ArticlePDF Available

Free groin flap for recurrent severe contractures of the neck in children

Authors:

Abstract and Figures

Severe post burns contracture in children not only leads to functional impairment but also has profound psychological impact on the child. Untreated neck contractures have been shown to inhibit mandibular growth. Skin grafting in children has a higher rate of recurrence and in these cases a thin pliable flap seems to provide a durable solution. To study the feasibility of using primarily thinned free groin flap in the treatment of recurrent neck contractures in children. Five patients, in the age group of 5-10 years, with recurrent neck contractures and operated between 2005 and 2008 were included in this study. The sternomental distance, lateral flexion angle and cervicomental angle were measured preoperatively, postoperatively and during the subsequent follow-up visits. The patients were followed up for a period between 1 and 3 years with a mean of 29 months. All the flaps survived. The cervicomental angle improved significantly to 90-105°, the lateral flexion angle improved to 35-45° and the sternomental distance increased considerably. Recurrent post burns contracture of the neck in children causes not only functional and aesthetic impairment but also psychological problems. A free microthinned groin flap provides a very attractive solution for this problem and should be seen as an effective alternative in recurrent cases.
Content may be subject to copyright.
Free groin ap for recurrent severe contractures of the
neck in children
Abhishek Ghosh, R. Jayakumar
Department of Plastic Surgery, Specialist Hospital, Kochi, India
Address for correspondence: Dr. Abhishek Ghosh, Specialist Hospital, Ernakulam (North), Kochi – 682 018, India.
E-mail: drabhishekghosh@gmail.com
ABSTRACT
Context: Severe post burns contracture in children not only leads to functional impairment but also
has profound psychological impact on the child. Untreated neck contractures have been shown
to inhibit mandibular growth. Skin grafting in children has a higher rate of recurrence and in these
cases a thin pliable ap seems to provide a durable solution. Aim: To study the feasibility of using
primarily thinned free groin ap in the treatment of recurrent neck contractures in children. Materials
and Methods: Five patients, in the age group of 5–10 years, with recurrent neck contractures and
operated between 2005 and 2008 were included in this study. The sternomental distance, lateral
exion angle and cervicomental angle were measured preoperatively, postoperatively and during
the subsequent follow-up visits. The patients were followed up for a period between 1 and 3 years
with a mean of 29 months. Results: All the aps survived. The cervicomental angle improved
signicantly to 90–105°, the lateral exion angle improved to 35–45° and the sternomental distance
increased considerably. Conclusions: Recurrent post burns contracture of the neck in children
causes not only functional and aesthetic impairment but also psychological problems. A free micro-
thinned groin ap provides a very attractive solution for this problem and should be seen as an
effective alternative in recurrent cases.
KEY WORDS
Free ap; recurrent post burns contracture neck
Original Article
Free full text on www.ijps.org
DOI: 10.4103/0970-0358.70722
INTRODUCTION
Severe post burns contracture of neck remains a
daunting challenge for any reconstructive surgeon.
It produces functional restriction of movements,
hampering the daily activities. It produces severe
disfigurement and the resultant psychosocial issues.
The airway access is hampered and the neck contracture
needs to be addressed on a priority basis for subsequent
reconstructions. If untreated, neck contractures in children
can lead to inhibition of normal mandibular growth[1-3]
and hence it is of utmost importance that a stable and
lasting solution be given to these patients. Different
techniques for treating scar contractures include skin
grafting, local and free flaps and tissue expansion. Skin
grafting with splinting is the most common modality of
treatment but prolonged splinting is difficult to maintain
in adults and more so in children. So, in children it is not
uncommon to come across recurrent neck contractures
in spite of adequate release and grafting.[4-6] It is for these
recurrent contractures of the neck that we propose to
use the free groin flap.
The free groin flap is one of the earliest free flaps
described. A large area of skin can be harvested with
minimal donor site morbidity and a two team approach
Indian J Plast Surg Supplement 1 2010 Vol 43 S80
is possible. It had become unpopular due to the
anatomical variation of the pedicle, the short length and
narrow diameter of the pedicle, and the thickness of the
conventionally raised groin flap. We still feel that the
groin flap is reliable, easy to harvest and meets all the
requirements for reconstructing the neck in post burns
contracture of neck. The shortcomings of the groin flap
have been overcome by elevating the flap from lateral
to medial as a perforator based flap in contrast to the
conventional technique of elevating the flap from medial
to lateral. This series studies the feasibility of using the
free thinned groin flap in treating post burns contractures
of the neck in children.
MATERIALS AND METHODS
We operated on five patients, of age between 5 and
10 years, with severe recurrent neck contractures,
during 2005–2008 [Figures 1 and 2]. All of them were
operated with skin grafting at least twice in other burn
centres but had recurrence. The sternomental distance,
lateral flexion angle and cervicomental angle were
measured preoperatively, postoperatively and during the
subsequent follow-up visits. The patients were followed
up for a period between 1 and 3 years with a mean of 29
months [Table 1].
Operative technique
The flap is marked as per the lint pattern with the vessel
in the centre. In contrast to the conventional technique
where the flap is elevated from medial to lateral, we
start elevating the flap from lateral to medial. As the flap
is raised from lateral side, the perforator to the skin is
identified [Figure 3]. This perforator is then skeletonised
to its origin. Thus, it does not make any difference
whether the perforator is from the superficial or the
deep vascular system and the problem of the variability
of the pedicle is solved. The perforator thus isolated is
dissected distally in a plane between the superficial and
deep layers of fat. This dissection is a little tedious and is
done under an operating microscope [Figure 4]. With this
technique, we obtain a pedicle length of 5–7 cm which is
sufficient in most cases. The flap is thinned primarily at
the level between the deep and superficial layers of the
fat; hence, a thin pliable skin flap is obtained.
In all the patients, the contracture with the platysma was
entirely released. The free groin flap harvested was used
to resurface the defect. The superior thyroid artery and
internal jugular vein were used as the recipient pedicle.
Flap inset was given with the cervicomental angle in
the range of 90–105° and primary neck contours were
recreated [Figure 5].
RESULTS
All the flaps survived. One flap had to be reopened
because of venous congestion but was salvaged. There
was no partial or total flap loss. The mean pedicle length
was 5.5 cm and the flap dimensions ranged from 10 ×
12 cm to 14 × 20 cm. The mean stay in hospital was for
15 days. The cervicomental angle improved significantly
to 90–105°, the lateral flexion angle improved to 35–45°
and the sternomental distance increased considerably
[Table 2].
All the observations were maintained in subsequent
follow-ups and there was no recurrence [Figures 6–9].
Ghosh and Jayakumar: Free groin flap for burn contracture neck in children
Table 1: Preoperative observations
Age (years) Grade Cervicomental angle Lateral exion Sternomental distance (cm)
Case 1 5 IV 30° 15° 3
Case 2 7 IV 20° 10° 3
Case 3 8 III 45° 20° 4.5
Case 4 10 IV 30° 15° 4
Case 5 7 III 30° 15° 3.5
Table 2: Postoperative observations
Age (years) Grade Cervicomental angle Lateral exion Sternomental distance (cm)
Case 1 5 IV 100° 40° 7
Case 2 7 IV 90° 40° 7.5
Case 3 8 III 105° 45° 7.5
Case 4 10 IV 100° 40° 8
Case 5 7 III 100° 40° 6.5
Indian J Plast Surg Supplement 1 2010 Vol 43 S81
Ghosh and Jayakumar: Free groin flap for burn contracture neck in children
Figure 3: Schematic representation of the elevation of the free groin ap. The
perforator to the skin ap has been identied. 1. Main branch, 2. Supercial
branch, 3. Deep branch, 4. Perforator from deep branch supplying the skin,
5. Sartorius fascia
Figure 4: Schematic representation of the elevation of the free groin ap. The
perforator to the skin ap has been identied. 1. Main branch, 2. Supercial
branch, 3. Deep branch, 4. Perforator from deep branch supplying the skin,
5. Sartorius fascia
Figure 5: Intra-operative picture of
the free groin ap after inset
Figure 6: Postoperative photograph
at 18 months of follow-up. There is no
recurrence of the contracture nad the
cervicomental angle is maintained
Figure 1: Preoperative photograph of Case 1. A 5 year old boy who had been
previously grafted for PBC neck twice in a burns centre with recurrenc
Figure 2: Preoperative photograph of Case 3. An 8 year old girl who had been
previously grafted twice in a burns centre with recurrent contracture
Figure 7: Postoperative picture at 24 months of follow-up with no recurrence
Indian J Plast Surg Supplement 1 2010 Vol 43 S82
Ghosh and Jayakumar: Free groin flap for burn contracture neck in children
DISCUSSION
The primary objectives in reconstructing severe neck
contracture are
• toreleasethecontracturecompletelywithrestoration
of range of movements,
• torestorethecontourofthecervico-mentalangle,
• tomaintaintheaestheticsubunitsoftheneckand
• topreventre-contracture.
In children, it is particularly important to release neck
contractures early as they may inhibit mandibular
development.[1-3] Daily activities become a problem and
there is huge psychological stress due to this deformity
not only for the child but also for the parents.[7-9] Hence, it
is imperative to provide a solution which satisfies all the
above criteria perfectly.
Skin grafts need prolonged splinting which is very difficult
to maintain in a child and hence are prone for recurrence.
Local flaps with tissue expansion require multiple
surgeries and is time consuming and expensive. It is not
well tolerated and creates a temporary disfigurement
which is difficult for children to comprehend and
accept. Tissue expanders in the neck also carry a high
complication rate with implant exposure and buckling
being the most common.[10] In this scenario, a free flap
which gives an excellent functional and aesthetic outcome
in a single surgery without the need for postoperative
splinting seems ideal for reconstruction in children.
In our opinion, a free groin flap meets all the desired
parameters for management of severe contractures of
neck. It is possible to take a large flap from the groin
Figure 8: Postoperative picture at 12 months of follow-up with no recurrence Figure 9: Postoperative picture at 36 months of follow-up with maintained
neck contours and no recurrence
area even in children where other flaps may not be
suitable. Also, the groin region is rarely affected in a
burnt patient and a flap can be harvested with ease. We
have solved the problem of variability of the pedicle and
the bulk of a conventional groin flap by raising the flap
from lateral to medial and identifying the perforator to
the skin first. The skin over the groin is thin and the flap
can be raised in a subcutaneous plane, providing a thin
and pliable skin flap. The raising of the free groin flap
in the subcutaneous plane by following the technique
described above provides excellent recreation of neck
contours and cervico-mental angle. The donor area can
be closed primarily or may need small graft which is well
hidden. There is no need for prolonged and cumbersome
splinting and there is no recurrence.
CONCLUSION
Recurrent post burns contracture of the neck is a very
difficult condition to treat. Contractures in children
need to be addressed on a priority basis as they cause
not only functional and aesthetic impairment but also
psychological problems. A free micro-thinned groin flap
provides a very attractive solution for this problem and
should be seen as an effective alternative in recurrent
cases.
REFERENCES
1. Fricke NB, Omnell ML, Dutcher KA, Hollender LG, Engrav LH.
Skeletal and dental disturbances in children after facial burns
and pressure garment use: A 4-year follow-up. J Burn Care
Rehabil 1999;20:239-49.
2. Katsaros J, David DJ, Grifn PA, Moore MH. Facial dysmorphology
in the neglected paediatric head and neck burn. Br J Plast Surg
Indian J Plast Surg Supplement 1 2010 Vol 43 S83
Ghosh and Jayakumar: Free groin flap for burn contracture neck in children
1990;43:232-5.
3. Uzunismail A, Iccen D. Long-term effect of postburn neck
contractures on mandibular growth. Plast Reconstr Surg
1997;99:918-9.
4. Iwuagwu FC, Wilson D, Bailie F. The use of skin grafts in
postburn contracture release: A 10-year review. Plast Reconstr
Surg 1999;103:1198-204.
5. Jonsson CE, Dalsgaard CJ. Early excision and skin grafting
of selected burns of the face and neck. Plast Reconstr Surg
1991;88:83-92.
6. Kraemer MD, Jones T, Deitch EA. Burn contractures: Incidence,
predisposing factors, and results of surgical therapy. J Burn Care
Rehabil 1988;9:261-5.
7. Gilboa D. Long-term psychosocial adjustment after burn injury.
Burns 2001;27:335-41.
8. McCann DL. Post-traumatic stress disorder due to devastating
burns overcome by a single session of eye movement
desensitization. J Behav Ther Exp Psychiatry 1992;23:319-23.
9. Van Loey NE, Van Son MJ. Psychopathology and psychological
problems in patients with burn scars: Epidemiology and
management. Am J Clin Dermatol 2003;4:245-72.
10. Antonyshyn O, Gruss JS, Zuker R, Mackinnon SE. Tissue
expansion in head and neck reconstruction. Plast Reconstr Surg
1988;82:58-68.
Source of Support: Nil, Conict of Interest: None declared.
Indian J Plast Surg Supplement 1 2010 Vol 43 S84
Article
One of the dramatic consequences of burns is scar contracture and deformities of the neck. Cervical contracture in children is especially dangerous leading to face disfigurement and kyphosis; therefore, early reconstruction is indicated. Despite the existence of many various surgical techniques, the successful neck contracture treatment in pediatric patients still remains a challenge for the surgeons. Eleven children (aged 5 to 14 years) with post burn neck anterior contractures were studied to develop a new approach for reconstruction that would employ the use of local scar-fascial flaps. The new approach and technique for post burn pediatric contracture treatment was developed which is especially effective in the treatment of children who cannot undergo complex and long surgical procedures that are aimed at both contracture elimination and neck skin restoration. The technique consists of two trapezoid scar-fascial flaps mobilization which includes all the anterior neck surfaces and consists of scars, fat layer, platysma, and deep cervical fascia. Counter transposition of flaps with tension elongated neck anterior surface was 100 to200%. The contracture was fully eliminated, and neck contours, mentocervical angle, and head movement were restored. In case of severe contracture, residual wound in submandibular region and above clavicles were skin grafted. The full range of head motion (functional results) was achieved in all the 11 patients. The flaps continued to grow and the skin grafts shrinkage was moderate. Local trapeze-flap plasty allows neck contracture elimination in children in the cases when a more complex technique is impossible or undesirable to use. Early surgical intervention prevents secondary complications, allotting enough time for patients to mature and be ready for more complex procedures.
Article
Introduction Free tissue transfer is a rarely indicated procedure in burns. However, in well selected cases it may play a pivotal role in optimizing outcomes in both primary and secondary burn reconstruction. We undertook a systematic review, based on the PRISMA statement for systematic reviews, of all published literature relating to the use of free flaps in acute burns and in secondary reconstructive procedures. Methods Inclusion and exclusion criteria were defined and Medline, Embase, PubMed and Google Scholar databases were searched from 1980 onwards to May 2013 with the search terms: “free flaps”, “free tissue transfer”, “microvascular”, “burns”, “acute burns”, “primary reconstruction” and “secondary reconstruction”. Results A total of 346 studies were retrieved following the search of which 30 studies met the inclusion criteria and were included in the review. Discussion We present the indications, timing, complications and failure rates for free flaps in primary and secondary reconstruction based on the available literature. We also provide a list of the various free flap options for the commonest sites undergoing reconstruction following burns. Finally an algorithm to ensure optimal success of free flaps when used in primary and in secondary burn reconstruction is presented.
Article
Background Anterior cervical hypertrophic scars caused by severe burn are prone to contracture deformation. Even after multiple skin graft procedures, limitation of neck motion still occurs, especially in patients with hypertrophic scarring. This study examines the feasibility of associating the free scapular flap and platysmaplasty for reconstruction of recurrent neck contracture. Methods Patients with severe scar contracture after multiple skin grafting and with hypertrophic scarring were under investigation. After complete release of the anterior cervical scar, a transection of platysma combined with suture fixation of platysma muscle flap to the surface of chin bone was performed, and the vascular anastomotic free scapular flap was covered. Functional exercise was strengthened postoperatively. Results All flaps (12 cases) survived well with obvious improvement of neck motion and satisfactory appearance. Conclusions Free scapular flap associated to platysmaplasty is one of the preferred alternatives for scar reconstruction in patients with recurrent neck contracture or severe hypertrophic scarring. Level of Evidence: Level IV, therapeutic study.
Article
The use of microsurgery in the management of burn sequelae is not a new idea and free flaps have been used in this context since the 1970s. New technologies like negative pressure treatment and skin substitute have certainly decreased the indication of free flaps. The authors with their experience combined to a review of the literature, try to clarify these indications for each anatomical location. From a technical point of view, they find that realizing a free flap for these patients is more complicated (venous damage, lack of donor site who has been burned…). Despite this, microsurgery must still belong in the decision tree and there are some irreplaceable indication specially for hand reconstruction.
Article
The objective of this study was to summarize our experience of using local flaps for the reconstruction of neck defects after cervical contractures release, particularly of using the extended deltopectoral flaps whose distal margin was beyond the anterior axillary line even reaching dorsalis for reconstruction of anterior neck scar contractures in a single-stage procedure. From 1987 to 2008, neck scar contractures were reconstructed using various local flaps in 68 patients with postburn anteriorly located neck contractures. The local flaps used consisted of 36 deltopectoral flaps, 6 extended deltopectoral flaps, 4 free scapular flaps, 8 neck-shoulder flaps, and 14 Z-plasties. The distal end of extended deltopectoral flaps was transferred as microvascular-free flap provided by the posterior circumflex humeral artery, but the proximal end as pedicle flap supplied by the anterior perforating branches of internal mammary artery. Other flaps were elevated conventionally as described previously in the articles. Of 68 patients, there were 59 cases (86.8%) whose release of the contractures was excellent. For 51 patients, the whole process of treatment was finished only in a single-stage procedure. We used extended deltopectoral flap, which was developed from our own anatomic studies and from previous reports in the literature, in 6 patients. This new flap extends the volume of the original deltopectoral flap, from 22 to 32 cm in length and 10 to 22 cm in width (at the apex). Postoperatively, all flaps survived completely. Patients were satisfied with their results. The follow-up period ranged 1 to 10 years; no obvious recontractures have been noted. There were no severe donor-site complications. The local flap with matching texture, color, elasticity, and pliability is still the best choice for reconstruction of postburn anteriorly located neck contractures. The extended deltopectoral flap has been used successfully to yield satisfactory outcomes for the scar contractures in the anterior neck and should be conserved as a selective method for reconstructive surgeons.
Article
Full-text available
Burn injury is often a devastating event with long-term physical and psychosocial effects. Burn scars after deep dermal injury are cosmetically disfiguring and force the scarred person to deal with an alteration in body appearance. In addition, the traumatic nature of the burn accident and the painful treatment may induce psychopathological responses. Depression and post-traumatic stress disorder (PTSD), which are prevalent in 13–23% and 13–45% of cases, respectively, have been the most common areas of research in burn patients. Risk factors related to depression are pre-burn depression and female gender in combination with facial disfigurement. Risk factors related to PTSD are pre-burn depression, type and severity of baseline symptoms, anxiety related to pain, and visibility of burn injury. Neuropsychological problems are also described, mostly associated with electrical injuries. Social problems include difficulties in sexual life and social interactions. Quality of life initially seems to be lower in burn patients compared with the general population. Problems in the mental area are more troublesome than physical problems. Over a period of many years, quality of life was reported to be rather good. Mediating variables such as low social support, emotion and avoidant coping styles, and personality traits such as neuroticism and low extraversion, negatively affect adjustment after burn injury. Few studies of psychological treatments in burn patients are available. From general trauma literature, it is concluded that cognitive (behavioral) and pharmacological (selective serotonin reuptake inhibitors) interventions have a positive effect on depression. With respect to PTSD, exposure therapy and eye movement reprocessing and desensitization are successful. Psychological debriefing aiming to prevent chronic post-trauma reactions has not, thus far, shown a positive effect in burn patients. Treatment of problems in the social area includes cognitive-behavioral therapy, social skills training, and community interventions. Sexual health promotion and counseling may decrease problems in sexual life. In conclusion, psychopathology and psychological problems are identified in a significant minority of burn patients. Symptoms of mood and anxiety disorders (of which PTSD is one) should be the subject of screening in the post-burn phase and treated if indicated. A profile of the patient at risk, based on pre-injury factors such as pre-morbid psychiatric disorder and personality characteristics, peri-traumatic factors and post-burn factors, is presented. Finally, objective characteristics of disfigurement appear to play a minor role, although other factors, such as proneness to shame, body image problems, and lack of self-esteem, may be of significance.
Article
This article reports on the effective use of a single session of eye movement desensitization (EMD) in the treatment of an exceptionally severe case of post-traumatic stress disorder (PTSD). The patient was the survivor of burns that left him with massive scarring, total deafness, bilateral amputations of the upper extremities above the elbow, severe contractures, and severely damaged feet and ankles. He had endured 8 years of intense suffering from symptoms of post-traumatic stress disorder.
Article
Since 1979, 16 patients with facial and neck burns have been treated with excision and skin grafting within the first 4 days of injury. The injuries were tangentially excised and immediately covered with split-thickness skin grafts. Detailed consecutive results are presented. The patients can be divided into three groups. Group 1 consisted of small subdermal or circumscribed deep dermal burns of the face (n = 8). Healing was quick. Some patients developed signs of overgrafting. As a late result, unevenness and discoloration were seen. Group 2 consisted of mixed deep dermal and subdermal burns of the face and neck (n = 5). Usually, minor areas had to be regrafted. Some patients developed hypertrophic scars at border areas. In the completely excised and grafted area, the skin was smooth, pliable, and discolored. Group 3 consisted mostly of subdermal burns of the face and neck (n = 3). The surgical trauma was significant. Small areas had to be regrafted. Ectropion and microstomia developed. It is concluded that in selected cases of deep dermal and subdermal burns, early excision and skin grafting will result in faster healing and less scarring than expectant treatment.
Article
The morphological distortion of the facial skeleton induced by untreated paediatric burns of the head and neck reinforces the theories of craniofacial growth and the modern principles of acute burn management and post-burn facial reconstruction.
Article
The present study reviews our clinical experience with tissue expansion in head and neck reconstruction. The clinical series consists of 33 expansions performed in 29 patients between 1983 and 1986. The results of tissue expansion in the head and neck were distinguished by a high complication rate, necessitating some revision in the original treatment plan in 48 percent of patients. Despite this high incidence of complications, sufficient tissue was generated to successfully complete the planned reconstruction in 79 percent of patients. Specific complications were observed with particularly high frequency within distinct anatomic sites. The highest incidence of complications occurred in the cheek and neck (69 percent) and forehead (50 percent) regions. Complications in the eyelid region (33 percent) and scalp (17 percent) were less common. Implant exposure was the most frequently observed complication. Other sequelae noted in this series included intractable pain, infection, and bone resorption.
Article
An important element in the care of the burn victim is the prevention and treatment of burn wound contractures. Since limited objective quantitative information is available on the incidence of contractures after thermal injury, or on the factors that predispose individuals to their development, a review of all patients seen from July 1980 through January 1986 for surgical correction of burn wound contractures was conducted. Among the 53 patients selected for study, the incidence of contractures was higher in the pediatric patients, 7.8%, than in the adult patients, 2.0% (P less than 0.001), although burn wound size was comparable in these two groups. There was a direct relationship between wound size and number of contractures per patient (P = 0.003). The majority of contractures occurred at the hand, head, neck, and axilla. Surgical release of contractures of these central body regions (P = 0.056) and of fascially excised burns (P = 0.04), yielded the poorest operative results. Patient age and race, type of operation performed, and timing of surgery did not affect the operative results.
Article
Postburn scarring and contracture affecting function remain the most frustrating late complications of burn injury. Various techniques are used to release contractures; the choice depends on their location and/or the availability of unaffected skin adjacent to the contracture or elsewhere. A retrospective review was carried out of the case notes of patients who had skin grafting for the release of postburn contracture at the Burns Unit, City Hospital, Nottingham between May of 1984 and August of 1994 to evaluate the experience over this period. Information was obtained about the burn injury, contracture site, interval between burn and release of contracture, indication, age at first release, intervals between releases, operative details (donor and graft sites), complications and nonoperative treatment, and follow-up to the end of the study period. A total of 129 patients underwent skin grafting for release of contractures as opposed to any other method of correction. Full-thickness skin grafts were used in 81 patients (63 percent) and split-thickness skin grafts in 26 (20 percent). Twenty-two patients (17 percent) had both types used on different occasions. Flame burns (41 percent) were the most common causes, followed by scalds (38 percent). Two hundred thirty-nine sites of contracture were released, with the axilla (59) and the hand/wrist (59) being the most common sites involved, followed by the head/neck region (42). It was found that for the same site, release with split-thickness skin grafts was associated with more rereleases of the contracture than with full-thickness skin grafts. Also, the interval between the initial release and first rerelease was shorter than with full-thickness skin grafts (p < 0.048). It was also noted that children required more procedures during growth spurts, reflecting the differential effect of the growth of normal skin and contracture tissue. Patients reported more satisfaction with texture and color match with the full-thickness skin grafts. There was comparable donor-site and graft morbidity with both graft types. The use of skin grafts is simple, reliable, and safe. Whenever possible, the authors recommend the use of full-thickness skin grafts in preference to split-thickness skin grafts in postburn contracture release.
Article
Pressure garment use alters facial growth during rehabilitation after a facial burn injury. We previously studied 3 children with full facial burns and 3 children with partial facial burns who wore pressure garments for 1 year, and we found that maxillary horizontal growth and mandibular anterior-inferior growth are inhibited during the time of pressure garment use. The purpose of this follow-up study was to prospectively document skeletal and dental changes after pressure garment use was discontinued. We found that although the growth and development of the facial bones seem to return to normal, lasting changes remain. The use of pressure garments after skin grafting is still recommended. However, it is also recommended that an orthodontist be included in the team of burn care specialists for children with facial burns to monitor facial and dental development. Close attention to facial development during and after pressure garment use is necessary to maintain normal dental and facial relationships.
Article
The paper examines the relevant professional literature in order to explore how adjustment after burn injury may be enhanced. For this purpose, the unique characteristics of burn injury, and particularly the psychological meaning of the skin injury, are examined. An attempt is made to understand why some researchers find that a majority of this population suffers psychological disturbance, while others show that it is a 'normal' population, with no premorbid psychopathology. The ways of enhancing the psychological adjustment of burn victims, beginning with the acute phase of hospitalization and until long-term adjustment in the community, are discussed. These include, mainly, integrative team work to create a 'cover' as a skin substitute around the patient, social support, different techniques of psychotherapy when necessary, and job placement. In an attempt to learn what happens to burn patients a year after injury and later, we reviewed studies of their situation in terms of work, the family (including sexual functioning) and social interaction. In light of all this, the possibility of predicting long-term psychological adjustment among burn victims and the variables that may be relevant to this, such as, size of the burn or, rather, the individual's personality traits, are discussed.