Book

Color Atlas of Burn Reconstructive Surgery

Authors:

Abstract

Post-burn scar contractures are a commonly encountered problem in the field of plastic and reconstructive surgery. Nevertheless, many physicians still lack adequate knowledge on beneficial treatments. In this up-to-date atlas, leading specialists in post-burn treatment and the reconstruction of post-burn scar contractures depict in detail not only surgical techniques but also a variety of advantageous wound treatments. Many new methods invented by the authors are presented. Operative techniques are depicted in detail, and clear guidance is provided on selection of the most appropriate flap surgery. Advice is also given on how to prevent permanently disabling restriction of joint movement as a result of contractures and how to achieve good aesthetic reconstruction. This atlas is designed to appeal to a wide audience, from beginners to specialists. It will prove invaluable for doctors of every kind who deal with wound management. © Springer-Verlag Berlin Heidelberg 2010. All rights are reserved.

Chapters (51)

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.
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.
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.
One of the great frustrations in burn care is the phenomenon of burn wound progression. In this process, the depth of burn worsens in the first few days after injury even with optimal medical care. Jackson [1, 2] explained this phenomenon with three zones of injury (Fig. 4.1). By this paradigm, the zone of coagulation in the center of the wound is the deepest and consists of a zone of nonviable tissue. The outermost zone, the zone of hyperemia, is a superficial injury much like a first degree burn and will go on to heal uneventfully almost regardless of the treatment provided. Between these two zones is the zone of stasis. In this zone, the tissue is severely metabolically compromised due to poor blood flow (stasis) leading to progressive tissue damage and ultimate burn wound progression. The etiology of this phenomenon is multifactorial and involves cytokines, free radicals, clotting cascade, and other factors involved with tissue damage and the inflammatory response that leads to progressive loss of blood flow and more tissue ischemia [3–6]. While infection will hasten this process, it is not a requirement for burn wound progression.
Skin is the largest organ of the body, and serious problems arise when the skin is damaged or missing. Grafting of skin from one part of the body to another is a dependable, well-accepted procedure for the management of skin loss. Unfortunately, split-thickness skin grafting for a full-thickness skin defect results in coverage that is often stiff, fragile, and scar-like rather than like normal skin. Also, grafting is not often feasible in cases of large surface area burns where there is not enough skin for a donor site. The ideal solution would be a product that would accurately simulate the physical and biologic properties of skin and remain integrated in the healing process, so that the final result is more like normal skin than scar. Such was the vision of Dr. John Burke and Dr Ioannis Yannas when they developed the skin substitute Integra® (Integra Life Sciences, Plainsboro, NJ.) [1–3]. This totally bioengineered artificial skin can be considered an early application of “regenerative medicine.”
ReCell® is a technique for harvesting cells from the ­dermal–epidermal junction of the skin for delivery to the wound as a cellular suspension [1]. It is used to facilitate rapid epithelialisation in isolation and in association with standard wound repair techniques. The kit harvests cells from a non-injured site, which are programmed for regeneration [2] and introduces them into a wounded site to enhance repair. The goal is to achieve a wound healing by a tailored approach to match the donor site with the recipient defect as closely as possible and to reduce donor site morbidity [3].
The history of burn treatment has evolved through time to reflect the advancing frontier of medicine. Egyptian texts dating from 1500 bc advocated a mixture of “cattle dung and black mud” for burns [1] and Hippocratic teaching promoted lukewarm lavage and ointment-based bandages [2]. During the middle ages, treatments like scalding oil for war wounds were gradually replaced with science-based therapies, notably guided by such surgical luminaries as Ambroise Pare and John Hunter [3]. In the nineteenth century, Louis Pasteur’s discovery of microorganisms and Lister’s contributions to antisepsis directed burn therapy toward an era of sterile wound care, antibiotics, and antimicrobial dressings [4].
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.
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 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].
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.
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, long-term follow-up and conservative therapies are needed for complete functional and cosmetic recovery (Figs. 11.1 (E)).
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.
Dermal substitutes have been developed during recent decades.
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.
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 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.
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.
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.
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.
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.
“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.
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.
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.
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.
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.
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 random-pattern 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.
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.
Scalp alopecia reconstruction usually requires full-thickness soft tissue coverage for functional purpose and hair restoration for aesthetical purpose. Since the hair-bearing 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 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].
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.
The incidence of pediatric burn (<18 years old) in Taiwan according to data from Childhood Burn Foundation Taiwan ROC was about 33.4%. The incidence of reconstruction needed for this age group was also about the same. From the data presented at Singapore in the year 2006, there was an average of 36.3% (patient number: 2,833/7,795) of pediatric burn (<18 years old) in Linkou burn center (LBC), Chang Gung memorial Hospital (CGMH) from 1986 to 2004 [1]. Among these, one-third of the patients needed reconstruction. This is a large reconstruction group and is of concern.
Initially, secondary flap made by vascular implantation was presented by a Chinese burn surgeon named Shen in 1980 [1]. In his paper, he described a procedure in which the vascular bundle was elevated and implanted in the proximal subcutaneous region, and 2 weeks later, the neo-vascularized flap was elevated as a pedicled flap for facial and helical reconstruction.
Flap prefabrication and prelamination are complex procedures reserved for cases in which conventional, simpler flaps will not achieve the desired goal or are unavailable [3, 6, 8, 9, 11]. The term prefabrication was first introduced by Shen [14] in 1982 and describes the implantation of a vascular pedicle into a new territory, followed by a period of maturation and neovascularization, and then the subsequent transfer of tissue based on its implanted pedicle [11]. Prefabrication allows any defined tissue volume to be transferred to any specified recipient site, greatly expanding the armamentarium of reconstructive options. Flap prelamination, first coined by Pribaz and Fine in 1994 [8], describes a process in which tissues or other devices are implanted into a vascular territory before it is transferred; the blood supply is not manipulated [9, 12]. Prelamination transforms a native axial flap into a multilayered flap by adding the appropriate support and lining structures for composite reconstruction.
Prefabrication was proposed in 1998 by Khouri et al. [1] as a solution for the neodevelopment of flaps when anatomy could not provide an adapted tissue for a specific surgical procedure, after seminal works done by Erol [2] and Pribaz [3]. The author developed a technique [4] using a vascular carrier placed above a large skin expansion device. This system induces an important angiogenetic process, allowing the expanded skin surface to be progressively vascularized by newly formed capillaries developed from the carrier. This technique may be used anywhere on the body, in particular for extensive scars of the face, to provide aesthetic improvement and a better quality of life.
For functional reconstruction in extensively burned patients, reconstruction using flaps is necessary, but sometimes healthy skin is missing. However, scars due to epidermal burn (EB), superficial dermal burn (SDB), and deep dermal burn (DDB) can be used as local flaps or regional flaps. There are two concerns about scarred flaps: (1) vascularity of the flap and (2) elasticity of the flap. However, appropriate design and careful preoperative and intraoperative assessment of scars make this procedure successful. In 1981, the present author reported the effectiveness of scarred flaps including the musculocutaneous vascular system [1], after which some cases were experienced [2–4].
Reconstruction of severe burns in patients remains a challenge. This is particularly problematic in wounds that require durable flap coverage such as exposed bony prominences, tendons, and joints due to the paucity of normal adjacent skin donor sites. Reluctance in using local or regional flaps previously burned or skin-grafted is based on the erroneous assumption of inferior blood supply in the burned skin from prior thermal damage. The initial thermal injury is generally limited to the skin and subcutaneous fat; the underlying fascia and its vasculature are usually spared.
In 1979, Lamberty [1] described the supraclavicular flap on the basis of illustrations taken from Toldt’s anatomical atlas, which was published in 1903 [2]. The author showed a vessel which emerged between the sternomastoid and trapezius in the lower part of the posterior triangle and passed over the acromion. After that, Pallua et al. [3] reported in 1997 that they had used this flap successfully in eight cases of neck contracture reconstruction. Since then, the supraclavicular flap has been employed widely. Of the various flap techniques that are available, the supraclavicular flap is excellent in terms of its match with the color and texture of the recipient area and the simplicity of the operative procedure [4–12]. The author has also successfully applied this flap in the clinic in numerous cases.
The superficial cervical artery (SCA) fasciocutaneous flap was first reported by Nakajima et al. in 1984 [1]. Hyakusoku developed it for use as a skin flap in 1990 [2], and in 1993, we succeeded in harvesting it as a free flap [3]. The SCA is now considered to be a “transverse cervical perforator” or “trapezius perforator” (Fig. 39.1); thus this flap is widely known as “superficial cervical artery perforator (SCAP) flap” [4]. The cranial part of the trapezius muscle is thought to contain the SCA (superficial branch of the transverse cervical artery), and the middle part the dorsal scapular artery (DSA; deep branch of the transverse cervical artery) [4]. With its wide arc of rotation, the SCAP flap is large enough to cover large defects after removal of neck scar contractures.
Along with the recent development of “perforator flaps,” thin flaps are now coming into widespread use. However, over the past 20 years, the authors have focused on flap thinning techniques which have allowed us to harvest extremely thin but large flaps. These techniques have been primarily used to reconstruct large areas in burn reconstruction.
The concept of thin flaps vascularized by subdermal vascular network was first described by Situ [1] in 1986; since then, various types of super-thin flaps have been applied successfully in China and Japan. Basic researches were also performed to better explain the excessive survival mechanism [2–5]. The authors have developed these thin flaps that are called “super-thin flaps,” which was first reported in 1994 [6]. Based on these successful clinical uses, supercharged super-thin flaps [7] and preexpanded super-thin flaps [8] were also reported and are widely used. Our ultimate goal, namely, the development of “thin and reliable flaps” is a unifying principle between “super-thin flaps” and perforator flaps.
The anterolateral thigh flap was originally described as a septocutaneous artery flap by Song et al. [1]. Almost at the same time, the detailed anatomy of this flap and clinical application were reported by two other Chinese doctors in a Chinese journal [2, 3]. The locations of the perforators on the skin were first reported by the author [4]. After that, the anatomy of this flap was further presented from cadaver dissections or clinical experiences [4–6]. It was found that the blood supply of the anterolateral thigh flap was based on the septocutaneous or musculocutaneous perforators or both, the vascular variations of which were also reported by Koshima et al. [7].
The concept of immediate excision and coverage of early burn wounds has been controversial in certain circumstances because of the clinical concept of the progressive necrosis [1]. However, radical debridement followed by early coverage with grafts and/or flaps has been performed. The main principle about the burn treatment and reconstruction is to jeopardise neither the patient nor any flap that might be lost because of the general status of the acute burn victim [2]. The surgical principles of burn care are preservation of life, prevention and control of infection, conservation of all viable tissue, maintenance of function and timely closure of burn wounds [3–5]. Thus, the timing of any reconstruction and closure of burn wounds should be considered after all other vital issues [6–8].
The demands of the twenty-first century dictate aesthetic excellence as well as functional correction in complex burn reconstructions. The severely disfigured burned face is marred by corrugated external scarring, distortion of facial features, and restricted facial movement. Z-plasties, local flaps, and full thickness skin grafts are useful in addressing more limited functional needs of ectropion release, nasal stenosis, perioral contractures, exposed ear cartilage, etc. [1]. However, in burns involving large surface areas of the face, these more limited applications are inadequate. Feldman has suggested “megaunits” of thick split-thickness skin grafts to cover large “aesthetic units” [2] (Fig. 44.1). Even in the most optimal circumstance, these will never simulate normal skin perfectly [3]. In my experience, large sheet grafts generate “flat facies” lacking texture, distinct facial planes, and facial expression, not to mention gross color mismatches.
The deltopectoral skin flap described by Bakamjian [1] is an axial flap, and therefore it can be harvested as a free skin flap for distant transfer via microsurgical technique [2–4]. This skin flap is useful for facial resurfacing because of excellent color and texture match, the feature particularly suitable for people with dark skin complexion. Shortness of the vascular pedicle and smallness of the vessel caliber, on the other hand, render flap revascularization technically difficult. The method is, furthermore, plagued with problems attributable to the bulkiness of skin flap and morbidities associated with the donor site deformity.
Radial forearm flaps were first reported by Yang et al. [1] in 1978 and are one of the most reliable conventional types of flaps. To overcome the donor-site morbidity associated with this flap, which includes problems due to major artery sacrifice, numbness of the dorsal hand, and the development of unfavorable scars, many modifications of the radial forearm flap method have been reported. These modifications have resulted in the expanded flap [2], the distally based flap [3], and the perforator-based flap/perforator flap [4–6] methods. In a further modification, we developed the “shape-modified radial artery perforator flap method” [7–9].
Although the coverage of deep burn defects on the dorsal hand is quite complex and time-consuming, it can be accomplished by several techniques. Introduction of reverse flow island flaps obtained from the ipsilateral forearm or hand [1–4] has made the reconstruction easier, but even with the use of those flaps, the following serious problems often arise: (1) the sacrifice of major vessels of the arm and hand [5], (2) an unacceptable donor scar on the forearm or dorsal hand, and (3) the need for careful and complex dissection of vascular pedicles of small caliber. I believe these are the disadvantages of the reverse flow flaps. To overcome these disadvantages of the reverse flow skin flaps, adipofascial flap, which is fascial flap with overlying fatty tissue, is preferable to simple fascial flap because adiposal tissue acts as an effective gliding surface of extensor tendons of the hand. We developed a radial artery perforator-based adipofascial flap for the repair of defects on the hand dorsum with minimal surgery [6]. In this chapter, we describe two cases in which radial artery perforator-based adipofascial flaps were successfully used.
Generally, the perforators give off several thick branches in the adipose layer after penetrating the hiatus of the deep fascia, and then finally run into the subdermal plexus. The blood circulation of the flap mostly depends on these perforators and their branches, which means that the adipose tissue of the flap can be thoroughly removed while preserving an adequate circulation in the flap. A thin flap is prepared conventionally by the removal of nearly the entire adipose tissue of the elevated flap, with a small amount around the perforator and branches retained intact [1, 2]. However, since the distribution of the perforator and branches cannot be detected completely during the thinning procedure, it is not easy to decide on the optimal amount and position of the residual adipose tissue. Moreover, in the worst case, the procedure may sever the essential branch supplying the blood circulation of the flap, thereby leading to partial necrosis of the thin flap. Moreover, it is impossible to prepare an evenly thin flap because of the residual adipose tissue.
Hyakusoku et al. [1] presented a propeller flap for reconstruction of axilla and cubitus in 1991. The original propeller flap has been used for intact fossa and was elevated as a subcutaneous pedicled island flap. Nowadays, this propeller flap has been refined and various types of propeller flaps have been reported [2–11]. The represented one is the perforator pedicled propeller (PPP) flap [5], and this procedure is now considered to be another option for use of perforator flaps. Acentric perforator pedicle (Fig. 49.1a) enables the flap to rotate 180° [6, 7], and this flap can cover a long-distance defect (Fig. 49.1b).
Most of our reconstructions have been extensive post-burn scar contracture cases, for which we need extremely large but thin flaps to reconstruct wide, contour-sensitive areas such as the face and neck [1–9]. For this reason, our flaps have been harvested mainly from the back and chest as “super-thin flaps”, with the help of perforator supercharging (Fig. 50.1).
Introduced in 1994 by Hyakusoku and Gao [1] Hyakusoku et al. [2], the “super-thin flap” is a distinctively thin flap primarily thinned to the layer where the subdermal vascular network (subdermal plexus) can be seen through minimal fat layer (primary defatting). Moreover, Hyakusoku et al. [3] developed various types of long, large super-thin flaps. These flaps can be harvested mainly on the back and chest by selecting flaps with attached perforators (perforator supercharging).
Free flaps have been traditionally used for the repair of burn sequelae since the beginning of microsurgery era. Over the past 20 years, the senior author has focused on the use of the back as a donor site for flaps to resurface the anterior neck burn sequelae.
... Free flaps such as groin flap [5], ALT [8], and scapular skin flaps [6,18] have been reported for reconstruction of cervical contractures. A large free flap could resurface large defect, but at the cost of high donor site morbidity. ...
... As for the flat anterior cervical region that is the biggest part of defect, and the submental region that consists of two layers of platysma after platysma flap turning, thick partial-thickness skin grafts can often achieve good functional and aesthetic results without contracture recurrence. In case of limited donor sites the acellular allo-dermis matrix combined with autologous epidermis grafting can be an alternative method [18]. ...
... (Para) scapular flaps are reliable with a consistent vascular pedicle of good length and large caliber. The color and structure of the back skin may provide a better match for mental region reconstruction than the flaps from extremities [6,8,18]. We have gained rich experience in (para)scapular flap harvest and application during past treatment. ...
Article
Full-text available
Severe cervical contracture after burns causes obvious impairment of neck movement and the aesthetic silhouette. Although various surgical techniques for treatment have been described, there is not a definitive strategy to guide treatment. Over the past 6 years, we have been utilizing a region-oriented and staged treatment strategy to guide reconstruction of severe cervical contracture. Satisfactory results have been achieved with this strategy. The first stage of treatment focuses on the anterior cervical region and submental region. Procedures include cicatrix resection, contracture release, division and elevation of the platysma to form two platysma flaps, and skin grafting. Three to six months later, the second stage treatment is performed, which localize to the mental region. This includes scar resection, correction of the lower lip eversion, and reconstruction with free (para)scapular skin flap. Three subtypes of cervicomental angle that we proposed were measured as quantitative tool for evaluation of the reconstruction. 24 patients who completed the treatment were reviewed. By the 3rd postoperative month, their CM angles changed significantly: the soft tissue CM angle was reduced from 135.0° ± 17.3° to 111.1° ± 11.3°, the osseous CM angle increased from 67.1° ± 9.0° to 90.5° ± 11.6° and the dynamic CM angle increased from 21.9° ± 8.7° to 67.4° ± 13.1°. 22 in 24 (91.7%) of these patients gained notable improvement of cervical motion and aesthetic contour. Our results suggest that the region-oriented and staged treatment strategy can achieve satisfactory functional and aesthetic results, combining usage of both skin graft and skin flap while minimizing the donor site morbidity.
... 9,10 To prevent infection of the wound, it is required an effort to lessen the exposure time of the wound. 6,11 Therefore, the wound healing process is expected to take place in less time. 11 Wound healing process on the skin may take up to several weeks. ...
... 6,11 Therefore, the wound healing process is expected to take place in less time. 11 Wound healing process on the skin may take up to several weeks. During the second week, the wound is already covered by new tissue and it will experience the growth in its tensile strength. ...
Preprint
Background: Wounded tissue is the most often incidence especially in post-operation of medical or dental treatment. The failure in wound healing process could happen because of an infection. Wound healing acceleration need to be done to prevent the incident. The wound healing time could be shortened by some compounds such as flavonoid, saponin, and vitamin C. One of the plants which contained those compounds is Physalis angulata L. Objectives: To prove the effectivity of Physalis angulata L. extract 70% for wound healing acceleration on Galur Wistar rats' skin. Methods: The method used is a laboratory experimental study with posttest-only Control Group design. The samples were 32 rats which back was wounded with 1 cm 2 width and measured by the caliper. The sample divided into two groups which were control group (without given treatment) and treatment group (which was given the extract). Each group consisted of 16 rats. Results: The data was tested by Mann-Whitney test. Average healing time of each group was 14,375 days for control group and 13,125 days for treatment group. Discussion: Wound healing with Physalis angulata L. extract 70% was faster than normal wound healing. It was caused by the presence of flavonoid, saponin and vitamin C. Flavonoid decreased inflammation and cell destruction around the wound so it can be continued to the next stage. Saponin and vitamin C makes angiogenesis and fibroblast formation faster for the wound closure. Conclusions: Physalis angulata L. extract 70% is effective for the wound healing acceleration on Galur Wistar rats' skin.
... 9,10 To prevent infection of the wound, it is required an effort to lessen the exposure time of the wound. 6,11 Therefore, the wound healing process is expected to take place in less time. 11 Wound healing process on the skin may take up to several weeks. ...
... 6,11 Therefore, the wound healing process is expected to take place in less time. 11 Wound healing process on the skin may take up to several weeks. During the second week, the wound is already covered by new tissue and it will experience the growth in its tensile strength. ...
Poster
Full-text available
Background: Wounded tissue is the most often incidence especially in post-operation of medical or dental treatment. The failure in wound healing process could happen because of an infection. Wound healing acceleration need to be done to prevent the incident. The wound healing time could be shortened by some compounds such as flavonoid, saponin, and vitamin C. One of the plants which contained those compounds is Physalis angulata L. Objectives: To prove the effectivity of Physalis angulata L. extract 70% for wound healing acceleration on Galur Wistar rats' skin. Methods: The method used is a laboratory experimental study with posttest-only Control Group design. The samples were 32 rats which back was wounded with 1 cm 2 width and measured by the caliper. The sample divided into two groups which were control group (without given treatment) and treatment group (which was given the extract). Each group consisted of 16 rats. Results: The data was tested by Mann-Whitney test. Average healing time of each group was 14,375 days for control group and 13,125 days for treatment group. Discussion: Wound healing with Physalis angulata L. extract 70% was faster than normal wound healing. It was caused by the presence of flavonoid, saponin and vitamin C. Flavonoid decreased inflammation and cell destruction around the wound so it can be continued to the next stage. Saponin and vitamin C makes angiogenesis and fibroblast formation faster for the wound closure. Conclusions: Physalis angulata L. extract 70% is effective for the wound healing acceleration on Galur Wistar rats' skin.
... Traditional treatment of burns capable of healing within 2-3 weeks, such as superficial and partial thickness burns, is to manage the burn with non-operative local wound care including debridement and dressing changes, and aggressive range of motion exercises 14,15 . Partial thickness burns can be tangentially excised and covered with a temporary skin substitute 16,17 . However, there is no strong consensus on which topical antimicrobial agent or dressing is optimal for burn wound coverage to prevent or control infection [18][19][20] . ...
... Surgical debridement of burns of the forearm and hand is specific because important and delicate structures are encased within a relatively limited space in the dorsal aspect and covered by skin without a thick subcutaneous layer. The challenging shape of the hand and fingers and excellent blood supply of upper extremity tissues should also be taken into consideration 16 . Surgical debridement reduces the chance of burn wound self-epithelialisation but has a high probability of serious complications, such as massive bleeding, and microvascular and neurological damage 21 . ...
Article
Full-text available
Introduction. Surgical debridement of marginal deep dermal burns of the forearm and hand frequently is too aggressive to residual healthy skin. Additional operation is needed-split thickness skin grafting. Donor site complications should be taken in consideration , also transplanted skin rejection and ulceration. Therefore, clinical trials should be targeted to assess effectiveness of alternative debridement methods. Materials and Methods. Our team performed a randomised, controlled, parallel-group clinical trial designed to compare enzymatic, mechanical, and autolytic debridement methods for the treatment of deep dermal burns of the forearm and hand. Laser Doppler Imaging (LDI) performed on the third day post-burn, was used to predict burn wound healing time. Patients who LDI predicted burn wound healing time of no more than three weeks, were included in the study. For the first (control) group received standard treatment-dress-ings with 1% silver sulphadiazine cream. The second patient group was treated with hydrocolloid dress-ings to promote autolytic debridement. The third patient group received a combination treatment-dressings with silver sulphadiazine and mechanical debridement using special single-use monofilament polyester fibre pads. The fourth group was treated with application of enzymatic dressings. The treatment period for each patient was 3 weeks, which was followed by assessment at 6 months to evaluate post-burn scars.
... Local fasciocutaneous flaps from adjacent tissue always require donor-site grafts, while the use of free flaps for the management of this area may lead to significant donor-site morbidity, which involves a time-consuming procedure requiring long-term hospitalization [2]. The propeller flap, first described in 1991 by Hyakusoku et al., is defined as an island flap with an axial rotation [3, 4]. The posterior tibial artery emerges and directly continues from the popliteal artery [5]. ...
... In particular, it is indicated for single linear or band contractures in the web spaces at various locations. Specifically, it is suitable for (1) type IIa and IIb axillary web scar contractures where single band contractures involve the anterior or posterior axillary line,11 (2) type I digital joint contractures where there is a single digital joint contracture on the palmar or dorsal side, (3) chin/anterior neck web scar contractures with linear or band contractures within the unit, and (4) type I cubital and wrist joint contractures where there are linear or band contractures on the flexor/palmar or dorsal surface.12 Larger and deeper tissue defects should be treated by other methods, such as skin grafts, propeller flaps,13 pedicled flaps, or free flaps. ...
Article
Full-text available
Background: Joint scar contractures are characterized by tight bands of soft tissue that bridge the 2 ends of the joint like a web. Classical treatment methods such as Z-plasties are mainly based on 2-dimensional designs. Our square flap method is an alternative surgical method that restores the span of the web in a stereometric fashion, thereby reconstructing joint function. Methods: In total, 20 Japanese patients with joint scar contractures on the axillary (n = 10) or first digital web (n = 10) underwent square flap surgery. The maximum range of motion and commissure length were measured before and after surgery. A theoretical stereometric geometrical model of the square flap was established to compare it to the classical single (60 degree), 4-flap (45 degree), and 5-flap (60 degree) Z-plasties in terms of theoretical web reconstruction efficacy. Results: All cases achieved 100% contracture release. The maximum range of motion and web space improved after square flap surgery (P = 0.001). Stereometric geometrical modeling revealed that the standard square flap (α = 45 degree; β = 90 degree) yields a larger flap area, length/width ratio, and postsurgical commissure length than the Z-plasties. It can also be adapted by varying angles α and β, although certain angle thresholds must be met to obtain the stereometric advantages of this method. Conclusions: When used to treat joint scar contractures, the square flap method can fully span the web space in a stereometric manner, thus yielding a close-to-original shape and function. Compared with the classical Z-plasties, it also provides sufficient anatomical blood supply while imposing the least physiological tension on the adjacent skin.
... The veins accompanying these arteries show anatomic variations (two, one, or even none of the veins accompanying the artery). This is very important to the initial survival of this flap [18,19]. ...
Article
Introduction : Reconstruction of distal leg region remained a difficult task. Free flaps had long been considered as a gold standard for these regions. However, due to various limitations of the free flap, a local fasciocutaneous flap could be considered as a good alternative. In this study, the use of a distally based posterior tibial artery perforator flap had been evaluated in the coverage of defects around the ankle, heel, and lower third of a leg. The study also outlined the donor-site morbidity and the technical details of the surgical procedure.
... The veins accompanying these arteries show anatomic variations (two, one, or even none of the veins accompanying the artery). This is very important to the initial survival of this flap [18,19]. ...
Article
Full-text available
Introduction Reconstruction of distal leg region remained a difficult task. Free flaps had long been considered as a gold standard for these regions. However, due to various limitations of the free flap, a local fasciocutaneous flap could be considered as a good alternative. In this study, the use of a distally based posterior tibial artery perforator flap had been evaluated in the coverage of defects around the ankle, heel, and lower third of a leg. The study also outlined the donor-site morbidity and the technical details of the surgical procedure. Methods In this prospective study, a total of 42 patients with distal lower leg defects were included. The defects were located on the lower third of the leg (n = 23), ankle (n = 11), and heel (n = 8). Reconstruction was performed using distally pedicled posterior tibial artery perforator flaps. Patients were evaluated in terms of viability of the flap, functional gain, and donor-site morbidity. The technical details of the operative procedure have also been outlined. Results All the flaps survived well, with the exception of one patient, who experienced complete flap loss. Minor complications were, however, noted in four other patients: One patient developed superficial epidermolysis; one developed postoperative venous congestion, which subsided within 3 days by conservative means, and in two patients, partial loss of the skin graft occurred at the donor site but healed completely with dressing and antibiotics. The patients were followed up for an average period of 6 months, ranging from 1 to 13 months. Donor-site morbidity was minimal. Conclusions It was concluded that the distally based pedicled posterior tibial artery perforator flap was a reliable, easy, less time-consuming, and versatile procedure for covering the defects around the ankle, heel, and lower third a leg. Level of Evidence: Level IV, therapeutic study Keywords Posterior tibial artery perforator Distal lower leg Tibial defect
Article
Authors of the paper are writing about a wonderful person, scientist, Professor Mateev Musa Asypbekovich and his contribution to the plastic and reconstructive surgery.
Chapter
The treatment of scarring in children can be a daunting task due to the complex interplay of the scar, physical growth and development, and the cognitive, social, and emotional development of the growing child. When should we intervene? How should we intervene? How can we optimize outcomes without traumatizing children through our interventions? This chapter explores these factors as well as the current treatment options for children with scar ranging from small superficial scars to the most severe burn-related reconstructive problems.
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Face burns are a singular pathology with great functional and psychological impact in the patients suffering them. The ears play a fundamental role in personal interactions and damage to this organ results in physical and emotional distress. The reconstructive treatment of the burned ear is a challenge. Multiple procedures have been described to achieve success in the reconstruction of the burned ear; immediate reconstruction with autologous rib cartilage, secondary reconstruction, alloplastic material reconstruction, tissue expansion, skin grafts and also microvascular flaps are some of the most common procedures used in this patients. All these techniques focus on giving a natural appearance to the patient. Burns to the ears affect 30% of the patients with facial burns, they require an excellent treatment given by a multidisciplinary team. Copyright © 2017 Academia Mexicana de Cirugía A.C. Publicado por Masson Doyma México S.A. All rights reserved.
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The review covers global trends in cell therapy research and clinical trials aimed at the treatment of ophthalmic diseases. Some definitions are provided and mechanisms of action of cell products studied to date are listed.
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We developed a transplantable tissue-engineered skin equivalent composed of autologous cultured keratinocytes, fibroblasts, and a decellularized allogeneic dermis (acellular allogeneic dermal matrix; ADM) obtained from cadavers. In a process taking 3 weeks, cultured autologous keratinocytes from burn patients were expanded and then grown on ADMs. The tissue-engineered autologous skin equivalents (TESE) were then transplanted in a one-stage procedure to the debrided third-degree burn wounds of four patients. The mean graft survival was 96%. Delayed graft loss and graft fragility were not observed. Histological and immunohistological findings indicated that the transplanted TESE had similar characteristics to normal human split-thickness skin grafts. These results suggest that the TESE using a ADM is able to be used for permanent repair of full-thickness skin defects.
Article
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Management of Achilles tendon and heel area defects is a common challenge for the reconstructive surgeon due to the lack of soft tissue availability in that region. In this article, we present our experience in covering these defects by using the distal perforator propeller flaps based on the posterior tibial artery. Perforator flaps are based on cutaneous, small diameter vessels that originate from a main pedicle and perforate the fascia or muscle to reach the skin. Their development has followed the understanding of the blood supply from a source artery to the skin. Six patients (five males and one female) underwent reconstruction by using the posterior tibial artery distal perforator flap for covering defects in the distal Achilles tendon region in patients with and without diabetes mellitus. Postoperative complications included a hypertrophic scar formation in one patient, partial marginal flap necrosis in another patient, and a wound infection in a third patient. All wounds were eventually healed by the last postoperative visit. In conclusion, perforator flaps based on the distal posterior tibial artery may be a reliable option for the coverage of small to moderate size defects of the Achilles tendon and heel area regions.
Article
Medical makeup, which can camouflage birthmarks or scars and which can have a positive effect on the psychological well-being of patients across many different medical disciplines, was first actively promoted by the British Red Cross in the 1970s. It is currently recognized as a specialist discipline and plays an essential role in the medical care systems of general hospitals in Europe and America. The author has developed this concept further by proposing the concept of "rehabilitation make-up therapy" and has implemented a procedure seeking to provide "mental care through makeup" to help patients overcome the debilitating psychological anguish resulting from postoperative or posttraumatic scars, burn scars, and the skin lesions associated with various collagen diseases at his plastic surgery outpatient clinic in cooperation with doctors from the University hospital since April 1999. In the past, medical services have focused primarily on curing the underlying disease, and not on supporting the patient's social recovery. However, patients living with the daily reality of disfiguring scars are not convinced of their cure, even though their wounds have been successfully healed or their lesions successfully removed. This fact has led to the realization that patients desire more than just a physical cure; they also desire the means to conceal their scars and obtain a sense of normalcy. This is the role that rehabilitative makeup serves. Finally, the author presents practical methods for the use of rehabilitation makeup and also discusses its role and its identity in a series of emerging medical trends.
Article
In recent years, the development of systemic therapy for burns has decreased the mortality rate of extensively burned patients. However, the number of patients suffering from scar contractures after burns is increasing. During operation, we often find it difficult to get sufficient skin for autografts and to make pedicle flaps because of extensive scar tissue. To improve the situation, we planned applications of myocutaneous flaps containing scar tissues to scar contractures. We had two cases of latissimus dorsi myocutaneous flaps and one case of a tensor fascia lata myocutaneous flap. In the former cases, the flaps were transplanted to the axillary regions and in the latter the flap was grafted onto the inguinal region. In all the cases, the flaps were successfully transplanted without necrosis and joint movement was improved. Therefore, we have concluded that we can obtain the same results by using myocutaneous flaps which contain scar tissue as with other myocutaneous flaps.
Article
Tissue engineered skin composed of cultured epidermal cells and fibroblasts with acellular allogeneic dermal matrix as a scaffold was developed. The tissue engineered skin showed multi-layered keratinized epidermis and a nearly normal structure of dermal collagen matrix. The basement membrane structure remained along the dermo-epidermal junction of the tissue-engineered skin. The sheets of the tissue-engineered skin composed of autologous cells were successfully transplanted to excised third degree burn wounds in two extensive burn patients. The transplanted sites were stable without any graft loss or fragility. Histological appearance of the transplanted tissue-engineered skin resembled the appearance of a normal split-thickness skin graft with the presence of the basement membrane. It is suggested that tissue-engineered skin based on acellular dermal matrix may be a useful therapeutic option in the treatment of extensive burns.
Article
In clinical usage, the rectus abdominis musculocutaneous flap has been found versatile but too bulky because of the extent of muscle involved, leading to the possibility of postoperative abdominal herniation due to the removal of the rectus abdominis muscle. To overcome these problems, a rectus abdominis muscle perforating artery flap, which is pedicled with the muscle perforator and the proximal deep inferior epigastric artery and has no rectus abdominis muscle, was installed in three patients. As a result, we found that the flap, without the muscle, can survive with a single muscle perforator, and that the flap could be used as an island flap to cover abdominal defects such as intestinal fistula and a radiation ulcer. Further, being the greatest advantage of this flap, the partial resection of the fatty tissue of the flap is an option that allows for the creation of a thin flap for the reconstruction of a thin defect, such as in dorsum of the foot and the intraoral region.
Article
There exists a quantitative relationship between bacterial contamination and clinical infection. Because of this relationship, delayed wound closure can be performed based on the number of viable bacteria present in the incision at the time of closure. This principle was applied to 95 delayed wound closures in a prospective series. Ninety-three cases were closed when the bacterial estimate was 105 bacteria or fewer per gram of tissue. This resulted in a 96% successful closure rate. The method of bacterial quantification on a tissue biopsy from the wound requires 1 hr from time of culture to quantitative report to the surgeon so that closure can be effected.
Article
Traditionally, the treatment for general burns has been divided into two types based on different objectives as follows: one type is used to cover the raw surface of the burn wound under intensive care, and the other type is used to correct scar contracture. In this comprehensive treatment protocol, these two categories are merged into a single series of consecutive surgical treatments derived from the prediction of the long-term prognosis of each wound. A keynote concept of this protocol is utilization of the limited recipient site as effectively as possible, so that only two types of skin in terms of thickness are transferred to cover the burn wound. These are thin split thickness skin grafts and microdissected thin flaps. Moreover, these two types of transfer are performed intensively in one period of hospitalization. Four patients were treated using of this protocol, and all patients recovered close to their full activities and no additional surgery was required after their discharge from the hospital.
Article
Electrical burn in the pubic region usually results in a severe and contractive scar with pubic hair loss. The aesthetic restoration of this area often has become very difficult. A 22-year-old male electrical engineer experienced severe pubic scarring with hair loss after electrical burn. He was treated successfully with an expanded free-forehead flap including a portion of hair-bearing scalp after microsurgical vascular anastomoses between the bilateral superficial temporal vessels and the bilateral deep inferior epigastric vessels. The donor forehead site was closed directly in the frontal hairline without visible scarring. The pubic area was repaired functionally and cosmetically with the flap, and the pubic hair was growing well after a 1-year following-up period. This successful case strongly indicates that a microsurgical tissue transfer can be a good option for reconstruction of a pubic defect and that the expanded forehead flap could fulfill the high cosmetic demands of pubic reconstruction with minimal donor morbidity.
Article
To explore the effects of tissue expansion on the anastomoses and the survival of the axial pattern flap with a crossing area supply so as to improve the survival of crossing area axial pattern flap and to provide a new idea for the development of original crossing area axial flap. The experiment included two parts. Experiment A was divided into expansion group and control group. Square flaps were randomly designed on own control bilaterally in each animal with a boundary of midline. Experiment B was divided into expansion group and delay group. The flaps were also randomly designed on own control bilaterally. Angiographic analysis and gross survival observation were carried on. Experiment A: Angiography showed that there were abundant anastomoses with big caliber between deep iliac circumflex artery and superior epigastric artery in expansion group and there were only 3-4 anastomoses in control group. Experiment B: Angiography showed that there were abundant anastomoses with big caliber in expansion group and there were two arterial systems with relatively less anastomoses and smaller caliber in delay group. The survival rates in expansion group was significantly higher than that in the control group (90.16% +/- 3.61% vs 72.67% +/- 5.35%) in experiment A, and in experiment B the survival rate was 92.08% +/- 3.30% in the expansion group and 80.79% +/- 4.52% in the delay group, showing significant difference (P < 0.01). Expansion prefabrication can and improve the survival of the crossing area supply axial pattern flap. The mechanism is the bridging effect.
Article
In percutaneous collagen induction, an alternative to laser resurfacing, the skin receives multiple punctures with a drum-shaped device that has fine protruding needles, to encourage the production of collagen and elastin. According to the author, advantages include preservation of the epidermis, thicker skin, a short healing phase, and use of local anesthetic alone. (Aesthetic Surg J 2002;22:315-317.).
Article
In thermal deep-dermal burns, surgical debridement is normally used in conjunction with skin grafting or skin substitutes and debridement alone as a burn treatment is not usually practiced. The current study addresses whether or not debridement alone would enhance burn wound healing on small deep-dermal-partial thickness burns. This was a prospective and blinded experimental trial using a porcine deep-dermal-partial thickness burn model. Four burns, approximately 50 cm(2) in size, were created on each of eight pigs. Two burns from each pig were immediately surgically debrided and the other two were not debrided as the internal control. Hydrate gel together with paraffin gauze were used to cover the burns for four pigs and silver dressings for the other four. Clinical assessment of wound healing was conducted over a 6-week period. Skin samples were collected at the end of the experiment and histopathological evaluation was performed. The results show thinner scar formation and lower scar height in the debrided compared with nondebrided wounds in the hydrate gel/paraffin gauze groups. There were no statistically significant differences in wound healing assessment between the debrided and nondebrided wounds dressed with silver dressings. This study provides supporting evidence that immediate debridement with an appropriate dressing and without skin grafting may promote wound healing, suggesting its potential benefit for clinical patients.
Article
Our experience in managing 117 patients with burn alopecia are presented. Most often we used staged excisions of the scarred scalp areas, and by this means we could cover up to 15 percent of the scalp. When the alopecia involved the anterior portion of the scalp, however, a rotational scalp flap was needed to restore the anterior hairline and/or sideburns. For those with burn alopecia of more than 60 percent of the scalp surface, no surgical treatment was effective; the women would often cover their scalps with hairpieces, but the men in our series preferred not to do so.
Article
We studied the inhibitory effects of tranilast, an anti-allergic drug, on the human keloid tissues implanted into the dorsal skin of athymic nude mice and on the growth of keloid fibroblast in vitro. In the keloid tissue-implanted model, tranilast (50-200 mg/kg, p.o.) decreased the weight of the keloid tissue as triamcinolone (25 mg/kg, p.o.) did. Tranilast (200 mg/kg, p.o.) reduced the hydroxyproline content of implanted tissues. Tranilast (3-300 microM) also inhibited the collagen synthesis by keloid fibroblast in vitro. Only a high concentration of tranilast (300 microM) suppressed the glycosaminoglycan synthesis and cell proliferation of keloid fibroblasts. Moreover, tranilast scarcely affected the fibronectin production. Triamcinolone (10 microM) also inhibited glycosaminoglycan synthesis and cell proliferation. These results suggest that the inhibitory effect of tranilast on the keloid tissues is related to its inhibition of the collagen synthesis of fibroblasts. Tranilast would be useful as a therapeutic drug for the treatment of keloids.
Article
A prospective study was performed that allowed a quantitative estimation of blood loss in excision and grafting of adult burn injuries. The average value for blood loss was 9.2 per cent of the patient's estimated blood volume or 387 ml per 1 per cent burn excised and grafted. There was no exponential increase in blood loss as the percentage excised and grafted increased apart from proportionality and there was no statistical difference between males and females for burns excised and grafted days 1-14 after injury or greater than 14 days after injury. It was therefore concluded that a useful working figure is 400 ml whole blood or 10 per cent of patient blood volume is lost per 1 per cent full thickness burn excised and grafted for an adult. These values do not apply to the very young, the very old and those patients who have bleeding disorders, and when using various methods to limit blood loss. This figure allows adequate cross-matched whole blood to be available preoperatively.
Article
Total or subtotal resurfacing of the face with suitable, well-matched skin from the upper trunk and neck is usually difficult because of the dearth of unscarred donor site. Tissue expanders have been used primarily to construct local advancement flaps of tissue immediately adjacent to a tissue defect or deformity. These flaps often lack adequate mobility to allow coverage of large areas. In this report, I describe a clinical experience of 11 patients followed for 27 to 75 months in whom tissue expanders were used to develop large, full-thickness skin grafts or transposition flaps for total or subtotal resurfacing of the face and neck. Large, full-thickness skin grafts were developed from relatively small donor sites using tissue expanders. They behaved identically to unexpanded full-thickness skin grafts. They were found not to shrink with storage. The donor sites were closed primarily, obviating the need to graft the donor site. The tissue expander-enhanced transposition flaps appeared to have enhanced vascularity and provided ample, suitable tissue for reconstruction of the face and neck. Tissue expansion resulted in very mobile, thin, hearty flaps that provided excellently matched skin cover for the face and neck. Complications, some of which are unique to these techniques, and indications for the techniques are reviewed.
Article
The priorities, timing, techniques, and philosophies of reconstruction of the burned face are outlined in this article. Each anatomic area is analyzed, and the appropriate procedure is described.
Article
Biopsy specimens from unburned skin were obtained from three severely burned patients and placed into tissue culture. After 2 to 3 weeks, the cultured keratinocytes were released from the Petri dishes and transplanted onto the patient's burn wound, which had been completely excised down to muscle fascia, thereby removing all cutaneous elements. Healing cultured autografts were found to become repopulated with Langerhans cells within 3 to 6 weeks. A neodermis rich in fibronectin rapidly formed between the autografts and muscle fascia. However, using monoclonal antibodies to cytokeratins as markers of differentiation, we found that the autograft keratinocytes expressed an abnormal pattern of differentiation that was similar to the differentiation seen in hyperproliferative states such as psoriasis. In contrast, healed split-thickness graft donor sites and reepithelialized interstices of mesh grafts maintained the basal keratinocyte staining pattern of normal skin with the AE-1 monoclonal antibody.
Article
For the local treatment of extensive burn patients including superficial dermal thickness burn and deep dermal thickness burn, it is often difficult to determine whether conservative treatment should be followed consistently or grafting be employed. The present study was made to determine when grafting should be provided if required and the treatment method to provide the best results. For the study, a total of 41 cases were taken to which the author rendered treatment from the initial stages, in the period from January 1981 to December 1985. In these cases, the burn area was more than 10 per cent of the body surface area (BSA) in infants and children, and more than 20 per cent BSA in adults. Both superficial dermal thickness burn and deep dermal thickness burn were coexisting. The treatments and results of examination after convalescence are as follows. 1. In conservative local treatment, impregnated ointment gauze, L(D)PS and silver sulfadiazine were used, with wet-to-dry dressing, and hydrotherapy or skeletal suspension used jointly in some cases. 2. Of 41 cases, 38 received grafting during the treatment process. Patch autograft was applied to all cases, and allograft was jointly applied to 5 cases. 3. From post-convalescence examination, most cases showed hypertrophic scar when grafting was provided at a later stage and with the younger age of the patient. From this, it can be emphasized that earlier grafting will cause reduction in treatment period, with better functional and esthetic results, even in deep dermal thickness burn.
Article
The unique properties of the temporoparietal fascial flap (TPFF) offer adaptability in reconstruction of a variety of composite defects. The broad, thin sheet of vascularized tissue may be transferred alone or as a carrier of subjacent bone or overlying skin and scalp. As a pedicled flap, it is ideal for defects of the orbital, malar, mandibular, and mastoid regions. As a free-tissue transfer, the large vessels and lack of bulk find broad utility in reconstruction of the extremities. This flap is our choice for reconstruction of the dorsal hand and non-weight-bearing surfaces of the foot. A viscous gliding surface decreases friction for tendon excursion. The thin contour is aesthetically superior to thicker flaps, allowing unmodified footwear or gloves. The pliable fascia convolutes into surface defects (e.g., bone craters) or drapes over skeletal frameworks (e.g., ear cartilage). The rich capillary network offers nutrition to saucerized bone, cartilage or tendon grafts, and overlying skin grafts. The geometry of the skull lends to fabrication of membranous bone for complex facial puzzles. The donor site is well disguised by hair growth. Twelve cases performed over a 2-year period demonstrate the versatility of this flap. These include complex foot reconstruction, ear and scalp avulsion, shotgun wound of the cheek and orbit, posttraumatic jaw recontouring, chronic osteomyelitis of the hand and foot, and acute resurfacing of dorsal hand with tendon reconstruction.
Article
Stable attachment is quite important for successful free skin grafts, especially in movable areas such as faces and extremities. In this report we show the effectiveness of using a frame made of Kirschner wire that is attached externally for fixing grafts in place. The utility of external wire frame has demonstrated several advantages. It protects grafts from external damage, and stabilizes the graft tissue to the graft bed. The external frame also prevents grafts from lifting up at the edge. Thus, palpebral ectropions and cheilectropions are prevented, and the pressure can be applied evenly to the entire graft.
Article
More than 100 patients (38 in the head and neck) have been treated by the insertion of tissue expanders since the technique was introduced six years ago. Our methods have been refined as we have learned more, and these improvements are described. Morbidity is high when untrained surgeons start to use the technique. The most important decision is the planning of the expander and filling port pockets, but above all the location of the incision(s): Incisions must be kept small and away from the defect, the pocket, and the future flap. Intraoperative filling of the expander reduces the need for drains by preventing haematoma and seroma formation, and reduces the formation of expander envelope folds. The optimal location of the valve is a "quiet" area above or lateral to (or both) the expander, and at least 7 cm away. Mathematical formulas are useless in predicting available flap length, as elasticity and contractility depend on individual factors. A good estimation of flap length is twice the height of the expander above the skin surface or the distance over the dome of the expander minus the corresponding measurement of its base. Overexpansion by 30-50% makes the procedure more predictable.
Article
Neck contracture after burn injury can result in severe functional as well as aesthetic deformities. Contracture can recur even after wide and complete release and full-thickness skin grafting. Recurrence is partly due to the inherent difficulties in both early postoperative immobilization and the required long-term splinting. When adjacent tissues are also burned, adequate local tissue for reconstruction may not be available; therefore, free-tissue transfer may be necessary. The large surface area that is required after adequate release may be provided by tissue expansion before free-tissue transfer. In the case presented the use of tissue-expanded radial forearm free flap for the reconstruction of a recurrent neck contracture is described.
Article
All patients hospitalized between May 1987 and June 1988 suffering from burns covering over 50 per cent of the body surface area were treated by topical application of a cream containing cerium nitrate (0.05 M) and silver sulphadiazine (0.03 M) (CN + SSD). Eleven patients were included in this series, with a mean age of 35 years (range 22-65), a mean total burn size of 78 per cent (range 50-96 per cent) and full skin thickness covering a mean of 48 per cent (range 10-91 per cent). Eight patients survived (73 per cent) (mean age 36 years; mean total burn surface 73 per cent; mean full skin thickness burn surface, 38 per cent). These results are far better than those obtained in our Unit where a survival rate of 34 per cent was obtained in a comparable series of patients treated before 1987. Sixty positive blood cultures were obtained, which included a large variety of organisms with a slight predominance of Staph. aureus, Candida albicans and Ps. aeruginosa. Wound cultures were positive in 72 per cent of swabs and showed a predominance of Ps. aeruginosa (59 per cent of all the strains isolated). Even if CN + SSD appears in this series not to be very efficient in preventing wound colonization and septic complications, it permitted a very high survival rate in the treated patients, taking into account the extreme severity of the injuries. This beneficial effect is probably the consequence of the protective action of the yellow-green eschar formed by CN + SSD.(ABSTRACT TRUNCATED AT 250 WORDS)
Article
When dehydration, infection, and mechanical trauma are prevented, procedures (such as cooling and/or oral antithromboxane) designed to diminish ischemia in experimental zone-of-stasis burns have been associated with no or only minor improvement in wound healing. To test the hypothesis that ongoing skin damage occurring postburn (PB) may in part be due to release of oxygen-derived free radicals during the 16-hour through 4-day PB period of reperfusion in such burns, beginning immediately and for a period of 5 days PB, equal numbers of guinea pigs received: allopurinol 150 mg/kg PO q 6 h vs. placebo, dimethylsulfoxide (DMSO) 75% applied topically q 12 h vs. placebo, or yeast-derived superoxide dismutase coupled with polyethylene glycol (PEG-SOD, Pharmacia) 10,000 U (Fridovich) given IV q 8 h producing a concentration of 16 U/cc of plasma 8 hr after injection vs. placebo. Gross and histologic examination of wounds by a 'blinded' investigator at 1 week and 3 weeks PB revealed no difference between treatment and control groups when rates of re-epithelialization and frequencies of hair-follicle retention were compared. Using the dosages, routes, and model described, treatment of a zone-of-stasis burn with PO allopurinol (a xanthine oxidase inhibitor), topical DMSO (a scavenger of the hydroxyl radical), or IV PEG-SOD (a scavenger of the superoxide radical) during the first 5 days PB was associated with no increase in the rate of re-epithelialization or frequency of hair follicle retention at 1 and 3 weeks PB when compared with controls.
Article
This report details the experience with nine patients over a 3-year period who had partial or total nasal reconstruction using an expanded forehead flap. The history of nasal reconstruction is reviewed, emphasizing the evolution of the forehead flap as the ideal donor site. The author's experience with skin expansion of the forehead to produce a thin ideal flap is presented in detail. Complications of the procedure are reviewed. Technical considerations to achieve a good result are emphasized. The forehead donor site is minimal and well accepted. This procedure provides a solution to a major problem with partial and total nasal reconstruction.
Article
During the past 18 months, 60 tissue expanders were utilized in the reconstruction of 42 children with burn alopecia of the scalp not amenable to a single excision and primary closure at the Shriners Burns Institute in Galveston, Texas. The children were grouped according to the degree of alopecia. All patients with defects of 15 percent or less of the total hair-bearing scalp were able to obtain complete closure of their defects with two operations, i.e., one to place the expander and the second to remove the expander and advance the flaps. Some patients with defects up to 40 percent were closed with serial expansion. Patients with even larger defects had a significant reduction in the percentage of alopecia and benefited from re-creation of anterior hairlines. We have encountered a postoperative complication rate of 10 percent. When compared to previous methods of treating burn alopecia, tissue expansion allows a more rapid closure, fewer operations and coincident anesthetics, and decreased total length of hospitalization.
Article
Burn reconstruction of the head and neck must first start with special care to this anatomic area in the early acute phase, with appropriate early débridement and coverage with sheet grafts of medium thickness into unit facial orientation. Postoperative garment and mask splinting, will help lessen the hypertrophic scar formation that frequently follows facial burns and skin coverage. Carefully planned reconstruction of these areas is indicated, with priority given first to the neck, then to the periorbital area, and then to perioral areas. Principles of scalp, ear, nasal, and cheek reconstruction following burns of the face are carefully outlined. The unit concept of burn scar resurfacing of the face has been the mainstay of our treatment. We have emphasized skin coverage of the face from similar donor site areas. The emotional and psychological effects of facial scarring secondary to severe burns are crippling to patients. Although numerous reconstructive surgical procedures may lessen the deformity, ultimately burn patients realize that their burn scars are permanent and no surgeon can give them back their original facial appearance. These patients need strong and continued support and reassurance from their physicians and nursing professional staff to maintain their self-identity and confidence.
Article
We report the usefulness of scar flaps and secondary flaps in the surgical repair of extensively burned patients. Burn scar contractures repaired with scarred axial pattern flaps, scarred musculocutaneous flaps and scarred fasciocutaneous flaps are described. However, it is our contention that their application should be strictly limited. An example of the use of scarred secondary axial pattern and musculocutaneous flaps for reconstruction of a burned ear is shown.
Article
A study was undertaken using the camouflage cosmetics available in Australia. Three camouflage cosmetics were compared in a variety of skin conditions. It was found Dermacolor was preferred to Covermark and Keromask. So far, a similar study has not been done.
Article
"Stretch-back" is a phenomenon which to a considerable extent reduces the benefits of scalp excisions for reduction of male pattern baldness. Tattoo marks placed on the scalp have revealed that about one-third to one-half the effect of the excision of the bald area of the scalp is lost postoperatively. Most of this stretch-back occurs during the first 8 postoperative weeks and is completed at 12 weeks. Most of the stretch-back originates from the wound area. It is important to be aware of the stretch-back for correct planning of the surgical program and for being able to predict the final result.
Article
This paper presents the planimetric Z-plasty and compares it with the traditional stereometric Z-plasty. The main advantages of the planimetric Z-plasty are plane adjustment to the body surface, elimination of scarred skin areas, and variable scar lines.
Article
We present our new approach for preserved subcutaneous vascular network (PSVN) skin transplantation. To confirm the revascularization of the grafts, we undertook a microscopic study and found that, because of the rich anascroscopic study and found that, because of the rich anastomotic communication between the recipient vessels and the PSVN on the undersurface of the skin graft, successful adaptation to the recipient bed is achieved--enhancing the transplantability of the skin graft. We also noted that the absence of injury to the dermis of the graft permits the undersurface of the graft to be in contact with the raw surface with a minimum of scar formation. Finally, neither contracture nor wrinkling of the skin grafts was observed during the six-year follow-up study.
Article
In my previous paper entitled ‘Vascular implantation into skin flap’1, it was experimentally shown that a ‘random-pattern’ skin flap, with a transposed vascular bundle or an artery alone buried underneath, could be transformed to a ‘secondary axial-pattern’ skin flap (unpublished findings). The establishment of vascular communications between the flap and implanted vessels is constant after a period of time. This type of secondary, or prefabricated, axial-pattern skin flap can be successfully used in island transposition or microvascular transfer. In the light of this rationale, a prefabricated free thigh flap was designed and put into practice in 1981.
Article
The present paper investigates the elongation of skin that can be achieved by Z-plasties. The following observations have been made: 1. Traditional Z-plasties always result in a stereometric transfer of skin with two kinds of elongation, the stereometric and the planimetric. 2. The stereometric elongation accomplished within the Z-plasty was immediately below the mathematical values if measured stereometrically under in vitro conditions. Stereometric elongation can effectively be used only in connection with stereometric structures. 3. The planimetric elongation of the skin was accomplished outside the Z-plasty and extended far into the surrounding tissue. Planimetric elongations are needed for scar corrections on plane surfaces. 4. Only Z-plasties with tip angles of alpha/beta = 75 and 60 degrees were suited to make optimum use of the planimetric elongation in the primary direction of a scar. All other Z-plasties under study provided smaller planimetric elongation values. Z-plasties with tip angles alpha/beta = 30 degrees even produced shortenings. The mechanical and geometric reasons for these findings have been discussed.
Article
A new technique is presented that combines the use of two juxtaposed Y-V plasties which, when advanced, create a W-shaped sutured wound used to correct bridle-burn scar deformities. Since a considerable amount of the scar can be removed and there are two Y-V advancements, the cosmetic results are better than those obtained with traditional or modified Z-plasty when contracted scars are wide, severe, and unsuitable for Y-V advancement.
Article
To determine the relationship between growth potential in culture and the age of the patient, skin biopsies were obtained from over 60 patients of varying ages. The relationship between the length of time elapsed since burn injury and growth potential was also examined, using biopsies obtained from patients with burns during their treatment. Keratinocytes were extracted from biopsies and assessed for colony-forming ability by standard methods. Repeated subculture of cells was undertaken to determine the reproductive capacity of cells in vitro. Age had no effect on the colony-forming ability of keratinocytes in primary culture; however age did affect the total number of generations achieved by these cells. The growth potential of keratinocytes from patients with severe burns showed considerable variation according to the amount of time which had elapsed since the injury. This was most apparent around one week post-burn. These results need to be investigated further to understand their clinical implications. The study provides an insight into the influence of age and physiological response on the wound healing process in burn injuries.
Article
One hundred eighty-six patients with electrical burns were treated within an 11-year period at The Hacettepe University Burn Unit. Both children and adults were treated in this burn unit. The main causes of injury were misuse of electrical appliances, inattentiveness, lack of education in safety precautions, and lack of parental supervision. Treatment consisted of first, normal resuscitation in which Ringer's lactate solution was administered (according to the Parkland formula). Fluid resuscitation was followed by debridement, fasciotomy, and escharatomy. Two major complications were encountered: musculoskeletal involvement in 44% of patients, which required major amputation in 79%, and acute renal failure in 14.51% of patients. In spite of treatment with peritoneal dialysis or hemodialysis, the mortality rate for patients with renal failure was quite high (59%). To decrease the number of complications, closer monitoring of patients and early surgical decompression were applied. The results of this survey demonstrate the need for burn prevention programs in Turkey. Physicians and health care officials have an obligation to educate the public about the prevention of electrical burns. The results of this study and other studies on electrical burns should be communicated to the public through every available means.