Download Post Burns reconstruction

BURNS RECONSTRUCTION
Introduction
 In general reconstruction is deferred until hypertrophic scars have matured and
optimal results obtained when scars have matured and the range of motion is
normal or has plateaued with nonoperative intervention.
 Exceptions to this occur in the presence of scar compromise of vital function, as in
eyelid contractures with corneal exposure keratitis.
 Team approach to post burns reconstruction with postoperative splinting, motion and
compression garments being essential adjunct to operative treatment.
 Function vs aesthetics
 two pathologic processes cause limitation of motion
1. hypertrophic scar formation
2. joint contracture.
Hypertrophic scar
 Hypertrophic scar formation is especially common in burns that are allowed to
granulate spontaneously for longer than 3 weeks.
 Best indicator of hypertrophic scar formation is the time required for healing When wounds heal in less than 3 weeks, 33% result in hypertrophic scars, whereas of
wounds that require more than 21 days to heal, 78% form hypertrophic scars
(landmark paper – Dietch J Trauma 1983)
 Grafting of wounds after 14 days of granulation also produces poor results.
 Silicone gel - hypertrophic scars lose erythematous appearance and become smoother
and less oedematous. E.M. indicates reduction in collagen cohesiveness and increased
number of vestibular fibroblasts. Intralesional steroid (triamcinolone) also advocated.
Wound Contracture
 pathologic process involves contraction of tissue by myofibroblasts until the limits of
motion are reached.
 occurs during scar remodeling as collagen undergoes reorganization
 resulting distortion may be either extrinsic or intrinsic.
1. Extrinsic contracture results from contracture of an adjacent body part—eg,
ectropion from a burn of the cheek
2. Intrinsic contracture results from direct contracture of the region—eg, shortening of
the lower lid from a burn of the lid itself.
 Extrinsic contracture requires release whereas intrinsic contracture requires
reconstruction/resurfacing
Strategies to prevent excessive scarring and contracture.
Nonsurgical
1. Constant external pressure
a. Pressure in the order of 25mmhg(ie exceeding capillary pressure) inhibits
hypertrophic scarring and pressure is now considered necessary for total period
of scar maturation i.e. 1-2 yrs.
b. widely believed that the pressure exerted by pressure garments:
i. Controls collagen synthesis by limiting the supply of blood, oxygen and
nutrients to the scar tissue.
ii. Reduces collagen production to the levels found in normal scar tissue more
rapidly than the natural maturation process by replacing the pressure
exerted by the destroyed skin on underlying tissues
iii. Encourages realignment of collagen bundles already present
c. These effects may hasten scar maturation and reduce the incidence of
contractures and the need for surgical intervention
d. Indications include
i. aid hypertrophic scar maturation
ii. prevent hypertrophic scar formation
iii. improve the appearance of scars
iv. control the itchiness and pain associated with hypertrophic scars
v. prevent contracture
vi. increase joint mobility
e. measurements of the pattern of change of the erythema can be used to predict
changes in scar thickness and vice versa.
2. Intralesional steroid injection.
3. Silicone topical therapy - the method of action of silicone gel is physical,
chemical or a combination of both.
Surgical
1. Intramarginal excision better than extramarginal (Engrav) 77% scars improved on
visual examination cf. 26%.
2. Skin graft
a. inhibit the proliferation of myofibroblasts in a wound bed thereby
hindering wound contracture.
b. Full thickness grafts are superior to SSG in preventing wound contracture
regardless of the thickness of the grafts. The key factor is the total
percentage of dermis in the graft thus the more dermis in the graft the
fewer the myofibroblasts in the wound bed.
3. Early burn excision and grafting noted to give better esthetic and functional
results.
General principles of post burn reconstruction (Feldman)
1. Analyze the deformity and note distorted and absent tissue.
2. Formulate a long-range plan for the reconstruction that establishes priorities, rations
donor site and combines complimentary procedures. Functional needs met before
esthetic needs.
3. Consider timing of surgery-, tangential excision before 10 days
4. Delay reconstruction until graft and scars have matured. Minimum of 12 months,
longer in children. Use other modalities pressure etc in the interim.
5. Early operative intervention required.
 Facilitate anesthesia during subsequent ops and to minimize extrinsic contraction
on adjacent area (neck release)
 Protect cornea from exposure keratitis
 Protect oral aperture and competence
6. Release extrinsic contractures before intrinsic.
7. Orient scars parallel to relaxed skin tension lines.
8. Ration potential donor sites with priority given for facial reconstruction.
9. Resurface according to regional aesthetic units. Adjacent units should be covered
with a single large graft whenever possible to avoid seams between esthetic
territories.
10. Match donor skin according to thickness, color, and texture. Thicker skin grafts
produce less postoperative contracture.
11. Strive for symmetry - asymmetry is obvious "do onto one side as you do onto the
other".
12. Protect scars and grafts from UV light for at least 12 months to avoid hyper
pigmentation.
Reconstruction ladder
Techniques
1. Skin grafts
o not bulky and do not mask facial expression
o FTSG better but limited donor sites
1. prevent future tissue contracture by virtue of the inhibitory properties
of the transferred dermis.
o contract and pigment with time.
2. CEA
o Useful where dermis present
3. Flaps
o useful for limb salvage, in coverage of unstable scars or a mobile joint, in
cases of recurrent contracture after previous Zplasty and when large amounts
of tissue are required.
o bulky but normal skin.
o Age is not a contraindication to free-flap use.
4. Tissue expansiono local expanded skin is similar in color, texture and thickness to the area to be
reconstructed but need two staged procedure
o complications common (60%)
o increased risk with paediatric patients, multiple expanders, use of internal
ports with the tissue expanders and a history of at least two prior expansions
o use of tissue expansion in pediatric burn patients is not associated with more
complications than tissue expansion in pediatric patients with other diagnoses.
o May be used as a free flap by expanding the flap pretransfer. Advantages:
1. Direct closure of donor site
2. enhanced flap vascularity due to neovascularization at the
papillary dermal level
3. potential increase in size of the pedicle vessel, which facilitates free
transfer
4. resultant fat atrophy accompanying tissue expansion, which
creates a thinner and more pliable cutaneous flap
o drawbacks of pretransfer tissue expansion are the potential obliteration of
surgical planes by the expander and edema around the flap pedicle making
dissection more difficult.
Face
Management guidelines :
i. Precise preoperative analysis of tissues missing or displaced
ii. Long range plan - functional before aesthetic
iii. Timing - delay until scars and grafts mature with pressure in interim. Early
intervention for functional reasons :
a. complete neck release to facilitate anaesthesia and help release extrinsic facial
contractures
b. eyelid reconstruction to protect cornea
c. release perioral scar
iv. Resurface according to regional aesthetic units (Gonzalez-Ulloa,1956)
v. Strive for facial symmetry
vi. Match added skin to existing skin
vii. Release extrinsic before intrinsic contractures
viii. Orient scars parallel to relaxed skin tension lines or hide in hairline
ix. Ration potential donor sites - set aside donor sites for face
x. Protect new scars and grafts from U.V. light to avoid pigmentation
xi. Cosmetics
Scalp burns
 differs from hereditary hair loss in that the scalp is tight, thin, and poorly vascularized
secondary to burn cicatrix.
 Despite these obstacles, there are recent reports of successful hair micrografting in
burn patients directly into scar.
 Options:
1. Local flaps (Juri or Orticochea)
 A common problem with these techniques is improper hair follicle orientation.
2. Tissue expansion
 Up to 50% defects
 Negatives of tissue expansion include prolonged treatment duration,
temporary external disfigurement from the expanders, and multiple surgical
procedures
3. Free tissue transfer – large burns
 Classic choices include the parascapular flap, the radial forearm free flap, and
the latissimus dorsi flap
Forehead burns
 Small burns – excision and direct closure
 <50% - tissue expansion
 >50% - thick SSG or FTSG - replace entire forehead from eyebrow to hairline and
from lateral canthus to lateral canthus.
 Care taken to preserve facial nerve.
 Forehead burns that involve skull cannot support skin grafts and require flap tissue for
reconstruction.
1. Millards "crane Principle "l: a scalp flap is transposed into the defect and allowed
to mature for 2 to 3 weeks then it is returned to its donor site, leaving soft tissue
over exposed cranium. Soft tissue is allowed to granulate and a SSG is applied 5
-7 days later
2. Free flap reconstruction of aesthetic unit with scapular fasciocutaneous flap or a
temporoparietal flap with vein graft.
Eyebrow reconstruction
 Follow the esthetic landmarks of the eyebrow as described by Ellenbogen
 Eyebrows play important role in facial expression and reconstruction after a burn
injury is usually accomplished by strip hair transplant or vascularized island pedicle
flaps.
1. Strip hair transplant harvested from the temporoparietal scalp and no wider than
5mm are the simplest way to bring hair-bearing tissue to the supraorbital ridge.
Two strips usually sufficient to create a new eyebrow.
o
To avoid injuring the neighboring follicular bulbs, all incisions should
parallel the hair shafts and defatting of the grafts should be kept to a
minimum.
o
False hair growth seen for the first 3 to 4 weeks after grafting followed by
shedding of this hair as the follicles go into telogen or resting state for the
ensuing 2 - 3 months. This is followed by new hair growth.
o
Clodius and smahel - hair follicles in catagen phase are more suitable for
grafting and show better follicular survival and they suggest pulling all hairs
from the follicle a few days before grafting to cause the hair follicles to go
into catagen.
o
Success of strip technique depends on the quality of recipient bed.
2. Vascularized Island pedicle flaps from the temporal scalp
o
Indicated if poor recipient bed due to scarring, contra lateral eyebrow is
bushy or free composite graft failure.
o
Flap based on anterior branch of Sup temp vessels and carry an overlying
island of scalp hair that is tunneled subcutaneously to the brow area
o
Complication: tissue loss and malalignment.
3. Micrografts
4. Surgical tattooing
o
Alternative to above methods
Eyelid
 Restoration of eyelid function is a priority in facial reconstruction after burn
 Lubricating drops and ointment must be used if necessary.
 Generally, tarsorrhaphy is inadequate in these situations because of the lack of
sufficient unburned tissue.
 Either extrinsic or intrinsic scar can cause ectropion.
 If extrinsic, release of the deforming scar should take care of the problem.
 If intrinsic then eyelid reconstruction is required.
Extrinsic
 Eyelid release incisions are designed 2-3 mm outside the ciliary margin - extend from
the medial canthus laterally beyond the outer canthus; the supratarsal crease is
preserved whenever possible.
 At the lateral canthus, grafts should extend out and UP; never downwards
 Upperlid resurfacing is best with SSG from opposite lid or inner arm and if all donors
are burned prepuce may be used.
 Lower lid thicker skin thus retro auricular skin gives the best match.
 Resurfacing done with a single skin graft for each aesthetic unit.
 A modified Tripier flap keeps the donor upper eyelid skin and orbicularis oculi muscle
pedicled to the lateral canthal region, and can be used to resurface the lower eyelid.
 A Fricke flap, which uses pedicled forehead skin in a similar manner, is also useful
when replacing skin in the upper eyelid
Intrinsic
 Intrinsic contractures require entire eyelid reconstruction.
 For burns of the upper eyelid, and only if the ipsilateral lower eyelid skin is of good
quality, either a Cutler-Beard or Hughes flap is an excellent alternative.
 For burns of the lower eyelid, Mustardé cheek advancement flaps are suitable
provided that unburned skin is available in the donor area.
 In the event that complex burns have destroyed all local tissue, reconstruction with
temporoparietalis fascia pedicled or free flap may be required.
Nose
 Post burn scar contracture causes foreshortening of the nose pulling up the tip and
everting the nostrils in a typical "nasal ectropion". The paranasal groove and upper lip
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are usually distorted placing tension on the alar and rotating the alar cartilages outward
to form the leading edge of the nostril. The vestibular lining and vibrissae come to lie
outside the nostril, and thin atrophic scar epithelium cover the remainder of the nose.
reconstruction must address all involved layers of the nose: the mucosa, the cartilage,
and the skin envelope.
Reconstruction of the of the nose involves realigning skeletal elements as well as
resurfacing the exterior and the nasal cavity
Since neighboring skin of the face is generally involved in the burn, adjacent tissue
transfers are often impossible.
For small defects of the ala rim, composite grafts from the ear work well
Alternatives from distant donor sites include the Washio retroauricular flap, Crane
principle, Tagliacozzi inner arm flap, radial forearm free flapor dorsalis pedis free
flap
Grace and Brody propose an incision at the junction of the skin and everted vestibular
lining to return the lining and lower lateral cartilages to their normal position. Skin
grafts, dermabrasion and overgrafting are then used to replace skin. Best skin match is
from forehead or retroauricular area
Ear
 Auricular burns are common and usually produce marginal loss of pinna.
 Defect is typically confined to helix but may be more extensive.
 biggest concern regarding burns of the ear is suppurative chondritis caused by
Pseudomonas.
 Prevention is far preferable to treatment of the infection, and is accomplished by
controlling the local bacterial environment with topical antibiotics.
 Mafenide (Sulfamylon) is the agent of choice because of its deep eschar penetration.
Protective ear cups are also helpful in preventing infection.
 Once the diagnosis of chondritis is made, incision and drainage is mandatory and all
necrotic tissue must be debrided.
 Standard techniques for ear reconstruction apply.
 small helical defects (<3 cm), scar excision and reconstruction with an Antia-Buch
advancement is adequate.
 For resurfacing helical defects a Davis “conchal transposition flap” in which the
spared conchal structures are elevated as a composite flap and transposed to the upper
third of the ear. The remaining concha and overlying skin are elevated on a narrow
pedicle in the area of the crus helix and transferred superiorly; the central area itself is
resurfaced with a skin graft.
 For more extensive deformities temporoparietal fascia as a pedicle island covering a
cartilage framework
 Skin expansion is limited by scar tissue anchoring the skin to the underlying cartilage
and thus is of limited value
Cheek
 The burned cheek is typically resurfaced with a large full-thickness skin graft, a skin
flap, or by tissue expansion.
 Adhere strictly to the aesthetic unit principle to avoid unsightly and obvious breaks on
the plane of the cheek. A compression masked should be worn continuously for at
least 4 months to inhibit scar hypertrophy at the suture lines.
 If the cervical skin is intact, the primary choice for reconstruction of the cheek is
tissue expansion and advancement of the unburned skin from the neck.
 Submental flap has been used for reconstruction of the beard area.
Perioral
 Functional disabilities of the mouth resulting from lip ectropion include drooling, oral
incontinence, constriction, feeding difficulty, speech difficulty and poor hygiene.
 lower lip is released first because contractures here are more disabling and contribute
to extrinsic contractures of the upper lip.
Oral commissure
 commonly seen when young children chew on electrical cords
 When there is full-thickness destruction of vermilion, mucosa, skin, and orbicularis
muscle, the resulting contracture alters adjacent structures, displaces the commissure,
and distorts facial animation.
 oral appliances are tried first – worn usually for 6-12 months
 must be informed of the risk of subsequent labial artery bleeding, which may occur 7
to 10 days after the injury as the eschar dries.
Surgical reconstruction
 Two principal types of deformity resulting from oral cavity electric burns are those
that are limited to the corner of the mouth and those that involve loss of a section of
lower lip.
 When the corner of the lip is destroyed, parts of the upper and lower lips adhere and
interfere with full opening of the mouth. The corner of the mouth can be reconstructed
by separating the adherent portions of the upper and lower lips and excising the scar.
 In most cases, skin loss is negligible and only mucous membrane is required to
establish the normal outline of the mouth.
 final reconstruction is best achieved after the scars are allowed to soften, usually 6-12
months after the injury.
1. Gillies-Millard commissure repair
2. V-Y advancement buccal mucosa
3. mucosal transposition flaps
4. tongue flaps (PRS 1995)
o composite ventral tongue flap of mucosa and muscle
o replaces destroyed mucosa and muscle bulk
o disadvantage - bulky and retains its papillary appearance
Upper lip
 The upper lip thus comprises three units the two lateral units and the philltrum
columns itself and resurfacing should respect these units
 Burn ectropion of the upper lip is released by incising both nasolabial folds and the
base of the nose to let the lip fall back into its native position.
 columella can be lengthened with forked flaps from the upper lip as in bilateral cleft
lip repair.
 A composite strip graft from the scalp or a scalp flap based on the superficial temporal
artery, either pedicled or free, can be used to restore the mustache
 The lateral lip unit can be considered as part of the cheek aesthetic unit itself and
covered with the same graft or flap used in the cheek. If the philtrum is involved it
should be left alone or resurfaced separately.
 Thin FTSG give best texture for lip reconstruction.
 Before applying the graft the scar should be sculpted with exaggerated philtral
columns and a philtral dimple to ensure that these will be visible post grafting.
Lower lip and Chin
 The mouth is second only to the eyelids in the reconstructive priorities in facial burns.
 The functional disabilities created by ectropion of the lips include
1. Oral incontinence – drooling.
2. Constriction of aperture - feeding difficulties.
3. Poor oral hygiene.
 Lower lip released as aesthetic unit before upper lip as it is more disabling and causes
extrinsic contracture of the upper lip.
 The perioral and chin respond well to the aesthetic unit replacement concept and can
be satisfactorily reconstructed with single FTSG or thick SSG.
 Enough tissue should be left on the apex of the chin for prominence and aesthetic
landmarks such as the labiomental crease should be carved deeply in the scar so they
will show through the resurfacing procedure.
 Unless associated contractures of the neck are also released, recurrence of lower lip
ectropion can be expected.
Neck
 goals of treatment in extensive neck contractures are
1. release the contractures thoroughly
2. to protect the neck from recontracture,
3. to regain the natural profile, contour, and appearance.
 Skin if the anterior neck is prone to flexion contracture. Scarring can cause physical
disfigurement by pulling down the face and distorting facial features extrinsically.
Scars in the neck also cause mechanical disability ranging from minimal restriction to
a crippling mentosternal synechia.
 Mentosternal synechiae are not uncommon, and in children can lead to micrognathia.
 May interfere with intubation and thus release required under LA with sedation prior
to intubation. Alternatively, fibreoptic intubation is used.
 If scar surface is light and aesthetically acceptable, a tight neck can be released by
incising across the scar. The release must be extensive and may include division of the
platysma, until strap muscles are seen
 If hypertrophic or widely restrictive scar then excision is indicated and resurfacing
with local flaps or skin graft or combination of the two. The grafts are applied and
tapered at the ends to avoid vertical suture lines. A tie over dressing is left in place for
7-10 days and then replaced by rigid heat labile splint over a layer of gauze. The splint
should extend the neck, mould the jaw angle and apply even pressure to the grafted
area.
 care must be taken not to injure the marginal mandibular branch of the facial nerve
 Options
1. FTSG/SSG
o Risk of recurrence
o Does not restore contour well
o May be combined with Integra for better contour
2. Z platies
o Localized neck burns produce vertical bands best treated by Z-plasty or
interdigitating flaps in a more favorable oblique or transverse position
3. Pedicled flaps
i. Unilateral neck scars may be released and resurfaced by cervical rotation
flaps from the posterior cervical or shoulder area.
ii. Dorsal scapular artery island flap
 Based on the superficial branch of the dorsal scapular artery emerging
from between levator scapulae and rhomboid minor.
iii. Lattisimus dorsi
 main disadvantage of using the latissimus dorsi myocutaneous flap to
reconstruct severe neck burn contractures is its bulkiness, which impedes
its smooth conformity to the contours of the anterior neck region.
 Divide the nerve to reduce the bulk is important
iv. Supraclavicular fascial island flap (laterally extended cervicohumeral flap)

main vascular supply of the flap - the supraclavicular artery, a branch of
the transverse cervical artery or, less frequently, of the suprascapular
artery
4. Tissue expansion
o When the skin adjacent to a burn contracture of the anterior neck is relatively
unscarred, tissue expansion has proved useful skin. Multiple expanders are
best placed subcutaneously in the lateral neck or infraclavicular region
5. Free tissue transfer is also an option for resurfacing.
i. pre-expanded free groin and scapular flaps (PRS Jan 2004)
 minimizes donor morbidity
 flap has increased size and improved vascularity
 fat atrophy from expansion leads to good contour matching
 incorporation of the capsule into the expanded flaps is important because
this adds to the blood supply of the flaps
 Pedicle dissection before free-flap transfer can be difficult as a result of
its displacement following expanding forces or because of scar
involvement.
ii. anterolateral thigh flap (PRS 2002)
iii. sensate preexpanded radial forearm flap
Breast
 Scarring inhibits normal breast development
 When the nipple-areola complex (NAC) is directly burned, progenitor cells of the
breast bud may be destroyed, but as long as the NAC is intact, breast tissue is likely
to be undamaged, as the progenitor cells lie deep.
 contracture of the skin envelope of the breast may impede normal breast development.
Lastly, excessive debridement during acute burn care can aggravate the breast
deformity.
 ideal time to reconstruct a young girl’s breast is before the burn scar has
constricted breast development.
 Guidelines (prepubertal)
o identify and preserve viable breast bud tissue
o begin when burned breast envelope starts to restrict normal growth
o palpate mammary structures as landmarks in release
o breasts should be outlined bilaterally to plan a symmetric release
o Once the scar is released and the breast is sculpted, skin grafts are used to cover
the defect.
o An inframammary incision will release most contractures, although superior and
lateral incisions are sometimes indicated too.
o silicone molds inside bra for 6-12 months
 Postadolescent female
o If breast parenchyma is intact but asymmetric, local scar release is required.
Maneuvers to obtain symmetry in cases of extrinsic contracture of the skin
envelope include scar excision, Z-plasty, STSG, and FTSG.
o If the breast parenchyma is burned, glandular volume becomes an issue.
o In these cases the reconstructive plan is similar to that of a postmastectomy
defect, with the added complication that surrounding tissue is constricted and
scarred from the burn, somewhat similar to a postradiation breast reconstruction.
o For adult women who were burned as children and failed to get adequate release
of the breast scars during puberty, significant tissue expansion is often required.
Liberal use of lat dorsi recommended with expanders due to risk of exposure
o Delayed nipple reconstruction is advisable. Medical tattooing of nipple and areola
is a good alternative
o Thus treat like postmastectomy defect post radiotherapy – scarred skin with poor
vascularity
Burns to the upper extremity
Guidelines for upper limb reconstruction
1. Begin reconstruction early, emphasizing functional return.
2. Balance early reconstruction with aggressive physical and occupational therapy.
3. Release contracture in a proximal to distal order.
4. Use SSG in the acute setting and after release of contractures unless exposed
bone, tendon, blood vessels in which case free flap or skin flap needed.
5. wrap grafted wounds in elastic compression garments for at least 12 months.
6. Treat early contractures with aggressive exercise s and splinting.
Axilla
 Adduction contractures are frequent and preventable by early splinting and active
range of motion exercises.
 Three types of axillary postburn contracture (Kurtzman and Stern)
Type 1 - involves anterior (1A) or posterior (1B) axillary fold.
Type 2 - involves both anterior and posterior folds.
Type 3 - Type 2 plus axillary dome
 Look for extrinsic contractures along the trunk – this will need releasing and often
reconstructed with skin grafts  Integra
 Traditional resurfacing of axilla was with thick SSG, but local flaps,
musculocutaneous flaps bring greater bulk of vascularized, flexible and noncontracting tissue into the area and shorten the postoperative period of immobilization.
 Kurtzman manage Type 1 and Type 2 scars with sequential release and local flap
reconstruction, while Type 3 contractures require generous amounts of skin in the
form of regional musculocutaneous or fasciocutaneous flaps.
 Local flaps
(A) Z-plasty; (B) 5-flap; (C) square flap; (D) transposition flap; (E) propeller flap –
(subcutaneous pedicled flap with a pedicle in the center)
 Pedicled flaps:
i. Lattisimus dorsi
ii. extended lower trapezius island myocutaneous flap / dorsal scapular island flap
iii. Pectoralis major
iv. Lateral thoracic flap
v. Medial arm flap
o may be elevated based on the superficial brachial artery, direct cutaneous
artery, or superior ulnar collateral artery.
o A neurosensory flap may be obtained by including the medial brachial
cutaneous nerve of the arm.
vi. superficial cervical artery flap
vii. Parascapular and scapular flap
 Free flaps if no regional options available
Elbow
 Flexion contractures of the elbow are often in continuity with a tight band contracture
of the axilla. Release should commence at the axilla and proceed distally.
 The elbow is usually resurfaced with a SSG.
 Hallock advocates the use of random fasciocutaneous flaps for repair of burned
elbow. The fasciocutaneous flaps must be designed to parallel the longitudinal axis of
circulation in the upper limb.
 For non-graftable defects or if the brachial artery is exposed or if poor bed, local
pedicled flaps are used
i. radial forearm flap
ii. Ulnar forearm flap
iii. reverse medial arm flap
 superior ulnar collateral artery with posterior ulnar recurrent
iv. reverse lateral arm flap
 posterior collateral artery anastamosis with radial recurrent artery
v. ulnar recurrent flap
 posterior ulnar recurrent artery coursing between the 2 heads of FCU
vi. inferior cubital artery flap
 inferior cubital artery – branch ofradial artery at junction of brachioradialis
with pronator teres
vii. anconeus flap
 Type I: interosseous recurrent artery

excellent coverage of moderate-sized soft tissue defects around the posterior
and lateral elbow
viii.
brachioradialis flap
 type II: radial recurrent artery
ix. FCU
 Type II: posterior ulnar collateral artery
x. ERCL
Heterotrophic ossification
 A burn to the upper extremity may result in heterotrophic ossification of the elbow
manifesting as affixed joint with essentially no motion.
 prevalence of the severe form of heterotopic ossification following a burn injury has
been reported to range from 0.1% to 3.3%
 Risk factors include TBSA>20%, prolonged bed rest/immobilisation, sepsis, increased
protein intake, metabolic changes (a hypermetabolic state or elevated levels of serum
calcium, phosphorus, or alkaline phosphastase).
 In the acute phase, the onset of heterotopic ossification may be heralded by pain. In the
chronic phase, the pain resolves, but the heterotopic ossification has a variable impact
on upper extremity function
 NSAIDs have been used during the early phase of heterotopic ossification and after
excision for prophylaxis
 location of the heterotopic ossification in these patients is most commonly
posteromedial.
 Removal of heterotrophic ossification is essential to the restoration of elbow function,
but waiting a period of 12-18 months has been recommended for the ossification to
mature before the joint is entered.
 Incision begun approximately 5 cm proximal to the medial epicondyle, curved
posterior to the medial epicondyle, and continued approximately 5 cm distally along
the course of the ulnar nerve
 The ulnar nerve may be entrapped by the extraneous bone leading to ulnar
compression syndrome.
 The joint capsule is entered through a posterior incision with minimal dissection on
the triceps insertion. The area of calcification is sharply resected and forearm
movement tested. Partial excision of an ossified medial collateral ligament may be
required. If rotation is still limited excision of the radial head is indicated.
Hand
 Functionally, hand burns are devastating
 Most agree that aggressive early surgical management of the acute burn combined
with proper splinting and early rehabilitation is responsible for the good long
term result after hand burn.
 Deformities
1. Burn syndactyly
 Most common deformity after a burn to the hand.
 Z-plasty or local flap interposition alone successfully corrects the deformity
only in the mildest cases, otherwise fingers can be separated by excising the
scar and resurfacing the interdigital areas with a FTSG.
 Because of the tendency for distal web migration over correction is
recommended.
2. Web space contracture

if between thumb metacarpal and index finger resulting in the thumb being
fixed in adduction, opposition and extension or flexion.
 As long as the adjacent skin is normal the linear contracture can be released
with simple Z plasty, Z and V-Y plasty, four-flap z plasty V-M plasty or
multiple V-M plasty.
 Alexander Classification
1. Grade 1
scar bands extend up to 1/4th the distance from MP to PIPJ
2. Grade 2
up to ½
3. Grade 3
up to ¾
4. Grade 4
>3/4th
 When the burn is extensive and the local tissues scarred, a linear release and
skin graft is indicated. The longitudinal incision is carried into the first
dorsal interosseous and adductor muscles and into the adjacent intact skin.
The thumb is forced into maximum abduction and wound resurfaced with a
split skin graft or FTSG.
3. Extension contractures of the MP joint
 common after burns and are classified according to the degree of limitation
of passive MP flexion.
1. Type 1 digits (47%) show more than 30
scarring is limited to the dorsal skin.
2. Type II (34%) shows less than 30 flexion with the wrists maximally
extended and scarring involves the skin, dorsal apparatus and MP
capsule.
3. Type III (19%) are fixed in greater than 30 MP extension with dorsal
subluxation of the MP joint
 Surgical correction depends on the amount of soft tissue and bony
involvement in each sub type, and includes scar release, scar excision and
joint capsulectomy through a dorsal approach with release of radial collateral
and subsequent ulna collateral ligaments. If this was unsatisfactory then
volar plate needs to be mobilized at the MP joint
4. PIPJ Extension Contractures
 result from direct injury to the central slip on the dorsum of the hand or are
secondary to extensor tendon adherence to neighbouring scar, preventing PIP
and subsequent DIP jt mobility
 The classic burn boutonniere deformity is produced by destruction of the
central slip of the extensor tendon at level of proximal-middle phalanx
resulting in lateral bands shifting volarly.
 No specific treatment offers a very effective release of contracture. Best
treated with transferring lateral bands dorsally resulting in the lateral bands
acting as an extensor of middle phalanx but correcting hyperextension of
DIP joint with extension occurring by the tenodesis effect of the oblique
retinacular ligaments
5. PIPJ Flexion Contractures


usually secondary to volar scar contraction, tendon, tendon sheath or volar
plate shortening .
Resection of the adhesions often improves joint function but the prognosis is
still guarded.
4. Metacarpal jt flexion contracture is corrected by palmar exploration
and gradual release of skin, flexor sheath, flexor tendon and volar
plate.
Perineum
 range from contracture release to complete external genital reconstruction.
 Of particular importance is the creation of a neourethra.
Lower Extremity Burns
 Early recognition of compartment syndrome can prevent limb loss.
 Early Wound closure and aggressive Physical measures can effectively prevent many
of the long-term sequelae of a burn to the lower extremity.
 Exposed vital structures—such as nerves, vessels, bone, cartilage, and tendons—
should be protected and covered with flap tissue, either pedicled or transferred by
microvascular anastomosis.
 Chronic lymphedema is best managed by elastic compression garments.
 Delayed reconstruction may be required for patients with contractors of hip, Knee,
ankle or toes; painful or abnormal gait.