MANAGEMENT OF POSTBURN SEQUELAE

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MANAGEMENT OF POST-BURN SEQUELAE
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Deep dermal or full-thickness burns produce
scarring. Scars are the sequelae of any burn
wound. The aim of scar management is firstly its
prevention and secondary the removal of
established contractures.
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Management of burn sequelae includes the
treatment of 1- post-burn scars. 2- post-burn
contractures.
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Types of scars after deep burn a. Hypertrophic
scars b. Keloids
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Usually seen with deep dermal burns, left to heal
spontaneously. The burn scar becomes raised, red
and itchy within weeks of healing. Not only these
scars are unsightly, but they contribute to joint
contracture and limitation of joint movement when
crossing them.
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Both hypertrophic scar and keloid, are included
in the spectrum of fibroproliferative disorders.
These abnormal scars result from the loss of the
control mechanisms that normally regulate the
fine balance of tissue repair and regeneration.
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Hyp. Sc.
Keloid Incidence
young
adult
Negroes Caucasians

Female Male
Extent confined to site
extends to surrounding
of injury
uninjured skin Result tend to resol
ve Persists and enlarges
after weeks or months
Recurrence Some tendency to Hi
gh tendency to recur after
excision recur after excision
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WAYS OF PREVENTION 1- Early release of tensi
on over flexion creases of joints. Tension in a
scar encourages hypertrophy, so that releasing it
by grafting or local flaps may prevent its
occurrence. 2- Continuous scar massage, after
application of skin emollient, can be quite
effective.
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3- Pressure on maturing scar tissue, appears to
reduce the incidence of hypertrophic changes.
Such pressure is most likely maintained by
compressive garments for 24hrs./day, for at least
six to twelve months. Mechanism of action is unk
nown. However, reducing the O2 tension in the
wound by occluding small vessels, will cause
reduction in tissue metabolism with cessation in
fibroblast proliferation and collagen synthesis.
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Treatment of an established keloid or
hypertrophic scar 1- The release of the contrac
ture by re-arranging the tissues by local flaps (
e.g. Z- plasty) or by the application of skin g
raft. 2- Intralesional steroid injection (e.g.
triamcinolone acetonide 1-2 cc of 40 mg./cc
at one or two weeks interval.). It inhibits
collagenase inhibitors causing degradation of col
lagen, thus decreasing dermal thickening.
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3- Application of silicone gel sheet as an
occlusive dressing. Ideally it should be placed
24hrs./day for about a year. Silicone does not
penetrate the skin, so its effect appear to be
secondary to occlusion and hydration. Occlusion
appears to increase the temperature of the scar,
possibly increasing the collagenase activity.
Hydration causes softening of the scar.
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4- Cryosurgery It uses liquid N2 to cause cell
damage and to affect microvasculature with
subsequent stasis, thrombosis and transudation of
fluid resulting in cell anoxia.
The protocol is 1-3 freeze cycles lasting for
10-30 sec., with repeating therapy every 20-30
days. Better results are obtained when
cryosurgery is combined with steroid injection
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5- Laser therapy The advantage of laser as an
excisional tool is that it is precise,
haemostatic with minimal tissue damage thereby el
iminating inflammatory reaction. The modalities
are - Pulse-dyed laser ----- microvascular thro
mbosis - CO2 laser Argon laser----- collagen sh
rinkage through heating. - Nd-YAG laser-----
inhibits collagen metabolism and production.
However the recurrence rate with laser therapy is
high.
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6- Interferon therapy The newest therapeutic
modality on the horizon is intralesional
injection of INF- alpha, INF- beta and INF- gamma
. They reduce fibroblast synthesis and collagen
type I, III and possibly IV and increase the c
ollagenase activity. Studies show that INF- alph
a 2b and INF- gamma are most effective when injec
ted immediately postoperatively into the excision
site.
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Management of burn sequelae in specific
regions 1- Head and Neck 2- Upper extremity
3- Lower extremity
4- Trunk
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Head reconstruction includes
1- The scalp 2- The face a- Eye lid
s b- Eye brows c- Mouth
d- Nose e- Ears
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Scalp reconstruction 1- Indications The primary
indication of scalp reconstruction after burn is
scar alopecia or an unstable scar.
2- Classification Minor defect up to 5 of
scalp involved. Moderate defect from 7-70 i
nvolved. Extensive defect more than 70 invol
ved.
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3- Reconstruction a- Minor defect immediate tr
eatment is done by skin graft. Later on,
advancement and rotation of adjacent scalp flaps
will be enough to fill the defect.
b- Moderate defect immediate treatment is done
by skin graft. Tissue expansion is the final
treatment of choice. This allows the area to be
reconstructed with like tissue and with no donor
defect.
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c- Extensive defect This is a difficult
situation. Defects in this range may be too large
to be corrected by tissue expansion. If
periosteum is intact, a skin graft is applied.
Otherwise free tissue transfer is required. The
most common flaps are the omentum and the
latissimus myocutaneous flaps.
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Reconstruction of the Face Diagnosis of the dept
h of burn in the face may be difficult and early
excision is contraindicated. It is often surpris
ing howmuch facial skin regenerates. Whatever
method of reconstruction is used, the aesthetic
unit of the face should be followed.
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1- The forehead is best resurfaced with a
single sheet of split thickness skin graft.
With bony exposure or destruction, flap
reconstruction is indicated. 2- The cheeks the
best is tissue expansion from adjacent non-injure
d tissue (e.g. neck). Thin free flaps may be con
sidered (e.g. radial forearm flap). Others descr
ibe the use of a large full-thickness graft as on
e aesthetic unit.
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Eye lid reconstruction Indications exposed co
rnea, contractor ectropion of upper and/or lower
eye lid and contractures at the canthi regions.
1- Total loss of eye lids the exposed cornea
can be covered by mobilizing the conjunctiva
which is covered with skin graft. Later on the
lids can be reconstructed with local flaps (e.g.
cheek flap or median forehead flap with septal
mucoperichondrial graft as lining).
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2- Ectropion we have to distinguish between
a- primary ectropion where the deep burn
affects the eye lids directly. The treatment is
release of the contrature and application of
thick split thickness graft to the upper eye lid
and a full thickness graft to the lower eye lid.

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b- secondary ectropion, due to contracture of
forehead, cheek or neck pulling on the eye lids.
Treating the cause will alleviate the condition.
3- Contracture web at the medial and/or lateral
canthi are corrected by local flaps in the form
of Z- plasty or V-Y plasty.
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Eye brow reconstruction Loss of the hair may
be compensated by the simple simulation done by
an eye brow pencil ( specially in women ).
However surgical reconstruction of the eye brow
may be done through 1- Hair transplantation si
ngle hair transplantation is better than a punch
graft. 2- Hair-bearing flap from the temporal sca
lp. It is based on the superficial temporal
artery and it is an island flap.
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3- Strip graft taken anywhere from the hairy
scalp with the dimension and shape of the eye
brow. Care is taken - not to exceed 4 mm. in wi
dth. - not to injure the hair follicles during el
evation of the flap by the scalpel.
- the direction of the hair should be oriented
from medial to lateral.
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Lip and mouth reconstruction
1- Extensive scarring of the upper or lower lip
excision and full thickness graft within the
aesthetic unit of the involved lip.
2- Microstomia (oral commissure contracture)
corrected by full thickness incisions at each
angle of the mouth as far as a line dropped verti
cally from the pupil of the eye. Then the oral mu
cosa is mobilized and everted onto the lip skin,
forming a new commissure. Some overcorrection is
generally advisable.
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Nasal reconstruction 1- Total destruction of th
e nose requires a- Flap reconstruction either
regional, like the forehead flap, or distant
by microvascular transfer. b- Prosthetic reconstr
uction. 2- Unacceptable hypertrophic or hypopigm
ented scars over a large surface of the nose may
be treated by dermabrasion, either mechanical or
by laser, and application of a single sheet of s
kin graft within the nasal aesthetic units.
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3- Alar rim reconstruction is done using a
composite graft from the ear. 4- Nostril stenosis
is treated by release and skin grafting. Splints
must be worn for at least six months after
surgery to prevent recurrence.
5- Web contracture between columella and upper
lip, may be released by V-Y advancement flap.
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Ear reconstruction - Indications Partial or tot
al loss of the external ear. - Classification H
elp to determine the treatment.
Mild defect loss of helix and upper part of
the auricle, without extensive scarring. Mo
derate defect concha nearly normal upper half
of the ear missing antihelix and its posterior
crura missing. Severe defect remnant of con
cha local soft tissue scarred external ear or
ifice normal or stenosed.
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Head neck reconstruction (Ear reconstr
.)
- Treatment 1- Total absence of the auricle
- Surgical reconstruction using a
costochondral graft, as described for micr
otia. - Osteointegrated prosthesis. 2- Subt
otal absence of helical rim - The Antia pr
ocedure is effective in restoring
the helical rim. - Local flap reconst
ruction is preferred. - When the entire heli
x is missing, a tubed cervical skin flap
is used.
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3- Ear lobe deformity - Adherence of the ea
r lobe to the neck is the main
deformity. Z-plasty or local flaps are
generally sufficient for correction. 4- M
eatal stenosis - Splinting may be used as a
preventive measure and may eliminate the n
eed for surgical correction - After re
lease, use local flaps if available. If not
use skin graft. - A conformer is worn
by the patient for 4 - 6 months to prevent
recurrence.
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Neck reconstruction Prevention of occurrence
of contracture 1- During the period of dressings
, the neck should be fully extended by putting
pillows below the scapulae not behind the head.
2- When the burn is dressed, a bulky foam collar
may be incorporated over the dressing to elevate
the chin and keep the neck extended.
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Treating established contractures
1- Mild cases mild scar bands can generally be
corrected surgically by using local flaps or
Z-plasties. 2- Moderate cases contractures invol
ving 1/3 - 2/3 of anterior neck, can be treated
using tissue expansion. The unscarred lateral
aspects of the neck are expanded.
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3- Severe cases contractures involving more than
2/3 of the anterior neck, are better treated by
release and split thickness skin graft or distant
flap by microvascular technique. Local flaps are
not adequate.
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Management of axillary contractures
Prevention of contracture For burn of the a
xilla, the patient should be nursed
with the shoulder abducted either by splinting
or applying copious dressing paddings in the axil
la.
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Treating established contractures
1- Scar bands and minor contractures are better
treated by local flaps e.g. Z-plasty or V-Y
plasty. They may be combined with the application
of skin graft, kept in place by tie-over dressi
ng.
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Treating established contractures
2- Moderate contracture may be released and the
defect filled with a latissimus dorsi
fasciocutaneous flap.
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Treating established contractures
3- Severe contracture, producing large defect on

release, are best treated with skin graft.
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Plaster of paris is applied at the end of the
operation where the joint is kept as fully
abducted as possible. Splintage should be maintai
ned for several weeks until the patient can put
the joint through a full range of movement.
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Prevention of contracture During burn healing
, the elbow is splinted 10 o short of straight,
but is put in a full range of movement three
times daily. Treatment of an established contra
cture Usually follows the same principles as for
the axilla. The joint should also be splinted
for several weeks.
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Prevention of contractures
1- Frequent active and passive movements of the
wrist, M P Js and I P Js through a full range of
motion. 2- We have to incorporate plaster of Pa
ris or aquaplast splint in the bandage, so that
the position of the wrist and hand is kept as fol
lows a- The wrist is extended 20o b- The M P J
s are flexed to 90o c- The I P Js are kept straig
ht
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3- Splintage of the hand while the patient is
asleep during night, helps to prevent contracture
s into a non-functional position. 4- Early ski
n grafting is preferable for full-thickness
burns, to allow early movement.
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Treatment of established deformities
1- Amputation deformity typically they involve
the DIJs, PIJs and possibly the middle phalanges
. Toes as well as fingers are usually involved.
The most common procedure, is deepening the
web space to produce a longer finger. The thumb
amputation deformity is treated either
by pollicization or toe to finger transfer.
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2- Dorsal burns a-Hyperextension deformity of t
he dorsum of the hand, is released by a transver
se incision across the distal part of the back of
the hand. The para- tenon of the extensor tendon
s should be preserved and a thick partial thickne
ss graft applied to the defect and maintained in
place with a tie-over dressing.
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b- In severe cases of joint capsule contracture,
we do capsulotomy and the joint is immobilized by
a K-wire for 3 weeks with the joints as flexed as
possible. c- The Boutonniere deformity may be cor
rected by releasing the lateral slips of the
extensor tendon and plicating them onto the
dorsum of the PIJ. The joint is immobilized with
K-wire for 3 weeks.
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d- Arthrodeis of the PIJ, may be the only
solution for the destruction of the central exten
sor slip. e- Hyperextension of the DIJ, is trea
ted by tenotomy of the lateral slips of the exten
sor tendon just proximal to DIJ. This will allow
the terminal phalynx to drop to neutral position
.
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3- Palmar burns Mostly due to grasping electric
fire filaments. It is more common in children.
The interphalyngeal spaces are usually webbed (
burn syndactly). They may be released by double
opposing Z-plasties, using full-thickness or
partial-thickness skin grafts for the residual
defects. To facilitate dressing, the fingers and
hand are immobilized in Banjo splint.
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Lower extremity reconstruction
Popliteal fossa 1- Prevention of contractur
e Bulky dressing or pillows behind the knee duri
ng the healing phase are avoided, so that the kne
e is fully extended. If the patient is sitting o
n a chair, legs are elevated on a footstool.
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2- Treatment of established contracture
a- Medial or lateral band contracture, are
released by local flaps. b- More extensive scarr
ing and contracture, are released with the appli
cation of skin graft, or reversed saphenous arter
y flap. For all modalities of treatment, splinti
ng and immobilization in extention, is recommend
ed for 1 week. Then daily stretching exercises an
d splinting at night for 3-6 months.
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• The ankle, dorsum of foot and toes
• During the healing phase, dorsi flexion or
  plantar flexion of the ankle, are prevented by
  applying the appropriate splintage.
  
• Treatment of an established contracture
• Usually in the form of dorsiflexion of the foot
  and toes. We do release till the level of the
  paratenon, with application of thick partial
  thickness skin graft. Tenotomy of the extensor
  tendons may be necessary to alow the toes to drop
  into the
• correct position maintained by K-wire for few
  weeks.

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Abdomen reconstruction Indication Unstable
or unattractive abdominal scar or scar
causing functional deficit or anatomic
deformity. Treatment 1- Small defects manag
ed by primary excision and closure. 2- Moderare
defects managed with staged serial
excision. Scar bands can be released and
reconstructed by local flaps and/or skin graft.
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3- Large defects Extensive hypertrophic scarrin
g may need extensive tissue expansion. Tissue e
xpansion provides the best approach for
like-for-like tissue.
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Breast deformity management Indications -
Scarring, deformity and assymetry are the major
indications for reconstruction.
- The surgeon must be extremely conservative
in debriding the nipple area. The first priority
is not to injure the breast bud. - Follow up sho
uld continue through puberty. After scar maturity
and puberty, reconstructive surgery can be plann
ed.
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Treatment 1- Restoring the breast projection
- Surgical intervention can range from a simple
release of a contracting inframammary scar, to
extensive scar excision and skin grafting,
allowing the breast to take its shape. - Total
destruction of the breast bud will need full
breast reconstruction using TRAM- flap, lat.
dorsi muscle flap with prosthesis or tissue expan
sion followed by insertion of a prosthesis.
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2- Reconstruction of the N/A complex
- A four-flap nipple procedure is done to
lengthen the nipple. A full-thickness skin graft
will simulates the areola. - Tattoing the nipp
le and areola, may enhance the result.
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Management of burn deformity of the
external genitalia 1- Scar contracture may le
ad to functional loss, such as difficulty with s
ex or urination. Release of the scar is by local
flaps or skin graft. 2- Penile loss may be seen w
ith electric burns. Total penile reconstruction i
s performed. The neurosensory radial forearm fla
p is preferred.