BURN RECONSTRUCTION
Proper acute burn care minimizes the need for burn reconstruction. Even in optimal circumstances, a predictable set of reconstructive operations commonly is required during the first postinjury years.
A reconstructive plan is made best collaboratively with the patient and family, the patient's burn therapist, and the surgeon. One should not rush these procedures; however, waiting until all scars have matured completely for over 2 years prior to embarking on any reconstructive operations may prolong recovery unnecessarily.
The physical and emotional trauma of surgery must be balanced against the patient's functional and cosmetic needs. These plans are never easy to develop and must be considered carefully and individualized. Imagination and patience are important components of planning staged burn reconstruction.
Most burn reconstructive procedures can be performed using a combination of some basic techniques: incisional release and grafting, excisional release and grafting, Z-plasty, and random flaps. Tissue expansion and free flaps are needed less commonly, but they can be useful in selected patients.
Incisional versus excisional release
Most burn reconstructive operations can be effective with an incisional, excisional, or the common combined release, closing the resulting wound with split thickness autograft (Image 10). The contracture is placed under tension, and the release is performed sharply.
Adjacent areas of hypertrophic scar can be excised if donor sites are adequate to close the larger wound. Full-thickness skin grafts are less likely to contract than thin split-thickness grafts; the former is the closure of choice in selected circumstances such as flexion contractures of the digits. Full-thickness graft site availability generally is more limited than split-thickness, and thicker split-thickness grafts are adequate in most situations.
Z-plasty in burn reconstruction
Although simple in concept, properly planned and executed Z-plasties are powerful reconstructive tools.
The basic steps involved in constructing a Z-plasty include the following:
Defining the line(s) of tension that need to be modified
Planning the central limb of the Z-plasty(s) on this line
Designing the lateral lines, if possible, so that they fall along natural skin lines (Langer lines) after transposition
Designing the angle between the central and lateral lines of the Z-plasty to be less than 90° with the lateral limbs curved and no longer than the central limb
Within these limits, infinite variety is possible by modifying the blood supply of flaps and local tissue elasticity.
A 5-flap Z-plasty can be constructed by placing 2 Z-plasties along the same band, oriented so that they are mirror images of one another. This results in a fifth "dog-ear" flap that can be inset to insert additional elastic tissue into the band.
Multiple Z-plasties can be used in series along a band for excellent effect.
The utility of the Z-plasty is limited more by the surgeon's imagination than the elasticity of adjacent available tissues.
Tissue expanders and flaps in burn reconstruction
Local flaps, tissue expanders, and free flaps have a more limited but important role in burn reconstruction. Thin random flaps can be raised on the chest wall to cover small fourth-degree wounds of the hands in selected cases; the flap is divided at 3 weeks.
More commonly used are groin flaps, which have earned an important role in reconstructing defects, particularly volar wrist defects associated with high-voltage electrical injury.
Tissue expanders are useful, particularly in the head and neck.
Perhaps most useful are tissue expanders to correct burn-associated alopecia. Like tissue expanders, free flaps offer an important option in selected, difficult wounds (eg, those associated with high-voltage injury and extensive soft tissue loss of the distal lower extremity).
In most patients, few reconstructive procedures are necessary during the first year after injury. Usual exceptions are any contractures that limit the ability to perform ADL. Any contracture around the mouth or the neck that makes airway access difficult assumes a high priority in early reconstruction.