (Images courtesy of Loren Engrav, MD)

Skin Grafting

a

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b

c

wrist contracture was released by incising the scar, leaving a large defect (b) that was closed using a split-thickness skin graft (c)

⊡ Fig. 17.4 (a–c) Split-thickness skin graft for wrist contracture. This 4-year-old girl developed severe wrist contracture following extensive full-thickness burn injury (a). The

a

b

c

⊡ Fig. 17.5 (a–c) STSG following hypertrophic scar excision. A 48-year-old man sustained deep partial thickness burns after a sulfuric acid burn. He developed a large area of

hypertrophic scar on his chest and neck that limited his neck range of motion (a). He underwent scar release (b) and wound closure with a thick (0.016˝ ) split-thickness skin graft (c)

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a

Skin Grafting

b

c

⊡ Fig. 17.6 (a–c) Split-thickness skin graft for neck contracture. This 9-year-old boy sustained full-thickness burns to his neck and chest. He developed a neck contracture (a) that was released and the resulting defect closed with

thick split-thickness skin graft (b). One year later, the graft has healed well and the patient has not developed a recurrent contracture (c) (Images courtesy of Loren Engrav, MD)

Skin Grafting

close, and results in permanent unattractive mesh marks. For these reasons, widely meshed grafts are rarely, if ever, used in burn reconstructive procedures. Sheet grafts should be used on the face, the neck, the hands, and, whenever possible, on the forearms and the legs. In these exposed areas, the superior cosmetic and functional results obtainable with sheet grafts make such grafts preferable. Since sheet grafts have no interstices, they must be closely monitored and periodically rolled with a cotton-tipped applicator to drain any fluid collection. Any serious or bloody blebs that form beneath the graft should be incised with a No. 11 scalpel and drained expeditiously. A common practice known as pie crusting, which involves making incisions in a sheet graft at the time of surgery, actually does not yield much improvement in graft survival, because blebs often form in areas without incisions.

Donor Site Selection and Skin Graft Harvest For burn reconstruction, donor site selection is based on the type of graft needed (full- vs. split-thickness) and the availability of donor sites. Inventory of available donor sites should be performed during the preoperative evaluation of the patient. If possible, previous operative notes should be reviewed to determine which areas have been harvested previously and how many times. Recropping of previous harvested donor sites is possible, but not ideal since this limits the amount of dermis that can be included in the graft. Color match should also be a consideration particularly while skin grafting the face and neck. The scalp provides optimal color match for the face and neck and should be considered when grafting these areas. Discussion and selection of appropriate donor sites should be done with the patient whenever possible. STSG are typically harvested by a dermatome. Dermatomes can be electric or air-powered. The thickness can be set prior to harvest, although this typically serves only as a guide as ultimate harvest thickness is determined both by the dermatome setting and the pressure applied by the person harvesting skin. The maintenance of appropriate skin tension is essential to ensuring a successful harvest. On certain anatomic areas such as the back, abdomen, and scalp, tumescence of the skin with isotonic solution is required to facilitate harvest. Epinephrine (1:500,000) is added prior to scalp harvest to minimize donor site bleeding. Ideally, when correcting burn contractures, thicker grafts are preferred since the amount of wound contraction is inversely related to

CHAPTER 17

dermal thickness. Therefore, if suitable donor sites are available, split-thickness grafts should be harvested at 0.016–0.020” to repair joint contractures (i.e., neck, axilla, and elbow). FTSG are typically used for closure of defects on the face (eyelids, lips) and hands (web space and digit contractures). FTSGs are typically harvested using a scalpel. The inguinal region provides an excellent donor site for FTSGs. Prior to harvest, a template of the recipient site is fabricated and used to guide the area of skin to be harvested. The donor site can be infiltrated with local anesthetic with epinephrine, again both to facilitate harvest and provide hemostasis. Following skin graft harvest, the wound edges are undermined so a tension-free closure can be achieved. For small defects on the face, FTSG can be harvested from the supraclavicular area, the neck, the upper eyelids (in older adults with skin laxity), or from behind the ear. Harvest from this area typically provides a superior color match than skin harvested from below the clavicles. However, in cases of extensive burn injuries, these preferred donor sites might not be available. In addition, attempt should be made to select donor sites for reconstruction from areas where the initial grafts were taken in order to optimize color match. For example, if the face was initially grafted using skin from the trunk or lower extremities, donor sites from the flank or inguinal region may be preferred over the supraclavicular or postauricular area.

Skin Substitutes An off-the-shelf skin replacement containing both a dermal and epidermal component would be ideal for burn reconstruction procedures – particularly if donor sites are limited. However, despite decades of research, a perfect artificial skin solution remains a distant hope. However, existing artificial technologies have been used in burn reconstruction [5, 6]. Artificial dermal templates provided by products such as Integra (Integra Life Sciences, Plainsboro, New Jersey) can be useful to augment the native dermis available in thinner split-thickness grafts, and therefore potentially reduce the risk of scarring and recontracture.

Skin Graft Dressings Once a skin graft is secured in place, a dressing may be applied to protect it from shearing, as well as to accelerate closure of meshed graft interstices. Numerous options

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for graft dressings exist, including wet dressings and greasy gauze. The use of a nonadherent dressing such as Conformant two (Smith and Nephew, Largo, FL), along with an outer antimicrobial wet dressing, allows the overlying dressings to be periodically removed without dislodging the graft from the wound bed. Bolsters consisting of cotton and greasy gauze are employed to help grafts conform to concave wound surfaces, and splinting of extremities may be necessary for safe graft immobilization, especially over joints. The Vacuum Assisted Closure system (Kinetic Concepts Inc., San Antonio, Texas) is another option for promoting graft healing. Alternatively, an Unna’s boot can be placed on both the upper and the lower extremity to immobilize the graft and provide vascular support, allowing mobilization of the extremity in the immediate postoperative period [7]. Sheet grafts can be either left open to the air to allow continuous monitoring and rolling (depending on the patient) or wrapped with dry dressings, which can be removed if necessary to allow interval inspection and deblebbing. Following contracture release, custom-made splints are used to maintain adequate positioning. These splints

Skin Grafting

are typically left in place for 1 week postoperatively. At that time, the splints are removed, graft healing assessed, and then range of motion is started. Splints are generally used for weeks to months following contracture release to minimize the risk of recurrent contracture. The duration and schedule of splint use are determined on a case by case basis. There are also various options for donor-site dressings. The ideal donor-site dressing would not only minimize pain and infection, but also be cost-effective. Greasy gauze and Acticoat® (Smith and Nephew, Largo, FL) are often employed for this purpose. Typically, these dressings are left in place until the donor site reepithelializes, at which time the dressing is easily separated from the healed wound. Op-Site®, a transparent polyvinyl adherent film, is also commonly used. With Op-Site®, the underlying wound is easily examined without the removal of the dressing. However, intermittent drainage of the wound fluid that accumulates is necessary. Op-Site® does not work well over joint surfaces and concave or convex areas (e.g., the back). Silver sulfadiazine in a diaper is an excellent covering for buttock donor sites in children; dressing changes can be done with each diaper change.

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Skin Graft for Burned Hand wassim raffoul and daniel vincent egloff

Introduction Hand lesions are found in more than 75% of major burns and in 50% of all burned patients [1, 2]. Mismanaging this trauma has deleterious consequences on patient rehabilitation and may leave lifelong, disgraceful, and invalidating scars [3]. The dorsum of the hand is its social side and most frequently presents deep burns. Superficial burns heal spontaneously without any functional or cosmetic consequences. On the other extreme, third-degree burns, in the best of cases, frequently end with severe functional and cosmetic prejudices and may even necessitate in the worst situations finger or hand amputations. Although the management of a second-degree burned hand is one of the most challenging surgical lesions, it should be managed as any severe hand trauma and according to the standards of acute burn modern treatment. During the past 10 years, the authors developed a management concept based on those two fundamental principles.

aspect of the thumb, index, and third finger, and on the radial aspect of the two other fingers. In case of severe hand edema, carpal tunnel has to be opened, as well as incision of the skin covering the thenar (Fig. 18.1). 2. Superficial burns are covered with a silver sulfadiazine cream for 24 h (Fig. 18.2) and then with hydrofiber or hydrocellular dressings. The dressings have to be maintained 10–12 days. The superficial layers will be changed every 5 days, but the hydrocellular dressing has to be kept in place until spontaneous detachment (Fig. 18.3).

Methods Hands are considered and treated as priority areas. A standard protocol is applied. 1. Edema prevention and treatment [4, 5]. Hyperhydration prevention. Hand elevation. Antioxydant supplementation. Escarotomy, if there are risk and signs of vascular and/ or neurological compression. Incisions have to be done on the lateral and dorsal side of the fingers and dorsum of the hand. The incision line should be on the ulnar

⊡ Fig. 18.1 Escarotomy incisions

W. Raffoul, MD (*) Plastic Surgery Department, BH 10, CHUV, 1011 Lausanne, Switzerland e-mail: [email protected] D. V. Egloff, MD Plastic Surgery Department, BH 10, CHUV, 1011 Lausanne, Switzerland

⊡ Fig. 18.2 Second superficial. Twenty-four hours treatment with silver sulfadiazine


Skin Graft for Burned Hand

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⊡ Fig. 18.5 Fibrin glue sealing ⊡ Fig. 18.3 Result after 12 days treatment with hydrofiber dressings

⊡ Fig. 18.6 Dressing, paraffin gauze

⊡ Fig. 18.4 Thin nonmeshed skin graft

3. Surgery. Early debridement third to fifth day posttrauma. Laser Doppler evaluation can help surgical decision. Tangential debridement with weck knife. Preservation, if possible, of all living tissues (fat, fascia, para-tendon, vessels…) Coverage with thin nonmeshed grafts sealed with fibrin glue (Figs. 18.4 and 18.5). First lightly compressive dressing (Figs. 18.6–18.9). First dressing replaced at the fifth day (Fig. 18.10). 4. Early rehabilitation. Early active and passive mobilization starts after the first dressing placement (between the third and the fifth post-op day). Pain prevention during the treatment. Early compression with elastic autoadhesive rubber bandages (Fig. 18.11). Splinting in functional position only during the night.

⊡ Fig. 18.7 Kerlix bandage

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⊡ Fig. 18.11 Autoadhesive elastic rubber bandage

⊡ Fig. 18.8 Light compressive bandage

⊡ Fig. 18.12 Compressive gloves

⊡ Fig. 18.9 Light compressive bandage

⊡ Fig. 18.10 First post-op dressing

5. Long-term rehabilitation. Compression with Jobst type gloves as soon as possible (depending on complete wounds healing) (Figs. 18.12 and 18.13). Long-term specialized physiotherapy and functional therapy (Figs. 18.14 and 18.15).

⊡ Fig. 18.13 Compressive gloves

6. Reconstruction and coverage of deep structures. Dermal substitutes are used if deep structures are exposed [6, 7] (capsular system, ligaments) (Fig. 18.16).


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In case of tendons exposure, the reconstruction with a free temporal fascia flap is our first choice (Figs. 18.17–18.22).

⊡ Fig. 18.14 Result at 3 months

⊡ Fig. 18.17 Extensor tendons reconstruction

⊡ Fig. 18.15 Result at 3 months ⊡ Fig. 18.18 Coverage with temporal fascia free flap

⊡ Fig. 18.16 Matriderm™ dermal substitute

⊡ Fig. 18.19 Nonmeshed thin skin graft sealed with fibrin glue

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utologous keratinocyte and fibroblast coculture in A association with dermal regeneration template are the best coverage solution in major burns (more than 80% BSA) [8, 9].

Conclusion Early debridement, coverage with thin nonmeshed skin grafts and early compression by elastic adhesive bandages, is our method of choice in the treatment of deeply burned hands. It allows the achievement of the two main goals in hand treatment, good function and a pleasant cosmetic aspect.


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Tips for Skin Grafting masahiro murakami, rei ogawa, and hiko Hyakusoku

Introduction Skin grafting is a common method of burn reconstructive surgery. The success of a skin graft depends on (1) appropriate debridement and cleanup of the recipient site down to the layer providing the blood supply; (2) adequate hemostasis of the recipient site to prevent the development of hematoma; and (3) sufficient compression of the graft from one corner to another, which can be achieved with the use of a tie-over dressing or bandages. We offer three suggestions to reduce complications: (1) use of a metallic sponge for debridement, (2) use of a flower holder to create a drainage hole, and (3) use of external wire frame fixation for skin grafting.

Debridement with a Metallic Sponge Appropriate debridement is necessary for wound bed preparations for skin grafting. Debridement by surgical [1], hydrosurgical [2], biological [3], and chemical [4] methods has been reported and the usefulness of these methods are discussed. However, simple metallic sponges of the sort used in kitchens are effective for intraoperative surgical debridement (Fig. 19.1a–c). Such sponges are readily available, cheap, and can be sterilized easily. Simple wiping of the wound surface is

M. Murakami, MD, PhD (*) Department of Plastic and Reconstructive Surgery, Nippon Medical School, Musashi Kosugi Hospital, Tokyo, Japan e-mail: [email protected] R. Ogawa, MD, PhD Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School Hospital, Tokyo, Japan e-mail: [email protected] H. Hyakusoku, MD, PhD Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School Hospital, Tokyo, Japan e-mail: [email protected]

enough to remove debris, especially granulation tissue and soft eschar. This may be a very primitive method compared with hydrosurgical or chemical debridement, but we believe that metallic sponges are ideal for the purpose.

Creation of Drainage Holes with a Flower holder Hemostasis is especially important in blood-rich regions such as the scalp, face, and hands. When skin grafts are used in such areas, they should include drainage holes, which are also useful for draining bacteria and exudates. However, since large drainage holes leave scars, several small holes are preferable. To make such holes, Japanese “Kenzan” flower holders (Fig. 19.2a) are far more effective than surgical knives or needles in order to prevent outstanding scars. The graft is placed on the flower holder’s needles and held in place with a rubber sheet (Fig. 19.2b, c). The rubber sheet is then beaten with a hammer (Fig. 19.2c), quickly perforating the graft with numerous small holes (Fig. 19.2d, e). These holes suffice for drainage and become epithelialized in about 10 days.

Skin Grafting by External Wire Frame Fixation We have used external wire frame fixation for skin grafts since 1986. In 1991, we reported this method and described two advantages: (1) the technique is useful for securing grafts to wound beds; and (2) it prevents the graft edges from lifting [5]. We also confirmed the usefulness of this technique for skin grafts in regions with free borders, such as the lips and eyelids [6]. External wire frame fixation is particularly useful for eyelid grafts, as it overcomes the disadvantages of tarsorrhaphy [6]. Moreover, threedimensional external wire frames are also useful for fixing digital joints as well as skin grafts [7]. If this method is used for digital skin grafting, the digital joints do not need


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c

b

a

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⊡ Fig. 19.1 Debridement with a metallic sponge. (a) Metallic sponge. (b) Preoperative view. (c) Intraoperative view

a

e

b

c

f

d

g

⊡ Fig. 19.2 Creation of drainage holes with a flower holder. (a) Japanese flower holder. (b) Flower holder, skin graft, rubber sheet, and hammer. (c) Perforation of skin graft with hammer. (d) Perforated skin graft. (e) View of small drainage

holes in the skin graft. (f) Intraoperative view; numerous drainage holes can be seen. (g) 1 month after the operation, the drainage holes are completely epithelialized with no scarring

to be fixed by pinning, which is particularly useful for grafting of the palmar surfaces of fingers. During surgery, the usual method is used to fix the skin graft with sutures (Fig. 19.3). At the same time, a wire frame consisting of 1.0-mm-diameter Kirschner

wire is made in the shape of the graft itself; it is applied to the graft and attached with the same sutures already used for stitching the graft. Tie-over fixation is performed in the usual way.

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⊡ Fig. 19.3 Schema of skin grafting by external wire frame fixation



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Clinical Cases of Skin Grafting with External Wire Frame Fixation + Case 1 (Fig. 19.4)

19

A 57-year-old man suffered facial burns in an accident, and left lower eyelid ectropion developed after 2 months of conservative treatment. A full thickness skin graft was harvested from the supraclavicular area. The graft was fixed using external wire frame technique without tarsorrhaphy, and the patient was able to open and use his left eye soon after the operation. The postoperative course was uneventful, and no contracture of the lower eyelid has been observed.


CHAPTER 19

a

b

c

d

⊡ Fig. 19.4 Lower eyelid reconstruction using skin grafting with external wire frame. (a) Preoperative view. (b) Applied skin graft and external wire frame. (c) Postoperative view (eyes open). (d) Postoperative view (eyes closed)

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+ Case 2 (Fig. 19.5)

19

A 13-year-old boy suffered burns to his entire face in a house fire, and severe upper lip contracture developed after 2 months of conservative treatment. A full thickness skin graft was harvested from the upper arm. Tight fixation of the grafted skin was achieved using external wire frame fixation technique, and the patient was able to open his mouth and eat normally soon after the operation. The postoperative course was uneventful, and no contracture of the upper lip has been observed.


a

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b

d

⊡ Fig. 19.5 Upper lip reconstruction using skin grafting with external wire frame. (a) Preoperative view. (b) Intra operative view; indicates the dermis of the full thickness

skin graft. (c) Applied skin graft and external wire frame. (d) Postoperative view

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+ Case 3 (Fig. 19.6)

19

A 42-year-old man suffered burns to his entire face in a suicide attempt; the left auricle was damaged. Auricle reconstruction without cartilage was planned to create a sulcus to support the arm of a pair of spectacles. A threedimensional external wire frame was made from 1.0-mm-diameter Kirshner wire, and a full thickness skin graft was harvested from the lower abdomen. Tight fixation of the grafted skin was achieved, and the postoperative course was uneventful.


a

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b

⊡ Fig. 19.6 Ear reconstruction using skin grafting with external wire frame. (a) Preoperative view: incision line. (b) Applied skin graft and three-dimensional external wire frame

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+ Case 4 (Fig. 19.7) Squamous cell carcinoma developed in the burned scar of the right cheek of a 61-year-old man. The carcinoma was excised along with the surrounding scar tissue and fatty tissue. The skin defect was reconstructed with a full thickness skin graft harvested from the supraclavicular area using external wire frame fixation technique. The grafting was completely successful and the postoperative course uneventful.

19


a

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b

c

⊡ Fig. 19.7 Cheek reconstruction using skin grafting with external wire frame. (a) Applied skin graft and external wire frame. (b) Immediately after removal of the tie-over fixation. (c) Postoperative view

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C h a p t e r 20

Z-Plasties and V-Y Flaps shigehiko suzuki, katsuya kawai, and naoki morimoto

Z-Plasties A linear scar contracture is usually repaired by using Z-plasty. However, the scar itself remains even if the contracture is released. Therefore, it would be useful to reduce any unsightly scarring at the time of release of contractures. Modified planimetric Z-plasties are useful for this purpose.

Conventional Z-Plasties Conventional Z-plasty is one of the most common techniques in plastic surgery (Fig. 20.1). The execution of a conventional Z-plasty produces stereometric elongation of a cutaneous contracture (Fig. 20.2). The scar ridge becomes a dent after the Z flaps are exchanged. Therefore, large Z-plasty is effective especially in concave linear longitudinal contractures.

Modified Planimetric Z-Plasties Planimetric Z-plasty was first reported by Roggendorf [7, 8]. In his method, the longer lateral limb A is as long as the longer central limb D, and the vertical angle is 75°. The shaded portions are excised when the flaps are transferred (Fig. 20.3a). Planimetric Z-plasty is useful

for irregular scarring with slight contracture, but when the contracture is severe, the longer lateral limb shrinks immediately after incision (Fig. 20.3b). Therefore, the central limb should be designed to be longer than the lateral limb. In other words, the vertical angle should be more acute than 75° (Fig. 20.3c) [6]. In practice, it is safer to prepare triangular flaps with slightly sharper angles than estimated. The excess tissue can then be trimmed after the flaps have been transferred. When the scar is wider and the skin tension in the transverse direction is lower, more tissue can be excised (Fig. 20.3d).

Continuous Planimetric Z-Plasties Planimetric Z-plasties can be connected obliquely to elongate an oblique contracture in the longitudinal direction. Angles sharper than 75° are required as described above (Fig. 20.3e). When the scar is wider and the skin tension in the transverse direction is lower, more tissue can be excised as extended oblique continuous planimetric Z-plasties (Fig. 20.3f). The shaded portions should be designed to excise unsightly scars as much as possible. Planimetric Z-plasties can be connected in an alternative direction according to the shape of the scar (Fig. 20.3g). It is possible to combine oblique and alternative continuous planimetric Z-plasties.

S. Suzuki, MD, PhD (*) Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Kyoto University, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan e-mail: [email protected] K. Kawai, MD N. Morimoto, MD Kyoto University, Kyoto, Japan


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⊡ Fig. 20.2 Appearance after execution of a conventional Z-plasty

⊡ Fig. 20.1 Design of conventional Z-plasty

Contracture line

Contracture line

D

A

B C

b

a

⊡ Fig. 20.3 Planimetric Z-plasties

e

d

c

f

g

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20

A 10-year-old boy presented with a hypertrophic scar with contracture on his left foot due to a crash injury (Fig. 20.4). Extended oblique continuous planimetric Z-plasties were designed (Fig. 20.5). After skin excision, the contracture was released and the hypertrophic scar was partially excised (Fig. 20.6). Then the flaps were transferred and sutured (Fig. 20.7). The remaining hypertrophic scar gradually became flattened. Fifteen months after the second operation, both the functional and cosmetic improvements were excellent (Fig. 20.8).


⊡ Fig. 20.4 Hypertrophic scar with contracture on the left foot of a 10-year-old boy

⊡ Fig. 20.5 Operative design

⊡ Fig. 20.6 Appearance during operation

Chapter 20

⊡ Fig. 20.7 Immediate postoperative appearance

⊡ Fig. 20.8 Fifteen-month postoperative appearance

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V-Y Flaps and Their Analogs There are various kinds of V-Y advancement flaps and their analogs. To make the selection of an appropriate method easier for the treatment of scars and scar contractures, we proposed a comprehensive classification of V-Y flaps and their analogs (Fig. 20.9) [5].

V-Y Flaps with Burow’s and Inverted Burow’s Triangle Excisions Burow’s triangle excisions are commonly applied in V-Y flaps to facilitate skin closure (Fig. 20.9a). We devised an alternative to the Burow’s triangle excision, namely, an inverted Burow’s triangle excision. This procedure results in a zigzag line of suturing (Fig. 20.9c). The zigzag is longer but less conspicuous, and contracts less than the straight scar produced by a conventional Burow’s triangle excision. Although we describe a triangle excision, the base of the triangle should be incised along the arch line of the central convex according to the degree of contracture. More practically, we recommend that a cut is made along the radial lines first before the excess tissue is trimmed after releasing the contractures.

Double V-Y Flaps The division of a wide V flap into two V flaps in the V-Y flap is named a double V-Y advancement flap. Double V-Y flaps with a pair of Burow’s triangle flaps (Fig. 20.9b) result in V-W plasty as reported by Koyama [4], and double V-Y flaps with a pair of inverted Burow’s triangle flaps (Fig. 20.9d) resemble V-M plasty reported by Alexander [1]. Turning the design of the double V-Y flap with Burow’s triangle excisions upside-down results in the V-Y flap with inverted Burow’s triangle excisions.

V-Y Flaps with Transposition Flaps In severe contracture, transposition flaps can be used instead of triangle excisions. You may notice that the


V-Y flap with a pair of transposition flaps (Fig. 20.9e) results in five flap-plasty [2], and that double V-Y flap with a pair of transposition flaps (Fig. 20.9f) results in seven flap-plasty [3].

Application of the Comprehensive Classification of V-Y Flaps and Their Analogs Separate maneuvers can be used in each arm of the V-Y or double V-Y flap. For example, a Burow’s triangle excision can be performed in one arm, and an inverted Burow’s triangle excision can be performed in the other arm (Fig. 20.9 g,h). On the basis of above-mentioned concepts, V-Y advancement flaps and their analogs can be classified comprehensively. With reference to the classification, an appropriate design can be determined according to the degree of contracture and the shape of the scar in each case. Therefore, we can easily design V-Y flaps according to the degree of contracture and the shape of the scar. It is also useful to combine V-Y flaps with planimetric Z-plasties. Maneuver of each arm

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⊡ Fig. 20.9 Comprehensive classification of V-Y flaps and their analogs


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+ Case 2

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A 22-year-old woman presented with a hypertrophic scar on her right elbow (Fig. 20.10). Taking the degree of the contracture and the shape of the scar into consideration, we designed a V-Y flap with a Burow’s triangle excision and performed planimetric Z-plasty (Fig. 20.11). After a skin incision along the violet mark, an additional skin incision was made along the green dotted line to further advance the V flap. Before skin closure, another Z-plasty was executed along the blue dotted lines. The hypertrophic scar was excised as much as possible. The transferred flaps were sutured (Fig. 20.12). The remaining hypertrophic scar gradually became flattened, and the 4 months postoperative appearance showed both functional and cosmetic improvement (Fig. 20.13).


⊡ Fig. 20.10 Hypertrophic scar on the right elbow of a 22-year-old woman

Chapter 20


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+ Case 2 (continued)

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⊡ Fig. 20.12 Immediate postoperative appearance

Chapter 20

⊡ Fig. 20.13 Four-month postoperative appearance

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+ Case 3

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A 74-year-old man presented with a postburn scar contracture between the right thumb and index finger. A double V-Y flap with transposition flaps, namely, a seven flap-plasty was planned. Double V flaps were designed on the dorsal side, and transposition flaps were designed for the palmar side (Fig. 20.14). After the skin incisions, dissection of the flaps on the dorsal side was minimized, and the flaps on the palmar sides were mainly transferred (Fig. 20.15). All flaps survived, and 1 year postoperatively, both the functional and cosmetic improvements were impressive (Fig. 20.16).


Chapter 20

⊡ Fig. 20.14 Scar contracture between the right thumb and index finger of a 74-year-old man ⊡ Fig. 20.16 One-year postoperative appearance


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Use of Z-Plasty in Burn Reconstruction rodney k. chan and matthias b. donelan

Background of the Technique “Surgical principles evolve slowly, gain a certain permanence and require periodic reassessment. Surgical techniques evolve rapidly, change frequently, and require constant refinement” [1]. Z-plasty is as much a principle as it is a technique in plastic surgery. While the description of a Z-plasty can be found in almost every plastic surgery text, the successful application of this seemingly, mathematically simplistic concept requires careful planning and deliberate execution. Denonvilliers, often credited with the first description of a Z-plasty, actually did not know that he was describing a new technique in 1856 when he used it for the treatment of lower lid ectropion. The first reference to Z–plasty in American literature, however, was not found until 1913 when McCurdy used it as a treatment for contracture at the oral commissure. Limberg, in 1929, provided a more detailed geometric description, and Davis subsequently popularized the technique with numerical data showing optimal angles and length relationships [2].

Characteristics and Indication of the Method In its most basic form, a Z-plasty transposes two interdigitating triangular flaps drawn in the form of a “z” or a reversed “z” and results in the lengthening of and directional change in the common limb. Within this basic premise, Z-plasty has found many uses in plastic surgery. This includes lengthening a scar contracture in M. B. Donelan, MD (*) Division of Plastic Surgery, Shriners Hospital for Children, 51 Blossom Street, Boston, MA 02114, USA R. K. Chan, MD Division of Plastic Surgery, Shriners Hospital for Children, 51 Blossom Street, Boston, MA 02114, USA e-mail: [email protected]

the longitudinal direction, narrowing the scar in the transverse direction, changing the direction of a scar, breaking up a scar, flattening an either raised or depressed scar, and correcting contour deformities such as creation of a web-space. In a postburn patient, Z-plasty is often used to camouflage a hypertrophic scar. The most obvious is the one which “bowstrings” across a hollow with excess tissue on either side. Z-plasty acts to lengthen the contracted common limb, borrowing tissue from either side. The direction of the scar is also secondarily changed, coinciding with the line of the shadow, and resulting in a pleasing visual outcome. Even when the contracture is more diffuse, Z-plasty can be used to flatten the scar, as long as the side limbs of the z can reach lax, normal skin. At the extreme, the scar is so diffuse that transverse skin laxity is absent, and autografting is needed. Commonly, a z-plastied hypertrophic scar might develop a second area of banding which requires additional z-plastic releases at a later date. Clinically, it is remarkable that hypertrophic scars soften and thin following Z-plasty even without the removal of any of the scar tissue. Part of this is mechanical as the previously protuberant scar has been halved and redistributed into different location and direction. Reorientation of the fibers and relief of tension also have biochemical consequences. Longacre et al. performed histochemical studies of tissue before and after Z-plasty and showed that abnormally sulfated mucopolysaccharides were replaced by normal acid mucopolysaccharides within 14 days [3]. Collagen that appeared in nodules in hypertrophic scar is decreased in quantity and reoriented into bundles at right angles to each other, resembling normal skin. Hydroxylprolene and hydroxylysine, molecules unique to collagen degradation, were found in higher concentration in urine following Z-plasty. All these findings indicate that biochemical scar remodeling occurs following Z-plasty, leading to a clinically more inconspicuous scar.


Use of Z-Plasty in Burn Reconstruction

Specific Skill of the Methods The most important factor leading to the successful outcome following Z-plasty is planning. One measure of the design and execution of a Z-plasty is the behavior of the flaps following division. With tension release, these flaps should literally fall into position with difficulty returning them into their original place. Each limb of the Z-plasty should be equal. For most applications, a 60° angle between the common limb and the side limbs results in a theoretical 75% gain in length of the common axis, although realistically it is usually less [4]. In practice, most surgeons maintain a 60° angle but vary the length of the common limb, as determined by the amount of transverse skin available. When the scar is long, it might be necessary to make tandem z-plasties, thereby limiting the required transverse length.

Chapter 21

The correct way to cut a Z-plasty is to first incise the central limb, then releasing the side limbs of the Z-plasty by cutting toward the middle, and rounding out the corners toward the end, almost orthogonal at the junction with the common limb. Tissue tends to retract as one cuts away from the corner leading to flaps that are smaller than intended, compromising blood supply. For the novice, it is important to incise deep enough beyond the scar plane down to healthy subcutaneous tissue. The corner stitches often bear the most tension during closure; additional stitches should be placed to take tension off that point. Z-plasty has found many uses in plastic surgery and is definitely part of every plastic surgeon’s armamentarium. The principle of Z-plasty is well established. Each surgeon will modify the technique to suit one’s individual needs. Continual evaluation of one’s results using preoperative and postoperative imaging is paramount.

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Clinical Cases + Case 1: Axillary Contracture

21

This postburn axillary contracture involves both the anterior and posterior axillary folds (Fig. 21.1a). This is typical of the hypertrophy seen with repeated tension, which in severe cases can even lead to ulceration (Fig. 21.1b). Incisional releases were designed using tandem Z-plasties within the hypertrophic scar (Fig. 21.1c). This achieves tension relief and reorientation of the collagen fibers, allowing the scars to favorably remodel. The central limb of the Z-plasty was designed over the hypertrophic band with the lateral limbs extending into adjacent normal, supple skin. Note immediate relief of the scar contracture without need for additional skin grafting or scar excision (Fig. 21.1d). After Z-plasty release, there is minimal need for therapy and no need for splinting. Three years after release, the scars are soft and supple and the contractures are completely corrected (Fig. 21.1e, f (before, after)).


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+ Case 2: Neck Contracture

21

Neck contracture developed following partial thickness flame burn, acutely treated with tangential excision and split thickness skin grafting. The contracture resulted in loss of a normal chin-neck angle (Fig. 21.2a). She underwent two separate Z-plasty procedures to release the contracture and improve neck contour. The initial procedure used two large z-plasties which included the entire area of graft and scar (Fig. 21.2b). This lengthened the vertical contracture, narrowed the scarred area transversely, and deepened the chin-neck angle by appropriate placement of the Z-plasty flaps (Fig. 21.2c). The second procedure uses more focal z-plasties to further narrow and lengthen the contracted tissues (Fig. 21.2d). One year following the two procedures, tension has been eliminated and the neck contour is normal (Fig. 21.2e).


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C h a p t e r 22

Local Flaps for Burned Face allen liu and julian pribaz

Principles in Facial Burn Reconstructions

Resurfacing

The burned face is the single most important anatomical structure a burn surgeon is called upon to reconstruct. The face serves important function in the identification of the individual and contains organs of sight, smell, speech, respiratory exchange, and nutrition intake. Its distortion can potentially cause functional impairment and also deformities that lead to the withdrawal of the victim from society. The complex shape and form of the human face renders reconstruction difficult and the exposed position of the face allows only limited camouflage with clothing and make-up. In general, local flaps bring in tissue with similar color and texture for reconstruction and potentially achieve the most optimal result. However, in the burned patient, the usual local flaps that may be available in other traumas are not available due to concomitant damage in the burn injury. The depth of the burn injury in the face is variable, and generally partial thickness burns are allowed to heal by secondary intention, producing scars of variable consistency that traverse the normally assigned subunits. In most cases, one should wait until scars are no longer itchy, red, raised, and tight before embarking on reconstruction. This usually occurs 6–18 months postburn [1]. Mature scars, which are white, soft, and relatively flat, are much more suitable for reconstructive surgery. This chapter will examine the role of local flaps in reconstructing the following problems encountered in the burned face: (1) resurfacing, (2) contracture release, (3) contour restoration, (4) restoration of hair-bearing tissue, and (5) secondary sculpting of free tissue transfer with local flaps.

It is much more common to use skin grafts – preferably full thickness or thick split sheet grafts that reconstruct an entire subunit. There is seldom enough laxity and unburned tissue to use local advancement or rotation flaps in reconstructing the burned face. With more limited burns, expanded flaps from the lateral cheek may be used to resurface more central defects, or flaps from the forehead to resurface the nasal tip (Fig. 22.1). Obviously, the unburned neck and supraclavicular areas can be expanded and used for facial resurfacing, but these flaps are discussed in other chapters.

J. Pribaz, MD (*) Division of Plastic Surgery, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115, USA e-mail: [email protected] A. Liu, MD Division of Plastic Surgery, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115, USA

Contracture Release The areas of the face that are most vulnerable to contractures, which produce both functional and aesthetic deformity, include the eyelids, the nostrils, the alar bases, the oral commissure, and the lips. General principles involve the release of the contracture, return of the tissue to its normal location, and repair of the resulting defect with either a full thickness skin graft or a local flap. Local flaps usually involve the transfer of adjacent healed burned tissues. Even though these tissues may have been burned and possibly even grafted, after healing and scar maturation, the tissue can be raised with its subcutaneous vascularized pedicle as a flap [3]. The simplest local flap is a Z-plasty, and this may be used to realign an eyebrow or an alar base displaced by scar contracture. A local transposition flap from either the lower forehead or upper eyelid may be used to reconstruct an ectropion of the lower eyelid. Local transposition flaps may also be used from the nasolabial region to release a contracture of the ala. The oral commissure is another area that is commonly injured in burns, resulting in scar contracture, which can greatly limit mouth opening (Fig. 22.2). Thermal circumoral burns commonly produce contracture at the commissure, and electrical burns, especially


Local Flaps for Burned Face

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Chapter 22

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⊡ Fig. 22.1 A middle-aged woman suffered thermal burns to the right side of her face. She had superficial burns to the majority of her forehead, right cheek, dorsum of the nose, nasal tip, upper and lower eyelids, and chin. The burn injury to her nasal alas was full-thickness, leading to full defect of her entire right ala and almost 90% defect of her left ala (a). Burn scarring and contracture also lead to loss of projection and abnormal contour of her nasal tip. Tissue expansion of

right forehead skin was performed for reconstruction of her nasal alar defects and also to resurface her nasal dorsum and tip (b). She also has local turn-over flaps of healed burn scar on distal end of the nose for nasal lining, and cartilage grafts were used for support of alar rim and tip projection (c). Appearance of the patient after reconstruction (d–f). Superficial burn scars of nasal dorsum and nasal tip had been excised and resurfaced with the forehead flap

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⊡ Fig. 22.2 This middle-aged man suffered acid burns to his eyes, nasal tip, nasal alas, cutaneous upper lip, as well as oral mucosa on the right side (a). He developed blindness, and upper lip incompetence due to scar contracture of the cutaneous upper lip. In addition, the contracture of his oral mucosal scarring on the right side limited his mouth opening on that side. Submental flap was designed based on the submental artery, which is a branch of the facial artery, to resur-

face the intraoral defect created after release of oral mucosal contracture on the right side (b). To store the hair-bearing cutaneous upper lip after burn scar excision, a bipedicled hair-bearing scalp flap, based on the superficial temporal arteries on both sides, was used (c, d). The scalp flap was rotated down like a “bucket handle” and inset. The pedicles were divided a few weeks later. Appearance of the patient 1 year after reconstruction (e)


in children who place live wires in their mouth, can produce extensive scarring. In electrical injuries the prolonged use of commissure splints can minimize the contracture. In both types of burns, once the contracture occurs, the reconstruction involves the release of the external skin contractures and resurfacing of the defect with a local intraoral mucosal flap into the crux of the defect, with vermilion advancement flap to restore the adjacent lip vermilion. If more bulk is needed, a facial artery musculomucosal flap from the buccal area or the tongue flap is a good alternative [8]. The superior surface of the tongue may have a texture that is too rough in comparison to the normal lip. This can be avoided in lower lip reconstruction by using the smoother undersurface of the tongue [5]. Ectropion of the lip vermilion is generally repaired with a full thickness skin graft rather than a local flap (Fig. 22.3).

Contour Restoration Burn injuries on the face can cause a loss of protruding facial features, such as the nose and its subunits, the ears, and the lips. Scarring of adjacent regions can further distort these structures and alter the contour of the cheek, the nasolabial fold, the lower lip, the chin, and the supramental crease area. Neck contractures can often cause extrinsic pull on the lips and even the eyelids. The neck contractures should be addressed before one proceeds with lip or eyelid reconstruction [6, 7]. Lower lip contractures can also lead to upper lip distortion, and should be released before the upper lip [7]. One of the axioms in reconstructive surgery is that contour restoration is more important than minimizing scars, which in time can lose its redness and tightness [4]. Scars can also be better camouflaged with make-up, whereas contour problems need to be reconstructed with rearrangement of surrounding tissues. Even if the surrounding tissues have suffered in the burn injury, the deeper blood supply is generally undisturbed, and thus local fasciocutaneous flaps can be raised and utilized to restore the contour lost from protruding structures, especially the nose. Thus, the forehead flap and nasolabial flaps are often used to reconstruct the nose. Often in facial burns there is a paucity of adequate tissue for reconstruction. As a result, one should consider the utility of any tissue before discarding it, in case it can be used for reconstruction. Even scar tissues can be utilized. One should keep this in mind before excising tissues to complete an aesthetic subunit [1]. A good

Chapter 22

example is concomitant burn to the upper lip and the nasal base, especially when there is also extensive facial and forehead burn injury. If the upper lip needs resurfacing, the disposable scar in the upper lip area may be transposed to augment the nose [2, 3]. The small scar flaps will usually survive if handled gently and cut thickly with some fat on their undersurface to preserve the subdermal blood supply. One can even delay these scar flaps 1–2 weeks before their actual use [3]. A combination of local flap rearrangement and sheet skin grafting of subunit areas is also a commonly used technique. In these cases after the burn scar is excised and contractures are released, the underlying tissue can be raised as small local flaps and transposed locally to restore the contour and then the entire area covered with a sheet of thick skin graft. One area that this technique is commonly used is the lower lip/supramental crease/chin region, where local turn-over flaps of tissue is moved from the region of the supramental crease, where an indentation is desired, to the area immediately above (in the lower lip), and immediately below (the chin prominence) (Fig. 22.3).

Restoration of Hair-Bearing Tissue Deeper facial burns often injure the hair follicles in hairbearing areas. In both sexes the scalp hairline, eyebrows, and sideburn may be involved, and in men, the bearded areas around the mouth and in the neck may be partially or totally lost. The use of hair-bearing local flaps to restore these regions is a very effective method of significantly enhancing a more normal appearance in burned patients. Tissue expanders are commonly used in the scalp, and this is discussed in detail in other chapters. Scalp flaps are also useful for restoring the sideburns. Eyebrow reconstruction works particularly well for those with extensive burn scarring of the face. The presence of hair can make the facial appearance more aesthetically pleasing by breaking up the uninterrupted area of scars. An island hair-bearing scalp flap based on the superficial temporal artery can be raised and tunneled through the temporal skin to reconstruct the eyebrow. For optimal result, one must ensure that the reconstructed eyebrow be symmetrical to the contralateral normal eyebrow and that the hair follicle direction mimics that of the normal brow [1]. In the beard area, if there are small areas of alopecia, advancement flaps (especially V-Y flaps) of adjacent hair-bearing tissue can be used effectively (Fig. 22.4).

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⊡ Fig. 22.3 This middle-aged woman suffered circumferential oral burns, as well as burns to her bilateral cheeks and nasal alas. Scar contractures of her cutaneous lower lip and chin area produced lower lip ectropion, oral incompetence, and limitation of mouth opening (a). The contour of her lower lip and chin area was also abnormal due to the absence of a supramental crease (b). The burn scar was first excised to release the contracture. To give her lower lip and chin area a more normal contour, local turn-over flaps of subcutaneous tissue was moved from the region of the supramental crease, where an indentation is desired, to the area immediately above (in the lower lip), and immediately below (the chin prominence) (c). Note the supramental indentation after flap transposition (d). A full thickness skin graft from the lower abdomen was used to resurface the cutaneous defect and bilateral commissuroplasties were performed (e). Appearance of the patient after reconstruction. Note the increased mouth opening and also the more natural contour of the lower lip and chin, imparted by the supramental crease and chin prominence (f–h)

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⊡ Fig. 22.4 This middle-aged man suffered thermal burns to his face, leaving him with a full-thickness defect of the lower third of his nose, scar contractures of his right central cheek and malar region, as well as a nonhealing ulcer over his right zygomatic prominence (a). His underwent a prelaminated free radial forearm flap for reconstruction of the lower third of his nose and to resurface his right central cheek and malar region (b). The area reconstructed by the prelaminated free flap lacked natural contours, with no clear boundary between the right cheek and the nasal sidewall, as well as an absent right nasolabial fold. The flap was sculpted to create these natural landmarks. Incisions were made along where the cheek is expected to border on the nasal sidewall and the nasal ala. The expected location of the nasolabial fold was also incised (c, d). Underlying soft tissue was trimmed and the incisional edges tacked down to deep fascial layer to further enhance the definition of the subunit borders. More natural contour of patient’s right face, with more defined cheek-nasal sidewall-ala borders and nasolabial fold (e). This patient also had a V-Y advancement of left upper lip hair-bearing tissue to reconstruct an area of burn alopecia centrally (f–h)

Chapter 22

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For larger areas, staged pedicle or bipedicle island flaps from the scalp based on the superficial temporal artery can be used – or if uninjured, the hair-bearing submental region is another source of local flaps to restore the beard area, though donor site scarring may be more prominent [3] (Fig. 22.2).

Secondary Sculpting of Free Tissue Transfer with Local Flaps Free flaps to resurface a burned face are seldom used, but when they are required, the initial result is suboptimal, as the reconstruction is flat and lacks the natural contours. The result in these patients can be significantly improved if at secondary revision, the free flap is sculpted according to the subunits. This can be achieved by placing scars


within the free flap in the nasolabial region, the supramental crease, and the philtrum, as well as by a combination of selective trimming and deeper subcutaneous flap rearrangement (Fig. 22.4). This way, the more natural contours of the face can be achieved. The scars that are left are a worthy trade-off to the improvement in contour. Local flaps provide the ideal tissue for facial burn reconstruction in terms of tissue color and texture match. Despite the challenges posed by facial burn reconstruction, the following general principles can be applied to optimize outcomes: (1) delay of reconstruction until after scar maturation, (2) release of contractures and extrinsic sources of distortion, (3) the primacy of contour restoration over scarring, (4) conservation of tissues, even those scarred, for reconstruction, and (5) use of hair-bearing flap to restore normal hairline in hair-bearing areas.

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C h a p t e r 23

The Square Flap Method hiko hyakusoku and masataka akimoto

Background of the Technique The square flap method was presented in 1985 [1] in Japanese and in 1987 [2] in English. This method consists of a square advancement flap and two triangle transposition flaps (45° and right angle, respectively) (Fig. 23.1). It was devised as an extension method of length between two points similar to Z-plasty. Initially, the method was applied to repair the cleft case such as the earlobe cleft (Fig. 23.2a). On the other hand, the method has superior lengthening effect to Z-plasty (Fig. 23.2b); this method can be applied to reconstruct scar contracture (Fig. 23.3).

Characteristics and Indication of the Method This is one of the methods for repairing scar contractures such as Z-plasty or the method derived from it. In particular, three-dimensional (3D) reconstruction of axilla, cubital fossa, neck, and digital space should be indicated when the scar band is narrow (Fig. 23.4). Moreover, we insist that an advantage of this method is that the square flap does not divide hairy areas of the axilla.

Specific Skills of the Method 1. The angle of the triangular flaps should not be acute to prevent necrosis. Sometimes triangular flaps include scars; thus, we should try to design the angle such that it is as blunt as possible.

2. Square and triangular flaps should be elevated to a conventional thickness of skin flap. 3. The marginal length of the square flap is determined based on the possibility of the flaps joining, that is to say, it depends on the tension of the vertical direction to the elongation course.

Mathematical Theory Geometrical Theory Geometrically, the lengthening rate of the method is +180% [2]. This rate is the longest of all the methods derived from Z-plasty.

Computer-Aided Analysis Here, a computer-aided analysis using the finite element method (FEA) is shown (Figs. 23.5a–c and 23.6). The superiority of the square flap method in repairing scar contracture seems to have been proven. The calculated elongation ratio of the square flap method is 1.9 (90%) by FEA, and 2.8 (180%) by simple geometrical analysis. The smaller elongation ratio is due to the consideration of elasticity and 3D deformation. Among other highpowered local flaps, such as 90° Z-plasty or four-flap Z-plasty, the square flap method shows a higher elongation effect (Fig. 23.6).

M. Akimoto, MD, PhD (*) Plastic and Reconstructive Surgery, Nippon Medical School, Chiba Hokusoh Hospital, Chiba, Japan e-mail: [email protected] H. Hyakusoku, MD, PhD Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School Hospital, Tokyo, Japan e-mail: [email protected] H. Hyakusoku et al. (eds.), Color Atlas of Burn Reconstructive Surgery, DOI: 10.1007/978-3-642-05070-1_23, © Springer-Verlag Berlin Heidelberg 2010

The Square Flap Method

Chapter 23

⊡ Fig. 23.1 The square flap method. A square advancement flap, 90° and 45° triangular transposition flaps are joined

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⊡ Fig. 23.2 (a) Application of the square flap method to repair a cleft. (b) The longest lengthening effect of the square flap method

⊡ Fig. 23.3 Application of the square flap for scar contracture releasing. Wider scar band can be divided by the square flap method

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⊡ Fig. 23.4 Postoperative view of the square flap method calculated using finite element analysis (FEA) program. Pink–red area indicates higher z-axis displacement. (a) Ninety

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degree Z-plasty. (b) The square flap method. (c) Forty-five degree four flaps Z-plasty

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⊡ Fig. 23.5 Computer simulation model analysis by FEA. Postoperative shape of each method is shown in bird’s eye view

3 2.5 2 FEA geometric

1.5 1 0.5 0 Z-plasty (90deg.)

Square flap method Four flaps Z-plasty

⊡ Fig. 23.6 Calculated elongation ratio of each method by FEA and simple geometrical analysis


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Clinical Cases + Case 1 (Fig. 23.7): Axillary Reconstruction A 9-year-old girl had a scar contracture in her left axilla after burns (a). The square flap method was used to correct it (b). The region where axillary hair will grow in the future was included in the square flap to avoid dividing it after the flap had been transposed (c).

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+ Case 2 (Fig. 23.8): Anterior Neck Reconstruction A 34-year-old man had a severe scar contracture on his neck after burns (a). As the scar was linear from the chest to the jaw, two square flap methods were used to release the contracture (b). The scar contracture was removed without any free skin grafts (c).

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+ Case 3 (Fig. 23.9): Elbow Joint Reconstruction A 9-year-old boy had a scar contracture of the right elbow joint due to burns (a). The square flap method was applied to reconstruct it (b, c). The length of the square flap was determined by skin tension in the vertical direction to the course of elongation.

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+ Case 4 (Fig. 23.10): Digital Web Reconstruction A 3-year-old boy had scar contractures of the right digital web space due to primary skin grafting caused by burns (a). The square flap method was applied (b, c, d).

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C h a p t e r 24

Propeller Flap and Central Axis Flap Methods hiko hyakusoku and masahiro murakami

Background of the Technique Extensively burned patients often lack ample healthy skin for skin grafts. We have developed a method for using several novel flaps composed of healthy skin left around recipient sites. In 1991, Hyakusoku et al. [1] presented a propeller flap with a subcutaneous pedicle. The original propeller flap has been used in intact fossa to reconstruct the axilla or cubitus. The flaps are designed in the center of the fossa and were elevated as island flaps. Hyakusoku et al. indicated that perforating vessels are often constant in their pedicles [1]. After this report, some improvements that were made on the methods have been reported such as the multilobed propeller flap [2], and scar band rotation flap [3]. A subcutaneous pedicle is under the center of every flap; thus, these methods were categorized as “central axis flap methods” [4]. Nowadays, subcutaneous pedicle has been refined and vascular (perforator) pedicle propeller (PPP) flaps [5] are in wide-spread use. This PPP flap is introduced in another chapter of this book.

Characteristics and Specific Skills of the Method Propeller Flap Method (Fig. 24.1a)

perforators using Doppler. We then released scar contractures by flap rotation. The flaps were easily rotated, and two scar bands could be released simultaneously. However, covering the donor sites was sometimes difficult, and small skin grafts may be needed when doing such covering.

Multilobed Propeller Flap Method (Fig. 24.1b) The “multilobed propeller flap method” [2] was recently developed in an attempt to overcome disadvantages of the original “propeller flap method.” Small lobules attached to the sides of the propeller flaps reduce the need for free skin grafts. We have applied the method to produce various shapes according to the shape of the scar. When using intact axilla, we ensure that the flap does not run off any hairy region over the edge of the fossa. Flaps are designed as bilobes, trilobes, or quadrilobes and the pedicle is as thick as possible to maintain the rotation angle and minimize tension. Flap rotation can be in the clockwise or counterclockwise direction. The larger lobe of the nonsymmetrical flaps should be used to divide the contracture. The donor site can generally be closed primarily after flap elevation and rotation at an angle of 90°. The lobes are ideally used on normal skin, but may be designed for scars.

Flaps were vascularized from the subcutaneous pedicle in the central portion. We generally need not identify

H. Hyakusoku, MD, PhD (*) Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School Hospital, Tokyo, Japan e-mail: [email protected] M. Murakami, MD, PhD Department of Plastic and Reconstructive Surgery Nippon Medical School, Musashi Kosugi Hospital, Kanagawa, Japan e-mail: [email protected] H. Hyakusoku et al. (eds.), Color Atlas of Burn Reconstructive Surgery, DOI: 10.1007/978-3-642-05070-1_24, © Springer-Verlag Berlin Heidelberg 2010

Propeller Flap and Central Axis Flap Methods

a

Chapter 24

b

⊡ Fig. 24.1 Original propeller (a). Multiloped propeller flap method (b)

199

Chapter 24

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Clinical Cases + Case 1 (Fig. 24.2)

24

A 17-year-old boy had scar contractures at the left elbow after severe flame burns in a traffic accident (a). Thus, we planned a propeller flap to release the scar contracture. After 90° rotation of the flap, the skin defects that resulted from the flap rotation were not covered with skin grafts, but were epithelialized within a month. After a year, functional recovery of the elbow joint region was perfect (b).


a

Chapter 24

b

⊡ Fig. 24.2 Properative view (a). 6 months postoperative view (b)

201

202

Chapter 24


+ Case 2 (Fig. 24.3) A 25-year-old man had scar contractures on his left axilla after an extensive burn. An operation was performed to release the contracture. A quadrilobed propeller flap method was used (a, b). The flap was rotated almost 90° and the contracture was released completely (c). The result was excellent not only functionally but also cosmetically; the axillary hair area was not divided (d).

24


a

Chapter 24

b

c

⊡ Fig. 24.3 Preperative view (a). intraoparative view (b). 6 months postperative view (c)

203

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Chapter 24


+ Case 3 (Fig. 24.4)

24

A 13-year-old boy suffered from an extensive flame burn. After emergency skin grafting, severe contractures occurred in the cubital fossa of both upper limbs. In the right limb, some normal skin remained in the cubital fossa. Therefore, a quadrilobed propeller flap was designed (a, b). A scar on the ulnar side was also included in the flap. The flap was elevated, and clockwise rotation was performed to release the contracture (c). The flap donor site was primarily closed without problems (d). In this case, release of the contracture proved insufficient soon after the operation because the remaining normal skin was little and the flap was too small. However, 3 years after the operation, full extension of the elbow joint was achieved as a result of an expansion effect in the flap, including normal skin (e).


a

d

Chapter 24

b

c

e

⊡ Fig. 24.4 (a) Preoperative view. (b, c) Flap elevation. (d) Postoperative view. (e) Three year postoperative view flap survived completely, including in the scarred area (arrow)

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+ Case 4 (Fig. 24.5)

24

A 17-year-old boy suffered from extensive burns. A right axillary scar contracture occurred after a life-saving skin graft was performed. Healthy skin remained in the center of the right axilla between the scar band in the anterior and posterior axillary lines. The scar contracture was reconstructed using the “multilobed propeller flap method.” The range of motion (ROM) of the right shoulder joint improved from 60 to 120°. The contracture has not recurred during the past 3 years since the operation.


a

d

b

Chapter 24

207

c

e

⊡ Fig. 24.5 Preperative view (a). Flap elevation (b, c). After flap rotation (d). Three months postoperative view (e)

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C h a p t e r 25

Facial Reconstruction pejman aflaki and bohdan pomahac

Introduction Facial burn reconstruction is one of the most challenging problems a plastic surgeon encounters. As much as 80% of the morbidity of burn injuries results from burns to the face and hands. Head and neck burns affect approximately 50% of the patients admitted to a burn center, the majority of which are partial-thickness, and they heal well without surgical intervention [1, 2]. Facial reconstruction should be an integral part of the acute management of facial burns and continued throughout the patient stay in hospital and the rehabilitation process.

Principles of Burn Facial Reconstruction Accurate assessment of the burn depth and extent is the key step in the treatment of facial burns and will largely dictate the subsequent management decisions. The goals of reconstruction are the protection of function, restoration and maintenance of the contour and shape of individual facial structures, and achieving good color and texture match, whenever possible. Except for unique circumstances, no skin graft will ever look as natural as preserved facial skin. The quality of reconstruction (aesthetics, mobility, and late complications) seems to correlate to the thickness of preserved or added dermis by the thickness of the graft. Preservation of dermis is therefore critical. We have adopted an aggressive removal of the superficial debris in mid to deep dermal burns to minimize inflammation and

B. Pomahac, MD (*) Division of Plastic Surgery, Harvard Medical School, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115, USA e-mail: [email protected] P. Aflaki, MD Division of Plastic Surgery, Harvard Medical School, Brigham and Women’s Hospital, Boston, MA 02115, USA

chance of superficial infection. Extensive third-degree burns should be excised early after injury, while small third-degree burns can occasionally be managed following the principles of facial reconstruction similar to cancer or trauma defects. Wherever possible, aesthetic units of the face must be respected to guide both excision and grafting or other reconstructive procedures [3]. The grafts and flaps should be designed in such a way that scars are located within the lines of facial expression (e.g., nasolabial fold) or lines of contour (e.g., mandibular margin). It is imperative that thick skin grafts are used, as thin skin grafts frequently lead to the development of contractures. In resurfacing only part of the face, the graft should be taken from an area with appropriate colormatch with the unburned areas, usually form the scalp, neck, or supraclavicular area. In resurfacing the entire face, the issue of color match becomes irrelevant.

Management of Superficial to Mid-Dermal Burns In light of the dynamic nature of the burn wound, management of the facial burn wound should be directed at prevention of progression to deeper injuries and achieving early closure. Adequate fluid resuscitation, prevention of wound sepsis and providing a wet/moist environment are key elements to minimize the conversion of areas of partial-thickness burn injuries that would heal spontaneously, to areas of deep dermal to full-thickness injuries that would require surgical intervention. Attempts must be made to accelerate skin regeneration by providing an optimal environment where keratinocytes can proliferate, migrate, and subsequently reepithelialize the burn wound. Such an environment can be provided by frequent hydrotherapy, topical antimicrobial agents, and occlusive dressing. Alternatively, in superficial and mid-dermal facial burns, use of Biobrane, a biosynthetic dressing, offers a number of advantages [4]. It adheres to the wound bed, prevents


Facial Reconstruction

evaporative water loss and desiccation, and serves as a barrier against invasion of microorganisms. In the facial region, it is particularly useful as it obviates the need for frequent painful debridement and hydrotherapy after the initial application and minimizes patient discomfort. It allows for frequent inspection without the need for being removed.

Management of Deep Dermal and Full-Thickness Burns Superficial to mid-dermal burns would typically heal within 2–3 weeks. Healing that takes longer than 3 weeks is indicator of a deep dermal or full-thickness injury. The distinction between these two groups of patients may not always be clear, necessitating a period of expectant management, in which the indeterminate burn injuries are given the opportunity to declare their true depth and regenerative capacity. Wound following 3 weeks is associated with ongoing inflammation, proliferation of granulation tissue, and scar formation prone to hypertrophy [5, 6]. Depending on location, scars can lead to contractures and secondary deformities. In small burns and certain locations, for example, where the concavities

Chapter 25

and flexion creases of face are not crossed, this process favoring healing by contraction and epithelial migration from the wound periphery may lead to superior results to grafting (forehead, dorsum of the nose). Mid to deep dermal burns develop by the end of tenth day a thin, superficial debris typically of a white shiny appearance that is avascular and prone to bacterial contamination and infection. We find surgical debridement of this debris highly valuable in our management of facial burns. Using dermabrasion or hydrocision (Versajet™, Smith and Nephew), this necrotic debris is removed in a very controlled fashion to punctuate diffuse dermal bleeding. Occlusive dressings can often be applied afterwards. Tangential excision of the facial burns is reserved for extensive, full-thickness injuries. It may not be easily applicable in particular in the complex central facial regions. Lack of delicate control over the level of excision makes it less than ideal when it comes to dealing with facial burns, where it is absolutely vital to avoid overexcision of the burned skin. In addition, it may cause excessive blood loss when used in the wellperfused facial skin threatening the take of autografts. For this reason, we have often staged the excision of facial full-thickness burns, and covered excised bed with allografts, followed by autografts several days later.

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Chapter 25

210


Clinical Cases + Case 1: Superficial burn with Biobrane

25

A 38-year-old male who sustained second degree burns including facial burn in a house fire. He underwent fluid resuscitation and mid-dermal burns were managed with Biobrane™ on admission (Fig. 25.1a). Two weeks later, the Biobrane completely came off the patient’s face that healed without further complications (Fig. 25.1b).


a

⊡ Fig. 25.1 (a, b)

Chapter 25

b

211

Chapter 25

212


+ Case 2: Deep Dermal Burn – Dermabrasion

and Biobrane

25

A 53-year-old woman with history of depression suffered from extensive facial burns following a cooking accident when pot of oil caught on fire (Fig. 25.2a, b). Due to her past medical problems, facial burns were managed with conservative moisturization protocol until day 10 when she was taken to the operating room for dermabrasion and application of biobrane. Same patient 4 months following her accident (Fig. 25.2c, d).


Chapter 25

a

b

c

d

⊡ Fig. 25.2 (a–d)

213

214

Chapter 25


+ Case 3: Full-Thickness Small Area Burn

25

A 41-years-old female suffering from epilepsy fell on a heat radiator during a seizure attack and sustained a contact burn to right side of her face while unconscious. The resulting contact burn was managed in an outside institution for 3 weeks prior to her presentation to our clinic (Fig. 25.3a, b). She was taken to the operating room and underwent local tissue undermining, rearrangement and neck advancement flap. Small skin graft was used behind the ear from a supraclavicular location. Healed face 3 months postoperatively is shown (Fig. 25.3c, d).


Chapter 25

a

b

c

d

⊡ Fig. 25.3 (a–d)

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Chapter 25


+ Case 4: Full-Thickness Extensive Burn

25

A 47-year-old male was involved in a motor vehicle accident. Car caught on fire and caused deep head and neck and other deep third-degree burns; 35% total body surface area. Facial, scalp, and neck burns were clearly deep third degree (Fig. 25.4a, b) and sequentially excised once patient’s overall condition allowed. The grafting continued with autografts and ultimately the exposed calvarium and nasal structures were reconstructed with two free tissue transfers, latissimus dorsi and radial forearm flap, respectively (Fig. 25.4c–e).


a

d

⊡ Fig. 25.4 (a–e)

b

Chapter 25

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c

220

C H A P T E R 26

The Expanded Transposition Flap for Face and Neck Reconstruction robert j. spence

Background of the Technique

Characteristics and Indication for the Technique

Resurfacing of the face and neck in burn survivors is best accomplished using skin from the “blush areas” of the upper body including the neck, shoulders, and upper chest. This gives the best color and texture match to the remaining normal skin of the face and neck. However, the amount of remaining normal blush area skin is frequently limited because of burn scarring in the area. Even when there is a normal amount of unscarred skin in the blush area, very large donor site deformities are left when large areas of the face and neck have to be replaced. Twenty-five years ago, I started using tissue expanders to expand the amount of normal skin particularly in the blush areas for resurfacing of the face and neck yielding enough normal skin to provide resurfacing with expanded full thickness skin grafts. The expansion also allowed the primary closure of the donor sites. From this, the use of the expanded skin as expanded transposition flaps for face and neck resurfacing evolved. Further experience and evolution led to the use of the redundant expanded pedicle skin as full thickness skin graft for resurfacing the central portion of the face where the thinner skin did not obscure the fine facial features of the central portion of the face as thicker flaps would. With time, an entire algorithm for resurfacing large facial deformities was developed with the expanded transposition flap as the central tool in the algorithm [1, 2].

1. When properly designed and executed, this technique provides the following: (a) Relatively thin, large expanded transposition flaps of well-matched color and texture for resurfacing of the entire large aesthetic units of the cheeks and neck. (b) Expanded full thickness skin graft for resurfacing of the aesthetic units of the central portion of the face allowing expression of the fine contours and subtle features of those aesthetic units. (c) Expanded skin remaining at the donor site for primary closure of the donor site. 2. The indications include: (a) The requirement for replacing the skin of one or more of the large aesthetic units of the cheeks or neck because of contracture, excess hypertrophic scarring, or severe differences in pigmentation from normal surrounding skin. (b) The requirement for a reproducible, reliable way of providing symmetrical reconstruction of both sides of the face with well-matched skin. (c) The desire to close the donor site primarily. (d) The requirement to resurface the entire neck with normal skin in a reproducible and reliable way.

R. J. Spence, MD, FACS National Burn Reconstruction Center, Good Samaritan Hospital, 5601 Loch Raven Blvd, Baltimore, MD 21239, USA e-mail: [email protected]

Specific Skills of the Method [3] 1. Tissue expander placement and inflation: (a) A rectangular tissue expander is placed under the normal skin of the shoulders parallel to the line between the base of the neck and the tip of the shoulder approximately 3 months before the planned use of the expanded transposition flap. (b) The incision for the insertion of the tissue expander should be parallel to this long axis of


The Expanded Transpositor Flap

the shoulder as it will become the anterior border of the expanded transposition flap. (c) The amount of skin available is measured by subtracting the anterior–posterior distance across the base of the tissue expander from the anterior–posterior distance over the dome of the tissue expander (Fig. 26.1) This leaves enough expanded skin to close the donor site once the flap has been transposed. The tissue expander is expanded until the amount of skin available is in excess of the area that requires resurfacing. (d) Once adequate skin is available, transposition of the expanded flap is scheduled 2 weeks after the last injection. 2. Expanded flap transposition: (a) A final measurement of the amount of skin available is measured and marked as a widened, D = DOME

CHAPTER 26

F.W. = D–B

B = BASE

-shaped pattern on the lateral two-thirds of the V expanded skin with the scar from the insertion of the tissue expander as the anterior margin of the marking (Fig. 26.2). (b) The area of abnormal skin to be excised is marked, usually as an aesthetic unit, and excised. Normal eyelid skin is preserved. (c) A pattern of the excision wound is made and checked to make sure that the amount of skin necessary fits within the widened V-shaped pattern marked above. Ideally, the flap is somewhat larger than the pattern. The pattern is used to help in the final orientation and modification of the original V-shaped pattern (Fig. 26.3). (d) The lateral portion of the flap is incised along the V-shaped lines and raised as half of a lenticular pattern (Fig. 26.4a). (e) The tissue expander is removed and the medial portion of the expanded skin is examined for the presence of substantial blood vessels which will become the pedicle of the flap. The position of these blood vessels is marked on the skin (Fig. 26.4b, c). (f) The remainder of the flap is incised roughly along a lenticular-shaped pattern preserving as much skin as possible in the pedicle around the medial blood vessels and still allowing transposition of the flap on to the recipient site.

Flap Width Determination

⊡ Fig. 26.1 The available width of the transposition flap is measured by subtracting the distance across the base of the tissue expander from the distance measured over the dome. This leaves on an expanded skin for donor site closure (previously published in The Journal of Burns and Wounds [3])

⊡ Fig. 26.2 A widened, V-shaped pattern of available skin is marked on the lateral two-thirds of the expanded skin with the tissue expander insertion scar as its anterior margin (previously published in The Journal of Burns and Wounds [3])

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222

The Expanded Transpositior Flap

⊡ Fig. 26.3 With proper preoperative judgment and measurement, the pattern of the excision wound should easily fit within the V-shaped lines. If it does not, the pattern becomes the shape of the distal flap with the best fit with the lines (previously published in The Journal of Burns and Wounds [3])

(g) The flap is transposed often turning it 180° causing the pedicle to tube on itself allowing the pedicle to be closed along a spiral line as the flap is inset. The donor site is closed over a drain (Fig. 26.5). (h) Important points: • Ideally, the flap that has been raised is larger than the amount of skin required for the recipient site. These small amount of excess flap margin allows flexibility while insetting the flap. Once inset, the flap conforms anatomically to the recipient defect with contraction in areas of least tension. • The flap margins are gently curved but are made to lie straight along the marionette lines and straight across the lower eyelids of the cheek aesthetic units. This forces the normal lower eyelid up and is redundant often

a

b

c

d

⊡ Fig. 26.4 (a) The lateral two-thirds of the flap are raised off the tissue expander. (b) The vessels in the medial base of the expanded skin are observed through the capsule.

(c) A mark is placed just anterior and posterior to these vessels, and (d) the line of incision is extended up to these marks (previously published in The Journal of Burns and Wounds [3])


⊡ Fig. 26.5 The flap is transposed and inset. (a) In the face, the flap is turned 180° causing the pedicle to tube itself. (b) In the neck, the flap is turned 90°, and the pedicle can often be included in the closure

CHAPTER 26

causing temporary closure of the patient’s eyelids postoperatively. However, this is important subsequently as the cheek flap descends somewhat by gravity causing the lower eyelid skin to unfurl without causing an ectropion. • In resurfacing the cheek aesthetic unit, the tip of the flap and that portion of the flap over the lateral orbital rim are sutured to the periosteum of the medial and lateral orbital rims, respectively, with 4-0 clear nylon sutures to suspend the flap against the force of gravity. 3. Division and insetting of the flap: (a) Division and insetting of the flap is routinely scheduled for 14 days after initial transposition of the flap. (b) The pedicle is divided at its base and the base wound is closed. (c) The spiral wound closure created by the tubing of the flap is reopened and the pedicle is unfurled. The pedicle is then re-draped over the margin of the recipient defect and marked. (d) The pedicle is then transected and inset along the margin of the recipient wound. (e) The residual, unscarred, expanded skin from the pedicle is frequently used as full thickness skin graft to resurface another aesthetic unit of the central portion of the face. (Please note that a more detailed description of this technique is found in ref. [1])

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CHAPTER 26

224



26

A 61-year-old woman sustained a 20% total body surface area burn off her face, neck, and bilateral arms in a house fire. She developed severe scarring of the right side of her face and a burn scar contracture of her neck (Fig. 26.6) Bilateral 13 × 7 cm rectangular shoulder tissue expanders were placed 1 year after her burn injury. Three months later, her neck burn scar contracture was released and a left shoulder expanded transposition flap was inset to resurface the release wound. One month later, the neck expanded transposition flap was divided and inset in the same operation with the excision of the scarred right cheek aesthetic unit and resurfacing with the right shoulder expanded transposition flap. Two weeks later, the right cheek expanded transposition flap was divided and inset and the full thickness skin graft from the pedicle was used to resurface the patient’s chin after the excision of hypertrophic burn scar contracture. Subsequently, residual hypertrophic scarring of the submental area was excised and resurfaced with a full thickness skin graft from the groin. The patient had two final operations to remove excess tissue bulk of first the lower half of the right cheek flap, and subsequently, the upper half of the right cheek flap. Five years after the surgery, she has had substantial improvement in the appearance and function of her face and neck, with excellent ability to show facial expression (Fig. 26.7).


CHAPTER 26

⊡ Fig. 26.6 Preoperative photos showing facial deformity and neck contracture

⊡ Fig. 26.7 Pre- and postoperative photos. Note the excellent ability to show expression through the right facial expanded transposition flap

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+ Case 2

26

A 38-year-old woman presented several years after a total anterior neck dermabrasion that resulted in intolerable scarring of her neck (Fig. 26.8). She requested total resurfacing of her rather long neck. Bilateral shoulder tissue expanders were placed and inflated. Three months later, the right expanded transposition flap was raised at its maximum dimension (Fig. 26.1) and transposed onto the neck to determine how much neck skin could be excised. That amount of neck skin was excised and the transposition flap was inset. Two weeks later, the first flap was ready for division and inset (Fig. 26.9). Its pedicle was divided at the base of the neck, and the left shoulder expanded transposition flap was elevated, and both were inset after excising the rest of the scarred right lateral neck skin (Fig. 26.10). Two weeks after that, the left expanded transposition flap pedicle was divided and inset after the final excision of the scarred neck skin completing the resurfacing of the neck (Fig. 26.11). Postoperatively, the patient did well and was pleased with her results 6 months after her surgery (Fig. 26.12).


⊡ Fig. 26.8 Preoperative photos showing extensive anterior neck scarring

CHAPTER 26

⊡ Fig. 26.9 Two weeks after transposition of the right expanded transposition flap

⊡ Fig. 26.10 Transposition and insetting of the left expanded transposition flap along with dividing and insetting the previously placed right expanded transposition flap pedicle

227

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+ Case 2 (continued)

26



CHAPTER 26

⊡ Fig. 26.11 Two weeks later, the left expanded transposition flap pedicle is divided and inset after final excision of the remaining scarred neck skin to complete the resurfacing

⊡ Fig. 26.12 Postoperative photographs 6 months after resurfacing

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C h a p t e r 27

Expanded Thin Flap chunmei wang, junyi zhang, and qian luo

Background of the Technique Extremely large and thin flaps are the first choice for reconstructing postburn scars in wide contour-sensitive areas such as the facial, cervical parts, and extremities. In 1996, Colson [1] initially repaired dorsal of hands with the thinned flap, which is now called “the graft flap.” After 1980, thin flaps with very narrow pedicel were developed in China [2], and Koshima [3] developed the free super-thin flap in Japan. In 1994, Hyakusoku [4] reported the perforator-supercharged subdermal vascular network (SVN) flap, which is the so-called perforator-supercharged super-thin flap. Thereafter, perforator-supercharged flaps were made much larger and that made thinner flaps possible [5–7]. Thus, on those antecedent models, we have used expanded randompattern flaps, perforator flaps, and prefabricated flaps to repair large areas of postburn scars, severe jaw and neck contractures, and scars in the dorsal area of hands that is highly required for the shape and function of the hand. As a result, problems like limitation of the donor site, difficulty in closure and operating have now been overcome.

Characteristics and Indication of the Method 1. Tissue expansion is a common way to harvest extra skin, especially for patients who have small amounts of normal skin around scars. 2. Tissue expansion has been applied to many kinds of flaps, such as random-pattern flaps, free flaps, perforator flaps, and prefabricated flaps.

C. Wang, MD, PhD (*) Dongguan Kanghua Hospital, Dongguan, China e-mail: [email protected] J. Zhang, MD and Q. Luo, MD Dongguan Kanghua Hospital, Dongguan, China

3. Expansion includes a delay procedure and a “passbridge” effect [8]. After implanting the expander, the flap loses connection with the bed. This effect stimulates the neogenesis of vessels and facilitates the formation of vessel network. From the animal experiments, we found the “pass-bridge” effect, because during the expansion, the skin perforator connected with others through neogenetic vessels to supply more areas (Fig. 27.1a) compared to control side (Fig. 27.1b). 4. In the early stage, the blood supply of the expanded and prefabricated thin flaps depends on the pedicle. Later, it quickly connects to the bed by the new-formed vessels. After being cut off from the pedicle, the flap depends on the blood supply from the bed. It is suggested that there is no ischemic phase during the time the flap is transferred to the recipient site. Moreover, the flap becomes thinner.

Specific Skills of the Methods 1. To expand the random-pattern flap, the expander is usually placed above the superficial fascia of the adjacent normal skin. To expand the perforator flap, the perforator artery should be detected by Doppler such as the superficial abdominal artery, intercostal artery, and descending branch of transverse cervical artery [9], after which the expander is put in the area dominated by the perforator at 2 cm away from the perforating point. 2. Design the flap according to the wound surface. After removing the expander, the flap will become thinner, and some parts of the capsule should be cut off. The SVN must then be preserved. 3. The perforator arteries should be detected by Doppler again in the expanded perforator flap. A narrow skin pedicle is also available. Venous drainage through the skin pedicle is strong, and will therefore facilitate safer harvesting of thin or large flaps. 4. After 9–14 days, the pedicles can be cut off.


Expanded Thin Flap

a

Chapter 27

b

⊡ Fig. 27.1 Angiograms of Expanded Swine Skin. (a) Expanded skin. (b) Non-expanded skin. The area between two large cutaneous perforators (red and blue arrows) were

expanded two-weeks. In the results, the neoangiogenesis of vessels were significant in the expanded skin

231

Chapter 27

232

Expanded Thin Flap

Clinical Cases + Case 1: Expanded Random-Pattern Flap

27

A 6-year-old boy suffered from flame burns (Fig. 27.2a). An expanded randompattern mandible skin flap and chest flap were designed to reconstruct the face (Fig. 27.2b). The expanded mandibular skin flap was advanced to cover the maxillary wound surface of the same side and the expanded chest skin was grafted to resurface the forehead and nose (Fig. 27.2c). In the follow-up after 3 years, the contour was clear and no hypertrophic scar was observed (Fig. 27.2d).

Expanded Thin Flap

a

Chapter 27

b

d

c

⊡ Fig. 27.2 (a–d)

233

234

Chapter 27

Expanded Thin Flap

+ Case 2: Expanded Perforator Flap

27

A 29-year-old male patient developed severe cervical contracture after extensive burns to the neck, shoulder, chest, and upper limbs (Fig. 27.3a).We designed an expanded superthin flap that was transferred from the back with the help of two perforators by “pass-bridge” (the descending branch of the transverse cervical artery and the circumflex scapular artery) (Fig. 27.3b). We rotated the left back flap (3 × 16 cm) with a 4-cm-wide pedicle to cover the neck wound surface and advanced the right back flap to the front to cover the shoulder wound surface. The flap is thin enough to visualize the contour clearly (Fig. 27.3c–f ). The closure of the back donor site was free of tension and no hypertrophic scar was left (Fig. 27.3g). No shrinking of the flap was observed after 2 years (Fig. 27.3h).

Expanded Thin Flap

Chapter 27

a

c

b

d

e

g

⊡ Fig. 27.3 (a–h)

f

h

235

236

Chapter 27

Expanded Thin Flap

+ Case 3: Expanded Prefabricated Flap

27

A 4-year-old girl suffering from fire burn had hypertrophic scars on the dorsal side of the hands (Fig. 27.4a). We prefabricated an abdominal perforator passbridge super-thin flap by expansion (Fig. 27.4b). The procedure included three steps. The first was to implant the expander (Fig. 27.4c).The next was to remove the scar and take out the expander forming the bipedicle flap to resurface the wound (Fig. 27.4d). The last was to cut off the pedicles and form the finger webs (Fig. 27.4e). The result after 1 month is shown in Fig. 27.4f. The donor site had no hypertrophic scar left (Fig. 27.4g). In the follow-up after 3 years, both the contour and the function of hand were satisfactory (Fig. 27.4h).

Expanded Thin Flap

a

c

d

⊡ Fig. 27.4 (a–d)

Chapter 27

b

237

238

27

Chapter 27

Expanded Thin Flap

Expanded Thin Flap

e

Chapter 27

f

g g

⊡ Fig. 27.4 (e–f)

239

240

C h a p t e r 28

Tissue Expansion for Burn Reconstruction huseyin borman and a. cagri uysal

Background The first published clinical report of tissue expansion was by Neumann in 1957 [1]. Neumann used a subcutaneous rubber balloon to achieve the expansion of an area of the scalp for ear reconstruction. Later, Radovan [2] used a sophisticated silicone implant for breast reconstruction. Following some clinical and experimental studies [3, 4], tissue expansion has been accepted as one of the routine procedures in reconstructive surgery.

Basic Principles of Tissue Expansion in Burn Reconstruction Reconstructive ladder in burn reconstruction includes direct closure, adjacent tissue transfer, skin grafts, flaps, and tissue expansion [5–9]. Tissue expansion besides all other remedies facilitates burn reconstruction. The expansion of the skin peripheral to the scar can provide sufficient skin of ideal color, texture, thickness, and sensation with very low donor site morbidity [10–16]. The main disadvantage of the technique is the necessity to have at least two surgical procedures. The complications are exposure or infection of the tissue expander, pain, and long time needed for the total expansion. Basic principles of tissue expansion in burn reconstruction can be listed as follows:

A. C. Uysal, MD (*) Department of Plastic and Reconstructive Surgery, Nippon Medical School, 1 – 1 – 5 Sendagi, Bunkyo-ku, Tokyo 113-8603, Japan e-mail: [email protected] H. Borman, MD Department of Plastic and Reconstructive Surgery, Baskent University, Ankara, Turkey

• The technique should be used after all burns have thoroughly healed and scars have matured. • Preoperative planning is crucial so that once flaps are rotated suture lines are not parallel to previous scars. All planning should be made depending on the localization. Head and neck, trunk, and extremities are the three main localizations where the planning and procedure might change. • All the incisions should be vertical to the expansion plane. • Incision can be placed in previous scars, but the scar should be mature and relatively thick so that the extrusion does not occur. • The placement of multiple tissue expanders of smaller volume is better than one large tissue expander. • Perioperative antibiotics are always used as the incidence of infection is higher in these patients. • The amount of expansion should be monitored to prevent the necrosis of the expanded tissue and exposure of the expander. • The planning of the expansion should be considered depending on the localization: –– Head and neck: Caution should be used in advancing expanded neck skin beyond the border of the mandible. The risk of scar widening, possible lip or eyelid ectropion need to be considered. The expanded skin flap could be used to replace the burned areas, but unburned facial aesthetic units should not be violated. The gravity should be taken into consideration especially when the expander is placed to the cheek region. Thus, multiple and serial small expanders are better than one large expander. The flap adaptation should be performed with the head in extension or turned away. Multiple expanders depending on the curvature of the cranial bones should be planned. Caution should be used for pediatric patients for the deformations of the cranial bones. Expansion should be continued as much as possible as the


Tissue Expansion for Burn Reconstruction

expanded scalp flaps are still immobile when compared to any other skin flap. –– Trunk: Abdominal region posses differences when compared to dorsal and costal region. The expanders should be placed accordingly so that the pressure would not hinder any visceral functions. Abdominal expansion might not be feasible and predictable as the pressure would not expand the tissue thoroughly. Multiple small expanders might help to overcome the gravity problem in long term expansions at the trunk region. –– Extremities: Small, serial and multiple expansions should be planned. The pressure over the expander

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could be high because of the mobility of the extremities, and so, injections should be small in amount and more frequent. An alternative method to decrease the complication ratio has been performed in our clinic, followed by the experimental studies [17]. A silicone sheet with a size equal to the base of the expander has been used in all of the tissue expanders to decrease the amount of pressure over the expanded tissue. The silicone sheet is placed over the tissue expander during the tissue expander insertion. Thus the exposure of the tissue expander is not encountered at all.

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A 10-year-old female was consulted with the complaints of scar tissue on her scalp and face due to flame burn. The left part of the frontal and parietal regions of the scalp were grafted as the acute treatment after burn. The scar was 8 × 17 cm. Preoperative planning was done for the reconstruction of the alopecia region of the scalp before the scar of the face (Fig. 28.1). Three expanders with dimensions of 150, 240, and 500 ml were placed on the right frontoparietal, right temporaparietal, and left temporoparietal region. As described above, a silicone sheet was inserted over each silicone expander to distribute the pressure evenly to the expanded skin (Fig. 28.2). Following the first operation, 1 week later, expansion was started and the expanders were injected with saline twice a week through the ports (Fig. 28.3). After 10 weeks, the second operation was performed. The scar tissue was excised and repaired with the expanded flaps. There were no complications during the expansion and after the flap adaptations (Fig. 28.4).


⊡ Fig. 28.1 The preoperative view of the patient. On the left lateral view (left), the scar with dimensions of 8 × 17 cm at the left frontal and parietal regions of the scalp was visible. On

⊡ Fig. 28.2 A silicone sheet was inserted over each silicone expander to distribute the pressure evenly to the expanded skin in every expander procedure to decrease any complication depending on our experimental data

Chapter 28

the right lateral view (right), the scar on the right temporal region and face was visible

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⊡ Fig. 28.3 Anterior (left) and left lateral (right) view of the patient on the postoperative second week during the expansion. External port utilization was preferred depending on the case


⊡ Fig. 28.4 Postoperative 6 months of the patient, cranial view (left above) and posterior view (right above). Postoperative 1 year of the same patient, anterior view (left

Chapter 28

below) posterior view (right below). The alopecia was treated successfully and uneventfully

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A 7-year-old female patient was seen at the outpatient clinic with the scar tissue at the scalp region. The scald burn at the biparietal regions with a size of 7 × 10 cm was grafted 4 years ago as the acute burn treatment (Fig. 28.5). Two silicone expanders of 240 and 225 ml were placed at the frontal and the occipital region. The expansion was accomplished with weekly saline injections. After 7 weeks, the expanders were taken out, the scar tissue was excised, and the expanded flaps were adapted. There were no complications throughout the treatment except minor pain during expansion (Fig. 28.6).


Chapter 28

⊡ Fig. 28.6 The postoperative sixth month view of the patient with a minimal acceptable scar

⊡ Fig. 28.5 The preoperative view of the patient with burn scar localized at the biparietal regions with a size of 7 × 10 cm. Two silicone expanders of 240 and 225 ml were planned to be placed at the frontal and the occipital region

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A 17-year-old female was admitted to our hospital with the complaint of scar tissue due to scald burn on her right forearm and right leg. There was a 8 × 16-cm scar tissue on the radial side of the right forearm. The scar tissue at the proximal part of the right anterolateral leg was 5 × 12 cm. Two expanders with sizes of 225 and 90 ml were inserted to the proximal and distal part of the scar tissue at the forearm, and simultaneously, two other expanders with sizes of 150 ml each were placed to the lateral and medial parts of the scar tissue at the leg. Two expanders were injected twice a week. After 8 weeks, the expanders were taken out and the scar tissues were reconstructed with the expanded flaps. There were no complications (Figs. 28.7 and 28.8).


Chapter 28

⊡ Fig. 28.8 The scar tissue at the proximal part of the right anterolateral leg was 5 × 12 cm (above). Two expanders with sizes of 150 ml each were placed to the lateral and medial parts of the scar tissue at the leg. The postoperative sixth month view of the patient with minimal scar (below)

⊡ Fig. 28.7 The preoperative view of the patient with a 8 × 16-cm scar tissue on the radial side of the right forearm. Two expanders with sizes of 225 and 90 ml were inserted to the proximal and distal part of the scar tissue at the forearm with external port localization. (above). The postoperative sixth month view of the patient with minimal scar. Dorsal view (middle) volar view (below)

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Scalp Alopecia Reconstruction jincai fan, liqiang liu and jia tian

Background Scalp alopecia reconstruction usually requires fullthickness soft tissue coverage for functional purpose and hair restoration for aesthetical purpose. Since the hairbearing scalp is fixed in number after birth, the ideal solution for scalp alopecia is redistribution of the remaining hair-bearing scalp. Although a small alopecia defect can be repaired by wound closure or numerous types of local scalp flaps [1], a defect of up to 3–5 cm in width is commonly difficult to correct with traditional techniques due to the great tension on the wound closure and “stretch-back” that occurs later on [2–4]. When the scalp flap is not sufficient to repair the scalp lesion, numerous distant flaps are traditionally applied to improve the functional demands. Moreover, hair grafting may be another option to treat scalp alopecia only for cosmetic purposes [5]. However, if a lesion has the problem of unstable scar or thin skin grafting on the skull bone that often breaks down, bleeds, or infects, the hair grafting does not usually work well due to the high risk of lack of hair growth. The advent of tissue expansion started a new era to aesthetically reconstruct scalp alopecia, as it provides a natural hair-bearing scalp with acceptable hair density [2, 5–10]. Currently, it is believed that an alopecia area of up to 50% or more of the total scalp surface can be repaired by using tissue expansion (multistaged tissue expansion or serial tissue expansion) [11]. However, when the scalp defect is such that the hair direction of

the adjacent donor is not parallel to the recipient site, like “sideburns” or hemi-scalp defect, the traditional advancement flap does not usually match the aesthetical demand of the recipient site. On basis of the achievement of the advancement flap and rotation flap, an expanded “flying-wings” scalp flap was developed in our unit to properly manage large sideburn and hemi-scalp defects (Fig. 29.1) [8, 12]. Tissue expansion is usually not indicated to repair acutely injured wounds due to the disadvantages of a high risk of infection and the long time required for any result. In such a case, the tissue expansion should be

J. Fan, MD, PhD (*) Ninth Department of Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences, No. 33 Ba-Da-Chu Road, Beijing 100144, China e-mail: [email protected] L. Liu, MD, PhD and J. Tian, MD Ninth Department of Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences, No. 33 Ba-Da-Chu Road, Beijing 100144, China

⊡ Fig. 29.1 A flying-wings flap is designed by following the principles of an advancement flap and a rotation flap


Scalp Alopecia Reconstruction

carried out secondarily after the wound is completely healed by using traditional techniques (case 4).

Scalp Anatomical Characteristics The layers of the scalp, from the superficial to the deep, are the skin, subcutaneous tissue, galea aponeurosis, loose areolar tissue, and pericranium. The special characteristics are as follows:

1. Between the skin and galea, there are rich connective tissue fibers that make the structures connect firmly. It also allows the scalp flap become less elastic. 2. The scalp is nourished with five pairs of arteries: the supratrochlear artery, supraorbital artery, superficial temporal artery, posterior auricular artery, and occipital artery. The scalp flap can survive in a large size with a narrow and long pedicle. 3. The scalp is mainly innervated from the surrounding to the top with pairs of supratrochlear nerves, supraorbital nerves, auriculotemporal nerves, great auriculars, lesser occipital nerves, greater occipital nerves, and third occipital nerves. Nerve blockade can be easily achieved with good anesthetic results. 4. The subgaleal layer consists of loose areolar tissue and is easily elevated with less bleeding. 5. The direction of the scalp hair growth is angulated to the scalp surface.

Chapter 29

Specific Skill of the Methods 1. The donor site exposed to a tissue expander was usually selected depending on the position of the defect to be corrected, the hair direction required in the recipient site, the convenience to the patient, and the area of hair that will last long. 2. One or two tissue expanders are placed under the subgaleal pocket on one or two sides of the lesion, usually through a small incision in the lesion scalp. 3. The expander is then serially inflated with normal saline at an interval of 5–7 days until the desired volume is attained. 4. An expanded hair-bearing scalp flap should usually be designed with the combination of an advancement flap and a rotation flap, based at least on one nominated vascular system as the pedicle. A flying-wings flap is often used to correct hemi-scalp alopecia, where the wings often work to correct the distant side-part of the lesion with a great change in hair direction. 5. The expanded hair-bearing flap is elevated in the subgaleal layer when the expander is removed. The incision should always be carried out alongside the direction of the hair growth. 6. The scalp flap is then advanced and rotated to the recipient site when the lesion is excised.

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A 6-year-old boy suffered from scalp alopecia after a scald in his infant period. About half of the scalp was coronally covered with about a 14 × 18-cm weak scar (Fig. 29.2a). A 600-mL rectangular tissue expander was placed into a subgaleal pocket of the posterior scalp of the head (Fig. 29.2b) and serially inflated to reach about 680 mL in volume with normal saline for about 4 months (Fig. 29.2c). Thereafter, a flying-wings hair-bearing flap was coronally designed and raised from the expanded scalp, based on the posterior pedicle including the vascular supply of the occipital arteries (Fig. 29.2d). The wing-parts of the flap were rotated to repair the sideburn defects, while the central part for coverage of the frontal defect was done with an advancement movement technique (Fig. 29.2e). Excellent results were achieved (Fig. 29.2f ).


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⊡ Fig. 29.2 An anterior hemi-scalp defect was repaired with a coronary design of a flying-wings hair-bearing flap. (a) Preoperative view. (b) View of selecting a desired tissue

f

expander. (c) View of the full-expanded hair-bearing scalp. (d, e) Intraoperative views. (f) Postoperative view after 2 weeks

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+ Case 2

29

A 5-year-old boy had scalp alopecia with right hemi-scalp loss after burns when he was young (Fig. 29.3a). Two 400 mL rectangular tissue expanders were inserted in a subgaleal pocket of the left head and serially inflated to reach about 900 mL in volume with normal saline for about 4.5 months (Fig. 29.3b). Thereafter, a flying-wings hair-bearing flap was sagittally designed and raised from the expanded scalp, based on the lateral pedicle including the vascular supply of the superficial temporal artery and postauricular artery. The wing-parts of the flap were rotated to repair the defects of the right pre and postauricular lesions, while the central part for coverage of the top defect of the head was done with an advancement technique (Fig. 29.3c). Excellent results were achieved (Fig. 29.3d).


Chapter 29

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⊡ Fig. 29.3 A right hemi-scalp defect was repaired with a sagittal design of a flying-wings hair-bearing flap. (a) Preoperative view. (b) View of full-expanded hair-bearing scalp.

(c) Illustration of transferring the flying-wings expanded scalp flap. (d) Postoperative view

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An 18-year-old young man suffered from posterior large scalp alopecia after a neurofibromatosis was excised. A 600-mL rectangular tissue expander was placed into a subgaleal pocket of the anterior scalp of the head and serially inflated to reach about 650 mL in volume with normal saline for about 4 months (Fig. 29.4a). Thereafter, a flying-wings hair-bearing flap was designed and raised from the expanded scalp, based on the anterior pedicle mainly including the vascular supply of the left superficial temporal artery (Fig. 29.4b). The flap was transferred into the posterior defect by the principles of the advancement flap and rotation flap, after the lesion was prepared (Fig. 29.4c). Good results were achieved with less change in the direction of the growing hair (Fig. 29.4d).


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⊡ Fig. 29.4 A large posterior scalp defect was repaired with a single flying-wing scalp flap. (a) View of the full-expanded hair-bearing scalp. (b, c) Intraoperative views. (d) Postoperative view

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A 12-year-old boy had an acute large open wound on the right temporal head in 2 weeks after a car accident, with deep important structural exposure and slight infection (Fig. 29.5a). After surgical debridement, an acute scalp flap was designed with a pedicle including the right occipital vessels for coverage of the defect, while the large scalp donor site was being repaired with a splitthickness skin graft for temporary coverage (Fig. 29.5b, c). After the wound had healed well in 2 weeks, a 200-mL round tissue expander was placed into a subgaleal pocket beside the lesion and serially inflated to reach about 250 mL in volume with normal saline for about 3 months (Fig. 29.5d). An expanded hair-bearing flap was then designed as a rotation flap for the secondary repair of the scalp alopecia (Fig. 29.5e, f ). Very good results were obtained (Fig. 29.5g).


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c g

⊡ Fig. 29.5 An acute scalp wound defect was repaired with an acute scalp flap and a delayed expanded scalp flap. (a) Preoperative view. (b, c) Primary intraoperative views of the

scalp flap transferring and the skin grafting. (d) View of fullexpanded hair-bearing scalp. (e, f) Secondary intraoperative views of expanded hair-bearing flap. (g) Postoperative view

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Nasal Reconstruction jincai fan, liqiang liu, and cheng gan

Background of Nasal Reconstruction The techniques of nasal reconstruction began with the Indian flap (cheek flap or forehead flap) in approximately 600 bc, which is as early as the history of plastic surgery [1, 2]. In the fifteenth century, the Branca family developed the upper arm flap, well known as the Italian flap, which is used to form a nose [1, 2]. Till now, many techniques of nasal reconstruction originated mainly from the above two techniques but with various degrees of modifications. Nevertheless, the process of nasal reconstruction has to be carried out in many stages. By the 60s of the last century, with the progression of the vascular microsurgical technique, a free flap could be transferred to a distant lesion in one-stage operation by anastomosing the vascular vessels. Thus, the process of nasal reconstruction thereafter shortened down to one stage, where it is carried out by the microsurgical technique. However, each technique has certain drawbacks. Currently, the major techniques of nasal reconstruction are generally considered to be the following: forehead flap, upper arm tube flap, and free flap. To match the high aesthetic demands of the reconstructed nose, the forehead flap, is frequently used as the first candidate, especially with the aid of a tissue expander to decrease donor morbidity. However, the traditional design of the forehead flap is based on the supratrochlear vessels from the midline or paramedian region of the forehead. The remaining donor lesion is still obvious, even with the aid of a tissue expander [3].

J. Fan, MD, PhD (*) Ninth Department of Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences, No. 33, Ba-Da-Chu Road, Beijing 100144, China e-mail: [email protected] L. Li, MD, PhD and C. Gan, MD Ninth Department of Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences, No. 33, Ba-Da-Chu Road, Beijing 100144, China

Based on the better anatomical understanding of the forehead blood supply from the temporal region, a new technique of the expanded forehead flap has been developed in our unit for nasal reconstruction, in which an island flap is designed from the frontal hairline of the lateral forehead with only a one-stage transferring process, based on the lateral pedicle including the frontal branch of the superficial temporal artery [4]. The donor morbidity of the forehead can be diminished to the minimum without showing any visible unsightly scar in the forehead [4–6].

Indications Considered The techniques for nasal reconstruction are diversified tremendously according to the size, depth, and location of the nasal tissue loss. If the lesion is very superficial i.e., in the skin layer only, a full-thickness skin graft may be a good choice. But the results are usually not satisfactory for Orientals, mainly due to the occurrence of high pigmentation after the surgery. For a small skin defect involving less than 50% of the subunit of the nose, a local flap in the nose is usually satisfactory. If over 50% of a nasal subunit is lost, a nasolabial flap is usually considered for the construction of the entire subunit. An auricular composite tissue grafting technique is often a good choice for the repair of a small lesion in the alar or columella. Moreover, for total or subtotal nasal reconstruction, a forehead flap, upper arm tubed flap, or free flap is commonly considered. But, the traditional forehead flap is usually the first choice. This approach is specially appreciated when combined with the technique of tissue expansion, which allows the secondary donor morbidity to decrease down to a linear scar at the midline or paramidline of the forehead. Even then, the remaining vertical scar is still embarrassing to both the patient and the surgeons (Fig. 30.1). Therefore, a new design of the expanded forehead flap has been developed in our unit not only to fulfill the demands of total or subtotal nasal


Nasal Reconstruction

reconstruction, but also to diminish donor morbidity to a minimum without showing visible scarring (case 1, 2, 3). Of course, when a forehead donor is unavailable, the upper arm tubed flap (Fig. 30.2) and the microsurgical free flaps (Fig. 30.3) could usually become the main alternatives.

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Characteristics of Nasal Burn 1. The lesion is usually very large, often spreading out to the surroundings of the face. When the design of the nasal reconstruction is carried out, the restoration of the surrounding lesion should be considered as a part of the design. 2. The burn defect is usually not too deep to completely damage the framework tissue and the lining tissue. 3. Often severe scar contraction occurs. A simple Z-plasty often achieves marvelous results. 4. In the Orientals, the nasal framework (bone and cartilage) is usually insufficient compared to the Caucasian, and the overlying skin becomes thick as well. Thus, the restoration of the overlying full-thickness soft tissue becomes more important during the nasal reconstructive process than the frameworks.

Specific Maneuvers of the Methods

⊡ Fig. 30.1 A vertical scar of the forehead after nasal reconstruction with an expanded midline or para-midline forehead flap

a

b

1. A tissue expander (usually 200–300 mL round shape) is first placed into a submuscular pocket of one side of the forehead, by passing it through a small incision in the top scalp. 2. The expander is then serially inflated with normal saline at an interval of 5–7 days until the desired volume is reached. 3. On the full expanded side of the head, a Doppler flowmeter is used to find the course of the superficial

c

⊡ Fig. 30.2 An upper arm tubed flap for nasal reconstruction. (a) Preoperatively. (b) Transferring process of the flap. (c) Postoperatively

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a


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b

⊡ Fig. 30.3 A free forearm flap for nasal reconstruction. (a) Preoperatively. (b) Intraoperative design. (c) Postoperatively

temporal artery with its frontal branch and to mark it on the surface of the skin. 4. The forehead flap is designed as a “leaf ” shape along the frontal hairline vertically or transversely. 5. When the tissue expander is removed, an island flap is carefully elevated along the frontal hairline, with the pedicle based on the frontal branch of the superficial temporal vessels on the temporal side, just below the scalp follicles. 6. The lesion of the nose is removed and the lining is often repaired with a turnover flap from the adjacent

tissue. The required framework is usually remodeled with a cartilage graft or secondarily implanted with a shaped silicone prosthesis. 7. The island flap is then transferred into the nose, by passing it through a subcutaneous tunnel between the base of the flap and the lesion. 8. The forehead donor site is directly closed into the frontal hairline by using the remaining forehead tissue.


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30

A 26-year-old young man suffered from nasal contractive scar after flame burn (Fig. 30.4a, b). A 300-mL tissue expander was placed into a submuscular pocket of the forehead and serially inflated with normal saline for about 2 months. Thereafter, a 5.5 × 7.5 cm island flap with a “leaf” shape was transversely designed along the hairline, based only on the superficial temporal vascular pedicle (Fig. 30.4c). After the dorsal scar of the nose was removed and the lining was repaired with a “turn-down” scar flap pedicled from the lower margin of the lesion (Fig. 30.4d), the island flap was elevated and transferred to the dorsal nose by passing it through a subcutaneous tunnel between the base of the flap and the lesion. The forehead donor site was closed directly into the frontal hairline by using the remaining forehead tissue (Fig. 30.4e, f ). During more than 7 months of follow-ups, an excellent result was achieved with the reconstructed nose (Fig. 30.4g, h).


⊡ Fig. 30.4 A total nasal reconstruction was carried out with an expanded forehead flap based on the temporal island pedicle. (a and b) Preoperatively. (c–f ) Intraoperatively. (g and h) Postoperatively

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A 24-year-old man had partial nasal defect after an injection of a unknown tissue filler (Fig. 30.5a). A 200-mL tissue expander was placed into a submuscular pocket of the forehead and serially inflated with normal saline for 7 weeks. A 4.5 × 4 cm expanded forehead flap with a “half-leaf” shape was vertically designed from the hairline region, based on the lateral pedicle (Fig. 30.5b). After the dorsal scar of the nose was removed and the lining was repaired with a “turn-down” scar flap pedicled from lower margin of the lesion (Fig. 30.5c), the island flap was elevated and transferred to the nasal lesion by passing it through a subcutaneous tunnel between the base of the flap and the lesion. The forehead donor site was directly closed into the frontal hairline by using the remaining forehead tissue (Fig. 30.5d, e). A good result was achieved in the 2.5 years of follow-ups (Fig. 30.5f ).


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⊡ Fig. 30.5 A subtotal nasal reconstruction was carried out with an expanded forehead flap based on the temporal island pedicle. (a) Preoperatively. (b–e) Intraoperatively. (f ) Postoperatively

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A 16-year-old girl suffered from partial nasal defect and soft tissue loss of the left nasolabial fold area after radiotherapy of hemangioma (Fig. 30.6a). A 200 mL tissue expander was placed into a submuscular pocket of the forehead and serially inflated with normal saline for 7 weeks. A 4.5 × 9 cm expanded forehead flap was transversely designed from the hairline region, based on the lateral pedicle (Fig. 30.6b). After the lesion was prepared, the island flap was elevated and transferred to the nasal lesion by passing it through a subcutaneous tunnel between the base of the flap and the lesion. The forehead donor site was directly closed into the frontal hairline by using the remaining forehead tissue (Fig. 30.6c, d). A good result was achieved with the 9 months of follow-ups (Fig. 30.6e).


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d

e b

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⊡ Fig. 30.6 A subtotal nasal lesion and its surroundings were repaired with an expanded forehead flap based on the temporal island pedicle. (a) Preoperatively. (b–d) Intraoperatively. (e) Postoperatively

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Ear Reconstruction chul park

Introduction Reconstruction of burnt ears can be a challenging task. The requisites for a successful ear reconstruction are twofold: one is the construction of a genuine cartilage framework, and the other is the provision of a durable, yet thin coverage. Among the several options available for ear reconstruction, cartilage fabrication by using autogenous costal cartilage followed by draping with a regional skin flap is the most widely-accepted. In most burnt patients, the vicinity of the deformed ears shows dense scarring, and prevents the use of the regional skin flap for draping the new ear framework. In those situations, use of the temporoparietal facial flap is the best choice. The temporoparietal facial flap provides thin and pliable tissue for wrapping the new framework. Tegtmeier and Gooding [1], Brent and Byrd [2], Brent et al. [3], Brent [4], Nagata [5], Park et al. [6], Park and Roh [7] have all successfully used the temporoparietal facial flap for auricular reconstruction.

Characteristics of Our Technique 1. Our operation is based on a one-stage reconstruction technique, during which an erect and highly convoluted ear is constructed. 2. Construction of a new framework (Fig. 31.1): The remaining, deformed ear cartilage with scarred skin is completely removed. The sixth through the ninth costal cartilages are harvested from the ipsilateral chest wall. A highly convoluted framework should be constructed, considering the thickness of the draped fascia flap, the grafted skin, and the layer of

C. Park, MD, PhD Department of Plastic and Reconstructive Surgery, Korea University Hospital, 126-1, Anam-Dong 5-Ga, Seongbuk-Gu, Seoul, Korea e-mail: [email protected]

⊡ Fig. 31.1 Above are depictions of the 6th, 7th, 8th and 9th costal cartilages of the chest wall (each numbered by 6, 7, 8 and 9, respectively? they were used for shaping the main body of the auricule, helix and antihelix); the leftover costal cartilage pieces are depicted by 7’ and 8’, respectively (7’ is used for support under the helical crus and for the buttressing of the erect framework, and 8’ is used for shaping the tail of the helix)

future scar tissue between them. In order to make the same projection of the opposite, normal ear, a piece of cartilage block is added to the undersurface of the framework. 3. Flap design: When conditions at the temporoparietal region of the defective ear side do not allow elevation of a fascia flap due to previous thermal injury of the scalp skin or of the distributed vasculatures, a contralateral temporoparietal fascia flap is used as a free flap. In order to wrap around an erect and highly


Ear Reconstruction

c onvoluted framework in one stage, a large flap should be harvested: for total ear reconstruction, a flap measuring 10–14 cm in length and 10 cm in width, from the upper auricular margin, is usually needed. 4. Flap elevation: Thickness of the fascia flap is variable in each individual. In a male or in an adult it is usually thicker than in a female or a child. The superior auricular muscle is contained within the temporoparietal fascia and variably developed in each patient. In a patient with a well-developed superior auricular muscle, the fascia is thick and tough. In order to use a reliable fascia flap, at least one artery and one vein should be included in the flap, and their branches should be distributed to the distal margin of the elevated flap. Patterns of dominant artery and vein distributed to the temporoparietal fascia flap are variable. The fascia flap is distributed by typical vascular patterns of the superficial temporal artery, and superficial temporal veins were observed in 70% of normal individuals. The flaps in others should be elevated based on a combination of the superficial temporal arteries or veins, the posterior arteries or veins, or the occipital arteries or veins. Extensive dissection would cause congestion of the elevated scalp skin. The congested scalp skin should

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be salvaged by using medical leech, or by dripping heparin mixed saline when congestion is suspected.

Operative Procedure 1. Preoperatively, the vascular axis is traced by using a Doppler ultrasound probe. The anterior margin of the flap is designed within the hairline. 2. After a straight, vertical incision, the scalp flap is elevated from the underlying temporoparietal fascia. On the cephalic half-region, vessels, especially veins, superficially traverse within the fat layer located under the scalp skin. If the vessels are damaged during dissection, they can be repaired by microanastomosis. 3. The template, which is measured over the anterior and posterior surface of the erect auricular framework fabricated with costal cartilage, is then placed over the facial layer. The edges are incised and the flap is elevated, leaving behind the innominate fascia (a loose areolar tissue layer). When an ipsilateral fascia is used, the elevated flap is turned insideout and draped over the framework. Full-thickness skin obtained from the lateral groin or mediumthickness scalp skin is then grafted over the fascia.

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A 14-year-old boy presenting with auricular defect as a result of a chemical burn on the face and neck suffered 2 years before visiting our department (Fig. 31.2a). With the sixth through the ninth costal cartilages harvested from the ipsilateral chest wall, an erect and highly convoluted framework was constructed (Fig. 31.2b). Through a vertical scalp skin incision, the temporoparietal fascia flap, measuring 11 × 9 cm was elevated. The flap, supplied by the superficial temporal artery and the posterior occipital vein (Fig. 31.2c), was turned inside-out and draped over the framework (Fig. 31.2d). In this case, a part of the helical crus was covered with a deep temporal fascia flap (Fig. 31.2e). Full-thickness skin from the lateral groin was grafted over the fascia. Two years after the operation, a well-convoluted and a bilaterally well-balanced reconstructed ear was shown (Fig. 31.2f–i).

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g

h

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⊡ Fig. 31.2 (a–i)

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+ Case 2

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A 28-year-old female presented with an auricular defect as a result of a contact burn on the left side of the scalp and face at the age of 4 years (Fig. 31.3a, b). Before visiting our department, the scalp region was reconstructed through an expansion technique. Preoperatively, significant vascular axes were not detectable on the ipsilateral temporal region using a Doppler ultrasound probe. Therefore, we prepared to harvest a contralateral temporoparietal fascia to use as a free flap. With the sixth through the ninth costal cartilages harvested from the ipsilateral chest wall, an erect and highly convoluted framework was constructed (Fig. 31.3c). Through a scalp skin incision, a temporoparietal fascia flap measuring 12 × 10 cm was elevated based on the superficial temporal artery and vein (Fig. 31.3d). After microanastomosis to the recipient superficial temporal artery and vein, the fascia flap was draped over the prepared framework. Full-thickness skin obtained from the lateral groin was grafted over the fascia. Two years after the operation, a well-convoluted and a bilaterally well-balanced reconstructed ear was shown (Fig. 31.3e, f).

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⊡ Fig. 31.2 (a–f)

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C H A P T E R 32

Reconstruction in Pediatric Burns jui-yung yang and fu-chan wei

Introduction The incidence of pediatric burn (

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