Principles of Burn Reconstruction Flashcards
Minor burn contractures can be treated with local tissue
and Z-plasties alone
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Advances in microsurgical techniques as well as
composite tissue allotransplantation have opened up new avenues
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Hypertrophic scarring is a major complication after burn injury with
a prevalence of 32% to 72%
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expression of transforming growth
factor beta and its receptors have been associated with postburn
hypertrohic scarring.
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apoptosis of myo
fibroblasts occurs 12 days after injury in normal wound healing
T hypertroph1c scar tissue, the maximum apoptosis occurs much
later at 19 to 30 months
Decraese thr incidance of hyper trophic scar
(1) Wound closure ofa burn that is likely not to heal on its
own in 3 weeks.
(2) Avoidance of sun contact of the scar during the
first 6 months.
(3) Compression garments for those who can tolerate
treatment for up to 1 year.
(4) Keeping the scar moist
cryotherapy one of treatment strategies for hypertrophic scars
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Intralesional corticosteroids enhance collagen degradation
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PDL excellent therapeutic option for the treatment of
younger hypertrophic scars
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PDL MOA
- collagen fiber realignment
- decreased fibroblast proliferation
- neocollagenesis
PDL should use two to six times, for the optimal resolution.
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Caut10n must be used to avoid high energy and high density, which
can cause an iatrogenic burn injury. in co2 laser
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erythematous and
hypertrophic, then a combination of PDL and CO laser can be used
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the benefits of z palsy in burn reconstruction
redirecting a scar, flattening a raised
or depressed scar, and recreating a webspace.
. Preserving the subdermal blood
supply by maximizing thickness and meticulous handling are paramount to a successful outcome and minimizes flap-tip necrosis in Z plasty
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most burn scar contractures that cross a mobile structure, such as an eyelid or a joint, will
require an incision designed across the entire axis of rotation.
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Scar excision can be don in any area of the body insteade of realese and skin graft
F Scar excision may be considered for hypertrophic scarring of the face when the subunit concept
is indicated
the use of CO2 laser scar resurfacing as an
alternative to scar excision should be considered
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use of preoperative tissue
expansion as a delay strategy has gained popularity to decrease the
thickness and bulk while maximizing vascularity.
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flap
debulking is almost guaranteed in the flap that used for burn reconstruction
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Tissue expansion is a valuable tool for the burn reconstructive surgeon
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maximizing advancements
from rectangular tissue expanders most commonly used in burne reconstraction
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Use of pedicled flaps to reconstruct defects in areas of functional
importance or those with exposed critical structures is often easy
F limited’’
by the presence of previously burned skin in the surrounding tissues
Many surgeons are reluctant to include this previously burned or
previously grafted skin as part of a local or regional flap because of
concerns about damage to its vascularity.
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these concerns
are often unfounded, as the initial thermal injury is generally limited
to the skin and subcutaneous fat, and the underlying fascia and its
axial blood supply are often spared
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ncorporating previously burned16 or grafted skin17·18
into fasciocutaneous flaps for the trunk, hand, and upper extremity
reconstruction without significant differences in flap necrosis
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The cheek is a peripheral
unit of the face and is of near-critical importance
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goals: a normal appearance at a conversational distance,
face that is balanced and symmetric
distinct aesthetic units connected by inconspicuous scars
soft skin texture that
will bear corrective makeup, and the ability for dynamic and natural
facial expression.
A good reconstructive outcome depends on appropriate Subsequent treatment in periorbital area
F good reconstructive outcome depends on appropriate acute treatment
Burns of the periorbita that are not thought to heal within the
first 10 to 14 days should receive early debridement and grafting
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For
the actual lid tissue, we recommend thin split-thickness grafts
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For
the region below the lower lid, thicker split- or full-thickness grafts
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Immediate intervention should be instated to avoid
damage to the globe if ectropion of the upper or lower lid is noted
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For periorbital reconstruction, it is important to address
all regions including the medial canthus, lateral canthus, and upper
and lower lids.
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In upper eyelid, the release can be extend till the lateral and medial canthus
F The release should be performed in the upper
eyelid crease along the entire length of the eyelid just beyond the
medial and lateral canthus
Traction sutures make it easer to perform
a more exact release
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When performing skin graft for upper eyelid should be in single compilerte sheet
F There should be two separate grafts with one over the palpebral lid and one proximal to the confluence of the septum and levator
Geaft consluent to the septum and levator could be thin flap
F proximal graft can be slightly thicker
In upper eyelid skin graft tarssorghafy can be put for 3 days
These tarsorrhaphy sutures can remain for up to 3 weeks,
or permanent tarsorrhaphy sutures can remain for several months
the lower lid, the release should be performed using
a subciliary incision extending the full length of the eyelid
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For the
lower lid, a thin split–thickness graft can be used
F For the
lower lid, a thicker split- or full-thickness graft can be used
the suborbicularis oculi fat can be mobilized
and suspended from the inferior orbital rim
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palatal graft provides tissue and support can be used for missed lamela
T middle and inner lamella
postoperative splinting with tarsorrhaphy or Frost sutures should be
used
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The lateral canthus usually does
not form a similar web in burn
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a canthoplasty best restores position of
the lateral canthus and prevents ectropion.
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If Webbing of the medial canthus is occures with
concurrent with medial canthal ectropion, a concurrent medial canthoplasty should be performed.
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excision and grafting of perioral burns is commonly performed
F excision and grafting ofperioral burns is not
typically performed
Two common sequelae of burns to the lips and
perioral region
microstomia and lower lip eversion
splinting can
prevent or manage successfully
microstomia
F Although splinting can
prevent or manage mild perioral contractures, the durable, successful
management of microstomia is typically surgical
Contractures at the
oral commissure can be insiced and the mucosa (along with underlying
orbicularis oris) can be advanced in a Y-to-V
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In case of lip contracture Small amounts of eversion can be corrected
by horizontal elliptical excision ofthe red lip posterior to the wetdry border
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For more severe contractures and eversion, the surgeon
should release along the entirety ofthe lip just below the white line
and extend beyond the lip slightly
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The release should carry down to
the orbicularis oris but not disturb this muscle layer
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For the upper and lower lips, the release should continue lateral to the modiolus
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the entire
lip subunit should be replaced with a full- or thick split-thickness
skin graft.
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For the upper lip, this subunit should extend up laterally
to the nasal ala
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Persistent incompetence of the lower lip what the option of reconstraction
strips of temporalis muscle and fascia,
tunneled in a subcutaneous plane but over the zygomatic arch, and
augmented with fascia lata graft to create a sling through the reconstructed lower lip
Using temporalis sling can yield dynamic restoration of the lower lip
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In scalpn reconstraction when
choosing an expander size, we usually choose the largest possible size
that a pocket can fit
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Using multiple expanders is preferable in scalp reconstraction
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When putting expander the scar area should be disected before puting the expander
F The region of the scar should not be dissected to prevent the
expander migrating in the wrong direction
Standing cutaneous deformities in the scalp should not be excised as in other regions of the face because they will usually flatten on their own
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If calvarial bone
is exposed, a more complex reconstruction might be required
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Small
scars can be addressed with a V-Y advancement flap in the scalp
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Larger defect
requires large rotational flaps that incorporate multiple vessels to
supply the scalp
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In larger defect in the scalp the flap can be unipedicles
F These should be bipedicled and include at least one
major artery
The Orticochea flap which
is most useful for defects in the occipitoparietal region
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large local tissue rearrangements less reliable in nose reconstraction after burne
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surgical delay should be considered when performing local
tissue rearrangements in nose burn reconstraction
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the goal is a functional nose for
normal breathing and speech
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Patient with intranasl burn should treated with imediate stent for 1 week
immediate nasal stenting for up to a month to prevent nasal stenosis
In case of nasal stenosis the nasal lining should adress only
F addressing the nasal lining and the nasal aperture
cartilage graft support can be used for nasal stenosis treatment
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Treatment of nasal stenosis
Realease and stent
releaase and graft
release with adding tissue
septa! mucosa, nasolabial flaps, or gingivobuccal mucosa! flaps with
or without additional cartilage graft support can be used for nasal stenosis
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If the nasal vestibule
is patent but the nasal ala is missing what the option of reconsatraction ?
1- forhead flap
2- Inferiorly based turndown flap using the dorsum of the nose can be
used to reconstruct even severely burned nose and maintain tip projection and alar contour
The inferior base turnover flap recreate a projecting tip
and the appearance of alar lobules even in the absence of cartilage
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If a small nasal alar defect is present, a helical composite graft
offers skin and cartilage
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helical composite graft can used to reconstract alar defect up to 2 cm
F UP TO 1 CM
For a larger alar defect a free helical root flap can be
performed based on the anterograde or retrograde branch of the
superficial temporal artery
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free helical root flap can be plugged into
the angular artery if it is available and size appropriate or to the facial
artery using an A-V loop
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If burn injury to the nose is superficial the external nose can be accomplished via excision and FTSG
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In case of the burn in the forhead we canot use the forhead flap
F forehead flap is a commonly preferred method of reconstruction; it
can be accomplished even with scarred skin as long as the frontalis
muscle is intact
Nasolabial or melolabial flaps can be used for reconstruction of
the nasal sidewall, dorsum, tip, and ala and collemula
F except the coollemula
In the case of inferiorly based melolabial flaps, the lips and columella
can also be resurfaced
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Early treatment of ear burns should follow similar principles of facial
reconstruction
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stage the subacute burns with
Integra to cover any exposed cartilage and to support subsequent
skin grafts can be employee with ear burn
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For ear reconstraction it prefer to use full thickness skin graf t
F recommend STSGs for visualization of the
underlying cartilage
THe most common complication after ear burn is scapha adheasion
F reconstructive challenge is a tethered lobule
Lobule adhesion can usually be corrected with a series of Z-plasties if there is a scar band. Alternatively, a
release is made with a V around the lobule and Y advancement
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local flaps difficult.
For complete ear reconstruction,
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conchal transposition
covered by a temporoparietal fascia] flap and a STSG can be used for ear reconstraction
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the redness or part of the deformities are caused from more proximal tension from neck scars
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In the cheek, it is typically unnecessary
to excise all adjacent normal tissue in the unit just to resurface a segment of it
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In the cheek region, muscle tissues are deeper than in the
periorbital and perioral regions.
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Thin STSGs or FTSGs can be used to resurface
regions ofthe cheek
F Thick STSGs or FTSGs can be used to resurface
regions ofthe cheek
Deep wounds to the cheek can be challenging because thick soft tissues and a functional oral lining
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the most important step
is to relieve tension.
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Iflocal flaps are used incorporating the fascia when possible
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truncating the tips of
Z-plasty flaps appears to improve the viability offlap tips
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Tissue expansion is useful in
postburn scars ofthe face and neck.
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Waht the type of the expander that we need to work on in check burn reconstraction
rectangular expanders were placed in a subcutaneous plane, filled until
the expanded skin was 10%-20% greater in width than the scar to be
excised
Tissue expansion is an excellent option in the face and especially the cheek
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Resuspending the superficial muscular aponeurotic system off the midface using a lower lid
transconjunctival approach helps take tension off the lower lid
T Canthoplasty and smas elevation
the neck isoneof the most common locationsfor
a functional burn contracture to form
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during face and neck burn reconstractoin first of all we need to adress the face and then neck
F The neck is also the first region of the face that should be addressed
when beginning reconstruction
For limited
scar bands, series ofZ-plasties can be used. LargeZ-plasties (unlike in
the hand) can be used owing to the robust blood supply
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release itself of the neck
should be aggressive expanding along the entirety of the neck and
should have fish tails at the end for the scar to fully open up without
having to chase the scar indefinitely
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during neck contracture release we can releasing at the base of the chin subunit.
F The downside of this placement is that the tissue covering the defect can creep onto the chin
by creating an aesthetically unappealing result
relaseing the neck contracture in middle can lead to surgical emergency
T tracheostomy
site should be assessed because an unhealed tracheal fistula can lead
to a surgical emergency
intraoperative laryngoscopy is madatory for the patients who did prevous surgry and planed for middle neck contracture relase
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Release at the base of the neck can give larg amount of release
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Release at the base of the neck provides a flat surface to bolster a graft.
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The limitation of skin grafting is a high rate of
recurrence unless a prolonged course of splinting is followed.
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Option for free flap reconstractoin of the neck contracture
ALT -flap –Thick
Abdominal base perforater - thick flap
A groin flap free tissue transfer based on the superficial branch of the superficial circumflex iliac artery –thin
superficial epigastric artery provides a thin
flap for reconstruction.
scapular or parascapular fasciocutaneous
flaps —thin
release and grafting in breast reconstraction after burn can be emplyed for develping breast only
F - This approach is useful during development if the breast
- useful, at times this approach fails to address the tight skin envelope,parenchyma asymmetry, and NAC malformations
exchanged for a permanent implant alone or an implant plus a
latissimus dorsi flap if a scar release is needed at the time of exchange.
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contralateral mastopexy
can be performed to improve symmetry in the developed adult
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The
NAC can be reconstructed 9 to 12 months after the final breast reconstruction.
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Lower extremity reconstruction in burn patients follows the same
principles of lower extremity reconstruction after trauma or wound
formation
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Even small scar bands can
result in significant functional impairment
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Immediate splinting is
important to prevent debilitating contractures iN hand
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Early aggressive debridement and grafting is recommended for the palm
F Early aggressive debridement and grafting for the dorsum of the hand is recommended, whereas more conservative treatment and possible staging
with Integra is recommended for the palm
The dorsum ofthe hand is
especially susceptible to hypertrophic scar mor than the palm
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Acute burns to the palm should give more time to heal secondarily
T because grafts to the palm will impair sensation for the remainder of
the patient’s life
Palmar burn scars commonly involve a large surface and
can therefore result in tight contractures
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FTSGs are
preferred over split-thickness graft to decrease secondary contraction
and to minimize scarring in the palm
The extensor tendons dorsally if eposed after burn what the options of reconstractins
a fascia-only reverse radial forearm flap with a skin graft for coverage or a reverse dorsal interosseous
flap
Severe burns on
the dorsal and volar surfaces of the hand often benefit from K-wire
placement
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Flexion contracture of the small finger is one of the most difficult
reconstructive challenges for surgeons because contracture of the collateral ligaments, flexor tendons, and skin results in shortening of the
vessels and nerves.
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The surgeon should also avoid the urge to straighten
the small finger in one operation, as this will often lead to venous congestion or ischernia
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in cases with joint and skin contracture, a Digit Widget can be used
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To treat the contracture and eponychial fold deformity we use a technique of release
and full-thickness graft proximal to the DIP.
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The five-flap jumping man Z-plasty (two Z-plasties
with an intervening Y-to-V
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Axillary scar contractures are the second most common contractures behind neck contractures
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Z-plasties
in the axilla should be designed large, and flaps should be kept thick
with subcutaneous fat
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thin fasciocutaneous flap will provide the optimal result in the neck
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Larger more restrictive contractures can be treated with release and apply thick STSG or
FTSG
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