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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 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.