Color Atlas of Burn Reconstructive Surgery

Color Atlas of Burn Reconstructive Surgery

Hiko Hyakusoku · Dennis P. Orgill Luc Téot · Julian J. Pribaz Rei Ogawa (Eds.)

Color Atlas of Burn Reconstructive Surgery

Hiko Hyakusoku, MD, PhD Professor Nippon Medical School Hospital Department of Plastic and Reconstructive Surgery 1-1-5 Sendagi Bunkyo-ku Tokyo 113-8603 Japan [email protected] Dennis P. Orgill, MD, PhD Professor of Surgery Harvard Medical School Brigham and Women’s Hospital Division of Plastic Surgery 75 Francis Street Boston, MA 02115 USA [email protected] Luc Téot, MD, PhD Professor CHU de Montpellier Service de Chirurgie Plastique et Reconstructrice 34295 Montpellier France [email protected]

Julian J. Pribaz, MD Professor of Surgery Program Director, Combined Residency in Plastic Surgery Harvard Medical School Brigham and Women’s Hospital Division of Plastic Surgery 75 Francis Street Boston, MA 02115 USA [email protected] Rei Ogawa, MD, PhD Associate Professor Nippon Medical School Hospital Department of Plastic and Reconstructive Surgery 1-1-5 Sendagi Bunkyo-ku Tokyo 113-8603 Japan [email protected]

ISBN: 978-3-642-05069-5     e-ISBN: 978-3-642-05070-1 DOI: 10.1007/978-3-642-05070-1 Springer Heidelberg Dordrecht London New York Library of Congress Control Number: 2009943441 © Springer-Verlag Berlin Heidelberg 2010 This work is subject to copyright. All rights are reserved, whether the whole or part of the material is ­concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilm or in any other way, and storage in data banks. Duplication of this publication or parts thereof is permitted only under the provisions of the German Copyright Law of September 9, 1965, in its current version, and permission for use must always be obtained from Springer. Violations are liable to prosecution under the German Copyright Law. The use of general descriptive names, registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant ­protective laws and regulations and therefore free for general use. Product liability: The publishers cannot guarantee the accuracy of any information about dosage and application contained in this book. In every individual case the user must check such information by consulting the relevant literature. Cover design: eStudio Calamar, Figueres/Berlin Printed on acid-free paper Springer is part of Springer Science+Business Media (www.springer.com)

Prefaces

Reconstructive surgery of burns, especially of extensive burns, is a topic that requires the ideas and inspiration of plastic surgeons. Traditionally, it is considered that almost all burn wounds can be reconstructed using simple skin grafting. However, sophisticated reconstructive surgery based on knowledge of various surgical methods is needed to accomplish both functionally and cosmetically acceptable long-term results. The contents of this book represent ideal guidelines for burn reconstructive surgery and were provided by authors from 14 different countries. In other words, this book is the grand sum of the newest surgical technologies and strategies proposed by plastic surgeons. I have been involved in reconstruction surgery for extensive burns since I became a plastic surgeon. I have developed many reconstructive procedures and have been able to apply these methods clinically. Burn reconstruction has brought many thoughts to develop flap surgical methods to me. Moreover, I have realized that burn reconstruction should be accomplished via an all-out mobilization of knowledge on flap surgery and that this is an area that requires continual development of surgical methods. However, I have met many plastic surgeons who are performing novel and innovative methods. This book is a collection of these worldwide experiences. I hope that this book will provide great benefits for burn patients worldwide. Tokyo, Japan

Hiko Hyakusoku, MD, PhD

v

vi

Prefaces

Damage to skin from thermal, electrical or chemical injury has devastating effects on aesthetic and functional outcomes of burn victims. The stigmata of burn patients remains one of the most devastating injuries that man can survive. Fortunately, over the last 30 years, there have been simultaneous advances in scar biology, materials science and knowledge of microanatomy, surgical techniques, transplantation and cell culture. As a result there are now many treatment options available that give greater hope to our patients restoring function and improving their societal interactions. In this atlas, Dr. Ogawa has brought together the world’s experts to review the important topics of super-thin flaps, pre-fabricated flaps, dermal and epidermal replacements as well as vacuum-assisted closure technologies. This atlas will be an important resource for practicing plastic surgeons as well as students and residents in training. Examples in the atlas will also be valuable for patient education of these varied techniques. Boston, MA, USA

Julian J. Pribaz, MD Dennis P. Orgill, MD, PhD

Prefaces

vii

Burns represent a pathology remaining among the hardest to heal wounds. Even if important progresses in rescucitation allowed life-threatening body surfaces to regress during the last 50 years, force is to recognize that restoring the original function after extensive and deep burns requires a long period of fight against contractures, hypertrophy and tissue shortening. A multi-disciplinarity approach is mandatory to obtain a return to the social and working life, but skin has changed for the rest of the life of the patient. The development of microsurgery in the 80s, followed by an intense activity in anatomical studies could evidence the angiosomes and the skin, muscle, tendon and bone vascular cartographies. From this era, all types of flaps were proposed, including pre-fabricated and perforator flaps, a founding melting pot and a source of intense activity for the new plastic and reconstructive surgery. This atlas details how to use them in burn reconstructive surgery. During the last decade, the surgical possibilities of dermal replacement becomes more and more efficient. The recent development of tissue engineering, leading to added biological similarities with the normal skin, opens a new space for reflexion and trials, based on cell–extracellular matrix interactions via cytokines and growth factors. The need for repairing the cosmetic outcome of facial burns remains a social ­challenge and will certainly be a long-term contract for the new generation of burns specialists and plastic surgeons. Montpellier, France

Luc Téot, MD, PhD

viii

Prefaces

Every reconstructive surgeon thinks that evidence-based burn reconstruction is an ideal method; however, it is yet to be established. The reason for this may be that every single wound or scar is unique. Moreover, the color, texture, thickness and hardness of the skin vary according to human race, age, sex and body site. Thus, we are forced to select treatment methods on a case-by-case basis according to the limited experience of each surgeon. Meanwhile, during the finishing stage of reconstruction, large parts of the surgical procedure should include elements of aesthetic surgery. In this stage, it may not be an exaggeration to state that evidence-based surgery is not beneficial. Treatment methods should be selected and performed based on the aesthetic sense and cultivated sensitivity of each surgeon. Evidence-based surgery and artistic reconstruction represent a big dilemma that is posed to every burn reconstructive surgeon. I believe this book, which is entitled Color Atlas of Burn Reconstructive Surgery provides an answer for this particular dilemma. This answer may be the fusion of evidence-based surgery and artistic reconstruction. After reading this book, the surgeon will recognize what part of the reconstruction should be carried out using evidence-based surgery and what part should be performed artistically. We should not give up on the generation of evidence-based standardized protocols for patient safety or on the education of younger-generation surgeons. In addition, we should not neglect artistic reconstruction at any time. In this book, international authors who have wide perspectives in burn reconstructive surgery shared their own valuable experiences and concepts about the characteristics and indications of their methods. The contents include wound management, classification and evaluation of wounds/scars, various artistic and geometric methods and future treatment strategies from a “regenerative medicine” standpoint. I hope that this book will enhance the work of burn reconstructive surgeons and confer tremendous benefits to burn patients. Finally, I thank all authors and coeditors who have taken time from their busy schedules to assemble this book. In addition, I appreciate the tremendous help of Ms. Ellen Blasig at Springer in Germany. Her contribution was essential for the accomp­ lishment of this project. Moreover, I thank the illustrator Mr. Kazuyuki Sugiu from Studio Sugi’s for preparing the figures. Tokyo, Japan

Rei Ogawa, MD, PhD

Contents

Part I

Primary Burn Wound Management................................................

1

  1 Primary Wound Management: Assessment of Acute Burns................... Luc Téot

2

  2 Primary Wound Management: Strategy Concerning Local Treatment.......................................................................................... Luc Téot

6

  3 Debridement of the Burn Wound.............................................................. 10 Hans-Oliver Rennekampff and Mayer Tenenhaus   4 Application of VAC Therapy in Burn Injury........................................... 16 Joseph A. Molnar   5 Use of Vacuum-Assisted Closure (V.A.C.)® and Integra® in Reconstructive Burn Surgery......................................... 22 Joseph A. Molnar   6 ReCell........................................................................................................... 26 Fiona M. Wood   7 Strategies for Skin Regeneration in Burn Patients.................................. 38 Victor W. Wong and Geoffrey C. Gurtner Part II

Burn Scar Management.................................................................... 43

  8 Diagnosis, Assessment, and Classification of Scar Contractures........... 44 Rei Ogawa and Julian J. Pribaz   9 Prevention of Scar Using bFGF................................................................. 62 Sadanori Akita 10 Medical Needling......................................................................................... 72 Hans-Oliver Rennekampff, Matthias Aust, and Peter M. Vogt

ix

x

11 Treatments for Post-Burn Hypertrophic Scars........................................ 76 Rei Ogawa, Satoshi Akaishi, and Kouji Kinoshita 12 Make-Up Therapy for Burn Scar Patients............................................... 82 Ritsu Aoki and Reiko Kazki

Part III Dermal substitutes/Skin Graft......................................................... 89 13 Dermal Substitutes...................................................................................... 90 Luc Téot, Sami Otman, and Pascal Granier 14 Acellular Allogeneic Dermal Matrix......................................................... 100 Yoshihiro Takami, Shimpei Ono, and Rei Ogawa 15 Application of Integra® in Pediatric Burns............................................... 108 Paul M. Glat, John F. Hsu, Wade Kubat, and Anahita Azharian 16 Pediatric Burn Reconstruction.................................................................. 118 Paul M. Glat, Anahita Azharian, and John F. Hsu 17 Skin Grafting............................................................................................... 132 Matthew Klein 18 Skin Graft for Burned Hand...................................................................... 140 Wassim Raffoul and Daniel Vincent Egloff 19 Tips for Skin Grafting................................................................................ 146 Masahiro Murakami, Rei Ogawa, and Hiko Hyakusoku

Part IV Local flap method............................................................................ 159 20 Z-Plasties and V-Y Flaps............................................................................ 160 Shigehiko Suzuki, Katsuya Kawai, and Naoki Morimoto 21 Use of Z-Plasty in Burn Reconstruction................................................... 172 Rodney K. Chan and Matthias B. Donelan 22 Local Flaps for Burned Face...................................................................... 178 Allen Liu and Julian Pribaz 23 The Square Flap Method............................................................................ 186 Hiko Hyakusoku and Masataka Akimoto 24 Propeller Flap and Central Axis Flap Methods....................................... 198 Hiko Hyakusoku and Masahiro Murakami

Contents

Contents

xi

25 Facial Reconstruction................................................................................. 208 Pejman Aflaki and Bohdan Pomahac Part V

Expanded flap, Prefabricated flap and Secondary vescularized flap............................................................ 219

26 The Expanded Transposition Flap for Face and Neck Reconstruction........................................................................... 220 Robert J. Spence 27 Expanded Thin Flap................................................................................... 230 Chunmei Wang, Junyi Zhang, and Qian Luo 28 Tissue Expansion for Burn Reconstruction.............................................. 240 Huseyin Borman and A. Cagri Uysal 29 Scalp Alopecia Reconstruction.................................................................. 250 Jincai Fan, Liqiang Liu, and Jia Tian 30 Nasal Reconstruction.................................................................................. 260 Jincai Fan, Liqiang Liu, and Cheng Gan 31 Ear Reconstruction..................................................................................... 270 Chul Park 32 Reconstruction in Pediatric Burns............................................................ 276 Jui-Yung Yang and Fu-Chan Wei 33 Secondary Vascularized Flap..................................................................... 288 Hiko Hyakusoku and Hiroshi Mizuno 34 Prefabricated and Prelaminated Flaps..................................................... 300 Brian M. Parrett and Julian J. Pribaz 35 Prefabricated Facial Flaps......................................................................... 310 Luc Téot Part VI Regional Flap and Thin Flap............................................................ 319 36 Scarred Flap................................................................................................ 320 Hiko Hyakusoku 37 Use of Previously Burnt Skin in Local Fasciocutaneous Flaps............... 330 Rodney Chan and Julian Pribaz 38 Supraclavicular Flap.................................................................................. 338 Vu Quang Vinh and Tran Van Anh

xii

39 Superficial Cervical Artery Perforator (SCAP) Flap.............................. 344 Rei Ogawa, Shimpei Ono, and Hiko Hyakusoku 40 Super-Thin Flap.......................................................................................... 356 Hiko Hyakusoku, Rei Ogawa, and Hiroshi Mizuno 41 Super-Thin Flaps......................................................................................... 368 Jianhua Gao and Feng Lu Part VII Free flap and Perforator flap......................................................... 377 42 Anterolateral Thigh Flap for Reconstruction of Soft-Tissue Defects.................................................................................. 378 Jianhua Gao and Feng Lu 43 Free Muscle Flaps for Lower Extremity Burn Reconstruction................................................................................... 388 Huseyin Borman and A. Cagri Uysal 44 Prepatterned, Sculpted Free Flaps for Facial Burns............................... 398 Elliott H. Rose 45 The Deltopectoral Free Skin Flap: Refinement in Flap Thinning, Pedicle Lengthening, and Donor Closure............................... 408 Kenji Sasaki, Motohiro Nozaki, and Ted T. Huang 46 Shape-Modified Radial Artery Perforator (SM-RAP) Flap for Burned Hand Reconstruction..................................................... 416 Musa A. Mateev and Rei Ogawa 47 The Radial Artery Perforator-Based Adipofascial Flap for Coverage of the Dorsal Hand...................................................... 428 Isao Koshima, Mitsunaga Narushima, and Makoto Mihara 48 Microdissected Thin Flaps in Burn Reconstruction................................ 434 Naohiro Kimura 49 Perforator Pedicled Propeller Flaps.......................................................... 442 Hiko Hyakusoku, Musa A. Mateev, and T. C. Teo 50 Perforator Supercharged Super-Thin Flap.............................................. 452 Hiko Hyakusoku and Rei Ogawa 51 Perforator Supercharged Super-Thin Flap.............................................. 462 Vu Quang Vinh 52 Extended Scapular Free Flap for Anterior Neck Reconstruction.......... 470 Claudio Angrigiani, Joaquin Pefaure, and Marcelo Mackfarlane References............................................................................................................ 478 Index .................................................................................................................... 495

Contents

2

Primary Wound Management: Assessment of Acute Burns

CHAPTER 1

luc tÉot

Introduction

Estimation of Burn Depth

The burn is depicted as a traumatic lesion provoked by several possible agents (thermal, chemical, mechanical, or electrical) involving different skin layers to a certain degree. Assessment of the clinical situation is based on (1) evaluation of the total body surface of the burns, and (2) estimation of burn depth. Visual assessment and vascular evaluation of the wound are crucial [1, 2].

Burn depth is traditionally defined in three degrees, and clinical observation remains the main source of information for the clinician, even though some complementary examinations can be useful to determine the exact extent of deep burns. In the majority of cases, the surgical indication for excision and grafting depends upon the visual evaluation of the wound. This part of burn assessment remains difficult and cannot be done with precision, even with experience, before the third day post injury. In second degree burns, the first assessment has been estimated to be accurate in less than 70% of cases.

Evaluation of the Total Body Surface of the Burns Rule of 9 Anatomical area

Head

Upper limb

Lower limb

Ant body (chest + abdomen)

Post body (thorax + back)

Genital area

Estimated % of surface

9

9

9

2 × 9

2 × 9

1

TBSA Following Age Anatomical area

Adult TBSA (% for each side of the structure)

Fifteen year TBSA (% for each side of the structure)

Ten year TBSA (% for each side of the structure)

Head

3.5

4.5

5.5

Neck

1

1

1

Trunk

13

13

13

Arm

2

2

2

Forearm

1.5

1.5

1.5

Hand

1.25

1.25

1.25

Genital area

1

1

1

Buttock

2.5

2.5

2.5

Thigh

4.75

4.5

4.25

Leg

3.5

3.25

3

Foot

1.75

1.75

1.75

L. Téot, MD, PhD Montpellier University, France e-mail: [email protected]

H. Hyakusoku et al. (eds.), Color Atlas of Burn Reconstructive Surgery, DOI: 10.1007/978-3-642-05070-1_1, © Springer-Verlag Berlin Heidelberg 2010

Primary Wound Management: Assessment of Acute Burns

CHAPTER 1

Clinical Evaluation First Degree The first degree corresponds to a shallow wound. The aspect is red, and the area is extremely painful, as the sensory endings remain intact. A typical example of this is sunburn. Only the superficial layer of the epidermis is involved. When the total body surface is important, complications like cerebral edema can be encountered, but the wound remains easy to heal.

Superficial Second Degree Superficial second degree burns usually present as blisters, appearing some hours after the accident. Once the blister is removed, the wound can be observed. Redness is uniform and pain is extreme, rarely allowing the physician to touch the lesion. Healing time is short, usually within the first 2 weeks, without aesthetic sequellae. The superficial dermis is exposed, without involving the basal membrane, which guarantees a quick healing in the superficial aspect of the skin (Figs. 1.1–1.5).

⊡ Fig. 1.1  Early assessment of second degree burns over the dorsum of the hand. Blister has just been removed. Diff icult to evaluate if deep. Reevaluate the next day and the day after

⊡ Fig. 1.2  Palmar aspect of the same hand. Same difficulty, but the fact that both aspects of the hand are involved is worse than when only one is involved

⊡ Fig. 1.3  Sand burns of the palmar aspect of the feet after walking over a long distance on a hot beach. Second degree, superficial

3

CHAPTER 1

4

Primary Wound Management: Assessment of Acute Burns

endings. Blanching of the skin under digital pressure cannot be obtained. These burns have a tendency to heal spontaneously, except in critical general conditions or if TBS burnt is extensive. The wound will stay unhealed or deteriorate and transform into a third degree burn. Usually, healing can be observed within 2–3 weeks, but as the deep dermis is exposed, a permanent scar will remain. These wounds can sometimes require an excision and a skin graft (Fig. 1.6).

Third Degree

⊡ Fig. 1.4  Fresh scald burns (second degree). Blister appearing progressively. Reevaluate after some hours before establishing a prognosis

Third degree burns are deep burns involving the subdermal structures. Extent in depth can be important, reaching aponeurosis or even bones. Lesions are sometimes circular on the limbs, a source of ischemia for the distal segments, necessitating emergency surgical procedures of discharge incisions to reestablish a normal distal blood flow. Lesions present with a white color and the tissues are hard. A black eschar will be observed after carbonization (Figs. 1.7 and 1.8). Establishing the risk of vital issue is an important step, most of the time to be realized in emergency. Factors like surface, location of deep burns around the orifices and

⊡ Fig.  1.5  Fresh burns of the face. Ophtalmologic assessment. Removal of blisters is necessary before a proper assessment of the burns

Deep Second Degree Deep second degree burns also present blisters, but after removal, the aspect is white or similar to patchwork. Sensibility to touch is not as important as in more superficial lesions, due to a partial destruction of sensory

⊡ Fig. 1.6  Deep grill burns of the plantar aspect of the foot on a diabetic patient. Excision and grafting

Primary Wound Management: Assessment of Acute Burns

⊡ Fig. 1.7  Electric burns of the scalp: third degree with possible cortical bone involvement. Deep excision and preoperative assessment of the bone. If necrosed, removal of the outer cortex. The use of NPT may then be necessary before skin grafting

CHAPTER 1

5

⊡ Fig.  1.8  Deep necrotic burns of the hand after digital amputation. Exposed tendons can be covered with negative pressure therapy, with serial excisions of still necrosed structures before skin grafting

Degrees of burns

First

Second superficial

Second deep

Third

Anatomical structure involved

Epidermis

Dermis above basal membrane

Dermis below basal membrane

Whole skin

Color

Red

Red below the blister

Red–white below the blister

White or black

Skin hardness and vascular density

Supple

Humid

Medium hard

Hard thick dry

Bleeding at contact

No bleeding

High

Moderate

No

Pain

Painful

Extremely painful

Painful

No pain

Time for closure

No wound

Less than 2 weeks

Within three to four weeks. Sometimes, needs skin graft

Needs skin replacement (graft, VAC, flap)

Scar formation

No scar

No scar

Notable scar formation and contractures

Notable scar formation and contractures

prevention of infection have to be determined urgently. Above a surface of >10% TBSA in adults and >5% TBSA in children, burns are considered serious. In over 30% of surface in adult and 10% in children, life-threatening difficulties can be encountered. It is important to check the face, nostrils, and hair, to assess the risk of tracheal and pulmonary burns (an endoscopy is often needed for diagnosis when in doubt). The risk of burns infection is higher when initial management is delayed (septicemia).

Conclusion Establishing the risk of functional issue is focused on reestablishing the limb vascularization and the need for discharge incisions when third degree burns are circumferential. Other functional issues are linked to possible exposure of joints. Immobilization of interphalangeal joints on the hands or ankle must be realized as soon as possible.

6

CHAPTER 2

Primary Wound Management: Strategy Concerning Local Treatment luc téot

Introduction Primary wound burn strategy depends on burn wound assessment. Deep second degree and third degree burns are candidates for surgery such as excision and grafting, while superficial burns can be treated using topical antimicrobials. In superficial burns, emergency management is based on cooling using water at a mild temperature. Burns are irrigated with water for a period of 5–10 min. Essentially, the aim of cooling is to remove pain. Antiseptics are applied to the wound, soaked with sterile water and dried using gauzes.

Blister Management Blisters are encountered both in superficial and deep second degree burns. A blister is an obstacle for the assessment of burns and should be removed. The top of the blister is gently cut with a sharp scalpel, allowing the liquid to leak out and then the whole non-adherent epidermis is excised, while trying to prevent painful contact with the base of the wound (Fig. 2.1).

When to Operate Assessment is determinant for strategy, but cannot be conclusive during the first examination. Surgical excision and grafting in deep second degree burn wounds will be decided after a period of 2–3 days, as the evolution of the burn wound can be positive. Diagnosis of burn depth is difficult during the first days. Thirty percent of burn experts cannot determine the exact wound depth when analyzing the burns at the first assessment. On the contrary, observation of a frank third degree

L. Téot, MD, PhD Montpellier University, France e-mail: [email protected]

⊡ Fig. 2.1  Blister is removed on the fourth finger, and not removed on the third finger. Debridement of blister allows a right assessment of the burn wound

burn will necessitate a surgical decision of immediate excision followed by a skin graft (Figs. 2.2–2.3).

Local Dressings Silversulfadiazine cream is the most commonly used local treatment, worldwide. This drug is a combination of sulfamides and silver, with a low risk of resistance and allergy, proposed in various situations. The cream modifies the local ground and can be applied over a period of 3 weeks. The need for a persistent antimicrobial dressing during the whole evolution of superficial burns has to be revisited (Demling). Most of the authors propose the use of non-antimicrobial dressings as soon as the diagnosis of superficiality is complete. Dressings formed by hydrofiber, a texturized carboxymethylcellulose frame including and delivering silver have been successfully proposed in the local management of second degree burn wounds. Silicone coated dressings (safetac technology), aiming at reducing pain during dressing changes, are often used in superficial burns (Heymans).

H. Hyakusoku et al. (eds.), Color Atlas of Burn Reconstructive Surgery, DOI: 10.1007/978-3-642-05070-1_2, © Springer-Verlag Berlin Heidelberg 2010

Primary Wound Management

CHAPTER 2

7

Indication for use

Acute second degree (1–3 days)

Clear superficial second degree

Clear deep second degree

Third degree

Silversulfadiazine

++

±

++

±

Modern dressing (foam, silicone)

±

++

±

±

Flammacerium

−

−

−

+ (waiting solution before grafting)

Excision skin grafting

−

−

+

++

Negative pressure after excision

−

−

−

++ if noble tissue is exposed

tools for pain are numerous and should be selected depending on the condition of the patient. The visual assessment scale is the most common mode of quantifying pain when the patient can communicate. Other scales may be suggested when the patient is under general anaesthesia. Pain is more pronounced when the burns are superficial, granulation tissue is present, and repetitive dressings are done. Pain at dressing change is a specific issue, more easily managed when using adapted modern dressings.

⊡ Fig.  2.2  Before, during and after the debridement of deep electrical burns wound using high power hydrojet

Surgery The aim of surgery is to remove potentially infected materials from the wound, cover the exposed tissues using skin grafting and reduce the length of stay in the hospital. This coverage can be done using either splitthickness skin graft, full-thickness skin graft or step by step reconstruction of the skin using bioengineered tissues like artificial dermis (Fig. 2.4).

Dermis and/or Skin Substitutes

⊡ Fig.  2.3  Before, during and after the debridement of deep electrical burns wound using high power hydrojet

Pain Management Pain should be correctly managed during the first hours after accident, then regularly reassessed. Assessment

Early excision and skin grafting is the most traditional method, where a skin graft is harvested on different possible areas (skull, thigh, legs, back, abdomen). Depending on the extent of surfaces to cover, the skin graft may be amplified using mesh grafts (×1.5, 2, 4, 6). The uniformity and regularity of the scar obtained with these methods mostly varies with the possibility to use unmeshed skin grafts. In moderate surfaces, the colour matching of the skin graft is also an issue and is better matched when harvested close to the recipient zone. When using a skin graft coming from further away, such

8

CHAPTER 2

Primary Wound Management

⊡ Fig. 2.5  Mesh grafting (×2) over the lower limb burns

⊡ Fig. 2.4  Non-cellularized dermal substitute before skin grafting after deep burns of the lower limb. Revascularization can be sped up by the use of negative pressure therapy

as thigh skin to resurface a cheek, the risk of having a bad colour match is higher, leading to a permanent hyperchromia of the transferred skin. The use of dermal substitutes will be dealt with in Chap. 13. Scar improvement was observed when using double layer dermal substitutes (Integra, Purdue, Heimbach, Renoskin, Hyalomatrix Pelnac), and more recently with single layer dermal substitutes (Matriderm™) being immediately covered using thin skin grafts (Van Zuijlen). Cadaver skin can safely be used, especially to cover temporarily deep burns wound (Sheridan). The use of these materials is dependent on the availability, which is an issue linked to tissue banks which are necessary to store them under adapted freezing conditions. Allografts can be used as a sandwich technique when autograft donor sites are limited (extensive TBSA) or when the

patient is in poor general health, thereby limiting the possibility of general anaesthesia. Autografts can be extensively meshed (×6) and covered using ×2 meshed allografts (Fig.  2.5). Keratinocyte Autologous Cell cultures provide hope for the future, if a functional dermis has been obtained (Rheinwald, Compton, Boyce). The use of xenograft has also been proposed, either to replace dermal components or to secure skin grafts. Early skin grafting may be contraindicated, due to various situations such as contraindications for surgery, exposure of joints, tendons or vascular bundles. Flammacerium (silver sulfadiazine plus 2% cerium nitrate) was proposed in the 90s, and was mainly used over extensive surfaces of third degree burns where surgery cannot be performed on a single occasion. Flammacerium presents the unique possibility of combining with necrotic tissue, transforming it into a calcified tissue strongly adhering to the wound edges for a very long period of time. This powerful antimicrobial agent should be used only over limited surfaces (no more than 30% TBSA), the risk of inducing methemoglobinaemia being a real and lifethreatening complication (Fig. 2.6) (Wassermann).

Primary Wound Management

CHAPTER 2

Negative pressure therapy is not the treatment of choice for burns, but presents some interesting capacities to promote granulation tissue over noble exposed tissues like joints, tendons or vascular pedicles, after complete surgical excision of the burnt tissues. This technique has indications when doubts persist on the vitality of the exposed tissues before skin grafts.

Conclusion

⊡ Fig. 2.6  Late result of skin grafting of the plantar aspect of the skin. Elasticity is required and the use of dermal substitute may help

Burns management is mainly based on excision and grafting techniques, in deep burns with the recent introduction of the use of dermal substitutes and on the use of antimicrobials in superficial burns, with the recent use of modern dressings.

9

10

CHAPTER 3

Debridement of the Burn Wound hans-oliver rennekampff and mayer tenenhaus

Rationale for Debridement At first glance, the rational for debriding a wound, a burn wound for example, seems evident. Nonviable, necrotic cells and tissue debris should be removed, and a clean, viable, and well-vascularized wound bed be established allowing for subsequent wound closure; and yet, what concrete evidence do we have to justify this approach? Steed et al. [1] analyzed wound healing rates in diabetic patients. In this study, he was able to demonstrate that when compared to conservative management, radical surgical debridement led to improved rates of healing. In the case of burn wounds, biochemical changes in the wound affect not only the rate of wound healing, but may pose systemic risk to the patient. Several experimental burn wound models have clearly demonstrated that toxic products are released from burned skin, and that these substances manifest a negative and potentially lethal systemic effect. A lipoprotein complex with high toxicity has subsequently been isolated from the thermally injured skin, and neutrophils derived from the burn wound have been shown to produce Leukotoxins which have been associated with both morbidity and mortality in the burn patient. Hansbrough et al. were able to show that the presence of thermally injured skin has a systemic immunosuppressive effect on the individual [2]. Necrotic, nonperfused tissue may serve as a nidus for bacteria and fungi, and as such, debridement of such tissue can potentially reduce the incidence of wound infection. While topical antimicrobial ointments may penetrate into the nonviable burned skin, systemic H.-O. Rennekampff, MD, PhD (*) Klinik für Plastische, Hand- und Wiederherstellungchirurgie, Medizinische Hochschule Hannover, Carl Neubergstraße 1, 30625 Hannover, Germany e-mail: [email protected] M. Tenenhaus, MD Division of Plastic Surgery, Medical Center, University of California San Diego, USA

antibiotics may not reach the nonperfused tissues. Local bioburden does not only pose a risk for delayed wound healing and further tissue loss but may also systemically compromise the patient when sepsis occurs. A bioburden of more than 105 bacteria/gram of tissue is considered to be an invasive infection, which impairs wound healing, leads to graft loss, and may similarly impair the successful application of temporary wound dressings. The successful reduction of bioburden below concentrations of 105 bacteria/gram of tissue is a key element of surgical wound debridement [3]. The effects of burn tissue on both local complication and generalized outcome were analyzed by Davis et al. and Deitch et al. [4, 5]. In their review, they were able to demonstrate that a burn wound which took longer than 21 days to heal posed a hypertrophic scar development risk of nearly 80%. Furthermore, they were able to show that early skin grafting could reduce the incidence of hypertrophic scaring as compared to late grafting of the debrided wound.

Debridement of Blisters The management of burn blisters has been a source of ongoing debate for many years [6]. While others have suggested that intact burn blisters may act as biologic bandages, keeping the underlying tissues safe from further trauma and desiccation, numerous researchers and clinicians have shown that blister fluid derived from the burn wound setting, in contradistinction to dermatologic and immunologically induced blisters, contains products which are inflammatory and vasoconstrictive in nature. In vitro testing has similarly shown inhibition of various key cellular elements involved in the epithelialization process. These findings have generally promoted the trend toward early debridement and cytoprotective strategies. This affords a proactive approach to the evaluation of depth of injury, while promoting standard wound healing strategies. This is particularly true of cases in which the mechanism of injury is known to have been

H. Hyakusoku et al. (eds.), Color Atlas of Burn Reconstructive Surgery, DOI: 10.1007/978-3-642-05070-1_3, © Springer-Verlag Berlin Heidelberg 2010

Debridement of the Burn Wound

deep in nature, i.e., contact burns in aesthetically and functionally critical areas or when presented with large and fragile blisters as well as blisters which have broken.

Timing of Debridement Is there an optimal time for debridement? Groundbreaking work by Janzekovic [7] demonstrated the clinical advantage of early debridement (3–5 days postinjury) and grafting vs. conservative management with 2–3 weeks of autolytic debridement, antimicrobial dressings and finally skin grafting. In a number of subsequent studies [8, 9], early debridement was shown to reduce length of stay; however, no difference in mortality was found as compared to late debridement. In contrast to these studies, Herndon et al. [10] could demonstrate that in the group age 17–30, without inhalation injury, an early intervention (<72 h post burn) could reduce mortality. Caldwell et al. [11] stated that early autologous grafting and subsequent wound closure could be of greater importance than early excision without autologous grafting. Important studies [12] in pediatric patients investigated the advantage of early excision. A significant reduction in length of stay, infectious complications, and metabolic demands was shown. However, overaggressive excision of indeterminate burn depth areas should be avoided. Conservative wound management can reduce the overall need for skin grafting in selected patients [13–15].

Technical Considerations The decision to perform extensive excisions in a single setting vs. staged procedures is dependent upon hemodynamic stability of the patient, availability of resources, and meticulous coordination of all parties involved in the care of the patient. No difference in survival has been shown when comparing either strategy. Single-stage excisions have been shown to shorten length of stay, and major excisions by simultaneous experienced teams can be performed safely and efficiently when well coordinated [16]. Planning the sequence of excisions in extensive surface area burns is an art and philosophy onto its own, dependent to a degree upon training, familiarity, surgical team size, injury distribution, the existence of concomitant injuries (i.e., cervical spine stability consideration), and pulmonary and hemodynamic considerations. In these cases, our general practice has been to excise and provisionally cover the largest areas of burn distribution as soon as possible, effectively reducing the

CHAPTER 3

overall biologic burden as quickly as safe. This usually amounts to the whole chest and/or back, as well as clearing areas critical for vascular and pulmonary access (peri-clavicular, neck, and groin sites) as needed. Two teams of surgeons communicating closely with anesthesia can perform rather large surface area excisions very quickly and efficiently, while minimizing obviate blood and temperature loss. Critical aesthetic and functional areas pose their own significant challenges as it often takes longer to establish absolute depth and extent of injury in these locations, and they often take much longer to meticulously excise and cover. For patients who have suffered extensive injuries, we prefer to address these areas on the second surgical intervention after the majority of the biologic and bacterial burden has been addressed. We do feel that this should be done rather quickly, and yet expertly, to minimize collateral injury, the effects of prolonged inflammation, and edema while expediting coverage so gentle range of motion, pressure, and rehabilitative therapies can be applied. Skin graft donor sites are carefully planned and designed to preserve and restore critical aesthetic and functional requirements while expediting general coverage. Blood losses can prove particularly challenging in larger excisions and this is especially true when there is a delay in presentation [17]. Inflamed and infected wounds tend to bleed more during tangential excision. As always, clinical judgment and experience should guide this decision. Numerous methods are employed, often in combination, to optimize hemostasis and minimize blood losses during burn surgery. These include meticulous attention to maintaining the patients’ core body temperature. Burn surgery is commonly performed in a very warm environment and isolated surgical fields are patterned to minimize losses from wide-span exposure. The use of Bair huggers (warm air blankets), warming lights, warm and humidified air circuits for inhalation anesthesia, and even actively warming peripheral and core intravenous fluids are all measures to this end. Efforts to minimize blood losses include the use of cautery, the application of topical epinephrine solutions, topical thrombin solutions, topical H2O2 solutions, topical fibrin sealants, and injecting dilute epinephrine solution below the eschar, all of which have their advocates. Excision of burns from the extremities under tourniquet control can significantly minimize bleeding with the added benefit of improving critical structural visualization. This technique does, however, require a learning curve as it can be quite challenging early on differentiating vital from nonvital tissue without the generally relied upon end point of punctuate bleeding.

11

CHAPTER 3

12

Debridement of Hand Burns Debridement of the hand requires special attention. Limited availability of specialized soft tissue coverage, the challenging contour of the hand and fingers with complex curves and concavities, and the superficial nature of critical neuromuscular elements make this area among the most difficult to judiciously excise. Full thickness injuries require excision and auto grafting as soon as possible (see above) with the best available autologous skin. When grafting, the skin is preferentially placed as sheet grafts, pie-crusted, or 1:1 meshed (nonexpanded), and placed at maximal length. While fascial excision is often required for very deep burns to the dorsum the hand, precise preservation of the paratenon as a graftable bed is sometimes difficult to accomplish (Fig. 3.1). Whenever viable fat or dermal remnants are still present (Fig. 3.2), we try to preserve this and cover

a

Debridement of the Burn Wound

the wound bed with a dermal substitute, e.g., Matriderm™ in an effort to improve subsequent graft take and potentially minimizing contracture. Indeterminate and superficial depth burns can be tangentially debrided and covered with a temporary skin substitute, e.g., Biobrane, in an effort to promote reepithelialization. If reepithelialization cannot be achieved within 21 days, an additional excisional debridement and skin grafting is necessary. Burns to the palmar hand have to be carefully assessed. The specialized anatomy of palmar skin and its underlying fascial expansion is not readily replaced by a skin graft and resultant contractures are particularly difficult to manage. Debridement should include removal of blisters and general wound management principles applied. A thickened palmar epithelium and deeply buried keratinocytes stem cells favor conservative management of palmar burns. However, if healing will not occur within 3 weeks,

b

⊡ Fig. 3.1  Full thickness burn to the dorsum of the hand (a). Fascial excision was intended. In some areas like the extensor hood of the fifth finger, the paratenon could not be preserved; part of the extensor hood had to be debrided (b)

a

b

⊡ Fig. 3.2  Deep partial to full thickness burn to the dorsum of the hand (a). Tangential excision was performed down to viable tissue. Dermal remnants and subcutaneous tissue were preserved (b)

Debridement of the Burn Wound

subcutaneous debridement and grafting with a skin graft is necessary. Splits are generally advocated to minimize shear and maintain optimal joint and capsular position during engraftment. Negative pressure systems can similarly be employed to maintain protective positioning and encourage graft take.

Debridement in Facial Burns As in the case of the burned hand and fingers, the management of the burned face requires specialized attention. Optimal aesthetic and functional outcomes challenge the burn surgeon in both the acute and reconstructive phases. Despite the critical nature of these areas, a critical review of the literature reveals a rather limited subset of articles describing a formal reconstructive plan while demonstrating subsequent results [18, 19]. The initial management generally encompass the removal of blisters and loose debris followed by the application of topical antimicrobial wound care. Areas which are likely to heal within 3 weeks are debrided with the Versajet system and Biobrane applied as a temporary dressing. Full thickness wounds should be addressed in the first week postburn with excision and allografting if the patient is stable enough. Indeterminate and partial thickness facial wounds should be reassessed at approximately postburn day #10 to determine which areas will not heal within 3 weeks postburn. It is classically advocated that those areas which will not heal within 3 weeks require debridement and grafting. The concept of acute aesthetic unit excision vs. only excising the burned areas continues to be a source of ongoing debate. Many practitioners acutely preserve as much specialized tissue as possible, leaving formal aesthetic reconstructional strategies for later, while others (Klein/Engrav) have advocated complete acute excision of aesthetic units if the deeply burned area constitutes greater than 80% of the aesthetic unit. Debridement of the necrotic skin is performed with the Goulian knife, scalpel, scissors, and the Versajet system (see below). Application of allogeneic skin is advocated by some to allow for reassessment the following day and assure a more hemostatic wound bed at the time of autologous skin grafting.

Tangential Excision Tangential excision describes the sequential and layered excision of devitalized tissues to a vital wound bed, generally recognized by punctuate bleeding. The hypothesis

CHAPTER 3

⊡ Fig.  3.3  The Goulian/Weck knife (above) and Humby knife (below) with attached guards which allow for defined levels of tissue excision

⊡ Fig. 3.4  Tangential excision with the Gouilan knife is performed until punctuate bleeding is observed. Hemostasis is performed with topical application of epinephrine-soaked towels

is that preserving vital dermis under a split thickness skin graft will improve functional outcome and reduce scar formation. It has similarly been reported [4] that early judicious tangential excision accelerates reepithelialization in partial thickness wounds by reducing the biologic burden effects of the overlying eschar and its byproducts. An inadequately excised wound is more likely to become infected and is unsuitable for flap or skin graft take, necessitating further surgery. Tangential debridement is generally performed with the Humby- or Goulian knife (Figs.  3.3 and 3.4), which have attached fixed depth guards.

Fascial Excision Fascial excision involves the complete excision of all skin and subcutaneous tissues down to the muscle fascia layer where defined vascular perforators are individually controlled minimizing blood loss (Fig. 3.5). Experienced surgeons can perform this form of excision very quickly using the electrocautery, and as a result, this technique can prove life saving when faced with very deep injuries

13

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14

Debridement of the Burn Wound

a

⊡ Fig. 3.5  Fascial excision is performed down to the muscle fascia

b

in a hemodynamically challenged patient. While skin grafting on fascia or muscle is generally very successful, this technique results in a permanently disfiguring cavitary appearance. Fascial excision and grafting is inferior to skin grafting on the subcutaneous level with respect to late functional outcome, and as such, is usually reserved for massive burns.

Hydrosurgical System Versajet In our experience [20], the use of waterjet debridement (Versajet, Smith and Nephew) has proven to be a great asset in wound bed preparation and surgical debridement by improving precision and control of debridement. Our clinical results demonstrate that the Versajet™ System can precisely and safely ablate burned necrotic tissue in vivo (Fig. 3.6). A controllable high power water stream allows adjustment to the clinically anticipated depth of necrosis. In areas where the skin is of critical thickness like the hand and the face, a tool like the Versajet™ System is likely to spare vital tissue. It is these protected and vital skin appendages which are necessary for timely wound healing and the subsequent reduction of scarring as it is well established that the process of successful reepithelialization is dependent upon the presence of an appropriate dermal substrate on which keratinocytes can migrate. In comparison with the difficulties often incurred during the use of a cold knife, a cutting width of 14  mm allows for a very precise and contoured debridement in areas like the web spaces of the hand and foot, as well as in areas of the face like the nasiolabial fold and eyelids. In larger areas necessitating rapid necrectomy, the maximum cutting width of 14 mm poses a potential disadvantage. An increase in the

⊡ Fig. 3.6  Delayed presentation of a partial thickness burn to the hand (a). The Versajet is used to debride down to viable dermis (b). Debridement is stopped as soon as punctuate bleeding is observed. The wound is then grafted with a split thickness skin graft

vacuum to debride at the faster speeds required for full thickness wounds results in a continuous decrease in cutting precision. We and others have found the Versajet™ System, in its present form, inadequate for the excision of full thickness and prefer leathery dried eschar instead of using sharp surgical excision. Middermal level burn wounds are effectively debrided using the Versajet™ System with the Exact handpiece (Fig. 3.6). We advocate beginning at very low setting levels till comfort and efficacy is established. In general, several passes at settings ranging from five to seven are required to treat these deeper wounds. Deep partial thickness wounds require multiple passes with settings ranging from seven to ten to obtain complete debridement. After debridement, all deep partial thickness wounds are grafted with split thickness skin grafts. In our experience, the result of engraftment and the quality of healing have proven comparable to that obtained with standard debridement techniques.

16

CHAPTER 4

Application of VAC Therapy in Burn Injury joseph a. molnar

Burn Wound Paradigm One of the great frustrations in burn care is the phenomenon of burn wound progression. In this process, the depth of burn worsens in the first few days after injury even with optimal medical care. Jackson [1, 2] explained this phenomenon with three zones of injury (Fig. 4.1). By this paradigm, the zone of coagulation in the center of the wound is the deepest and consists of a zone of nonviable tissue. The outermost zone, the zone of hyperemia, is a superficial injury much like a first degree burn and will go on to heal uneventfully almost regardless of the treatment provided. Between these two zones is the zone of stasis. In this zone, the tissue is severely metabolically compromised due to poor blood flow (stasis) leading to progressive tissue damage and ultimate burn wound progression. The etiology of this phenomenon is

⊡ Fig. 4.1  Jackson’s paradigm of burn injury. The central zone of coagulation is nonviable and cannot be recovered. The outer zone of hyperemia will heal almost regardless of the treatment. The zone related to burn wound progression is the intermediate zone of stasis. How the wound and patient are managed may result in improvement or worsening of this zone

multifactorial and involves cytokines, free radicals, clotting cascade, and other factors involved with tissue damage and the inflammatory response that leads to progressive loss of blood flow and more tissue ischemia [3–6]. While infection will hasten this process, it is not a requirement for burn wound progression. One harmful byproduct of burn injury that leads to progressive tissue damage is edema. When tissue is damaged by burn injury, there is a capillary leak that results in interstitial edema [3–6]. The edema alters cell shape and cellular activities leading to progressive cellular injury [7]. In addition, the increase in tissue volume results in decreased vascular density, increased diffusion distances, and ultimately stretching of the vessels, decreased blood flow, and altered colloid osmotic pressure (Fig. 4.2). These factors are also an integral part of the progressive tissue damage in burn injury [8].

Zone of coagulation

Zone of stasis

Zone of hyperaemia

J. A. Molnar, MD, PhD Wake Forest University School of Medicine, USA e-mail: [email protected]

H. Hyakusoku et al. (eds.), Color Atlas of Burn Reconstructive Surgery, DOI: 10.1007/978-3-642-05070-1_4, © Springer-Verlag Berlin Heidelberg 2010

Application of VAC Therapy in Burn Injury

Normal

Edema

2003 WFUSM Plastic Surgery Collection

⊡ Fig.  4.2  In a “normal” state the number of vessels is in balance with the needs of the tissue. “Edema” results in an enlargement of tissue volume, and of necessity, a decreased vascular density and increased diffusion distances. Ultimately, the vessels stretch and decrease flow, and with altered osmotic pressures, there is worsening of tissue ischemia

Subatmospheric Pressure Wound Therapy In the 1990s, Argenta and Morykwas developed a new device to treat chronic wounds. The device was a simple closed cell polyurethane sponge placed in the wound that was sealed off with an adherent drape and then subatmospheric pressure (SAP) (−125 mmHg) was applied. While the original concept was primarily to contain and remove wound exudate, subsequent studies demonstrated that SAP treatment of wounds resulted in increased blood flow, decreased edema, decreased bacterial counts, and earlier wound closure [8–10]. The mechanism for this effect on wounds is unclear, but may involve macrodeformations and microdeformations, as well as the removal of inflammatory mediators and other yet undetermined effects [10, 11]. Despite these uncertainties, it is apparent that the specific nature of the sponge is important and not just the SAP exposure [10, 12]. It was logical that such treatment would be helpful in the management of the burn wound. Initial studies in an animal model showed that SAP treatment of burn

CHAPTER 4

wounds resulted in improved blood flow and decreased tissue damage when compared to standard wound care [13] (Figs. 4.3 and 4.4). The results were also better if the device was placed earlier suggesting an effect on the early response to burn injury (Fig. 4.5). Based on this initial success in the animal model, this technique was applied to acute human burn wounds. After initial anecdotal success with a partial thickness flashburn, the device was evaluated in a prospective fashion in two studies (Fig. 4.6) [8, 14–16]. Patients with bilateral hand burns were evaluated so that each patient could be at his or her own control allowing for optimal statistical power. In the initial study, it appeared that hands treated with SAP had less edema and improved range of motion (Fig. 4.7). The device was also very useful to splint the hands in the “intrinsic plus” position to optimize range of motion in patients who are not able to actively participate in therapy. In a prospective, randomized, controlled, blinded, multicenter trial of the effect of SAP on the burn wound, evaluation of the size of the burn wound was accomplished with a standardized digital photography technique and edema was measured by volume displacement [16, 17]. This study indicates that SAP treatment of acute burns has a positive and statistically significant effect to minimize burn wound progression and minimize edema. Areas of burn wound progression were decreased by approximately 15%. Similar findings have been demonstrated by others [18, 19].

Summary Studies, to date, suggest that SAP has a positive effect to minimize burn wound progression and may be an appropriate alternative dressing for acute burns. While decreased edema has been observed with this technique, other possible mechanisms for this positive effect include microdeformational changes, removal of inflammatory mediators and free radicals, and improved blood flow. Further studies will be required to determine the mechanism of this change and the appropriate indications for this dressing.

17

CHAPTER 4

18

Application of VAC Therapy in Burn Injury

a

b

SAP

Control

c

SAP

Control

SAP

Control

d

SAP

Control

⊡ Fig. 4.3  Histologic changes with burn injury in an animal model [13]. Identical burns were treated with conventional dressings (control) or subatmospheric pressure (SAP). At days 1(a), 3(b), 5(c), 9 (d), biopsies showed a relative amelioration of burn wound progression using SAP. With the healed

wounds on day 9 (d), it is readily apparent that much more tissue was salvaged using the SAP treatment (depth of control burns = 0.885 ± 0.115  mm; SAP treated burns (0-h delay) = 0.095 ± 0.025  mm). With permission: Morykwas et al. [13]

mm 0.9

⊡ Fig. 4.4  Graphic representation of histologic findings with SAP applied at various time intervals after burn injury in the swine model of Fig. 4.3. The Y axis (mm) indicates the depth of burn. The X axis represents the delay time after burn injury until placement of the SAP treatment. The differences in tissue salvage are only statistically different at 0 and 12 h (asterisk). As predicted, the prevention of burn wound progression was greatest when applied early after injury [13]

0.8 0.7 0.6 0.5 0.4

*

0.3

*

0.2 0.1 0 Untreated

0 hr

12 hr

18 hr

24 hr

Application of VAC Therapy in Burn Injury

CHAPTER 4

a

b

c

d

⊡ Fig.  4.5  (a) The hand dressing as supplied by KCI, Inc. (b) The polyurethane sponge must have components between the digits to avoid potential pressure damage to the skin by direct digital contact. (c) Once the sponge is sealed off and SAP applied, the patient may be kept in the “intrinsic plus”

position. (d) To optimize range of motion when the dressing is discontinued, care should be taken to avoid the intrinsic minus position which can cause damage to the tissue over the proximal interphalangeal joints

19

CHAPTER 4

20

Application of VAC Therapy in Burn Injury

a

b

c

d

⊡ Fig.  4.6  Acute flash burn of the right upper extremity treated with SAP [14]. (a) Acute injury suggesting deep partial thickness injury. (b) Hand after 2 days of treatment with

SAP. (c, d) Ultimate complete healing without skin grafting viewed at 5 weeks after injury. Note healing of fingernails indicating the depth of burn

Application of VAC Therapy in Burn Injury

CHAPTER 4

a

b

c

d

⊡ Fig.  4.7  In a prospective clinical study of the effect of application of SAP to acute bilateral hand burns, each patient could be at his or her own control by treating one hand with traditional antibacterial dressings while treating the other with SAP. (a) Right hand treated with SAP for 2 days after burn injury. (b) Left hand of same patient as (a) treated with silversulfadiazine dressings. Note that despite the right hand having a more extensive burn, the dorsal hand edema is

s­ ubjectively less after SAP treatment. (c) Right hand treated with SAP for 2 days after burn injury. (d) Left hand of same patient treated with silversulfadiazine Note that the range of motion of the subatmospheric-treated hand is greater than the control hand, despite the control-receiving hand therapy during this 2 day interval while the subatmospheric-treated hand did not receive such therapy

21

22

CHAPTER 5

Use of Vacuum-Assisted Closure (V.A.C.)® and Integra® in Reconstructive Burn Surgery joseph a. molnar

Skin Substitutes Skin is the largest organ of the body, and serious problems arise when the skin is damaged or missing. Grafting of skin from one part of the body to another is a dependable, well-accepted procedure for the management of skin loss. Unfortunately, split-thickness skin grafting for a full-thickness skin defect results in coverage that is often stiff, fragile, and scar-like rather than like normal skin. Also, grafting is not often feasible in cases of large surface area burns where there is not enough skin for a donor site. The ideal solution would be a product that would accurately simulate the physical and biologic properties of skin and remain integrated in the healing process, so that the final result is more like normal skin than scar. Such was the vision of Dr. John Burke and Dr Ioannis Yannas when they developed the skin substitute Integra® (Integra Life Sciences, Plainsboro, NJ.) [1–3]. This totally bioengineered artificial skin can be considered an early application of “regenerative medicine.” Since skin is bilaminate, it is logical that a bioengineered skin organ substitute should also be bilaminate. Integra consists of a temporary silicone “epidermal” substitute and a permanent dermal regeneration template made of collagen and the glycosaminoglycan, chondroitin-6-phosphate. Once applied to the wound, the dermal matrix is invaded with fibroblasts and becomes vascularized, integrating with the recipient bed and directing cellular activities. Once this dermal matrix is vascularized, the temporary silicone “epidermis” is removed and a thin split-thickness autograft is applied to complete the process. In this manner, the silicone layer provides a barrier to bacterial invasion and desiccation, while the collagen/glycosaminoglycan matrix provides a template to produce a neodermis [1–3].

J. A. Molnar, MD, PhD Wake Forest University School of Medicine, NC, USA e-mail: [email protected]

Histologic data and subjective evaluations have suggested that this construct looks more like skin and has more distensibility than split-thickness skin grafting alone, but this remains controversial [4, 5]. While initial reports demonstrated that Integra could be a lifesaving skin substitute for burn injury, the rates of engraftment were often disappointing being as low as 40% [5–7]. Rarely were engraftment rates reported to be above 90% except by the inventor suggesting that the process of learning to work with the product was slow. Much like skin grafting, loss of Integra was due to hematoma, seroma, shear forces, infection, etc. Numerous attempts were made to find the best dressing to prevent these complications, but there was no one widely accepted answer [5–7]. In addition, engraftment took 2–4 weeks prior to placing a skin graft. While this delay was acceptable in acute burn care, this was an undesirable characteristic for reconstructive surgery.

Negative Pressure Wound Therapy Approximately 15 years after the first clinical reports of the use of Integra, the subatmospheric pressure wound treatment device, now known as the VAC® (KCI, Inc, San Antonio, TX), was developed by Argenta and Morykwas [8–10]. This device was shown to promote healing of wounds with rapid vascularization, granulation, epithelialization, decreasing of bacterial counts, and removal of fluid from the wound. The device consists of a polyurethane foam sponge placed in the wound sealed by an occlusive dressing. A tube is inserted into the foam and subatmospheric pressure applied. As a whole, the device promotes wound healing, and recent data have shown that the individual components of the VAC are uniquely suited to wound healing. Attempts at similar but different components have yielded unpredictable results [11, 12]. The VAC has proven to be an ideal treatment for skin grafts since the subatmospheric pressure causes the sponge to conform to the shape of the wound, removes fluid, promotes neovascularization,

H. Hyakusoku et al. (eds.), Color Atlas of Burn Reconstructive Surgery, DOI: 10.1007/978-3-642-05070-1_5, © Springer-Verlag Berlin Heidelberg 2010

Use of Vacuum-Assisted Closure (V.A.C.)

and protects from bacterial contamination and shear forces [13]. It was logical that if this device was a superior dressing for skin grafts, it would be useful in optimizing engraftment of the skin substitute, Integra.

VAC with Integra Our initial laboratory studies in a swine model showed that the use of the VAC with Integra resulted in faster vascularization and improved adherence in the first 3–5 days when compared to a standard bolster dressing [14]. This information allowed us to rapidly apply this technique to reconstructive surgery including acute burns [15]. Currently, this is our preferred dressing for use of Integra and has proven to have routine engraftment rates of approximately 95%, and, with vascularization, usually within 1 week instead of the previously reported 2–4 weeks [15]. The use of the VAC and Integra in complex wounds with exposed bone, tendon, ligaments, and joints has proven to be a powerful tool for reconstructive surgery. Poorly vascularized structures such as tendon cannot provide the metabolic needs of a skin graft placed directly on them and uniformly the graft dies before it can become vascularized. Since Integra is initially not viable but becomes incorporated into the body through the process of fibroblast ingrowth and vascularization, it can be placed directly on poorly vascularized structures

a

⊡ Fig. 5.1  A 16-year-old girl received full-thickness burns to her lower extremities from groin to ankle. (a) Acute injury after escharotomies. (b) In the first 3–5 days the patient underwent full-thickness excision sparing the viable subcutaneous tissue. It is crucial to have meticulous hemostasis and a wound free of necrotic debris that could be a nidus for infection before placing the Integra. (c) Integra is stapled onto the patient before dressing application. (d) Wrapping the legs with polyurethane sponges (V.A.C., KCI, Inc, San Antonio, TX) often requires at least two members of the team. (e) Once the sponge is sealed with adherent drape, 125  mmHg subatmospheric pressure is applied using the

CHAPTER 5

awaiting vascularization. In fact, it can be placed directly over an open joint and still vascularize. While this might be possible with only routine dressings, the VAC facilitates healing with immobilization of the joint much as a splint, minimizing shear forces and speeding vascularization (Fig. 5.1). With experience, we have found this to be an ideal dressing in an outpatient setting [16]. Patients undergoing reconstructive surgery may have the Integra placed and covered directly over the silicone layer with the V.A.C. These patients typically stay in the hospital overnight for pain management and to ensure that there are no leaks in the seal. They routinely return in 1 week when the V.A.C. is removed in the operating room, and the split-thickness skin graft applied. The skin graft is covered with a nonadherent dressing such as Adaptic® (Johnson & Johnson, Inc, New Brunswick, N.J.) and the V.A.C. is reapplied. The patient returns in 5–7 days to clinic for V.A.C. removal. The grafted construct is then again covered with nonadherent dressing and gauze. Range of motion of extremities begins immediately and outpatient therapy is ordered. This technique is even feasible in small children (Fig. 5.2). Additional studies have demonstrated our ability to use this technique for one-stage engraftment of Integra and not waiting for the period of vascularization [17]. While this has been applied clinically, in our practice this is more routinely used in ideally vascularized beds rather than complex wounds.

b

proprietary V.A.C. pump. Use of wall suction is discouraged due to the variable pressure that may interfere with healing and allow the possibility of exsanguination. In this case, one pump is used for each leg to simplify problem solving in the case of leaks. With the V.A.C. dressing in place, there is no need for splinting across the ankle or knee since minimal motion is possible once the subatmospheric pressure is applied. The dressing remains in place for at least 1 week to allow vascularization prior to skin grafting. (f) Results at 6 months. The patient has full range of motion and returned to competitive swimming. (g) Close-up of popliteal fossa showing lack of scarring and full extension

23

CHAPTER 5

24

c

Use of Vacuum-Assisted Closure (V.A.C.)

d

e

f

g

⊡ Fig. 5.1  (continued)

Use of Vacuum-Assisted Closure (V.A.C.)

CHAPTER 5

25

a

b

c

d

e

f

h1

h2

g

i

j

h3

⊡ Fig.  5.2  (a) Four-year-old female with fixed axillary scar contracture due to injuries received at 9 months of age. (b) The axilla is released on the arm to avoid injury to the breast tissue with a simple incision revealing the required tissue to allow axillary movement to 90° abduction. The Integra was stapled into place and the V.A.C. subatmospheric pressure dressing applied. After an overnight stay for pain management, the patient was discharged home ambulatory with the V.A.C. (c) After the placement of Integra and subatmospheric pressure treatment for 1 week, the patient is reevaluated in the operating

room. The Integra is adherent and well-vascularized. (d, e) The silicone layer is teased free of the dermal regeneration template in order to avoid disturbing the adherent and vascularized dermal construct. (f) A 0.010 split-thickness skin graft is applied. (g) The skin graft is covered with Mepitel (Molnlycke Health Care, Norcross, Georgia) and the V.A.C dressing applied. (h1–3) The V.A.C. Sponge is sealed with adherent drape and the suction tubing attached. (i) The patient was treated as an outpatient for 1 week with subatmospheric pressure. (j) Result at 4 months with improved range of motion

26

CHAPTER 6

ReCell fiona m. wood

Background of the Technique ReCell® is a technique for harvesting cells from the ­dermal–epidermal junction of the skin for delivery to the wound as a cellular suspension [1]. It is used to facilitate rapid epithelialisation in isolation and in association with standard wound repair techniques. The kit harvests cells from a non-injured site, which are programmed for regeneration [2] and introduces them into a wounded site to enhance repair. The goal is to achieve a wound healing by a tailored approach to match the donor site with the recipient defect as closely as possible and to reduce donor site morbidity [3]. The treatment of the acute burn wound is directed by the knowledge that rapid wound closure is essential for survival and quality of survival [4]. To achieve rapid wound closure, the clinical interventions are tailored to the wound and directed by the assessment of the extent of the injury. Understanding the natural history of the burn wound is pivotal in timing the interventions. The clinical outcome will be a result of the extent of the injury, the patient’s ability to heal and the technologies available for use [5]. Tailored wound care is bringing together the knowledge, experience and technology to meet the patients’ needs [6]. This requires information on the area of skin involved, the depth of the injury and the body site affected [7]. In all but minor burn injuries, the ability of the skin to regenerate is overwhelmed. Every intervention from the time of injury influences the scar worn for life. Therefore the first steps in the healing process, to achieve the best quality of outcome, must pay attention to tissue preservation, limiting the extent of injury and reducing the extent of surgical intervention. If the wound involves the superficial dermis, it will be expected to heal in less than 10 days with a risk of F. M. Wood, FRACS, AM McComb Research Foundation, University of Western Australia, 11th Floor Royal Perth Hospital, Wellington Street, Perth, WA 6000, Australia e-mail: [email protected]

hypertrophic scar incidence less than 4% [8]. As the wound extends into the mid and deep dermal zones, a conservative non-surgical approach is associated with an increasing risk of poor scar outcome. The challenge is in wound assessment to proceed to surgery in a timely fashion to improve the scar outcome [9]. When all the dermis is lost then surgical intervention is indicated to reduce the risk of contracture and poor scar. In tailoring the repair the donor site tissue available is a key factor in designing the repair of both the dermis and epidermis. A number of methods have been used to increase the area of cover from a given skin donor site including meshing of split thickness skin grafts, the Meeks or Chinese method in addition to the laboratory-based tissue expansion with cultured epithelial autografts [10]. ReCell® has been developed as a peri-operative technique which harvests the cells from the dermal–epidermal junction. The ability to expand the area of cover in a ratio of 1–80 has the following advantages.

• A small donor site with proportional reduction in donor site morbidity. • Since the donor site is small, the recipient and donor can be site-matched. • The process takes approximately 30  min and is available for immediate use.

Characteristics and Indications for Use The cells are harvested by a combination of enzymatic and physical dissociation. They are a mixed population of cells including the basal keratinocytes, papillary dermal fibroblasts, melanocytes and langerhans giant cells [11]. The cells are in a suspension for delivery onto the prepared wound bed via an aerosol or via a dripping technique [12]. The kit is designed to process a 4-cm2 piece of skin for a 5-mL suspension to cover an area of 320 cm2. The cells can be used in isolation to facilitate rapid wound closure in a wound with salvageable dermal remnants [13]. For example, the use in paediatric scalds with

H. Hyakusoku et al. (eds.), Color Atlas of Burn Reconstructive Surgery, DOI: 10.1007/978-3-642-05070-1_6, © Springer-Verlag Berlin Heidelberg 2010

ReCell

a minimal debridement to preserve the dermis is a method of rapid epithelisation with minimal donor site. The cells are used in association with meshed split thickness skin grafts in deeper wounds, to assist in closure with expansion of the mesh to improve the quality of the outcome [14]. The cells can be used with meshed graft in the second stage of an Integra repair to speed the rate of epithelisation with the aim of improving the quality of the scar outcome. In extensive burns, the donor sites need repeated harvest; the cells can be used to speed the rate of epithelisation of the donor site for secondary harvest [15]. In areas where the donor site tissue is limited, the cells can be used to achieve a site-matched repair; for example, the sole of the foot or palm of the hand and the use of post-auricular skin for repair of the face. In post-burn scars, the techniques can be used for resurfacing, to improve the surface quality of the scar, colour and the pigment blending the scar with the surrounding skin.

Specific Skill of the Method The ReCell® kit contains an enzyme trypsin, balanced salt solution for suspension of the cells, a filter and a nozzle for cell delivery to the wound. A thin split thickness piece of skin is harvested from a site-matched donor site. The biopsy needs to be this to

CHAPTER 6

allow enzyme penetration to dissociate the skin at the dermal–epidermal junction. After a period of 15–30 min in the enzyme the skin is removed from the enzyme and placed on a petri dish in balanced salt solution. It is then scrapped to release the cells, which can be seen as a plume moving into the surrounding fluid. The cell bearing fluid is aspirated into a syringe and filtered to remove keratin debris prior to collection in a clean syringe for delivery to the wound bed. The volume of fluid is related to the area of cover required with smaller volumes being preferable, reducing the fluid run off from the surface. The cells will adhere to the wound surface and proliferate and migrate under favourable conditions [16]. The wound bed preparation is an essential element to the success of cell function and hence wound healing [17]. The wound should be prepared to remove all necrotic tissue and establish haemostasis. Wound infection must be treated aggressively. The surface is fragile in the initial weeks and requires a primary dressing that remains in place for the first week, with protective secondary dressings that can be changed. Subsequently the surface needs protection as it matures for approximately a further 2 weeks [18]. The dressing systems can and should allow movement to minimize the impact of intervention on functional outcome (Figs. 6.1 and 6.2)

27

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28

Epidermis

ReCell

Superficial - no treatment Partial thickness injury - ReCell alone

Dermis

Subcutaneous layer

Partial dermal injury - Mesh SSG + ReCell Full thickness injury - Dermal replacement + Mesh SSG + ReCell

Deep Fascia

⊡ Fig. 6.1  Example of tailoring the wound repair to the injury using ReCell® to facilitate epidermal repair

⊡ Fig. 6.2  ReCell® cell harvesting kit

ReCell

CHAPTER 6

29

CHAPTER 6

30

ReCell

Clinical Cases + Case 1

6

An acute burn injury in a toddler who fell into a camp fire, resulting in a complex defect. The area requires specialized epidermis for the palm of the hand and epidermal repair over the dorsum (a). In addition, dermis is lost on the ulna palmer and surface and on the dorsum of the hand (b). As the scar matures there is no evidence of a meshed pattern and the surface appears site appropriate (c, d). Repair was tailored to the defect using the following steps: • • • • •

Split thickness skin graft meshed 1–1.5 harvested from the buttock to the dorsum of the hand over the ulna deeper area to introduce the dermis. Cell suspension harvested from the ReCell® kit was applied over the meshed graft and the surrounding area where dermis was preserved. A split thickness dermal graft was harvested from the same donor site and meshed 1–1.5 and applied to the deep areas of the palm. Cell suspension was applied to the donor site. Cells were harvested from a split thickness biopsy (1 cm2) from the sole of the foot and applied to the palm.

ReCell

CHAPTER 6

a

b

c

d

31

32

CHAPTER 6

ReCell

+ Case 2: One-Year-Old Patient Four days post-scald from boiling (a, b).

6

Seven days post-burn the wound was debrided using predominantly dermabrasion to ensure the removal of necrotic contaminated tissue. Autologous cell suspension was used as the repair technique re-seeding the retained dermal elements with cells harvested from the dermal–epidermal junction. Surfasoft®, Jelonet®, Betadine®, dry gauze and Fixomull® applied in layered dressings (c). Thirteen days post-burn and six days post-theatre, small areas remain moist and are treated with Algoderm® and Fixomull® dressings. Massage is commenced to all healed areas and protected with a soft hydrophobic fabric vest tailor made by Second Skin PTY LTD (d, e). At 7 weeks post-burn, the areas are fading rapidly with no evidence of developing hypertrophic scar (f).

ReCell

a

CHAPTER 6

b

c

d

f

e

33

CHAPTER 6

34

ReCell

+ Case 3 An 80% TBSA burn injury in a road traffic accident with full thickness injury to the limbs and sparing of the back. The area on the abdomen was cleaned and escarotomy performed due to respiratory compromise in the resuscitation phase (a).

6

Four days post-injury the wounds were debrided and the skin on the back harvested. The arms were treated using meshed split thickness skin graft and autologous cell suspension. The wounds of the legs were covered with Integra; as a staged repair the abdomen was debrided to retain the dermal elements and repaired using autologous cell suspension harvested from the dermal– epidermal junction using the ReCell® technique. The primary dressing used to protect the cells was Biobrane (b). Fourteen days post-surgery the wounds treated with cell suspension under Biobrane are 90% healed prior to the second stage Integra procedure (c).

ReCell

a

c

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b

35

CHAPTER 6

36

ReCell

+ Case 4 An established scar from a flame injury. Years post-flame burn, the scar persists as an area of uneven texture and irregular pigmentation (a).

6

One-year post-dermabrasion and resurfacing with cells harvested using the ReCell® kit from a post-auricular donor site demonstrating scar modulation of the surface and pigment distribution (b).

ReCell

a

CHAPTER 6

b

37

38

CHAPTER 7

Strategies for Skin Regeneration in Burn Patients victor w. wong and geoffrey c. gurtner

Evolution of Burn Treatment

Seed vs. Soil Paradigm

The history of burn treatment has evolved through time to reflect the advancing frontier of medicine. Egyptian texts dating from 1500 bc advocated a mixture of “cattle dung and black mud” for burns [1] and Hippocratic teaching promoted lukewarm lavage and ointmentbased bandages [2]. During the middle ages, treatments like scalding oil for war wounds were gradually replaced with science-based therapies, notably guided by such surgical luminaries as Ambroise Pare and John Hunter [3]. In the nineteenth century, Louis Pasteur’s discovery of microorganisms and Lister’s contributions to antisepsis directed burn therapy toward an era of sterile wound care, antibiotics, and antimicrobial dressings [4]. As the physiological complications of burn injury became more manageable and victims were able to return to society, functional and aesthetic complications became more prevalent, necessitating the development of early excision and skin grafting, contracture release, and reconstructive tissue flaps. These surgical techniques have also been combined with bioengineering advances such as decellularized human dermis, synthetic dermal matrices, and autologous cultured keratinocytes to offer an array of therapeutic options [5]. The survival rate for burn victims continues to improve in parallel with advances in trauma and critical care [6]. Consequently, hypertrophic scarring following deep dermal injury must no longer be viewed as an inevitable consequence, and the modern burn surgeon must be familiar with novel strategies at the forefront of burn medicine.

The exact pathophysiology of hypertrophic scar formation is unknown, but many factors have been implicated in this dermal fibroproliferative process [7, 8]. A paradigm often used to conceptualize the complex wound environment is “seed vs. soil” (Fig. 7.1) [9]. Cellular components such as wound fibroblasts, keratinocytes, stem cells, and inflammatory cells constitute the “seeds” of the wound, and noncellular elements such as extracellular matrix, mechanical force, oxygen tension, and the cytokine milieu form the “soil.” The intricate interactions between these myriad factors influence the healing trajectory and determine whether a fibrotic or regenerative phenotype results [10]. Not surprisingly, mono-therapeutic strategies against scarring have been largely unsuccessful because they fail to address this sophisticated interplay between wound cells and their environment.

G. C. Gurtner, MD (*) Hagey Laboratory for Pediatric Regenerative Medicine, 257 Campus Drive, Mail Code 5148, Stanford, CA 94305, USA e-mail: [email protected] V. W. Wong, MD Hagey Laboratory for Pediatric Regenerative Medicine, 257 Campus Drive, Mail Code 5148, Stanford, CA 94305, USA

Understanding Skin Regeneration Attempts to understand skin regeneration begin with embryonic skin morphogenesis (Fig.  7.2) and lower organism development [11]. Molecular studies in regenerative organisms such as salamander and zebrafish have revealed a diverse array of cellular mechanisms involved in recreating complex structures [12, 13]. Although simple organisms and lower vertebrates display the most impressive regenerative capacity, the ability to restore injured or diseased organs has not been entirely lost in higher vertebrates. Nude mice, which lack a mature inflammatory response, exhibit a minimally fibrotic phenotype [14]. Human fetal skin also demonstrates scarless healing up to the third trimester, which has been attributed to a distinctive inflammatory response and unique matrix organization [15, 16]. Furthermore, adult organs such as liver and pancreas display robust regenerative potential, involving both dedifferentiation of mature cells and proliferation of progenitor populations [17].

H. Hyakusoku et al. (eds.), Color Atlas of Burn Reconstructive Surgery, DOI: 10.1007/978-3-642-05070-1_7, © Springer-Verlag Berlin Heidelberg 2010

Strategies for Skin Regeneration in Burn Patients

⊡ Fig. 7.1  Cellular (“seed”) components of the wound environment include fibroblasts, keratinocytes, stem cells, inflammatory cells, and endothelial cells. Noncellular (“soil”) elements

EMBRYONIC SKIN DEVELOPMENT:

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39

include matrix, mechanical tension, oxygen levels, and the cytokine milieu. Complex interactions between these factors determine whether scarring or regeneration dominates

2-3 Months

1 Month

Epidermal Thickening

Periderm Ectoderm

Matrix & Blood Vessel Development

Mesoderm

>5 Months

4 Months

Stratum Corneum Epidermal Stratification Basement Membrane

Papillary & Reticular Dermis

Appendage Development

Skin Glands

⊡ Fig.  7.2  Attempts to understand skin regeneration begin with embryologic skin morphogenesis. Following gastrulation, the embryo surface is covered with a single layer of ectoderm and periderm. In the second month, ectoderm develops into epidermis that thickens and mesoderm develops into connective

tissue and blood vessels. Around the fourth month, periderm regresses, epidermis undergoes stratification and basement membrane formation, and early dermal appendages form. After the fifth month, a protective keratinized layer forms, dermis further matures, and rudimentary skin glands form

CHAPTER 7

40

Despite these studies, skin regeneration remains a complex process that is poorly understood. Epithelialmesenchymal interactions play an important role in hypertrophic scarring [18] and fibroblasts harvested from different dermal regions exhibit a fibrotic potential that positively correlates with depth [19], demonstrating spatial determinants in scarring. Furthermore, genetic and microarray studies on wound repair and genetically-modified mice models have revealed developmental profiles that underscore the complexity of wound repair [20–22]. The discovery of multipotent human epidermal stem cells (Fig. 7.3), which are critical to both normal skin homeostasis and wound repair, promises to expand on progenitor cell-based therapies for burn treatment [23, 24]. Thus, human skin displays remarkable plasticity which we are only starting to understand.

Epithelium

Hair Shaft

Strategies for Skin Regeneration in Burn Patients

Current Research and Strategies for Skin Regeneration Inflammation has long been an obvious target for anti­ fibrotic therapy but to limited clinical success. Based on fetal wound healing studies, attempts have been made to recapitulate the in utero cytokine environment using transforming growth factor b isotypes [25]. Recently, our laboratory has shown that wound mechanical forces can modulate fibrosis in a small [26] and large animal model and attenuation of intrinsic skin stresses recapitulated a regenerative stress state with minimal scarring (being prepared for submission). Matrix components such as hyaluronic acid [27] and fibromodulin [28] have been explored as structural factors potentially critical for skin regeneration. Additionally, enhancement of neovascularization in wound healing via gene delivery [29] and growth factor-seeded scaffolds [30] has yielded positive results. Current cell-based therapies like cultured epithelial autografts have proven useful when donor site availability is limited but clinical results have been suboptimal considering the resources needed for processing and maintenance [31, 32]. The future of skin regeneration Native Sources: Skin “Stem Cells”

Outer Root Sheath

Sebaceous Gland

Adipose Tissue

Bulge Stem Cells

Putative Progenitor Types: Bone Marrow

Inner Root Sheath

• Epithelial Stem Cells • Endothelial Progenitor Cells • Hematopoietic Stem Cells • Mesenchymal Stem Cells • Adipose-derived Stem Cells

Dermal Papilla

⊡ Fig. 7.3  Epidermal stem cells are found in the hair bulge region and migrate to defined skin microenvironments. Selfrenewing bulge stem cells can migrate to the sebaceous gland, epidermis, and dermal papilla both to maintain normal skin homeostasis and in response to injury

Other

⊡ Fig.  7.4  In addition to epidermal stem cells, progenitor populations used experimentally in burn treatment include bone marrow-derived and adipose tissue-derived progenitor populations. Stem cells from other sources, including umbilical cord blood and embryonic lineages, may also play an important role in the future of burn therapy

Strategies for Skin Regeneration in Burn Patients

CHAPTER 7

⊡ Fig.  7.5  The future of regenerative burn therapy will require multifaceted approaches utilizing control release growth factor gradients, tissue-engineered matrix scaffolds,

and exogenous pluripotent stem cells to recapitulate a regenerative wound environment

will undoubtedly involve progenitor cells both within the skin and from distant sites (Fig. 7.4) [33, 34]. There are multiple stem cell populations that can be derived from various sources, and they have been utilized to accelerate acute and chronic wound healing [35]. Embryonic stem cells are the most pluripotent cell type but ethical issues have impeded their use. Adult progenitor cells are readily available and include epidermal stem cells, a diverse population of skin progenitors critically involved in skin homeostasis and wound repair [36, 37]. Bone marrow-derived mesenchymal stem cells (MSCs) have also been implicated in skin repair [38] and a recent study utilized MSC-seeded dermal scaffolds to improve burn wound healing [33]. Hematopoietic stem cells are readily harvested from human umbilical cord blood and display the potential to regenerate skin [39], and endothelial progenitor cells are known to regulate vasculogenesis following hypoxic injury [40]. Finally, adipose-derived stem cells have been shown to improve wound healing via dermal matrix delivery [41] and have even been used to fabricate new skin [42]. These studies highlight the tremendous potential of progenitor-based therapies, providing

novel paradigms for both tissue engineering and regenerative medicine.

Future of Regenerative Medicine in Burn Therapy As researchers continue to elucidate the molecular mechanisms underlying wound repair and tissue engineers further develop regenerative biomaterials, the biological secrets of scarless wound repair will continue to be revealed. As such, the future of burn treatment demands a multifaceted approach exploiting these diverse technologies (Fig. 7.5). Ideally, temporal and spatial biomimetic cues are replicated with control release of cytokines and patterned matrix components. These signals (“soil”) then direct implanted progenitor and/or resident cell (“seed”) differentiation toward a regenerative profile with scarless repair. It is the hope that these promising laboratory discoveries make their way bedside and to the operating room, so that burn patients and physicians can expect a complete functional and aesthetic recovery.

41

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CHAPTER 8

Diagnosis, Assessment, and Classification of Scar Contractures rei ogawa and julian j. pribaz

Diagnosis of Postburn Scar Contractures Differential diagnosis of ankylosis or contracture is important (Fig.  8.1). Ankylosis is a stiffness of a joint, and can vary from moderate to severe. Ankylosis may involve the deeper tissues, including bone, cartilage, and joint capsule and may require orthopedic surgical release. In soft tissue contractures, myogenic and neurogenic contractures should be excluded for surgical reconstruction. In connective tissue contracture, differential diagnosis by anatomical structures should be

performed before the planning of surgical methods. Connective tissue contractures can be classified by affected tissues (Fig. 8.1); (a) Cutaneous, subcutaneous or fascial contracture, (b) Tendon contracture, (c) Ligament contracture and (d) Muscle contracture. Many of burn scar contractures are classified into cutaneous/ subcutaneous contracture. If tendon, ligament, and muscle contracture were diagnosed, these replacement/ reconstruction methods should be considered in addition to releasing scar contractures.

1. Distinguish between soft tissue contractures and joint anchylovsis

2. Distinguish between connective tissue contracture and myogenic/neurogenic contracture

3. Differential diagnosis of contractures by anatomical structures a. Cutaneous , subcutaneous, or fascial contracture Scar contracture b. Tendon contracture c. Ligament contracture d. Muscle contracture

4. Assessment and classification of scar contractures to decide treatment methods

5. Functional and aesthetic evaluation of joints/tissues on both pre-and post-treatment

⊡ Fig. 8.1  Differential and exclusive diagnosis of post-burn scar contractures R. Ogawa, MD, PhD (*) Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School Hospital, Tokyo, Japan e-mail: [email protected] J. J. Primbaz, MD Department of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, USA H. Hyakusoku et al. (eds.), Color Atlas of Burn Reconstructive Surgery, DOI: 10.1007/978-3-642-05070-1_8, © Springer-Verlag Berlin Heidelberg 2010

Diagnosis, Assessment, and Classification of Scar Contractures

Assessment and Classification of Postburn Contractures “Scar contractures” are diagnosed by abnormal resting position of anatomical structures or movement disturbance of joints and other tissues. To decide the treatment

CHAPTER 8

of scar contractures, careful assessment and classification of contractures by site are needed (Fig. 8.2). Shape and depth of scars should be diagnosed pre- and/or intraoperatively. Postoperative assessment is also important to evaluate the selected methods.

1. Periorbital region 2. Perioral region 3. Neck 4. Digital joints (DIPj ,PIPj, MCPj) 5. Digital web 6. Wrist joint 7. Cubital joint 8. Axilla 9. Anterior Chest 10. Lumbar region 11. Inguinal region 12. Knee joint 13. Ankle joint 14. Toe joints (DIPj ,PIPj, MTPj) 15. Toe web 16. Other special regions (Nose, Ear, Palmar, Plantar, Genital region, etc. )

⊡ Fig. 8.2  Therapeutic-objective sites of post-burn scar contractures

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46

Periorbital Region (Fig. 8.3) If the contracture is associated with mild dysfunction of eye closure over 3 months after burn injury (type I), minimal incision for releasing contracture and wound closure with local flaps can be performed. If conjunctiva and middle lamella are intact but if there is severe dysfunction of eye closure (type II), skin grafting should be used. Local flaps are also available for partial contracture

Diagnosis, Assessment, and Classification of Scar Contractures

(type IIa). With respect to skin grafting, split thickness skin grafts (STSG) for the mobile upper eyelids and full thickness skin grafts (FTSG) for the lower lids have been routinely used [1]. Complete eyelid loss from burn is rare; however, sometimes conjunctiva and/or middle lamella is damaged (type III). In this case, skin grafting, local or free flaps should be selected on a case-by-case basis according to the necessity of appropriate material transfer such as cartilage and fascia.

* Upper eyelid and lower eyelid should be evaluated separately I Contractures with mild dysfunction of eye closure II Contractures with severe dysfunction of eye closure (with normal conjunctiva and middle lamella)

Lower eyelid Type IIa

IIa Partial contractures IIb Extensive contractures

III Contractures with severe dysfunction of eye closure (with contracture of conjunctiva and/or middle lamella)

IV Unclassified

Lower eyelid Type IIb

⊡ Fig. 8.3  Periorbital region

Diagnosis, Assessment, and Classification of Scar Contractures

Perioral Region (Fig. 8.4) Contracture with mild dysfunction of mouth movements should be reconstructed with minimal scar release and reconstructed with FTSG or local flaps (type I). Contracture with severe dysfunction without commissure contracture should be reconstructed with FTSG according to the aesthetic units/subunits theory [2–5] (type II). If contractures are partial but the commissure is

CHAPTER 8

contractured, not only FTSG but also local flaps should be used for complete releasing of contracture and reconstruction of commissure (type IIIa). If the contracture is extensive and commissure is also contractured (type IIIb), extensive releasing and reconstruction with flaps such as pedicled regional flap, free flap, and prefabricated flap should be selected on a case-by-case basis. In the case of male patients, beard and mustache reconstruction can be considered by flaps harvested from beard region [6].

* Upper lip and lower lip should be evaluated separately

I Contractures with mild dysfunction of mouth movements II Contractures with severe dysfunction of mouth movements (with normal commisure) Lower lip Type IIb

III Contractures with severe dysfunction of mouth movements (with contractures of commisure) IIIa Partial contracture IIIb Extensive contracture

IV Unclassified

Uper / Lower lip Type IIIb

⊡ Fig. 8.4  Perioral region

47

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48

Chin and Anterior Neck (Fig. 8.5) Short linear contractures can be released using single z-plasty or small local flap (type I). However, long linear contracture extended to next unit should be reconstructed by multiple z-plasties, local flaps, or skin grafting (type II). With respect to the skin grafting, FTSG should be selected to prevent recontracture. Broadband contracture should be released completely and reconstructed by

Diagnosis, Assessment, and Classification of Scar Contractures

FTSG or thin flaps. If the wounds, after removal of scar tissues, have platysma at the base, FTSG can be selected (type IIIa). However, if the platysma is missing, thin flaps should be used (type IIIb). “Super-thin flaps” [7] harvested from chest or dorsal region, perforator flaps, supraclavicular flaps [8] may be used. Broadband contracture extended to the next units should be reconstructed by a sheet of large and thin flaps such as perforator-supercharged “Super-thin flaps” (type IV).

* Mental-submental, anterior neck, and lateral neck on both sides should be evaluated separately

I Short linear contracture within the unit II Long linear contracture extended to next unit III Broadband contracture within the unit IIIa not including platysma IIIb including platysma IV Broadband contracture extended to next units V Unclassified Anterior neck Type I

⊡ Fig. 8.5  Chin and Anterior Neck

Mental-submental/Anterior neck Type IV

Diagnosis, Assessment, and Classification of Scar Contractures

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49

Digital Joints (DIP, PIP, MCP) (Fig. 8.6)

Digital Web (Fig. 8.7)

Short linear contracture can be released by a small rotation or transposition local flap designed next to the contracture (type I); however, long linear contracture should be reconstructed by skin grafting (type II). Broadband contracture should be reconstructed by skin grafting (type III), but a contracture less than a quarter of circumferences can be reconstructed by local flaps designed on the digit adjacent to the contracture (type IIIa). In this case, flaps such as a digital artery flap and metacarpal artery flap may be used. Contracture of entire circumferences can be treated by not only skin grafting but also distant abdominal or groin flaps [9] (type V).

Single web contracture should be reconstructed by a local flap such as a square flap 10 based on the web and a five flap z-plasty designed on the intact side (type I). Contractures on both the palmar and dorsal regions should be reconstructed by skin grafting or digital artery flap (type II). If web contracture is severely affecting adjacent digits, complete releasing of contracture and reconstruction using skin grafting should be performed (type III).

* DIPj, PIPj and MCPj should be evaluated separately I Short linear contracture on one of joints II Long linear contracture extended to next joint III Broadband contracture IIIa less than a quarter of circumferences IIIb over a quarter of circumferences

⊡ Fig. 8.6  Digital joints (DIPj, PIPj, MCPj) contracture

IV Contractures of entire circumferences MCPj Type I

DIPj / PIPj Type II

V Unclassified

I Single web contractures Ia palmar side contracture Ib dorsal side contracture II Double web contractures (contractrures on both palmer and dorsal sides) III Web contractures severely affecting adjacent digits IV Unclassified

⊡ Fig. 8.7  Digital web

Type Ib

Type III

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50

Wrist Joint (Fig. 8.8) Linear contracture should be excised completely and can be closed primarily with z-plasties, w-plasty, or small-wave incision to release tension (type I). Broadband contracture on one surface should be reconstructed by skin grafting (type II), but extensive

Diagnosis, Assessment, and Classification of Scar Contractures

contractures extending to subsequent surfaces should be reconstructed by skin grafting or local flaps designed on intact surfaces (type III). In the case of contracture of the entire circumferences, not only skin grafting but also flaps designed from the proximal forearm, distant abdominal or groin flap, or free flaps (type IV) can be used.

I Linear contracture involving palmar, dorsal, radial or ulner surface

II Broadband contracture involving palmar, dorsal, radial or ulner surface III Broadband contracture extended to next surfaces IV Contractures of entire circumfrences

V Unclassified Type Ia

⊡ Fig. 8.8  Wrist joint

Type III

Diagnosis, Assessment, and Classification of Scar Contractures

Cubital Fossa/Elbow Joint (Fig. 8.9) Linear contracture should be excised completely and can be closed primarily with z-plasties, w-plasty, or smallwave incision to release tension (type I). In the case where the patient has linear scar contractures on both radial and ulnar surfaces, contractures can be released by propeller flaps designed on the cubital fossa (type Ib). Broadband contracture on one surface should be reconstructed by skin grafting or local flaps designed on

CHAPTER 8

the intact surface (type IIa), but for broadband contractures on both radial and ulnar surface, propeller flap [11] designed on the cubital fossa can be used (type IIb). Broadband contractures extended to next surfaces sometimes need vascular pedicled relatively large flaps harvested from upper arm or forearm (type III). In the case of contracture of the entire circumferences, flaps such as vascular pedicled flaps or free flaps are useful to prevent recontracture (type IV).

I Linear contracture of the cubital joint Ia flexor, radial, ulnar or dorsal surface Ib radial and ulnar surface Type Ia II Broadband contracture of the cubital joint IIa flexor, radial, ulnar or dorsal surface IIb radial and ulnar surface

III Broadband contracture extended to next surfaces

IV Contractures of entire circumfrences

V Others Type III

⊡ Fig. 8.9  Cubital joint

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52

Axilla (Fig. 8.10) Minor area of contracture within the axillary area can be reconstructed by skin grafting (type I). Single linear contracture can be released by a large z-plasty, multiple z-plasties, or other local flaps, but sometimes hair bearing regions must be divided. Square flap [10] is a good choice for these cases (type II). Square flap should be designed on the intact surface. Double linear contracture

Diagnosis, Assessment, and Classification of Scar Contractures

exists on both anterior and posterior axillary line, propeller flaps designed on the center of axilla and contractures can be released at the same time (type IIIa). If a contracture is found between linear contractures, all of the contractured area should be excised and reconstructed by local or regional flaps from the chest or dorsal region (type IIIb). Broadband contracture over the axillary area should also be reconstructed by regional flaps or free flaps (type IV and V).

I Minor area of contracture within the axillary area II Single linear contractures Type IIa

IIa anterior axillary line IIb posterior axillary line III Double linear contractures IIIa Both anterior and posterior line with normal tissues between the lines IIIb Both anterior and posterior line with contractures between the lines IV Broadband contracture over the axillary area

Type IIb

IVa The contractures extended to the chest IVb The contractures extended to the back IVc The contractures extended to the upper arm V Broadband contractures surrounded with scars VI Others

Type IIIa

⊡ Fig. 8.10  Axilla

Diagnosis, Assessment, and Classification of Scar Contractures

Anterior Chest (Fig. 8.11) Anterior chest contractures should be reconstructed by skin grafting. In the case of a hemilateral contracture, displacement of nipple after skin grafting should be avoided

CHAPTER 8

(type Ib and IIb). In the case of contractures with displacement of the nipple, contracture should be released completely and reconstructed by adequate size and thickness of FTSG to prevent recontracture. Very severe cases should be reconstructed by STSG (type III and IV).

I Contractures with no displacement of the nipple Ia Central contracture Ib Hemilateral contracture Ic Bilateral contracture

II Contractures with displacement of the nipple IIa Central contracture Type Ia

Type IIa

IIb Hemilateral contracture IIc Bilateral contracture

III Entire chest contractures with normal breathing

IV Entire chest contractures with breathing difficulty

V Unclassified

Type IIb

⊡ Fig. 8.11  Anterior chest

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54

Lumbar Region (Fig. 8.12) Linear contracture can be excised completely and closed primarily with z-plasties, w-plasty, or small-wave incision to release tension (type I). However, broadband

Diagnosis, Assessment, and Classification of Scar Contractures

contractures should be reconstructed by skin grafting or local flaps harvested from abdomen or dorsal area (type II). If lateral curvature exists, complete resection of scars and reconstruction using a sufficiently large STSG is necessary (type III).

* Right and left lumbar regions should be evaluated separately I Linear contractures Type I II Broadband contractures without lateral curvature IIa Minor boradband contractures within the luber region IIb Major broadband contractures extended to other regions with no lateral curvature III Broadband contractures with lateral curvature IV Unclassified

Type III

⊡ Fig. 8.12  Lumber region

Diagnosis, Assessment, and Classification of Scar Contractures

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Inguinal Region (Fig. 8.13) Linear contracture can be excised completely and closed primarily with z-plasties, w-plasty, or small-wave incision to release tension (type I). However, broadband

contractures where anterior thigh extension is compromised should be reconstructed by skin grafting or local flaps harvested from abdomen or anterior thigh (type II). Broadband contracture surrounded by scars should be reconstructed by STSG (type III).

* Left side and right side should be evaluated separately

I Minor contractures with the normal anterior thigh extension

Type I

II Broadband contractures with difficulty of the anterior thigh extension

III Broadband contractures surrounded with scars IV Unclassified

Type III

⊡ Fig. 8.13  Inguinal region

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56

Knee Joint (Fig. 8.14) Linear contracture should be excised completely and can be closed primarily with z-plasties, w-plasty, or small-wave incision [12] to release tension (type Ia). In the case that has linear scar contractures on both tibial and peroneal surface, contractures can be released by propeller flaps [11] designed on the center of posterior knee (type Ib). Broadband contracture on one surface should be reconstructed by skin grafting or local flaps

Diagnosis, Assessment, and Classification of Scar Contractures

designed on the intact surface (type IIa), but for ­broadband contractures on both tibial and peroneal surface, propeller flap designed on the popliteal fossa can be used. (type IIb). Broadband contractures extending to adjacent surfaces sometimes need vascular pedicled ­relatively large flaps harvested from thigh or lower leg (type III). In the case of contracture of the entire circumferences, flaps such as vascular pedicled flaps or free flaps are useful to prevent recontracture (type IV).

I Linear contracture on the knee joint Ia anterior, posterior, tibial or peroneal surface Ib tibial and peroneal surface II Broadband contracture on the knee joint IIa anterior, posterior, tibial or peroneal surface IIb tibial and peroneal surface III Broadband contracture extended to next surfaces IV Broadband contracture of entire circumfrences Type Ia

⊡ Fig. 8.14  Knee joint

Type Ib

Type III

V Others

Diagnosis, Assessment, and Classification of Scar Contractures

CHAPTER 8

Ankle Joint (Fig. 8.15) Linear contracture should be excised completely and can be closed primarily with z-plasties, w-plasty, or smallwave incision [12] to release tension (type I). Broadband contracture on one surface should be reconstructed by

skin grafting (type II), but extensive contractures extending to adjacent surfaces should be reconstructed by skin grafting or local flaps designed on intact surfaces (type III). In the case of contracture of the entire circumferences, not only skin grafting but also flaps designed on the lower leg or free flaps (type IV) can be used.

I Linear contracture involving plantar, dorsal, tibial or peroneal surface II Broadband contracture involving plantar, dorsal, tibial or peroneal surface Type Ia

III Broadband contractures extended to next surfaces IV Broadband contractures of entire circumfrences V Unclassified

Type II

⊡ Fig. 8.15  Ankle joint

57

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58

Toe Joints (DIP, PIP, MTP) (Fig. 8.16) Short linear contracture can be released by a small rotation or transposition local flap designed next to the contracture (type I); however, long linear contracture should be reconstructed by skin grafting (type II). Broadband

Diagnosis, Assessment, and Classification of Scar Contractures

contracture should be reconstructed by skin grafting (type III), but a contracture less than a quarter of the circumferences can be reconstructed by local flaps designed next to the surface of digit (type IIIa). Contracture of the entire circumferences should be treated by skin grafting (type V).

* DIPj, PIPj and MTPj should be evaluated separately I Short linear contracture on one of joints II Long linear contracture extended to next joints Type I

III Broad band contracture extended to next joints IIIa less than a quarter of entire circumflerences IIIb over a quarter of entire circumflerences V Major contractures of entire circumfrences

VI Unclassified

Type IIIb

⊡ Fig. 8.16  Toe joints (DIP, PIP, MTP)

Diagnosis, Assessment, and Classification of Scar Contractures

Toe Web (Fig. 8.17) Single web contracture should be reconstructed by a local flap such as a square flap and five z-plasty flap that are designed on the intact side (type I). Contractures on

CHAPTER 8

both plantar and dorsal regions should be reconstructed by skin grafting (type II). If web contracture is severely affecting adjacent digits, complete releasing of contracture and reconstruction using skin grafting should be performed (type III).

I Single web contractures Ia plantar side contracture Ib dorsal side contracture

II Double web contractures Type Ib

(contractrures on both planter and dorsal sides)

III Web contractures severely involved with next toes

IV Unclassified

Type III

⊡ Fig. 8.17  Toe web

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60

Other Special Regions (Nose, Ear, Genital Regions, etc.) (Fig. 8.18) Other regions should be evaluated by degree of cosmetic and functional dysfunction, and the size of tissue defects.

I Cosmetic dysfunction with no major tissue defects II Cosmetic dysfunction with major tissue defects III Cosmetic and functional abnormality with no major tissue defects IV Cosmetic and functional abnormality with major tissue defects V Unclassified

⊡ Fig. 8.18  Other special regions (nose, ear, palmer, plantar, genital region, etc.)

Diagnosis, Assessment, and Classification of Scar Contractures

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CHAPTER 9

Prevention of Scar Using bFGF sadanori akita

Background of the Method Hypertrophic scars or keloid scars caused by burns are sometimes problematic when functional regions such as articular joints or conspicuous areas on the face or extremities are involved [1]. Massive burn wound scars have a tendency to develop progressive hypertrophic scars, and earlier skin grafting may improve the overall skin quality as well as shorten the hospital stay [2]. Humoral and cellular mediators have been considered for the pathogenesis of burn wound-induced hypertrophic scars. One possible role of the growth factors or cytokines in wound healing is to promote high cellular proliferation, differentiation, and migration of keratinocytes of the epidermis and the recruitment of inflammatory cells [3]. A basic fibroblast growth factor (bFGF) may play a pivotal role in cutaneous wound healing by activating local macrophages, with the effects continuing up to the remodeling stage, several weeks after the initial injury. Burn wound fluids or skin graft wound fluids limited to the dermis contain lower concentrations of bFGF compared to surgical wounds, which is deeper than the dermis with subsequently lower endothelial cell proliferative and chemotactic activities [4]. The bFGF is increased by silicone gel application in normal and fetal fibroblast cultures and may result in the prevention of hypertrophic scars. The healing of burn wounds is more complicated than acute wound healing. Sustained burn wounds are more susceptible to bacterial contamination and bring about unfavorable results, particularly in children [7]. Faster wound healing is highly expected to prevent severe systemic damage or sequelae such as invasive wound infection and sepsis. The bFGF was effective for second-degree burn wound healing in a randomized control trial although bovine

S. Akita, MD, PhD Nagasaki University, Japan e-mail: [email protected]

recombinant bFGF was employed [5]. The bFGF was regulated in spatial and temporal expression in accordance with the recruitment of inflammatory cells and interaction with keratinocytes [3] and was lower in second-degree burn wound fluid, therefore decreasing endothelial cell proliferative and chemotactic activity [4]. Wounds treated with bFGF produced scars that were significantly less hard 1 year after final wound closure [6]. Pediatric burn wounds can be problematic since accurate evaluation is difficult due to anatomically immature vasculature or immobilization failure, especially in second-degree burns, and the burn surface areas and the burn depth tend to worsen over time. Delayed wound healing results in unsightly scarring, such as hypertrophic scars, which are problematic both esthetically and functionally. Among cytokines and growth factors, bFGF is clinically proven, having demonstrated accelerated acute and chronic wound healing. Accelerated wound healing may lead to improved scarring. To elucidate the effects of bFGF on second-degree pediatric burn wounds, a comparative study was performed. bFGF-treated pediatric burn wounds demonstrated better scarring and well-organized stratum corneum after healing both clinically and by moisture meter analysis [7]. The bFGF demonstrated endogenous immunolocalization in the human dermis in partial-thickness burns from day 4 to day 11. The bFGF participates in cutaneous wound healing by activating local macrophages up to the remodeling phase, which occurs several weeks after injury. The bFGF in burn wounds may be a presynthesized mediator that is released locally from injury sites, and thus may play an important role in early wound healing [8]. In adult second-degree burns, the topical application of bFGF within 5 days postinjury demonstrated significantly better regeneration of granulation tissues and newly formed capillaries in a randomizedcontrol clinical trial. Our therapeutic regimens of bFGF treatment for the second-degree burns in this investigation started as early

H. Hyakusoku et al. (eds.), Color Atlas of Burn Reconstructive Surgery, DOI: 10.1007/978-3-642-05070-1_9, © Springer-Verlag Berlin Heidelberg 2010

Prevention of Scar Using bFGF

as on arrival day of postburn, and burn wound healing was completed at 12 days for the bFGF-treated group; this may be compatible with the endogenous bFGF expressions observed during day 4 to day 11 as observed in rat immunohistochemically [9]. Reconstruction of the lower extremities can be a concern. After extensive soft tissue defects due to metabolic changes such as diabetes, atherosclerosis and subsequent osteomyelitis as well as local infection, contusion, traffic accident or tumor resection, it is more difficult to resurface the skin if the raw surface consists of bone and tendon tissues. The combination of an artificial dermis with the topical administration of bFGF is the only angiogenic cytokine currently available in Japan. The bFGF also demonstrated acceleration and improvement in burn wounds in terms of the healing rate and hardness of the postskin grafting. Staged lower extremity reconstruction with daily bFGF-treated artificial dermis and subsequently thinner split-thickness skin grafting was beneficial for the quality of reconstructed skin in comparison with the artificial dermis and split-thickness skin grafting alone in terms of hardness and moisture parameters such as transepidermal water loss (TEWL), water content and thickness. The bFGF-treated reconstruction demonstrated almost equal values in water content and thickness, consistent with the softer and thus better nature of the reconstructed lower extremity. The advantage of using an artificial dermis includes immediate coverage for deeper tissue exposure such as tendon and bone, protecting from fluid, protein, and electrolyte loss, from microorganism invasion, and reducing secondary donor-site morbidity as only thinner skin grafting is required. Also, the combination of artificial dermis with bFGF demonstrated the reconstruction of deep diabetic soft tissue loss, diabetic pressure ulcer healing in a mouse model and intractable fingertip ulcers caused by burn injury [10].

CHAPTER 9

Characterization and Indication of the Method Genetically recombinant basic human fibroblast growth factor (bFGF) is used for spraying: the recombinant human bFGF with 154/153 aa residues (E.Coli). The molecular weight of the recombinant human bFGF is 17 kDa. The isoelectric point is 10.1., basic, and nonglycosylated single chain peptide. The beginning of bFGF use varied from 2 to 4 days postburn injury. The concentration of bFGF is 30 mg of bFGF per 30  cm2 area as 100 mg of freeze-dried bFGF dissolved in 1 mL of benzalkonium chloride solution, with 300 mL sprayed over a 30 cm2 area from 5 cm distance, and 0.3 mL of such concentration solution is applied by this method. Ointmentimpregnated gauze is applied to wounds treated with bFGF after waiting for 30  s. The bFGF administration continues until the wound had healed. For comparison, the non-bFGF treatment group receives only ointment-impregnated gauze without bFGF spraying. Standard procedures for stabilizing the burn wounds are applied for all the cases. For application with artificial dermis, the bFGF containing solution, which is reconstituted in the same way as the spray form, at a concentration of 1 mg/cm2 is delivered to the undersurface of the artificial dermis.

Specific Points of the Method 1. The reconstituted bFGF solution, either spray form or solution form, should be stored at 4° until use and each vial should be used up within 2 weeks period. 2. Major foreign body or large necrotized tissues should be debrided off before applying bFGF. 3. The principle is once per day application. Even another dressing change is required within 24 h. 4. Prevent the eyes from contacting bFGF directly.

63

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64

Prevention of Scar Using bFGF

Clinical Cases + Case 1

9

A 78-year-old woman living alone in a remote hilly house. The fire from a candle spread over her clothes and she fell down on the floor. The bilateral buttocks and posterior thighs and part of leg developed totally 12% surface area burns. Eight percentage of TBSA was third degree and required debridement and split-thickness skin grafting. This patient was also suffering from dementia she thus had little understanding of the burn was so little. In 5 days, after she was found and brought to us by ambulance, the first debridement and skin grafting was performed. In third degree burn areas in posterior thighs, debridement was performed up to the fat tissues and sheet grafts were placed over bilateral ischiums and majority of wound was covered with mesh or patched grafts. In 18 months, the left buttock with bFGF spray demonstrated softness and more durability to trauma compared to the right buttock (control). The histology in both the buttocks showed quite different findings. The bFGF-treated wound demonstrated stratified epithelia and matured collagen fiber in the transverse direction; on the other hand, the control histology demonstrated thinner epithelia and loss of rete ridges, along with the deranged dermis and partly hyalinized collagens, which was consistent with the durometer readings (Fig. 9.1a–d).

Prevention of Scar Using bFGF

CHAPTER 9

a c

b

d

⊡ Fig. 9.1  78-year-old woman demonstrated total 12% BSA IIIrd-degree flame burn (a). Immediately after debridement (b). Histology of the control scar in 18 months. There is ran-

domized array of the collagen fibers (×100) (c). Histology of the bFGF-treated scar in 18 months. There is organized array and the rete ridges are obtained (×100) (d)

65

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66

Prevention of Scar Using bFGF

+ Case 2

9

A 2 and a half year-old girl mistakenly spilt hot water over her forearm and upper arm. In the forearm (left of the Fig. 9.2a), the bFGF spray as well as the ointment-impregnated gauze was applied and the arm side (right of the Fig. 9.2a) was treated with the ointment-impregnated gauze daily. The depth of the burn wounds in both upper arm and forearm seems comparable and indistinguishable between superficial dermal burn (SDB) and deep dermal burn (DDB) initially. In 1 year after complete healing, the appearance of the scar was much better in the bFGF-treated wounds in terms of color, hardness and height (Fig. 9.2a–b).

Prevention of Scar Using bFGF

CHAPTER 9

a

⊡ Fig. 9.2  2.5-year-old girl with scald burn. Let (forearm) was treated with the bFGF and right was the control (a). One year after complete wound healing. The bFGF-treated scare is much flatter, softer and well-matched in color with surrounding tissue (b)

67

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68

Prevention of Scar Using bFGF

+ Case 3 An 80-year-old woman who developed sudden onset infection in the left lower extremity. The severe cellulitis after minor burn wound and partial infection to the bones and some tendons were exposed.

9

In 5 days after she was referred to our hospital, the secondary debridement, bFGF spray for wound bed and the artificial dermis were applied. The bFGF injection was continued at 30 mg up to the secondary spit-thickness skin grafting. After the continuation of 14-day bFGF from the side of the artificial dermis, 10/1,000 inch-split-thickness skin grafting was performed over the bFGFtreated wound bed. In 3 years after skin grafting, the wound healed uneventfully with softer and much normalized appearances (Fig. 9.3a–e).

Prevention of Scar Using bFGF

a

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b

c d

e

⊡ Fig.  9.3  80-year-old woman developed the severe cellulitis of sudden onset in the left calf (a). After thorough debridement, the bFGF was sprayed over the wound and covered with the artificial dermis (b). With 14-day continuous injection of the bFGF from the side of the artificial

dermis, the would bed was optimally ready for secondary skin grafting (c). Right after 10/1,000 inch-split-thickness skin grafting was applied (d). In three years after the final surgery, the scar is softer and demonstrated normal appearance (e)

69

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70

Prevention of Scar Using bFGF

+ Case 4 An 82 year-old man who mistakenly spilt the flamed kerosene over his upper back, posterior neck, and arms. There was a DDB area in the upper left back. Daily bFGF spraying along with the ointment-impregnated gauze dressing up to 14 days when all the wounds completely healed. In 1 year after healing, the scar is pliable and color-match favorably with the adjacent intact skin (Fig. 9.4a–b).

9

Prevention of Scar Using bFGF

a

CHAPTER 9

b

⊡ Fig. 9.4  82-year-old man spilt the flamed kerosene over his back, neck and arms (a). With 14-day continuous spraying of the bFGF until wound healing, it is pliable, color-matched scars in one year (b)

71

72

C H A P T E R 10

Medical Needling hans-oliver rennekampff, matthias aust, and peter m. vogt

Background of the Technique Patients with post-burn scarring frequently request help in improving the aesthetic appearance of their residual cicatricial deformity. It is their hope to eradicate the physical evidence of a scar and to re-establish a normal appearance and texture to the site of injury. This quest has led to the application of many different topical therapies which have included carbon dioxide (CO2) laser resurfacing, dermabrasion and deep chemical peels. All these modalities share a similar mechanism of action, topically ablating the skin in an attempt to yield a more homogenous surface. This therapeutic injury destroys the epidermis and the basement membrane. Ablating the epidermis of already scarred skin with subsequent protracted re-epithelialization may render the skin more sensitive to photodamage and dyschromia and may possibly cause additional dermal fibrosis by initiating a prolonged inflammatory response. Rejuvenation of scarred skin and re-establishment of a more normal appearance require the maintenance or establishment of a normal epidermis with normal colour and a normal dermis with natural dermal papillae, good hydration, and normal resilience. New therapeutic interventions have attempted to preserve the epidermis either completely as in radiofrequency tissue heating or partially as effected by fractionated laser ablation. Initiating a wounding stimulus in the dermis and causing necrosis of dermal cells create a stimulus for fibrosis, inducing new collagen and elastin synthesis by fibroblasts, resulting in skin tightening. H. Rennekampff, MD, PhD (*) Klinik für Plastische, Hand- und Wiederherstellungchirurgie, Medizinische Hochschule Hannover, Carl Neubergstrasse 1, 30625 Hannover, Germany e-mail: [email protected] M. Aust, MD and P. M. Vogt MD, PhD Klinik für Plastische, Hand- und Wiederherstellungchirurgie, Medizinische Hochschule Hannover, Carl Neubergstrasse 1, 30625 Hannover, Germany

Orentreich and Orentreich [1] and Fernandes [2] independently described “subcision” as a way of building up collagen beneath retracted scars and wrinkles by separating the tethered and depressed surface tissue from the underlying deeper scar tissue. Camirand and Doucet [3] treated scars using a tattoo gun to “needle abrade” them, and although this technique can be used on extensive areas, it is laboriously slow. The holes created in the epidermis by a tattoo gun are generally felt to be too close and too shallow to effect optimal improvement. Severing old, short and vertically oriented collagen strands which tether the bed of the scar to the most superficial layer of the dermis, promotes the removal of damaged collagen, and inducing new collagen formation immediately below the epidermis. Ideally, one would prefer to effect the reticular dermis, stimulating the production of collagen and elastin fibres while avoiding excessive bleeding under the skin and scar. Percutaneous collagen induction by medical needling results from the natural response to wounding the skin. This can be initiated through even minute injuries [4, 5]. A single needle prick created through the skin would generally cause an invisible response. A completely different picture emerges when multiple fine wounds are placed close to each other. Building upon these principles and experiences, a specialized tool was designed by Fernandes [1] employing rows of needles which range in length between 1 and 3  mm to achieve percutaneous collagen induction by medical needling.

Topical Adjuncts Vitamin A, as retinoic acid, is an essential vitamin, actually a hormone, for skin that expresses its influence on approximately 400–1,000 skin cell related genes. Vitamin A is thought to be essential for maintaining the normal physiologic processes of the skin, for preserving collagen content and ensuring quality wound healing. It controls proliferation and differentiation of all the major cells of the epidermis and dermis and is felt to be

H. Hyakusoku et al. (eds.), Color Atlas of Burn Reconstructive Surgery, DOI: 10.1007/978-3-642-05070-1_10, © Springer-Verlag Berlin Heidelberg 2010

Medical Needling

essential for rapid healing of the skin [6, 7]. Vitamin A has been shown to facilitate collagen and glycosaminoglycans production by fibroblasts and appears to control the release of transforming growth factor (TGF) b3 in preference to TGF-b1 and -b2 favouring the development of a lattice-patterned collagen network as opposed to the more visible and contracted appearing-scar pattern of parallel collagen deposition . Retinyl esters are the main form of vitamin A in the skin, and only tiny fractions of vitamin A are found as retinoic acid [8–10]. Fortunately, retinyl esters are easily and rapidly converted into retinoic acid at physiologic doses. As opposed to the retinoic acid formulations, retinyl esters are not considered cellular irritants and as such are generally well tolerated when applied topically. It is for that reason that we have elected to utilize products with high levels of retinyl esters when treating problem scars. Vitamin C is a potent reducing agent and is critical for the formation of normal collagen [11]. It is poorly absorbed through the skin and can be quite irritating when applied topically. Ascorbyl tetraisopalmitate has been shown to be an efficient topical form of vitamin C, easily penetrating the skin and incorporated into skin cells. Once inside the cell, it is de-esterified and becomes bioavailable as ascorbic acid.

Needle Depth When performing 3-mm Roll-Cit needling, needles penetrate 3 mm into the dermis and initiate a complex chemical cascade. Platelets instigate the release of various growth factors e.g. PDGF [12]. Fibroblasts migrate into the micro wound sites, and this surge of activity inevitably leads to the production of more collagen and more elastin . Keratinocytes migrate rapidly across the minute epidermal defects and then proliferate establishing a thickened epidermis. If the 1-mm Roll-Cit device is used for micro needling, the bleeding is microscopic and occurs entirely within the papillary and upper reticular dermis as the needles penetrate only to a depth of approximately 0.75–1 mm. Because the epidermis is, on average, 0.2 mm, one can be certain that the injury will be limited to the upper layers of the dermis. It is hypothesized that micro needling excites a smaller inflammatory response, yet the cascade of growth factors still gets initiated by the release of platelets through the puncturing of small vessels by micro needling. The possibility that with micro needling, one gets a purer stimulus for collagen synthesis without the

CHAPTER 10

heavy inflammatory reaction, exists because subdermal fat is certainly not damaged at the same time. It is believed that because the epidermis remains intact, this might favour predominantly TGF-b3 rather than TGF-b1 and -b2, which are associated with scar collagen deposition. TGF-b3 is implicated in scarless healing and normal lattice weave collagen deposition. Percutaneous collagen induction seems to induce normal lattice weave collagen rather than scar collagen [2]; so, theoretically, TGF-b3 may play an important part in this very early phase [13–15].

Characteristics and Indication of the Method The first step is to topically address deficiencies as well as supply the antioxidant vitamins C and E and vitamin A. Medical-needling is done with a roller that is filled with numerous tiny needles that penetrate the skin by 3 mm. Medical needling uses 3-mm needles to penetrate deeper into the skin, and this does cause bruising and swelling. On the other hand, micro needling uses needles that only penetrate to a maximum of 1 mm, and this causes virtually no bruising and minimal swelling. With micro needling you can return to work the day after the treatment without any signs except some pink skin, as though you have been exposed to the sun. The number of treatments required will depend on how each individual responds to the treatments, and the extent of damage at the beginning (Fig.  10.4). Most patients will begin to see results after the very first appointment (Fig.  10.5). Depending on the degree of improvement that is required a series of needling sessions can be necessary.

Indications for Medical Needling Post-Burn Using the 1-mm Roller 1. As an alternative to dermabrasion for mild to moderate scarring. 2. Scars can be made less obvious by 1-mm needling, and if the scars are depigmented, one can achieve a better colour match with the surrounding skin.

Indications for Medical Needling Post-Burn Using the 3-mm Roller 1. Burn scars (Fig. 10.4)

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74

Medical Needling

Advantages of Medical Needling 1. Percutaneous collagen induction does not ablate the epidermis. 2. Any part of the body may be treated. 3. Skin becomes thicker. 4. The healing phase is short. 5. The skin does not become sun sensitive. 6. Telangiectasias may disappear. 7. Hyperpigmentation has not yet been described.

Disadvantages of Medical Needling

⊡ Fig. 10.1  Medical needling roller

1. Exposure to blood and a sharp instrument. 2. Although we cannot achieve as intense a deposition of collagen as in CO2 laser resurfacing, treatment can be repeated with possibly better results. 3. There is a need for anaesthesia of the skin when doing 3-mm needling. 4. It takes a longer time to see the result than with laser resurfacing. 5. There is unsightly swelling and bruising for the first 4 days when 3-mm needling has been done. 6. At present no keloids have been described after medical needling, but caution should be taken in patients prone to keloid formation.

Specific Skills of the Method 1. The scarred skin is evaluated and photographs should be taken pre-treatment. 2. The skin is prepared with topical vitamins A and C and antioxidants for at least 3 weeks, but preferably for 3 months. 3. Under topical, local or general anaesthesia, the skin is closely punctured with the special medical needling tool (Fig.  10.1), consisting of a rolling barrel with needles at regular intervals. It comes in a sterile plastic container and is mounted on a handle at the time of use. Two different needle lengths are available, that is, 1 and 3  mm. By rolling backward and forward with some pressure in various directions, one can achieve an even distribution of the holes (Fig. 10.2). The needles penetrate through the epidermis but do not ablate it, and because the epidermis is only punctured, it will heal rapidly. The skin bleeds for a short while and develops multiple microbruises in the dermis. We use wet gauze swabs to soak up any ooze of serum

⊡ Fig. 10.2  Medical needling performed with a 3-mm roller on a post-burn scar

when 3-mm needles have been used. Once the serous ooze has stopped, the skin is washed thoroughly and then covered with a special vitamin A, C, and E oil. If the skin has been needled with the 1-mm roller, the bleeding under the skin is microscopic, and one does not get serious ooze post-operatively. If 1-mm needling has been done, the patient will only experience a flushed appearance of the skin and will not develop bruises or swelling. 4. If 3-mm needling has been done, the patient should be instructed that he/she will look bruised and ­become quite swollen (Fig.  10.3). The patient is ­encouraged to shower within a few hours of the procedure, and that by day 4–5, the skin will develop a moderate pink flush that can be concealed with makeup. Some residual bruising may still be present at this time.

Medical Needling

CHAPTER 10

⊡ Fig. 10.5  Three months after 3-mm medical needling of the same area. The patient was very satisfied with the outcome

⊡ Fig. 10.3  View of the skin immediately after medical needling with a 3-mm roller; notice bruised appearance

⊡ Fig. 10.4  Post-burn scarring after partial thickness burn to the lower face

5. Post-treatment, the patient is encouraged to use topical vitamin A and vitamin C cream or oils to promote better healing and greater production of collagen. The addition of peptides such as palmitoyl pentapeptide could possibly ensure even better results. Iontophoresis also tends to reduce the swelling of the skin. Low-frequency sonophoresis can be used to enhance penetration of palmitoyl pentapeptide or other peptides.

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C H A P T E R 11

Treatments for Post-Burn Hypertrophic Scars rei ogawa, satoshi akaishi, and kouji kinoshita

Treatment Strategy of Post-Burn Hypertrophic Scars

Partial/Complete Surgical Contracture Releasing (Fig. 11.1 (A))

Hypertrophic scars (HSs) occur within weeks after burns, rapidly increase in size for 3–6 months, and then, after a static phase, begin to regress. The full maturation process may take up to 2–5 years. In the treatment of post-burn HSs, indication of treatment methods should be decided based on whether scar contracture is associated with HSs (Figs. 11.1 and 11.2) [1], because, surgery should be selected for HSs cases with scar contracture, to avoid functional dysfunction. Releasing scar contractures improves joint function, and even if it is partial releasing of contractures, it accelerates maturation of surrounding immature scars and HSs (Fig. 11.1 (A)). However, small and linear HSs with mild scar contractures can be treated with complete surgical resection radically (Fig. 11.1 (B)) or with non-surgical multi-modal therapy (Fig.  11.1 (C)). Intractable recurring HSs can be treated according to the algorithms of keloid treatment [1], among which the combination of surgery and adjuvant therapy (e.g. radiation or corticosteroid injection) is the treatment of choice (Fig. 11.1 (D)). After these treatments, longterm follow-up and conservative therapies are needed for complete functional and cosmetic recovery (Figs. 11.1 (E)).

For type 1 and 2a cases of HSs (Figs. 11.1 and 11.2), partial release of scar contractures (sometimes can be treated radically by complete resection of contractures) should be considered. Flaps are more effective than skin grafting from the aspect of the prevention of re-contracture. Even if it is a partial contracture-releasing and a small-resection of scars, transferred flap (interposed flap between scars) can be expanded gradually, and that accelerates maturation of surrounding immature scars and HSs (Fig. 11.3; Case 1). Skin grafting is also useful for the total replacement of scars on contour sensitive areas such as the dorsal hand (Fig. 11.4; Case 2).

Complete Surgical Resection (Fig. 11.1 (B)) Small or linear HSs with mild contracture (Fig.  11.1; type 2b) can be treated with complete surgical resection. At that time, a type of tension-releasing technique, which includes as z-plasty, w-plasty and small wave incision, should be applied to prevent recurrence of HSs.

Non-Surgical Multi-Modal Therapy (Fig. 11.1 (C))

R. Ogawa, MD, PhD (*) Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School Hospital, Tokyo, Japan e-mail: [email protected] S. Akaishi, MD, PhD Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School Hospital, Tokyo, Japan K. Kinoshita, MD Department of Plastic and Reconstructive Surgery, School of Medicine, Fukuoka University, Fukuoka, Japan

HSs without scar contractures (Fig. 11.1; type 3) naturally improve during the process of scar maturation; thus non-surgical therapy should be tried. Various kinds of non-surgical therapies can accelerate the maturation process and improve subjective symptoms, which include irritation, pain, and itch, as well as objective symptoms, which include redness and scar elevation; thus, multiple non-surgical therapies should be employed to their full extent, but non-invasive therapies, which include compression therapy and gel sheeting (Fig. 11.5; Case 3), should be prioritized (Fig. 11.1 (C)).

H. Hyakusoku et al. (eds.), Color Atlas of Burn Reconstructive Surgery, DOI: 10.1007/978-3-642-05070-1_11, © Springer-Verlag Berlin Heidelberg 2010

Treatments for Post-Burn Hypertrophic Scars

CHAPTER 11

77

Post-Burn Hypertrophic Scars (HSs)

(Type 1) HSs With severe scar contractures

(Type 2)

(Type 3)

HSs With mild scar contractures

HSs Without scar contractures

(Type 2a)

(Type 2b)

Large /Wide HSs

(A) partial / complete surgical contracture releasing

Small / Linear HSs

(B)

(C)

Complete surgical resection

Non-surgical multimodal therapy

a. Skin grafting

a. Compression therapy

b. Flap transfer

b. Gel sheest

Recurrencce

Effective

c. Corticosteroid injection Satisfactory improvement

d. Laser

Unsatisfactory results

(D)

Repeat

(C)

Non-surgical multimodal therapy

e. External agents

Surgery + adjuvant therapy

f. Internal agents g. Make-up / camouflage therapy

a. Surgery + radiation b. Surgery + corticosteroid injection

h. Others

(E) Long-term follow-up + conservative therapices

Effective

Recurrence

Satisfactory improvement

Unsatisfactory results

a. Gel sheets b. Taping fixation c. Compression therapy d. External agents e. Internal agents

(C)

Repeat

Non-surgical multimodal therapy

f. Make-up / camouflage therapy

⊡ Fig. 11.1  Algorithm of post-burn hypertrophic scars (HSs)

Compression therapy has been widely studied [2, 3], but the number of high level studies is still small. Further analysis of the mechanisms of acceleration of scar maturation is needed, but the application of appropriate pressure on HSs should be considered.

however, it seems that there are “resting and fixation effects” that protect wounds from extraneous stimulus, and “tensile reduction effect” [5]. There are some reports that the materials of gel sheets may not be vital (Fig. 11.5; Case 3: a case treated by polyethylene gel sheets) and that, instead, education of patients may be the most important factor in the treatment of HSs with gel sheets [6].

Gel Sheeting

Corticosteroid Injection

According to a recent meta analysis [4], there is weak evidence of benefit in using silicon gel sheeting;

The effect of corticosteroid injection is rapid, but injections must be limited to small areas, because of severe

Compression Therapy

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⊡ Fig. 11.2  Types of post-burn HSs. Type 1: contractured areas are large, so partial contracture releasing should be considered. Type 2a: contractures are not so severe, but a part of scars caused contractures, and that results in dysfunction; thus partial con-

Treatments for Post-Burn Hypertrophic Scars

tracture releasing should be considered. Type 2b: contractures are mild, and entire scars can be resected radically, or non-surgical therapy can be used. Type 3: there are no contractures, and non-surgical multi-modal therapy should be used

Treatments for Post-Burn Hypertrophic Scars

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79

b

a

⊡ Fig.  11.3  (a) Six months after burn injury. (b) Postoperative view. (c) Six months after contracture releasing. A 39-year-old male suffered from extensive burn in the lower extremities. Motion of sitting was painful according to the contracture associated with HSs on the left thigh. A 11 × 3 cm of small local flap was interposed on the upper region of the

a

b

d

c

scars and 5 × 2 cm of another local flap was also interposed in the lower region. Three months after the operation, flap widths were clearly expanded to 5  cm (167%) and 3.5  cm (175%), respectively. Moreover, redness and elevation of surrounding HSs were reduced significantly

c

e

⊡ Fig. 11.4  (a) Two years after burn. (b) Total scar resection. (c) Sheets of skin graft were transplanted from the right inguinal region. (d) Taping and bandage fixation. (e) One year after the operation. A 56-year-old female suffered from post-burn HSs with mild contracture on the hand. Total

removal of scars and skin grafting were performed. A sheet of skin grafting was used and small drainage holes were made on the grafts using “Kenzan”, a Japanese flower holder. Taping and bandage fixation were performed and the post-operative course was uneventful

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Treatments for Post-Burn Hypertrophic Scars

a

b

c

d

e

f

g

h

⊡ Fig.  11.5  (a) One week before starting polyethylene gel sheeting. (b) Post 1 month. (d) Post 2 months. (e) Post 3 months. (f) Post 1 year. (g) Post 18 months. (h) Post 28 months. A 1-year-old female suffered from scald burn on her chest. It was a superficial dermal burn (SDB) and a deep dermal burn

a

(DDB), which were epithelialized after 5 weeks of conservative treatments. Polyethylene gel sheeting has been applied since then. It was effective to protect the scars from extraneous stimuli, and the maturation course was uneventful. Anterior chest contracture was not observed after the treatment

c

b

⊡ Fig.  11.6  (a) Six months after burn. (b) One year after treatment. (c) Two years after treatment. Post-burn HSs on the right thigh of a 39-year-old male. Those with a diameter of 15 cm and were treated by Nd: YAG laser with non-contact mode every 3–4 weeks from 9 to 13 month. The laser swung

from right to left about 2 or 3 cm above the scars with a spot size diameter of 5 mm, an energy density of 14 J/cm2, an exposure time per pulse of 0.3 ms, and a repetition rate of 10 Hz, 500–1,000 pulses/cm2. After 13 months, the scars were treated every 3–4 months. Elevation and redness were improved

pain associated with their injection, and the local side effects that include thinning and atrophy of the skin, and subcutaneous tissues, steroid acne, capillary dilatation, hypopigmentation will be a problem. These complications sometimes hamper combination treatments; thus, careful planning with patients is necessary.

Laser Pulsed dye laser (PDL) [7,8] or Nd: YAG laser (Fig. 11.6; Case 4: a case treated by Nd: YAG laser) are suggested as effective for the treatment of post-burn HSs. However, laser alone may not be the ideal method to treat HSs, but

Treatments for Post-Burn Hypertrophic Scars

it may provide significant benefits when used as part of a multi-modal therapy. For example, it is beneficial to use laser before injecting steroids.

CHAPTER 11

to a reduction in symptoms of HSs. Anti-inflammatory drugs and anti-allergic drugs can be used for strong subjective symptoms.

Make-Up Therapy/Camouflage Therapy External Agents Corticosteroid ointments, tape, and non-steroidal antiinflammatory drugs (NSAIDs) are effective in reducing symptoms. Moreover, onion extract gels and mugwort lotion [9] have also been suggested for the treatment of scars, but large-scale RCT studies are required to confirm their beneficial effects.

Internal Agents The oral administration of the anti-allergic drug tranilast [10] has been used to treat HSs, and it reportedly led

Make-up therapy or camouflage therapy [11] should also be considered in the management of psychological stress of patients, as these therapies improve not only the cosmetic appearance of scars but also reportedly promote physiological changes; however, this contention warrants scientific confirmation.

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Make-Up Therapy for Burn Scar Patients ritsu aoki and reiko kazki

Background The advances in the burn medicine have brought an increase in the survival rate of extensive burn patients. However, unfortunately, the increase in survival from severe burn is not directly connected with the happiness of the patients. According to our data, only 25% of the patients whose BSA was more than 30% could recover their original position after the discharge from plastic surgical ward [1]. Most of them had to live on social welfare because they could not obtain jobs due to their appearance. Plastic and reconstructive surgery could help mainly functionally. For those who had injured extensively, as the donor site for skin grafting or flaps were very limited, the aesthetic results were not satisfactory. So we introduced the make-up therapy combined with plastic and reconstructive surgical treatments. The history of make-up therapy for the camouflage of the scar can be traced back to 1940s. The British redcross nurses started to hide the scars of the soldiers who were injured in the World War II [2]. They have proved that even nonmedical procedures such as make-up could ease the pain of the patients. Recently, camouflage makeup is recognized as a good method of scar management and is utilized and researched widely [3, 4].We have been utilizing the make-up therapy combined with plastic surgical services since 2000 to find that this method is pretty effective for the improvement of the quality of life of the patients, especially those with extensive burn scars [5]. However, when we give make-up therapy, we always have to remember the patients’ favor and their social or cultural background. They may not become happier or even become less happy when unfavorable make-up is R. Aoki, MD (*) Nippon Medical School, Greenwood Skin Clinic Tachikawa, Tokyo, Japan e-mail: [email protected] R. Kazki, MD Nippon Medical School, Reiko Kazki co ltd, Tokyo, Japan

applied. Improving their figure is more difficult than functional improvement. Since 2000, we have treated more than 350 patients with make-up therapy.

The Method of the Make-Up Massage Patients of burn scars may sometimes have edemas. Even if not so, facial massage is effective for the improvement of skin texture and color. Massage should start with lower eyelid laterally to medially (Fig.  12.1). Then upper eyelid massage in the opposite direction should be followed. Next sides of the face are massaged from top down. This massage is performed consecutively with a sponge moistened by squalan oil or face lotion.

Foundation The choice of foundation should be made considering the patient’s skin condition, age, social status, and patient’s make-up ability. There are various types of cosmetic foundations, such as lotion type, cream type, hard type, mixing type, and covering type. The cosmetic foundation is made in three layers: total face basement, total face upper, and local top (scar part). If the patients require quick make-up, lotion type would be selected as the basement. If there is unevenness of color, yellow foundation of hard type or covering type foundation should be selected. The yellow color is good for erasing the erythema (redness) due to burn scar. For total face upper foundation, hard type and cream type foundation are used for standard patients. If patients require light cosmetic, cream type and mixing type should be chosen, and if strong coverage is required, cream type or mixing type and covering foundation should be used. If there are some scars which need to be

H. Hyakusoku et al. (eds.), Color Atlas of Burn Reconstructive Surgery, DOI: 10.1007/978-3-642-05070-1_12, © Springer-Verlag Berlin Heidelberg 2010

Make-Up Therapy for Burn Scar Patients

CHAPTER 12

covered more, covering foundation is used partially in some cases.

Make-Up When the scar is covered by foundation, the scar becomes less visible; however, the appearance of surrounding areas is also important for patients’ satisfaction. Shaving and drawing eyebrows, eye make-up, cheek make-up, and other make-up procedures are made. At first, our make-up therapists explain the application of make-up, but the goal of make-up therapy is for the patient to independently apply make-up. Therefore, we have to consider whether the patient can apply make-up by herself if she has injured her hands. In such a case, glasses, a hat, or a scarf can help to cover the scar.

⊡ Fig. 12.1  Massage should be performed before make-up. It starts from lower eyelid to upper eyelid drawing a clockwise circle, then from temple to check

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Clinical Cases + Case 1

12

A 55-year-old female who had attempted suicide had extensive burn on her face, upper arms, and trunk. She underwent operations more than 10 times including the total nasal reconstruction with a distant flap. As her eyebrows were burnt out, only drawing eyebrows in a good shape helped her to change her impression. Also making up her eyelids can make her eyes look larger.

Make-Up Therapy for Burn Scar Patients

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Make-Up Therapy for Burn Scar Patients

+ Case 2 A 52-year-old female was found with 55% BSA. Her mentum was reconstructed with a free flap of which the skin, color, and texture are far different from the surrounding skin. Even after make-up, the shape of her chin could not be changed, and so a scarf was used to cover it. After make-up therapy, she was able to go outside to shop by herself which she had not been able to do.

12

Make-Up Therapy for Burn Scar Patients

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88

Meaning of Make-Up Therapy The application of make-up to cover the scar does not simply mean the treatment of the patients’ injured mind, because make-up is not the method to erase the scars completely. Once the patient removes the make-up, the scar appears again. Therefore, the better the scar can be hidden, the more the patient becomes uneasy when it is removed. When the patient decides to marry or begin a job, he or she distresses over when to confess that he or she has a scar. The important thing in doing make-up therapy is not to cover and hide the scar completely, but to encourage the patients to mix with society. Most of the patients wonder whether their scar may make others uncomfortable. If the scars become less visible, it would not annoy the patients as well as the neighbors. For that purpose, Ms. Kazki who is in charge of our make-up clinic, named her method of make-up as “Rehabilitation Make-up” which emphasizes the improvement of the patients’ quality of life [5]. In rehabilitation make-up, the patients are always made-up not only on the scar, but the whole face, because the key is not only to diminish the scar, but also to make the patient more beautiful. The rehabilitation make-up always starts with facial massage to accelerate the venous return which results in the deflation of the face and the improvement of facial skin color. This step also makes it easier to apply foundation

Make-Up Therapy for Burn Scar Patients

powder evenly to the scar, which is too smooth for normal foundation powder to stay on. Shaving and drawing eye brows are also important for the change of the impression of the patient. According to the survey of patients who had self-injured scars on their forearms, even though they don’t have any scarring on the face, if make-up is performed on their face at the same time as the make-ups over the arm scars, their scores assessed by the satisfaction of their appearance by VAS (visual analog scale) improves significantly [6]. The benefits of make-up therapy are 1. Noninvasive. Even those who are suffering from internal organ dysfunction or disorder can have this therapy. 2. Reasonable cost. No special equipment or material is required. Only standard cosmetics are necessary. No specific license is essential even though the staff should be trained in make-up therapy. 3. Reversible. If the patient doesn’t like the appearance after make-up therapy, the patient can wash the face to recover. Accordingly, make-up therapy is a good option for the treatment of burn scars, especially for the patients who almost finish the surgical operations. Make-up therapy is not an enemy of medical profession, and can benefit both the patient and the medical staff.

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C H A P T E R 13

Dermal Substitutes luc téot, sami otman, and pascal granier

Background of the Technique Dermal substitutes have been developed during recent decades. Integra, a substitute for dermis, was initially developed by Burke and Yannas. This device is derived from bovine collagen and contains glycosaminoglycannes. Safety issues (prions) have been solved. The device was initially proposed for burns coverage, and although randomized studies have determined the efficacy of the technique, no statistical difference has been observed in terms of scar characteristics of the obtained skin tissue. Alternative collagen or noncollagen products of different thicknesses were more recently developed, with or without silicone covering films. These products can be derived from porcine, bovine, or human origin. We may now divide dermal substitutes into two categories, double layer DS and single layer DS.

Double Layer Dermal Substitutes Integra is composed of bovine collagen and glycosaminiglycannes. Initially indicated in acute burns for scar pliability improvement, this DS has demonstrated its capacities to be used over extensive burns after a sharp early excision. In a pivotal study on burns, Heimbach et al. showed the interest of using Integra to restore skin suppleness and prevent skin graft adherence to the depth of the exposed structures. Other authors, using Integra in reconstructive surgery, concluded that the product could be used in traumas, skin excision after skin cancer removal, and other types of L. Téot, MD, PhD (*) Burns and Plastic Surgery Unit, Montpellier University Hospital, France e-mail: [email protected] S. Otman, MD and P. Granier, MD Burns and Plastic Surgery Unit, Montpellier University Hospital, France

skin replacement. The product seems particularly indicated over exposed tendons or bones in thin skin reconstruction, for example, in hand and feet skin reconstruction. Integra may be used as originally described, with a period of revascularization and neoangiogenesis lasting 3 weeks. After this period, the silicone film is removed, and a thin skin graft is applied over the collagen. It is also possible to reduce the length of revascularization by applying negative pressure therapy over the silicone layer, thereby saving a week. When using VAC™, a skin graft can be applied after a period of 10 days (Jeschko). Rehabilitation should start early in order to prevent skin adherences, especially when applied over mobile structures. Transient inflammation and redness of the skin can be observed for a period of 1 year. Renoskin™ is a double layer DS, with the same composition as Integra. This product is indicated in acute burns (Braye). Pelnac™ is comparable to the previously described DS, presenting a capacity of dermal regeneration within a period of 3 weeks (Akita). Hyalomatrix 3D™ is based on the principle of bringing hyaluraonic acid inside the neodermis. Clinical series describing good results were recently proposed, especially in acute burns. The product allows an intense and rapid granulation tissue formation and needs a secondary skin graft (Scalise). Matriderm™ thick layer has been recently proposed by Middlekoop et al. (Van Zuijlen). The promotion of angiogenesis in the DS, using Negative Pressure Therapy in conjunction with the application of DS, has been proposed (Jeschke et al.). When negative pressure is permanently applied over the dermal substitute, this significantly shortens the delay before it is possible to apply a skin graft. Within a period of 10 days, the collagen can be revascularized. A decrease in the infection rate has also been observed, certainly due to the isolation of the treated area from external contamination. VAC therapy is applied with moderate negative pressure (50 mmHg) in order not to harm the collagen matrix.

H. Hyakusoku et al. (eds.), Color Atlas of Burn Reconstructive Surgery, DOI: 10.1007/978-3-642-05070-1_13, © Springer-Verlag Berlin Heidelberg 2010

Dermal Substitutes

Single Layer Dermal Substitutes A new generation of DS has recently been proposed. Some of them are based on the same collagen composition, while others present different properties. Reduction in the thickness of these DS and the absence of a covering silicone layer make them possible to perform an immediate skin graft during the same surgical procedure. Matriderm™ is composed of collagen mixed with elastin fibers. This product has been proposed as a single layer matrix in burns and reconstructive surgery. The product presents interesting capacities of hemostasis. Elasticity of the structure helps when the device is applied over irregular surfaces. The product is more suited to extensive well-vascularized structures, particularly over the face or the skull. Integra™ thin layer is identical in structure to Integra, without a silicone film covering. The product is under clinical evaluation.

CHAPTER 13

Alloderm™, Strattice, and Permaform are derived from porcine dermis. These products may be used as solid thick structures. Their capacity of being penetrated by vessels is lower than the previous ones. Used in dura matrix replacement, they can be proposed as fixation devices for abdominal wall reconstruction or internal brass in mammary ptosis or after reduction. Gliaderm™ has recently been proposed by the Dutch skin bank. Clinical indications include burns coverage and trauma. The device is immediately covered using skin grafts during the same surgical procedure or some days after. Gammagraft™ has been proposed and used in Germany. The combination to NPT is also possible, in order to reduce the length of take of the compound skin graftdermal substitute.

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Dermal Substitutes

Clinical Cases + Case 1

13

A 12-year-old boy sustained flame burns over about 36% of TBSA. He was intubated and maintained under artificial respiration for rescusitation needs (a–c). After stabilizing his general condition, his face and hands were operated on. A tangential excision was performed, followed by an immediate application of Matriderm™ and then a thin split skin graft. The result was good as per healing was concerned, as the epidermis was stable after 5–7 days. A transient hyperchromic pigmentation and a retraction in the fingers were noted as minor complications. The situation of both hands and the color of the face improved after 6 months (d). No retraction was noted at this time.

Dermal Substitutes

a

c

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b

d

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Dermal Substitutes

+ Case 2

13

A 14-year-old boy presented with large scar areas over the neck and the lower part of the face after extensive burns sustained at a young age (a). He was operated on for scar correction. After removal of scar contractures, a skin defect (60 cm long 45 cm wide) was immediately covered using Integra double layer (b). The revascularization process took 3 weeks. The silicone film was then removed and the area covered using a split-thickness skin graft harvested on the skull. Results were good, with no seroma or hematoma observed, and no infection. Rehabilitation could be started after 3 weeks (c).

Dermal Substitutes

a

c

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b

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Dermal Substitutes

+ Case 3 A depressed 40-year-old, was severely burnt by the autoprojection of boiling liquid (oil). She was deeply burnt over 10% of TBSA, mainly on the head, neck, and over both hands. She was intubated and artificially ventilated.

13

Several days later, a pan facial excision was achieved. As the cranial cortical bone was involved, an excision of the outer portion of the bone was carried out, exposing an area 30  cm long and 25  cm wide. A dermal substitute (Matriderm™) was applied over the whole defect, and immediately covered using a split skin graft. The skull was used as donor site area (a–c). Final results concerning healing, color, smoothness, hand and digit mobility, facial expressions, and periorificial muscles functions were good (d).

Dermal Substitutes

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a

b

c

d

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98

Discussion Dermal substitutes, used as temporary or permanent devices, have been developed over the previous decade. Their use is in rapid progression in reconstructive surgery, some of them replacing flaps when contraindicated or when not possible, especially in extensive burns. The purpose of the use of these techniques is to improve the quality of scar and increase suppleness of the final coverage by increasing elasticity of the dermal part of the skin. The use of negative pressure therapy contemporary to the postoperative period, which is limited in time and in level of pressure (50 mmHg for 5 days), has been used in some cases. This technique may decrease the rate of postoperative infections. The use of dermal substitutes looks better than using a simple skin graft, especially when applied over a bone structure. Adherence to the depth is minimized when

Dermal Substitutes

compared to split skin grafts applied over the same anatomical area. Functional results of Matriderm™ can be considered as good. The skin may transitorily be hyperchromic, especially in acute burns, a return to a normal color having been observed in one patient after a period of 8 months. Scar retractions were not observed in this series. The tendency of the scar to hypertrophy after Matriderm™ was only noted once on a facial scar reconstruction. Limiting the number of surgical procedures has to be evaluated in terms of cost efficacy, but reducing the number of anesthetics can also be considered a positive aspect of the use of single layer dermal substitutes that are immediately covered with a split skin graft. This has to be compared with the two-step procedures necessary until now in the use of dermal substitutes like Integra.

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C H A P T E R 14

Acellular Allogeneic Dermal Matrix yoshihiro takami, shinpei ono, and rei ogawa

Available donor skin is so limited in extensive burns that thin meshed split-thickness skin grafts (STSG) or cultured epidermal autografts are commonly used to close the wounds. However, a lack of sufficient dermal beds results in poor cosmetic appearance with thin meshed STSG and poor graft survival with cultured epidermal autografts. In order to resolve these problems, a number of dermal substitutes have been produced. Among them, acellular allogeneic dermal matrix (ADM), which is produced by decellularizing allogeneic cadaver skin, has physiological properties closest to those of normal human dermis [1, 2]. We attempted to use ADM for two different purposes in burn surgery. One is simultaneous skin graft overlay with ADM transplantation on excised full-thickness burn wounds [3]. The other is the use of an ADM as a scaffold of a tissue-engineered autologous skin equivalent (TESE) [4, 5].

3 h at 37°C to remove the epidermal cells and then washed in a mixed solution of 0.25% tritonX-100 and 0.125% trypsin to remove all the cellular components of the dermis for 4 h at 37°C. The decellularized dermis (trypsintreated ADM) was stored at 4°C. These procedures remove the basement membrane structure from the skin. The other method was to create an ADM suitable for tissue-engineered skin equivalents. Pieces of split-thickness skin from the same source above were incubated with 1 M sodium chloride at 37°C for 12 h to separate the epidermis from the dermis. Then, the separated dermis was incubated in PBS with continuous agitation at room temperature for 7–10 days to remove all the cellular components, and then stored at 4°C. The decellularized dermis (sodium chloride-treated ADM) with this method retains intact basement membrane structure. All procedures for the preparation and clinical application of ADMs were performed under the approval of the ethics committee of Kyorin University, Tokyo, Japan.

Preparation of Acellular Allogeneic Dermal Matrix (ADM)

ADM Transplantation with Simultaneous Skin Graft Overlay

Introduction

ADM (Fig. 14.1) was prepared by the following two methods. The first method was to create an ADM suitable for simultaneous skin graft overlay. Pieces of split-thickness (0.015 inch-thick) cryopreserved cadaver skin obtained from the official skin bank of Japan were rapidly thawed at 37°C in phosphate-buffered saline (PBS). The skin was treated with 0.25% of trypsin/1 mM EDTA solution for Y. Takami, MD, PhD (*) Plastic Surgery, Seibu General Hospital, Saitama, Japan Burn Center, Kyorin University Hospital, Tokyo, Japan e-mail: [email protected] S. Ono, MD, PhD Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School Hospital, Tokyo, Japan R. Ogawa, MD, PhD Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School Hospital, Tokyo, Japan e-mail: [email protected]

Clinical Results Trypsin-treated ADMs were used for the following clinical application. ADM was transplanted on excised full-thickness burn wounds with simultaneous STSG overlay (six wounds of five cases). All the transplanted ADMs and the overlaid thin (less than 0.010 inch-thick) STSGs (three meshed STSGs: and three sheet grafts) survived completely. The interstitial scar formation of overlaid meshed STSG was inhibited by ADM transplantation (Fig. 14.2). Histologically, the transplanted ADM was fully vascularized and remained as a stable dermal matrix in the wound (Fig. 14.3).

Discussion and Conclusion Dermal component was added and regenerated by ADM transplantation in full-thickness burn wounds. It is

H. Hyakusoku et al. (eds.), Color Atlas of Burn Reconstructive Surgery, DOI: 10.1007/978-3-642-05070-1_14, © Springer-Verlag Berlin Heidelberg 2010

Acellular Allogeneic Dermal Matrix

a

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b

⊡ Fig.  14.1  Histological appearance of acellular allogeneic dermal matrix (ADM). (a) Cryopreserved allogeneic skin. (b) ADM after decellularization of the allogeneic skin. H&E, original magnification, ×40

suggested that ADM transplantation may be a useful method to improve the conspicuous scar after thin meshed STSG in beep burn wounds.

Tissue-Engineered Autologous Skin Equivalent (TESE) Based on ADM as the Scaffold Preparation of TESE (Figs. 14.4 and 14.5) Sodium chloride-treated ADMs were used for the scaffolds of TESE. To prepare autologous keratinocytes, small samples of healthy skin (about 2 cm2) were obtained from four patients with extensive burns. The epidermis and dermis were separated by incubation with Dispase (Godo Shusei Co. Ltd., Tokyo, Japan) for 3 h at 37°C. The epidermis was treated with 0.25% trypsin/1 mM EDTA for 15  min at 37°C to disaggregate keratinocytes. The keratinocytes were collected, centrifuged, and resuspended in a keratinocyte growth medium (KGM; defined Keratinocyte-SFM, Gibco). The separated dermis was

cut into small pieces and placed in culture dishes to produce a culture of dermal fibroblasts. After the pieces of dermis had become attached to the culture dishes, 10% fetal calf serum (FCS)/Dulbecco’s modified Eagle’s medium was added to the dishes, which were then incubated at 37°C in 5% CO2/air. To create the TESE, the subcultivated autologous fibroblasts were seeded on the reticular side of the ADM with 2% FCS and KGM. Two days later, subcultivated keratinocytes were seeded on the basement-membrane side of the ADM. After 2 or 3 days of culture, the medium was changed to 10% FCS/KGM to induce keratinocyte differentiation. After an additional day of culture, the cultured TASE was transferred to an air–liquid interface to promote stratification. The resulting TESEs were washed thoroughly with Hanks balanced salt solution, then transplanted to patients. The average time required to create a TESE from the biopsied skin was 21 days. Histologically, TESE showed a well-developed epidermal layer, rete ridges, and normal dermal structures (Fig. 14.5c).

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102

a

b

Acellular Allogeneic Dermal Matrix

c

e

⊡ Fig. 14.2  Appearance of ADM transplantation with simultaneous meshed split-thickness skin grafts (STSG) overlay. Case: a 38-year-old, female. A deep burn wound of the right thigh was excised. Wound before ADM transplantation (a) and the transplanted ADM with meshed STSG overlay (b). On the area below the black line, 5 × 7 cm of an ADM was placed and overlaid with

a 0.008 inch-thick, meshed STSG (c–e). On the area above the black line, only meshed STSG was placed. (c) Appearance at 7 days after the transplantation. (d) Appearance at 14 days after the transplantation. (e) Appearance at 21 days after the transplantation. The meshed scar formation was inhibited in the area with ADM transplantation (below the line)

Clinical Application

third-degree burn wound of the right thigh (Fig. 14.8). Case 4 was a 63-year-old man with second and thirddegree burns to 60% of the body surface. Seven sheets of TESE (four sheets of 5 × 5  cm-sized TESE and three smaller sized TESEs) were transplanted to the excised third-degree burn wound of the abdomen (Fig. 14.9).

Case 1 was a 29-year-old woman with second and thirddegree burns to 75% of the body surface. One sheet of TESE (5 × 2.5 cm) was transplanted to the excised thirddegree burn wound of the right thigh (Fig. 14.6). Case 2 was a 41-year-old woman with second and third-degree burns to 98% of the body surface. Four sheets of TESE (mean size: 5 × 5  cm) were transplanted to the excised third-degree burn wound of the abdomen (Fig.  14.7). Case 3 was a 36-year-old woman with third-degree burns to 46% of the body surface. Four sheets of TESE (mean size: 5 × 5  cm) were transplanted to the excised

Clinical Results (Figs. 14.6–14.9) Graft survival was evaluated 14 days after transplantation. The survival rate was 100% for case 1, 96% for case 2, 93% for case 3, and 90% for case 4. By 28 days after

Acellular Allogeneic Dermal Matrix

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103

⊡ Fig.  14.4  Appearance of tissue-engineered autologous skin equivalent (TESE). A 5 × 5-cm-sized TESE in a Petridish is ready for the clinical transplantation

⊡ Fig.  14.3  Histology of transplanted ADM and overlaid STSG, 14 days after the transplantation. H&E, original magnification, ×40. S indicates area of the STSG. A indicates the area of transplanted ADM

a

b

⊡ Fig. 14.5  Production of TESE. (a) Cryopreserved allogeneic skin. (b) ADM after decellularization of the allogeneic skin. (c) Produced TESE. Keratinocytes and fibroblasts from

c

­ iopsied patient’s skin were seeded and cultivated in the b ADM. H&E, original magnification, ×40

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Acellular Allogeneic Dermal Matrix

a

b

c

d

⊡ Fig. 14.6  Appearance of transplanted TESE. Case 1, a 29-year-old, female, right thigh. Wound before TESE transplantation (a), the transplanted TESE (5 × 2.5 cm) (b), 7 days after (c), and 42 days after (d). The TASE survived completely

a

b

c

⊡ Fig.  14.7  Appearance of transplanted TESE. Case 2, a 41-year-old, female, abdomen. Wound before TESE transplantation (a), the transplanted TESE (four sheets of TESEs,

mean size: 5 × 5 cm) (b), and 42 days after (c). The TASE survived well. Arrow indicates an ulcer due to biopsy for the histological examination

Acellular Allogeneic Dermal Matrix

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a

b

c

d

⊡ Fig.  14.8  Appearance of transplanted TESE. Case 3, a 36-year-old, female, right thigh. Wound before TESE transplantation (a), the transplanted TESE (four sheets of TESEs,

mean size: 5 × 5 cm) (b), 14 days after (c), and 9 months after (d). The TASE survived well

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Acellular Allogeneic Dermal Matrix

a

b

c

d

⊡ Fig.  14.9  Appearance of transplanted TESE. Case 4, a 63-year-old, male, abdomen. Wound before TESE transplantation (a), the transplanted TESE (four sheets of 5 × 5 cm-sized TESEs and three smaller sized TESEs) (b), 14 days after (c),

and 60 days after (d). Partial graft loss due to bacterial infection was observed, but the wound was healed with additional TASE transplantation

surgery, the areas to which TESEs had been transplanted had become completely epithelialized. There was no delayed graft loss, or graft fragility during the observation period (42–270 days). Abnormal pigmentation on the transplanted site was seen in all cases. Only case 4 suffered partial graft loss due to bacterial infection, but the wound was healed with additional TESE transplantation. Cases 1 and 2 died of multiple organ failure some 50 days after TESE transplantation. However, no evidence suggests that transplantation contributed to their deaths. Cases 3 and 4 were discharged to go home.

and epidermal structure with positive staining of antitype IV collagen (Figs. 14.10a and 14.11b). Transplanted ADM as the scaffold of TESE remained as a stable dermal matrix in the regenerated skin (Fig. 14.10b).

Histological Examination (Case 1) The TESE had become keratinized with a fully stratified epidermis and normal polarity of differentiation (Fig. 14.10a). The epidermis was firmly attached to the remaining basement membrane of the ADM (Fig. 14.11a). Transplanted TESE showed stable dermal

Discussion and Conclusion Although several types of ADM-based cultured skin have been introduced previously, results of the clinical trials have been far from satisfactory [6, 7]. In order to improve the clinical results, we have prepared ADMs without protease, surfactants, and further sterilizing procedures, which have been commonly used to prepare ADMs [6, 7]. It is suggested that our method of ADMpreparation retained more natural dermal structures, and thus, improved the property of ADMs as a scaffold of a tissue-engineered skin [4, 5]. We have concluded that TESEs based on ADM as a scaffold may be a useful tool for permanent repair of full-thickness burn wounds.

Acellular Allogeneic Dermal Matrix

a

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b

⊡ Fig. 14.10  Histological appearance of TESE (case 1). Before transplantation (a), and 42 days after the transplantation (b). Arrow indicates the part of acellular ADM. H&E, original magnification, ×40

a

b

⊡ Fig. 14.11  Immunohistochemical staining of anti-type IV collagen to TESE (case 1). Before transplantation (a), and 42 days after the transplantation (b). Original magnification, ×100

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Application of Integra® in Pediatric Burns paul m. glat, john f. hsu, wade kubat, and anahita azharian

Background Treatment of burn wounds has always proved challenging in the pediatric population. When treating large surface area or complex burn wounds, pediatric patients frequently have limited area of graft donor sites [1]. Infants often have skin too thin to be harvested for skin grafting and to provide adequate coverage for reconstruction. Burn scars repeatedly become hypertrophic and are hard to treat. When they are treated successfully, recurrence rates are high. In the traditional surgical reconstructive ladder, various methods are available for the treatment of simple to complex wounds [1–3]. Simple wounds can be treated with primary or secondary closures and various graft materials. Complex wounds are often closed with tissue expansion and a variety of musculocutaneous or fasciocutaneous flaps. The development of Integra® has dramatically changed the treatment of burn wound by providing an additional option to the armamentarium of the reconstructive burn surgeon [1–3].

Integra® Integra® (Integra LifeSciences, Plainsboro, NJ) is a biosynthetic, implantable, bi-layered membrane system for skin

P. M. Glat, MD (*) Department of Plastic and Reconstructive Surgery, St. Christopher’s Hospital for Children, Philadelphia, PA 19134, USA e-mail: [email protected] J. F. Hsu, DO, MPA W. Kubat, DO A. Azaharian, DO, MPH Department of Plastic and Reconstructive Surgery, St. Christopher’s Hospital for Children, Philadelphia, PA 19134, USA

replacement [1, 4, 5]. It contains a dermal regeneration layer and a temporary epidermal layer. The temporary epidermal layer is composed of synthetic polysiloxane polymer (silicone) [4, 5]. This layer enables immediate wound closure and provides a mechanical barrier against bacterial invasion. It also functions similar to normal skin by retaining moisture while allowing water vapor transmission [1, 6]. The dermal regeneration layer is composed of a three-dimensional porous matrix of cross-linked bovine collagen and glycosaminoglycans (chondroitin-6-sulfate) [4, 5]. This layer functions by promoting cellular growth and collagen synthesis. Biodegradation is defined while the layer is being replaced by autologous dermal tissue. Integra® application begins with complete excision of the full-thickness wound or scar contracture down to viable tissue [1, 6]. Once a viable tissue bed is achieved, meticulous hemostasis is important to prevent postoperative hematoma and complications. A sheet of Integra® is then applied to the wound bed with the silicone layer remaining intact. When multiple sheets are applied, they should abut each other to prevent dense granulation formation which later results in scar [1]. Integra® should adhere to the tissue bed and wound edges to promote neovascularization into the matrix (Fig. 15.1).

Neodermis Generation The neodermis generates in the dermal layer over the next 21 days. The integration and replacement can be divided into four phases: imbibition, cellular migration, neovascularization, and remodeling and maturation [1, 7]. During imbibition, red blood cells and fibrin assist in adhering the matrix to the wound. In the second phase (~day 7), fibroblasts migrate into the matrix and begin to produce collagen [1, 7]. Neovascularization begins when endothelial cells migrate in and carry with them blood and nutrients (~day 14) [1, 7]. Remodeling and maturation occurs in the last stage similar to normal wound healing. The

H. Hyakusoku et al. (eds.), Color Atlas of Burn Reconstructive Surgery, DOI: 10.1007/978-3-642-05070-1_15, © Springer-Verlag Berlin Heidelberg 2010

Application of Integra® in Pediatric Burns

CHAPTER 15

⊡ Fig.  15.1  Integra® application begins with complete excision of full-thickness wound. This is followed by meticulous hemostasis. A sheet of Integra® is then applied to the wound bed with the silicone layer remaining intact

neodermis gradually changes color during the process from red to peach colored to yellow (Fig. 15.2). The neodermis formation is completed around day 21. The silicone layer is removed in the operating room immediately prior to autografting. Due to the neodermis generated from Integra®, only a thin epidermal autograft is needed for the final stage of the surgery [1, 6] (Fig. 15.3).

This results in faster donor site healing with minimal scarring while providing opportunities for earlier donor graft reharvesting (Fig.  15.4). This also provides the equivalent of a full-thickness skin graft with only the donor site of a split-thickness graft. The aesthetic appearance of the graft is also generally improved when compared to standard split-thickness autograft (Fig. 15.5).

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Application of Integra® in Pediatric Burns

Day 0

Day 7

Day 14

Day 21

⊡ Fig. 15.2  The integration and replacement can be divided into four phases: imbibition (day 0), cellular migration (day 7), neovascularization (day 14) and remodeling and maturation (day 21)

Advantages and Disadvantages Some of the clinical advantages of Integra® are listed below:

• • • • • •

Minimize size/number of reconstructive procedures Immediate physiologic wound closure No temporary coverings No risk of rejection Potential for early ambulation/rehabilitation Delay in the need to create donor site wounds

However, the clinical disadvantages should also be noted and include:

• Requirement of multiple operations (minimum two) • Requirement of rigorous surgical technique and monitoring • Labor intensive postoperatively • Cost With Integra®, the advantages far outweigh the disadvantages. The single greatest benefit of Integra® is its versatility in the treatment of pediatric wound care. Integra® can be applied in every level of the traditional reconstructive ladder (Fig. 15.6). Several representative cases are provided below as examples of the excellent results obtainable with the use of Integra® (Figs. 15.7–15.9).

Application of Integra® in Pediatric Burns

CHAPTER 15

⊡ Fig. 15.3  Due to the neodermis generated from Integra®, only a thin epidermal autograft is needed for the final stage of the surgery

⊡ Fig. 15.4  Integra® result in faster donor site healing with minimal scarring while providing opportunities for earlier donor graft reharvesting

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Application of Integra® in Pediatric Burns

Split-Thickness Autograft Integra® Template Site Split-Thickness Autograft Integra® Template Site

⊡ Fig. 15.5  The aesthetic appearance of the graft is also generally improved when compared to standard split-thickness autograft

Application of Integra® in Pediatric Burns

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113

The Reconstructive Ladder Bone, Tendons, etc ...

Complicated

Skin Expansion Single Sequential

INTEGRA template (could be an alternative)

Flaps Free Flaps Penninsular Island Local Distant Random Cutaneous pattern Myocutaneous Axial Arterial

{

INTEGRA template (could be an alternative)

{

Grafts Split-thickness Full-thickness Autografts, Allografts, Xenografts

INTEGRA template (could be an alternative) INTEGRA template (if donor sites could be a problem)

Wound Closure Primary: Direct approximation: (z-plasty) Secondary: Spontaneous healing: (granulation) Tertiary: Delayed wound closure: (infected)

Simple

⊡ Fig. 15.6  The reconstructive ladder

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114

Application of Integra® in Pediatric Burns

a

b

c

d

⊡ Fig.  15.7  Seven-year-old boy, 2 years status post third degree scald burn to left chest and upper extremity with split-thickness skin graft. (a) Hypertrophic scars of left chest and upper extremity. (b) Mature Integra® in place 2 weeks

after excision of scar. (c) Thin autograft applied to neodermis in the operating room. (d) Well-healed Integra® with thin autograft 8 years post operation

Application of Integra® in Pediatric Burns

CHAPTER 15

a

b

c

d

⊡ Fig. 15.8  Eighteen-year-old boy 1 year status post third degree burn to head and neck. (a) Hypertrophic right cheek scar at the time of excision in operating room. (b) Mature Integra® in place 2 weeks after placement. (c) Thin autograft

applied onto neodermis in the operating room. (d) Wellhealed wound with Integra® 1 year post operation. Note the good aesthetic result despite crossing aesthetic units

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a

b

c

d

e

f

⊡ Fig. 15.9  Case of necrotizing fasciitis of left hand dorsal surface. (a) Open wound on the dorsum of left hand after debridement. (b) Integra® in place 2 weeks after placement.

(c) Mature neodermis prior to autograft. (d) Well-healed autograft. (e, f) Excellent range of motion after Integra® with thin autograft

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Pediatric Burn Reconstruction paul m. glat, anahita azharian, and john f. hsu

Background In the past, pediatric burn injuries were devastating and often fatal. With improved burn resuscitation techniques in children, multidisciplinary approach to burn management and early excision and grafting, survival has become the norm. Now, with better survival, burn reconstruction has taken on a major role in the management of these patients. The basic concerns in pediatric burn reconstruction are function, comfort, and appearance. Normal and hypertrophic scarring, scar contractures, loss of anatomic structures, loss of function, and changes in color and texture of injured skin are common concerns among all burn patients and yet unique to each [7, 8]. To understand burn reconstruction, one must have a good understanding of wound healing and scar maturation in order to plan for adequate timing and reconstructive technique. The reconstructive ladder principle of starting simple when possible and progressing to more complex techniques is the basis for pediatric burn reconstruction.

Selection of Methods In all instances, the burn injury is assessed for the deficiency of tissue and distortion of anatomy. Traditionally, if there is no deficiency and local tissues are easily

P. M. Glat, MD (*) Department of Plastic and Reconstructive Surgery, St. Christopher’s Hospital for Children, Philadelphia, PA 19134, USA e-mail: [email protected] A. Azharian, DO, MPH J. F. Hsu DO, MPA Department of Plastic and Reconstructive Surgery, St. Christopher’s Hospital for Children, Philadelphia, PA 19134, USA

mobilized, excision and direct closure or Z-plasties can be performed. However, if there is deficiency in tissue, the need for skin replacement becomes critical. With advances in burn reconstruction, tissue expanders have become a great option not only for improved cosmetic results, but also for decrease in donor site morbidity. Tissue expanders are useful, particularly in the head and neck, especially in correction of burn-associated alopecia. This, however, involves multiple visits for expansion and a final surgery, weeks to months later for the reconstructive phase. Tissue expanders also have a high incidence of complications, including infection, tissue ischemia, and even extrusion of the expander, requiring removal and restarting the reconstructive process. Like tissue expanders, regional and even free flaps offer an important option in selected difficult wounds, such as those associated with high voltage injury and extensive soft tissue loss of the distal lower extremity [8]. For example, fasciocutaneous flaps can be raised on the chest wall to cover small full-thickness burns of the hands in selected cases. The flap is then usually divided in 3 weeks from its donor site to provide coverage [8]. Another example is a latissimus dorsi microvascular free flap being used to cover a large scalp defect with exposed calvarium after a high voltage electrical injury. These flaps not only provide excellent quality tissue replacement, but also have potential complications such as ischemia, flap loss, and high rates of donor site morbidity. Cultured epidermal autograft is another approach for skin coverage of the excised burn wound. These grafts are grown in the laboratory from a biopsy of the patient’s own skin. Several weeks after the biopsy, the grafts are applied to the wound bed. These grafts are particularly useful in very large surface area burns where there is minimal to no donor site availability for autologous grafts [1, 3]. However, the healed grafts are extremely fragile and susceptible to infection, shear, and dressing changes. In addition, the cost to produce these grafts is high.

H. Hyakusoku et al. (eds.), Color Atlas of Burn Reconstructive Surgery, DOI: 10.1007/978-3-642-05070-1_16, © Springer-Verlag Berlin Heidelberg 2010

Pediatric Burn Reconstruction

Further Advancements In the last decade there have been further advances in the world of pediatric burn reconstruction such as the use of dermal replacement matrices such as cadaveric acellular dermal grafts or Integra® dermal regeneration template. These dermal matrices allow for a better quality graft with a much thinner autograft harvest, which in turn improves functional outcome (decreased scarring

CHAPTER 16

and contractures) and decreases donor site morbidity [4]. This may also result in improved cosmesis of the grafting procedure by reducing hyperpigmentation, hypopigmentation, and mesh pattern seen in the recipient graft site as well as improved cosmesis in the thin donor site area [2, 5]. Several representative cases are provided below as examples for some of the above mentioned reconstructive techniques.

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Pediatric Burn Reconstruction

Clinical Cases + Case 1 Two-year-old female with full thickness cigarette burns to the lateral aspect of the right eye (a). Intraoperative markings of myocutaneous rotational flap reconstruction (b). Myocutaneous rotational flap from upper eyelid to the lower eyelid (c). Six month follow-up status-post flap reconstruction (d).

16

Pediatric Burn Reconstruction

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a

b

c

d

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122

Pediatric Burn Reconstruction

+ Case 2 One-year-old male with full thickness burns on the palm of the hand (a). Reconstruction with cadaveric acellular dermal grafts, split-thickness and fullthickness skin grafts. Six month follow-up status-post reconstruction (b).

16

Pediatric Burn Reconstruction

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b

123

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124

Pediatric Burn Reconstruction

+ Case 3 Comparison of recipient sites from traditional split-thickness skin graft vs. STSG and Integra® (a, b). Decreased donor site morbidity and improved cosmesis with thinner split-thickness skin graft harvest when used in conjunction with Integra® (c). Increased donor site morbidity and scarring with traditional split-thickness skin graft harvest site (d, e).

16

Pediatric Burn Reconstruction

a

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b

c

d

e

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126

Pediatric Burn Reconstruction

+ Case 4 Eight-year-old female with full-thickness burns to left flank (a, b). Intraoperative application of Integra® (c). Three weeks status-post Integra® application with thinner split-thickness skin graft reconstruction (d). Eight year follow-up visit. Donor site at 8 year follow-up (e).

16

Pediatric Burn Reconstruction

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a

b

c

e

d

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128

Pediatric Burn Reconstruction

+ Case 5 Eight-year-old male with full-thickness burns to right axilla with grafting. Patient developed contracture with decreased range of motion of right upper extremity (a). Intraoperative markings for scar excision (b). Wound defect after scar excision (c). Single stage application of Integra® and split-thickness skin graft (d). Three month follow-up with full range of motion of the right upper extremity (e).

16

Pediatric Burn Reconstruction

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a

b

c

d

e

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Pediatric Burn Reconstruction

+ Case 6 Two-year-old male with 87% total body surface area full-thickness flame burns. Patient status-post burn excision and Integra® application (a). Three weeks after excision and Integra® application, cultured epidermal autograft was applied (b). Four weeks after the application of cultured epidermal autograft and newly regenerated skin (c).

16

Pediatric Burn Reconstruction

a

c

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b

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Skin Grafting matthew klein

Introduction and Historical Perspective Timely burn wound excision and skin grafting form the cornerstone of acute burn surgical management. In addition, skin grafting remains one of the most useful tools in the burn reconstruction armamentarium. Grafts are often the first choice to fill defects created from scar contracture release and from excision of large areas of hypertrophic scar. The first known report of skin grafting comes from the Sushruta Samhita, an ancient Indian surgical text that may date as far back as the seventh century, bc. This text described the use of both skin grafts and flaps for a variety of facial reconstructive procedures. The Indian method of grafting was first introduced to Western medicine by English surgeons in the eighteenth century. It was not until 1804 that successful transplantation of free skin grafts was reported by Baronio of Milan, who successfully grafted large pieces of autogenous skin onto different sites on sheep [1]. Several decades later, in 1869, Guyon and Jacques Reverdin described the use of a small epidermal graft, which became known as the pinch graft, in a report to the Societe Imperiale de Chirurgie [1]. However, this technique did not gain wide recognition until 1870, when successful experiments in skin grafting for the treatment of burn patients were performed by George David Pollock [2]. In 1872, Ollier described the use of both full-thickness and split-thickness skin grafts, and realized the possibility of covering large areas with such grafts if a satisfactory method of cutting them could be devised [1]. It was not until the description of grafting techniques by Blair and Brown that skin grafting gained wide acceptance. They distinguished between

M. Klein, MD University of Washington Burn Center, USA e-mail: [email protected]

epidermal, partial thickness, and full-thickness grafts and, importantly, demonstrated reliable healing of donor sites if a portion of the dermis was not harvested [3, 4]. Over the past several decades, there have been a number of advances in the tools available for skin graft harvest, as well as graft meshing. The decision to use skin grafts rather than local flaps or tissue rearrangement should be based on the availability of local tissue (i.e., if there is significant scarring in tissue adjacent to the area requiring coverage) and the amount of tissue deficiency. Areas with scar contracture typically have a significant amount of tissue deficiency that cannot be adequately addressed with a Z-plasty, V-Y plasty, or Y-V plasty. However, there are many potential challenges to skin grafting for burn reconstruction primarily related to donor site deficiency. Patients who have sustained extensive burns have few areas of skin that were either unburned or not previously used as donor sites to achieve initial wound closure.

Classification of Skin Grafts Skin grafts can be classified by both their thickness and whether or not they are meshed following harvest.

Split-Thickness and Full-Thickness Grafts Skin grafts can be classified by their thickness – as either split-thickness skin grafts (STSG) or full-thickness skin grafts (FTSG). This classification is based on the amount of dermis included in the graft – with FTSGs including the entire thickness of the dermis and STSGs including a portion of the thickness of dermis. STSGs can be further classified as thin or thick, again depending on the depth of dermal harvest. The thinner the skin graft, the greater the degree of contraction that is likely to occur at the recipient site. This is an important consideration

H. Hyakusoku et al. (eds.), Color Atlas of Burn Reconstructive Surgery, DOI: 10.1007/978-3-642-05070-1_17, © Springer-Verlag Berlin Heidelberg 2010

Skin Grafting

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a

b

c

d

⊡ Fig.  17.1  (a–d) Technical aspects of skin grafting. (a) Templates using glove wrapper can be used to ensure an appropriate area of skin graft is harvested. (b) Split-thickness skin grafts (STSG) are used when larger areas of coverage are needed. In order to facilitate harvest, particularly over areas of bony prominence or lax tissue, tumescing the donor site with isotonic solution can be used. In the scalp, epinephrine

(1:500,000) can be used to assist in hemostasis. (c–d) In order to minimize graft sheer and ensure adequate contact between the wound bed and graft, particularly in areas of concavity, bolster dressings or the vacuum-assisted closure as shown here over a neck graft (c) can be used. For extremity grafts, an Unna’s boot (d) can provide vascular support and minimize shearing

when skin grafts are applied across mobile joint surfaces. Split-thickness grafts are commonly used to cover larger defects such as following an axillary contracture or the following excision of a large area of hypertrophic scar (Figs. 17.1–17.3). FTSG are particularly useful for reconstructing defects of the hand and the face. For example, moderate to severe web-space contractures in the hand are often managed with full-thickness grafts, particularly when there is a significant amount of tissue deficiency that cannot be adequately addressed using a Z-plasty. Fullthickness grafts are commonly harvested from the inguinal region, flank, or from postauricular area. These donor sites can be closed primarily and care should be taken to select a harvest site that does not contain hair. Larger full-thickness grafts can be harvested following tissue expansion [5] (Figs. 17.4–17.6).

Meshed vs. Sheet Grafts Skin grafts can be further classified as meshed or unmeshed (sheet) grafts. Sheet grafts are applied without altering following harvest, whereas meshed grafts are passed through a machine that produces fenestrations in the graft. Grafts can be meshed at ratios of 1:1– 4:1. Meshing allows the egress of serum and blood from wounds, thereby minimizing the risk of the formation of hematomas or seromas that could compromise graft survival. In addition, meshed grafts can be expanded or stretched to cover larger surface areas. When grafts are meshed at ratios of 3:1 or higher, allograft skin or another biologic dressing can be applied over them to prevent the interstices from becoming desiccated before they close. Because of the lack of dermis in the interstices, widely expanded mesh always scars, takes a long time to

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134

Skin Grafting

a

b

c

d

⊡ Fig.  17.2  (a–d) Full-thickness skin grafts (FTSG) for digit contractures. FTSG are commonly used following release of contractures in the hand and face. This is a 16-yearold male who sustained a hand burn as a child and developed flexion contractures of his two to five digits (a). Following

a

scar release, k-wires were placed to maintain the digits in extension (b) and the soft-tissue defects were filled with FTSG harvested from the inguinal region. Three months following surgery, the grafts are well healed and the patient has full extension (c, d)

b

c

⊡ Fig. 17.3  (a–c) Full-thickness skin grafting for ectropion repair. This is a 25-year-old male who sustained full thickness burns to his face. He developed severe cicatricial ectropion (a). Following scar release, the skin defects were closed using FTSG from the flank (b). Traction sutures were used to

facilitate ectropion release and were kept in place for 1 week postoperatively. A bolster of cotton rolls was used to secure the graft and minimize fluid accumulation and sheer. Graft healing and lid position are shown at 3 months postoperatively in (c) (Images courtesy of Loren Engrav, MD)

Skin Grafting

a

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b

c

wrist contracture was released by incising the scar, leaving a large defect (b) that was closed using a split-thickness skin graft (c)

⊡ Fig.  17.4  (a–c) Split-thickness skin graft for wrist contracture. This 4-year-old girl developed severe wrist contracture following extensive full-thickness burn injury (a). The

a

b

c

⊡ Fig.  17.5  (a–c) STSG following hypertrophic scar excision. A 48-year-old man sustained deep partial thickness burns after a sulfuric acid burn. He developed a large area of

hypertrophic scar on his chest and neck that limited his neck range of motion (a). He underwent scar release (b) and wound closure with a thick (0.016˝ ) split-thickness skin graft (c)

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136

a

Skin Grafting

b

c

⊡ Fig.  17.6  (a–c) Split-thickness skin graft for neck contracture. This 9-year-old boy sustained full-thickness burns to his neck and chest. He developed a neck contracture (a) that was released and the resulting defect closed with

thick split-thickness skin graft (b). One year later, the graft has healed well and the patient has not developed a recurrent contracture (c) (Images courtesy of Loren Engrav, MD)

Skin Grafting

close, and results in permanent unattractive mesh marks. For these reasons, widely meshed grafts are rarely, if ever, used in burn reconstructive procedures. Sheet grafts should be used on the face, the neck, the hands, and, whenever possible, on the forearms and the legs. In these exposed areas, the superior cosmetic and functional results obtainable with sheet grafts make such grafts preferable. Since sheet grafts have no interstices, they must be closely monitored and periodically rolled with a cotton-tipped applicator to drain any fluid collection. Any serious or bloody blebs that form beneath the graft should be incised with a No. 11 scalpel and drained expeditiously. A common practice known as pie crusting, which involves making incisions in a sheet graft at the time of surgery, actually does not yield much improvement in graft survival, because blebs often form in areas without incisions.

Donor Site Selection and Skin Graft Harvest For burn reconstruction, donor site selection is based on the type of graft needed (full- vs. split-thickness) and the availability of donor sites. Inventory of available donor sites should be performed during the preoperative evaluation of the patient. If possible, previous operative notes should be reviewed to determine which areas have been harvested previously and how many times. Recropping of previous harvested donor sites is possible, but not ideal since this limits the amount of dermis that can be included in the graft. Color match should also be a consideration particularly while skin grafting the face and neck. The scalp provides optimal color match for the face and neck and should be considered when grafting these areas. Discussion and selection of appropriate donor sites should be done with the patient whenever possible. STSG are typically harvested by a dermatome. Dermatomes can be electric or air-powered. The thickness can be set prior to harvest, although this typically serves only as a guide as ultimate harvest thickness is determined both by the dermatome setting and the pressure applied by the person harvesting skin. The maintenance of appropriate skin tension is essential to ensuring a successful harvest. On certain anatomic areas such as the back, abdomen, and scalp, tumescence of the skin with isotonic solution is required to facilitate harvest. Epinephrine (1:500,000) is added prior to scalp harvest to minimize donor site bleeding. Ideally, when correcting burn contractures, thicker grafts are preferred since the amount of wound contraction is inversely related to

CHAPTER 17

dermal thickness. Therefore, if suitable donor sites are available, split-thickness grafts should be harvested at 0.016–0.020” to repair joint contractures (i.e., neck, axilla, and elbow). FTSG are typically used for closure of defects on the face (eyelids, lips) and hands (web space and digit contractures). FTSGs are typically harvested using a scalpel. The inguinal region provides an excellent donor site for FTSGs. Prior to harvest, a template of the recipient site is fabricated and used to guide the area of skin to be harvested. The donor site can be infiltrated with local anesthetic with epinephrine, again both to facilitate harvest and provide hemostasis. Following skin graft harvest, the wound edges are undermined so a tension-free closure can be achieved. For small defects on the face, FTSG can be harvested from the supraclavicular area, the neck, the upper eyelids (in older adults with skin laxity), or from behind the ear. Harvest from this area typically provides a superior color match than skin harvested from below the clavicles. However, in cases of extensive burn injuries, these preferred donor sites might not be available. In addition, attempt should be made to select donor sites for reconstruction from areas where the initial grafts were taken in order to optimize color match. For example, if the face was initially grafted using skin from the trunk or lower extremities, donor sites from the flank or inguinal region may be preferred over the supraclavicular or postauricular area.

Skin Substitutes An off-the-shelf skin replacement containing both a dermal and epidermal component would be ideal for burn reconstruction procedures – particularly if donor sites are limited. However, despite decades of research, a perfect artificial skin solution remains a distant hope. However, existing artificial technologies have been used in burn reconstruction [5, 6]. Artificial dermal templates provided by products such as Integra (Integra Life Sciences, Plainsboro, New Jersey) can be useful to augment the native dermis available in thinner split-thickness grafts, and therefore potentially reduce the risk of scarring and recontracture.

Skin Graft Dressings Once a skin graft is secured in place, a dressing may be applied to protect it from shearing, as well as to accelerate closure of meshed graft interstices. Numerous options

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for graft dressings exist, including wet dressings and greasy gauze. The use of a nonadherent dressing such as Conformant two (Smith and Nephew, Largo, FL), along with an outer antimicrobial wet dressing, allows the overlying dressings to be periodically removed without dislodging the graft from the wound bed. Bolsters consisting of cotton and greasy gauze are employed to help grafts conform to concave wound surfaces, and splinting of extremities may be necessary for safe graft immobilization, especially over joints. The Vacuum Assisted Closure system (Kinetic Concepts Inc., San Antonio, Texas) is another option for promoting graft healing. Alternatively, an Unna’s boot can be placed on both the upper and the lower extremity to immobilize the graft and provide vascular support, allowing mobilization of the extremity in the immediate postoperative period [7]. Sheet grafts can be either left open to the air to allow continuous monitoring and rolling (depending on the patient) or wrapped with dry dressings, which can be removed if necessary to allow interval inspection and deblebbing. Following contracture release, custom-made splints are used to maintain adequate positioning. These splints

Skin Grafting

are typically left in place for 1 week postoperatively. At that time, the splints are removed, graft healing assessed, and then range of motion is started. Splints are generally used for weeks to months following contracture release to minimize the risk of recurrent contracture. The duration and schedule of splint use are determined on a case by case basis. There are also various options for donor-site dressings. The ideal donor-site dressing would not only minimize pain and infection, but also be cost-effective. Greasy gauze and Acticoat® (Smith and Nephew, Largo, FL) are often employed for this purpose. Typically, these dressings are left in place until the donor site reepithelializes, at which time the dressing is easily separated from the healed wound. Op-Site®, a transparent polyvinyl adherent film, is also commonly used. With Op-Site®, the underlying wound is easily examined without the removal of the dressing. However, intermittent drainage of the wound fluid that accumulates is necessary. Op-Site® does not work well over joint surfaces and concave or convex areas (e.g., the back). Silver sulfadiazine in a diaper is an excellent covering for buttock donor sites in children; dressing changes can be done with each diaper change.

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Skin Graft for Burned Hand wassim raffoul and daniel vincent egloff

Introduction Hand lesions are found in more than 75% of major burns and in 50% of all burned patients [1, 2]. Mismanaging this trauma has deleterious consequences on patient rehabilitation and may leave lifelong, disgraceful, and invalidating scars [3]. The dorsum of the hand is its social side and most frequently presents deep burns. Superficial burns heal spontaneously without any functional or cosmetic consequences. On the other extreme, third-degree burns, in the best of cases, frequently end with severe functional and cosmetic prejudices and may even necessitate in the worst situations finger or hand amputations. Although the management of a second-degree burned hand is one of the most challenging surgical lesions, it should be managed as any severe hand trauma and according to the standards of acute burn modern treatment. During the past 10 years, the authors developed a management concept based on those two fundamental principles.

aspect of the thumb, index, and third finger, and on the radial aspect of the two other fingers. In case of severe hand edema, carpal tunnel has to be opened, as well as incision of the skin covering the thenar (Fig. 18.1). 2. Superficial burns are covered with a silver sulfadiazine cream for 24 h (Fig. 18.2) and then with hydrofiber or hydrocellular dressings. The dressings have to be maintained 10–12 days. The superficial layers will be changed every 5 days, but the hydrocellular dressing has to be kept in place until spontaneous detachment (Fig. 18.3).

Methods Hands are considered and treated as priority areas. A standard protocol is applied. 1. Edema prevention and treatment [4, 5]. Hyperhydration prevention. Hand elevation. Antioxydant supplementation. Escarotomy, if there are risk and signs of vascular and/ or neurological compression. Incisions have to be done on the lateral and dorsal side of the fingers and dorsum of the hand. The incision line should be on the ulnar

⊡ Fig. 18.1  Escarotomy incisions

W. Raffoul, MD (*) Plastic Surgery Department, BH 10, CHUV, 1011 Lausanne, Switzerland e-mail: [email protected] D. V. Egloff, MD Plastic Surgery Department, BH 10, CHUV, 1011 Lausanne, Switzerland

⊡ Fig.  18.2  Second superficial. Twenty-four hours treatment with silver sulfadiazine

H. Hyakusoku et al. (eds.), Color Atlas of Burn Reconstructive Surgery, DOI: 10.1007/978-3-642-05070-1_18, © Springer-Verlag Berlin Heidelberg 2010

Skin Graft for Burned Hand

CHAPTER 18

⊡ Fig. 18.5  Fibrin glue sealing ⊡ Fig. 18.3  Result after 12 days treatment with hydrofiber dressings

⊡ Fig. 18.6  Dressing, paraffin gauze

⊡ Fig. 18.4  Thin nonmeshed skin graft

3. Surgery. Early debridement third to fifth day posttrauma. Laser Doppler evaluation can help surgical decision. Tangential debridement with weck knife. Preservation, if possible, of all living tissues (fat, fascia, para-tendon, vessels…) Coverage with thin nonmeshed grafts sealed with fibrin glue (Figs. 18.4 and 18.5). First lightly compressive dressing (Figs. 18.6–18.9). First dressing replaced at the fifth day (Fig. 18.10). 4. Early rehabilitation. Early active and passive mobilization starts after the first dressing placement (between the third and the fifth post-op day). Pain prevention during the treatment. Early compression with elastic autoadhesive rubber bandages (Fig. 18.11). Splinting in functional position only during the night.

⊡ Fig. 18.7  Kerlix bandage

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⊡ Fig. 18.11  Autoadhesive elastic rubber bandage

⊡ Fig. 18.8  Light compressive bandage

⊡ Fig. 18.12  Compressive gloves

⊡ Fig. 18.9  Light compressive bandage

⊡ Fig. 18.10  First post-op dressing

5. Long-term rehabilitation. Compression with Jobst type gloves as soon as possible (depending on complete wounds healing) (Figs. 18.12 and 18.13). Long-term specialized physiotherapy and functional therapy (Figs. 18.14 and 18.15).

⊡ Fig. 18.13  Compressive gloves

6. Reconstruction and coverage of deep structures. Dermal substitutes are used if deep structures are exposed [6, 7] (capsular system, ligaments) (Fig. 18.16).

Skin Graft for Burned Hand

CHAPTER 18

In case of tendons exposure, the reconstruction with a free temporal fascia flap is our first choice (Figs. 18.17–18.22).

⊡ Fig. 18.14  Result at 3 months

⊡ Fig. 18.17  Extensor tendons reconstruction

⊡ Fig. 18.15  Result at 3 months ⊡ Fig. 18.18  Coverage with temporal fascia free flap

⊡ Fig. 18.16  Matriderm™ dermal substitute

⊡ Fig. 18.19  Nonmeshed thin skin graft sealed with fibrin glue

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⊡ Fig. 18.20  Result at 3 months

Skin Graft for Burned Hand

⊡ Fig. 18.21  Result at 3 months

 utologous keratinocyte and fibroblast coculture in A association with dermal regeneration template are the best coverage solution in major burns (more than 80% BSA) [8, 9].

Conclusion Early debridement, coverage with thin nonmeshed skin grafts and early compression by elastic adhesive bandages, is our method of choice in the treatment of deeply burned hands. It allows the achievement of the two main goals in hand treatment, good function and a pleasant cosmetic aspect.

⊡ Fig. 18.22  Result at 3 months

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Tips for Skin Grafting masahiro murakami, rei ogawa, and hiko Hyakusoku

Introduction Skin grafting is a common method of burn reconstructive surgery. The success of a skin graft depends on (1) appropriate debridement and cleanup of the recipient site down to the layer providing the blood supply; (2) adequate hemostasis of the recipient site to prevent the development of hematoma; and (3) sufficient compression of the graft from one corner to another, which can be achieved with the use of a tie-over dressing or bandages. We offer three suggestions to reduce complications: (1) use of a metallic sponge for debridement, (2) use of a flower holder to create a drainage hole, and (3) use of external wire frame fixation for skin grafting.

Debridement with a Metallic Sponge Appropriate debridement is necessary for wound bed preparations for skin grafting. Debridement by surgical [1], hydrosurgical [2], biological [3], and chemical [4] methods has been reported and the usefulness of these methods are discussed. However, simple metallic sponges of the sort used in kitchens are effective for intraoperative surgical debridement (Fig. 19.1a–c). Such sponges are readily available, cheap, and can be sterilized easily. Simple wiping of the wound surface is

M. Murakami, MD, PhD (*) Department of Plastic and Reconstructive Surgery, Nippon Medical School, Musashi Kosugi Hospital, Tokyo, Japan e-mail: [email protected] R. Ogawa, MD, PhD Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School Hospital, Tokyo, Japan e-mail: [email protected] H. Hyakusoku, MD, PhD Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School Hospital, Tokyo, Japan e-mail: [email protected]

enough to remove debris, especially granulation tissue and soft eschar. This may be a very primitive method compared with hydrosurgical or chemical debridement, but we believe that metallic sponges are ideal for the purpose.

Creation of Drainage Holes with a Flower holder Hemostasis is especially important in blood-rich regions such as the scalp, face, and hands. When skin grafts are used in such areas, they should include drainage holes, which are also useful for draining bacteria and exudates. However, since large drainage holes leave scars, several small holes are preferable. To make such holes, Japanese “Kenzan” flower holders (Fig. 19.2a) are far more effective than surgical knives or needles in order to prevent outstanding scars. The graft is placed on the flower holder’s needles and held in place with a rubber sheet (Fig.  19.2b, c). The rubber sheet is then beaten with a hammer (Fig. 19.2c), quickly perforating the graft with numerous small holes (Fig. 19.2d, e). These holes suffice for drainage and become epithelialized in about 10 days.

Skin Grafting by External Wire Frame Fixation We have used external wire frame fixation for skin grafts since 1986. In 1991, we reported this method and described two advantages: (1) the technique is useful for securing grafts to wound beds; and (2) it prevents the graft edges from lifting [5]. We also confirmed the usefulness of this technique for skin grafts in regions with free borders, such as the lips and eyelids [6]. External wire frame fixation is particularly useful for eyelid grafts, as it overcomes the disadvantages of tarsorrhaphy [6]. Moreover, threedimensional external wire frames are also useful for fixing digital joints as well as skin grafts [7]. If this method is used for digital skin grafting, the digital joints do not need

H. Hyakusoku et al. (eds.), Color Atlas of Burn Reconstructive Surgery, DOI: 10.1007/978-3-642-05070-1_19, © Springer-Verlag Berlin Heidelberg 2010

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⊡ Fig. 19.1  Debridement with a metallic sponge. (a) Metallic sponge. (b) Preoperative view. (c) Intraoperative view

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⊡ Fig. 19.2  Creation of drainage holes with a flower holder. (a) Japanese flower holder. (b) Flower holder, skin graft, rubber sheet, and hammer. (c) Perforation of skin graft with hammer. (d) Perforated skin graft. (e) View of small drainage

holes in the skin graft. (f) Intraoperative view; numerous drainage holes can be seen. (g) 1 month after the operation, the drainage holes are completely epithelialized with no scarring

to be fixed by pinning, which is particularly useful for grafting of the palmar surfaces of fingers. During surgery, the usual method is used to fix the skin graft with sutures (Fig. 19.3). At the same time, a wire frame consisting of 1.0-mm-diameter Kirschner

wire is made in the shape of the graft itself; it is applied to the graft and attached with the same sutures already used for stitching the graft. Tie-over fixation is performed in the usual way.

CHAPTER 19

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⊡ Fig. 19.3  Schema of skin grafting by external wire frame fixation

Tips for Skin Grafting

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Clinical Cases of Skin Grafting with External Wire Frame Fixation + Case 1 (Fig. 19.4)

19

A 57-year-old man suffered facial burns in an accident, and left lower eyelid ectropion developed after 2 months of conservative treatment. A full thickness skin graft was harvested from the supraclavicular area. The graft was fixed using external wire frame technique without tarsorrhaphy, and the patient was able to open and use his left eye soon after the operation. The postoperative course was uneventful, and no contracture of the lower eyelid has been observed.

Tips for Skin Grafting

CHAPTER 19

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⊡ Fig. 19.4  Lower eyelid reconstruction using skin grafting with external wire frame. (a) Preoperative view. (b) Applied skin graft and external wire frame. (c) Postoperative view (eyes open). (d) Postoperative view (eyes closed)

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+ Case 2 (Fig. 19.5)

19

A 13-year-old boy suffered burns to his entire face in a house fire, and severe upper lip contracture developed after 2 months of conservative treatment. A full thickness skin graft was harvested from the upper arm. Tight fixation of the grafted skin was achieved using external wire frame fixation technique, and the patient was able to open his mouth and eat normally soon after the operation. The postoperative course was uneventful, and no contracture of the upper lip has been observed.

Tips for Skin Grafting

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CHAPTER 19

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⊡ Fig.  19.5  Upper lip reconstruction using skin grafting with external wire frame. (a) Preoperative view. (b) Intra­ operative view; indicates the dermis of the full thickness

skin graft. (c) Applied skin graft and external wire frame. (d) Postoperative view

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+ Case 3 (Fig. 19.6)

19

A 42-year-old man suffered burns to his entire face in a suicide attempt; the left auricle was damaged. Auricle reconstruction without cartilage was planned to create a sulcus to support the arm of a pair of spectacles. A threedimensional external wire frame was made from 1.0-mm-diameter Kirshner wire, and a full thickness skin graft was harvested from the lower abdomen. Tight fixation of the grafted skin was achieved, and the postoperative course was uneventful.

Tips for Skin Grafting

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CHAPTER 19

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⊡ Fig. 19.6  Ear reconstruction using skin grafting with external wire frame. (a) Preoperative view: incision line. (b) Applied skin graft and three-dimensional external wire frame

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+ Case 4 (Fig. 19.7) Squamous cell carcinoma developed in the burned scar of the right cheek of a 61-year-old man. The carcinoma was excised along with the surrounding scar tissue and fatty tissue. The skin defect was reconstructed with a full thickness skin graft harvested from the supraclavicular area using external wire frame fixation technique. The grafting was completely successful and the postoperative course uneventful.

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⊡ Fig. 19.7  Cheek reconstruction using skin grafting with external wire frame. (a) Applied skin graft and external wire frame. (b) Immediately after removal of the tie-over fixation. (c) Postoperative view

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Z-Plasties and V-Y Flaps shigehiko suzuki, katsuya kawai, and naoki morimoto

Z-Plasties A linear scar contracture is usually repaired by using Z-plasty. However, the scar itself remains even if the contracture is released. Therefore, it would be useful to reduce any unsightly scarring at the time of release of contractures. Modified planimetric Z-plasties are useful for this purpose.

Conventional Z-Plasties Conventional Z-plasty is one of the most common techniques in plastic surgery (Fig. 20.1). The execution of a conventional Z-plasty produces stereometric elongation of a cutaneous contracture (Fig.  20.2). The scar ridge becomes a dent after the Z flaps are exchanged. Therefore, large Z-plasty is effective especially in concave linear longitudinal contractures.

Modified Planimetric Z-Plasties Planimetric Z-plasty was first reported by Roggendorf [7, 8]. In his method, the longer lateral limb A is as long as the longer central limb D, and the vertical angle is 75°. The shaded portions are excised when the flaps are transferred (Fig.  20.3a). Planimetric Z-plasty is useful

for irregular scarring with slight contracture, but when the contracture is severe, the longer lateral limb shrinks immediately after incision (Fig.  20.3b). Therefore, the central limb should be designed to be longer than the lateral limb. In other words, the vertical angle should be more acute than 75° (Fig.  20.3c) [6]. In practice, it is safer to prepare triangular flaps with slightly sharper angles than estimated. The excess tissue can then be trimmed after the flaps have been transferred. When the scar is wider and the skin tension in the transverse direction is lower, more tissue can be excised (Fig. 20.3d).

Continuous Planimetric Z-Plasties Planimetric Z-plasties can be connected obliquely to elongate an oblique contracture in the longitudinal direction. Angles sharper than 75° are required as described above (Fig. 20.3e). When the scar is wider and the skin tension in the transverse direction is lower, more tissue can be excised as extended oblique continuous planimetric Z-plasties (Fig. 20.3f). The shaded portions should be designed to excise unsightly scars as much as possible. Planimetric Z-plasties can be connected in an alternative direction according to the shape of the scar (Fig. 20.3g). It is possible to combine oblique and alternative continuous planimetric Z-plasties.

S. Suzuki, MD, PhD (*) Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Kyoto University, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan e-mail: [email protected] K. Kawai, MD N. Morimoto, MD Kyoto University, Kyoto, Japan

H. Hyakusoku et al. (eds.), Color Atlas of Burn Reconstructive Surgery, DOI: 10.1007/978-3-642-05070-1_20, © Springer-Verlag Berlin Heidelberg 2010

Z-Plasties and V-Y Flaps

Chapter 20

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⊡ Fig.  20.2  Appearance after execution of a conventional Z-plasty

⊡ Fig. 20.1  Design of conventional Z-plasty

Contracture line

Contracture line

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⊡ Fig. 20.3  Planimetric Z-plasties

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Clinical Cases + Case 1

20

A 10-year-old boy presented with a hypertrophic scar with contracture on his left foot due to a crash injury (Fig. 20.4). Extended oblique continuous planimetric Z-plasties were designed (Fig. 20.5). After skin excision, the contracture was released and the hypertrophic scar was partially excised (Fig. 20.6). Then the flaps were transferred and sutured (Fig. 20.7). The remaining hypertrophic scar gradually became flattened. Fifteen months after the second operation, both the functional and cosmetic improvements were excellent (Fig. 20.8).

Z-Plasties and V-Y Flaps

⊡ Fig. 20.4  Hypertrophic scar with contracture on the left foot of a 10-year-old boy

⊡ Fig. 20.5  Operative design

⊡ Fig. 20.6  Appearance during operation

Chapter 20

⊡ Fig. 20.7  Immediate postoperative appearance

⊡ Fig. 20.8  Fifteen-month postoperative appearance

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V-Y Flaps and Their Analogs There are various kinds of V-Y advancement flaps and their analogs. To make the selection of an appropriate method easier for the treatment of scars and scar contractures, we proposed a comprehensive classification of V-Y flaps and their analogs (Fig. 20.9) [5].

V-Y Flaps with Burow’s and Inverted Burow’s Triangle Excisions Burow’s triangle excisions are commonly applied in V-Y flaps to facilitate skin closure (Fig.  20.9a). We devised an alternative to the Burow’s triangle excision, namely, an inverted Burow’s triangle excision. This procedure results in a zigzag line of suturing (Fig. 20.9c). The zigzag is longer but less conspicuous, and contracts less than the straight scar produced by a conventional Burow’s triangle excision. Although we describe a triangle excision, the base of the triangle should be incised along the arch line of the central convex according to the degree of contracture. More practically, we recommend that a cut is made along the radial lines first before the excess tissue is trimmed after releasing the contractures.

Double V-Y Flaps The division of a wide V flap into two V flaps in the V-Y flap is named a double V-Y advancement flap. Double V-Y flaps with a pair of Burow’s triangle flaps (Fig. 20.9b) result in V-W plasty as reported by Koyama [4], and double V-Y flaps with a pair of inverted Burow’s triangle flaps (Fig.  20.9d) resemble V-M plasty reported by Alexander [1]. Turning the design of the double V-Y flap with Burow’s triangle excisions upside-down results in the V-Y flap with inverted Burow’s triangle excisions.

V-Y Flaps with Transposition Flaps In severe contracture, transposition flaps can be used instead of triangle excisions. You may notice that the

Z-Plasties and V-Y Flaps

V-Y flap with a pair of transposition flaps (Fig.  20.9e) results in five flap-plasty [2], and that double V-Y flap with a pair of transposition flaps (Fig. 20.9f) results in seven flap-plasty [3].

Application of the Comprehensive Classification of V-Y Flaps and Their Analogs Separate maneuvers can be used in each arm of the V-Y or double V-Y flap. For example, a Burow’s triangle excision can be performed in one arm, and an inverted Burow’s triangle excision can be performed in the other arm (Fig.  20.9 g,h). On the basis of above-mentioned concepts, V-Y advancement flaps and their analogs can be classified comprehensively. With reference to the classification, an appropriate design can be determined according to the degree of contracture and the shape of the scar in each case. Therefore, we can easily design V-Y flaps according to the degree of contracture and the shape of the scar. It is also useful to combine V-Y flaps with planimetric Z-plasties. Maneuver of each arm

Double V-Y Plasties

V-Y Plasties

Burow’s triangle excisions

A

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a Inverted Burow’s triangle excisions

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⊡ Fig. 20.9  Comprehensive classification of V-Y flaps and their analogs

Z-Plasties and V-Y Flaps

Chapter 20

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+ Case 2

20

A 22-year-old woman presented with a hypertrophic scar on her right elbow (Fig. 20.10). Taking the degree of the contracture and the shape of the scar into consideration, we designed a V-Y flap with a Burow’s triangle excision and performed planimetric Z-plasty (Fig. 20.11). After a skin incision along the violet mark, an additional skin incision was made along the green dotted line to further advance the V flap. Before skin closure, another Z-plasty was executed along the blue dotted lines. The hypertrophic scar was excised as much as possible. The transferred flaps were sutured (Fig.  20.12). The remaining hypertrophic scar gradually became flattened, and the 4 months postoperative appearance showed both functional and cosmetic improvement (Fig. 20.13).

Z-Plasties and V-Y Flaps

⊡ Fig.  20.10  Hypertrophic scar on the right elbow of a 22-year-old woman

Chapter 20

⊡ Fig. 20.11  Operative design

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+ Case 2 (continued)

20

Z-Plasties and V-Y Flaps

Z-Plasties and V-Y Flaps

⊡ Fig. 20.12  Immediate postoperative appearance

Chapter 20

⊡ Fig. 20.13  Four-month postoperative appearance

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Z-Plasties and V-Y Flaps

+ Case 3

20

A 74-year-old man presented with a postburn scar contracture between the right thumb and index finger. A double V-Y flap with transposition flaps, namely, a seven flap-plasty was planned. Double V flaps were designed on the dorsal side, and transposition flaps were designed for the palmar side (Fig. 20.14). After the skin incisions, dissection of the flaps on the dorsal side was minimized, and the flaps on the palmar sides were mainly transferred (Fig. 20.15). All flaps survived, and 1 year postoperatively, both the functional and cosmetic improvements were impressive (Fig. 20.16).

Z-Plasties and V-Y Flaps

Chapter 20

⊡ Fig. 20.14  Scar contracture between the right thumb and index finger of a 74-year-old man ⊡ Fig. 20.16  One-year postoperative appearance

⊡ Fig. 20.15  Operative design

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Use of Z-Plasty in Burn Reconstruction rodney k. chan and matthias b. donelan

Background of the Technique “Surgical principles evolve slowly, gain a certain permanence and require periodic reassessment. Surgical techniques evolve rapidly, change frequently, and require constant refinement” [1]. Z-plasty is as much a principle as it is a technique in plastic surgery. While the description of a Z-plasty can be found in almost every plastic surgery text, the successful application of this seemingly, mathematically simplistic concept requires careful planning and deliberate execution. Denonvilliers, often credited with the first description of a Z-plasty, actually did not know that he was describing a new technique in 1856 when he used it for the treatment of lower lid ectropion. The first reference to Z–plasty in American literature, however, was not found until 1913 when McCurdy used it as a treatment for contracture at the oral commissure. Limberg, in 1929, provided a more detailed geometric description, and Davis subsequently popularized the technique with numerical data showing optimal angles and length relationships [2].

Characteristics and Indication of the Method In its most basic form, a Z-plasty transposes two interdigitating triangular flaps drawn in the form of a “z” or a reversed “z” and results in the lengthening of and directional change in the common limb. Within this basic premise, Z-plasty has found many uses in plastic surgery. This includes lengthening a scar contracture in M. B. Donelan, MD (*) Division of Plastic Surgery, Shriners Hospital for Children, 51 Blossom Street, Boston, MA 02114, USA R. K. Chan, MD Division of Plastic Surgery, Shriners Hospital for Children, 51 Blossom Street, Boston, MA 02114, USA e-mail: [email protected]

the longitudinal direction, narrowing the scar in the transverse direction, changing the direction of a scar, breaking up a scar, flattening an either raised or depressed scar, and correcting contour deformities such as creation of a web-space. In a postburn patient, Z-plasty is often used to camouflage a hypertrophic scar. The most obvious is the one which “bowstrings” across a hollow with excess tissue on either side. Z-plasty acts to lengthen the contracted common limb, borrowing tissue from either side. The direction of the scar is also secondarily changed, coinciding with the line of the shadow, and resulting in a pleasing visual outcome. Even when the contracture is more diffuse, Z-plasty can be used to flatten the scar, as long as the side limbs of the z can reach lax, normal skin. At the extreme, the scar is so diffuse that transverse skin laxity is absent, and autografting is needed. Commonly, a z-plastied hypertrophic scar might develop a second area of banding which requires additional z-plastic releases at a later date. Clinically, it is remarkable that hypertrophic scars soften and thin following Z-plasty even without the removal of any of the scar tissue. Part of this is mechanical as the previously protuberant scar has been halved and redistributed into different location and direction. Reorientation of the fibers and relief of tension also have biochemical consequences. Longacre et al. performed histochemical studies of tissue before and after Z-plasty and showed that abnormally sulfated mucopolysaccharides were replaced by normal acid mucopolysaccharides within 14 days [3]. Collagen that appeared in nodules in hypertrophic scar is decreased in quantity and reoriented into bundles at right angles to each other, resembling normal skin. Hydroxylprolene and hydroxylysine, molecules unique to collagen degradation, were found in higher concentration in urine ­following Z-plasty. All these findings indicate that biochemical scar remodeling occurs following Z-plasty, leading to a clinically more inconspicuous scar.

H. Hyakusoku et al. (eds.), Color Atlas of Burn Reconstructive Surgery, DOI: 10.1007/978-3-642-05070-1_21, © Springer-Verlag Berlin Heidelberg 2010

Use of Z-Plasty in Burn Reconstruction

Specific Skill of the Methods The most important factor leading to the successful outcome following Z-plasty is planning. One measure of the design and execution of a Z-plasty is the behavior of the flaps following division. With tension release, these flaps should literally fall into position with difficulty returning them into their original place. Each limb of the Z-plasty should be equal. For most applications, a 60° angle between the common limb and the side limbs results in a theoretical 75% gain in length of the common axis, although realistically it is usually less [4]. In practice, most surgeons maintain a 60° angle but vary the length of the common limb, as determined by the amount of transverse skin available. When the scar is long, it might be necessary to make tandem z-plasties, thereby limiting the required transverse length.

Chapter 21

The correct way to cut a Z-plasty is to first incise the central limb, then releasing the side limbs of the Z-plasty by cutting toward the middle, and rounding out the corners toward the end, almost orthogonal at the junction with the common limb. Tissue tends to retract as one cuts away from the corner leading to flaps that are smaller than intended, compromising blood supply. For the novice, it is important to incise deep enough beyond the scar plane down to healthy subcutaneous tissue. The corner stitches often bear the most tension during closure; additional stitches should be placed to take tension off that point. Z-plasty has found many uses in plastic surgery and is definitely part of every plastic surgeon’s armamentarium. The principle of Z-plasty is well established. Each surgeon will modify the technique to suit one’s individual needs. Continual evaluation of one’s results using preoperative and postoperative imaging is paramount.

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Use of Z-Plasty in Burn Reconstruction

Clinical Cases + Case 1: Axillary Contracture

21

This postburn axillary contracture involves both the anterior and posterior axillary folds (Fig. 21.1a). This is typical of the hypertrophy seen with repeated tension, which in severe cases can even lead to ulceration (Fig. 21.1b). Incisional releases were designed using tandem Z-plasties within the hypertrophic scar (Fig. 21.1c). This achieves tension relief and reorientation of the collagen fibers, allowing the scars to favorably remodel. The central limb of the Z-plasty was designed over the hypertrophic band with the lateral limbs extending into adjacent normal, supple skin. Note immediate relief of the scar contracture without need for additional skin grafting or scar excision (Fig.  21.1d). After Z-plasty release, there is minimal need for therapy and no need for splinting. Three years after release, the scars are soft and supple and the contractures are completely corrected (Fig. 21.1e, f (before, after)).

Use of Z-Plasty in Burn Reconstruction

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Use of Z-Plasty in Burn Reconstruction

+ Case 2: Neck Contracture

21

Neck contracture developed following partial thickness flame burn, acutely treated with tangential excision and split thickness skin grafting. The contracture resulted in loss of a normal chin-neck angle (Fig. 21.2a). She underwent two separate Z-plasty procedures to release the contracture and improve neck contour. The initial procedure used two large z-plasties which included the entire area of graft and scar (Fig. 21.2b). This lengthened the vertical contracture, narrowed the scarred area transversely, and deepened the chin-neck angle by appropriate placement of the Z-plasty flaps (Fig. 21.2c). The second procedure uses more focal z-plasties to further narrow and lengthen the contracted tissues (Fig. 21.2d). One year following the two procedures, tension has been eliminated and the neck contour is normal (Fig. 21.2e).

Use of Z-Plasty in Burn Reconstruction

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C h a p t e r 22

Local Flaps for Burned Face allen liu and julian pribaz

Principles in Facial Burn Reconstructions

Resurfacing

The burned face is the single most important anatomical structure a burn surgeon is called upon to reconstruct. The face serves important function in the identification of the individual and contains organs of sight, smell, speech, respiratory exchange, and nutrition intake. Its distortion can potentially cause functional impairment and also deformities that lead to the withdrawal of the victim from society. The complex shape and form of the human face renders reconstruction difficult and the exposed position of the face allows only limited camouflage with clothing and make-up. In general, local flaps bring in tissue with similar color and texture for reconstruction and potentially achieve the most optimal result. However, in the burned patient, the usual local flaps that may be available in other traumas are not available due to concomitant damage in the burn injury. The depth of the burn injury in the face is variable, and generally partial thickness burns are allowed to heal by secondary intention, producing scars of variable consistency that traverse the normally assigned subunits. In most cases, one should wait until scars are no longer itchy, red, raised, and tight before embarking on reconstruction. This usually occurs 6–18 months postburn [1]. Mature scars, which are white, soft, and relatively flat, are much more suitable for reconstructive surgery. This chapter will examine the role of local flaps in reconstructing the following problems encountered in the burned face: (1) resurfacing, (2) contracture release, (3) contour restoration, (4) restoration of hair-bearing tissue, and (5) secondary sculpting of free tissue transfer with local flaps.

It is much more common to use skin grafts – preferably full thickness or thick split sheet grafts that reconstruct an entire subunit. There is seldom enough laxity and unburned tissue to use local advancement or rotation flaps in reconstructing the burned face. With more limited burns, expanded flaps from the lateral cheek may be used to resurface more central defects, or flaps from the forehead to resurface the nasal tip (Fig. 22.1). Obviously, the unburned neck and supraclavicular areas can be expanded and used for facial resurfacing, but these flaps are discussed in other chapters.

J. Pribaz, MD (*) Division of Plastic Surgery, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115, USA e-mail: [email protected] A. Liu, MD Division of Plastic Surgery, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115, USA

Contracture Release The areas of the face that are most vulnerable to contractures, which produce both functional and aesthetic deformity, include the eyelids, the nostrils, the alar bases, the oral commissure, and the lips. General principles involve the release of the contracture, return of the tissue to its normal location, and repair of the resulting defect with either a full thickness skin graft or a local flap. Local flaps usually involve the transfer of adjacent healed burned tissues. Even though these tissues may have been burned and possibly even grafted, after healing and scar maturation, the tissue can be raised with its subcutaneous vascularized pedicle as a flap [3]. The simplest local flap is a Z-plasty, and this may be used to realign an eyebrow or an alar base displaced by scar contracture. A local transposition flap from either the lower forehead or upper eyelid may be used to reconstruct an ectropion of the lower eyelid. Local transposition flaps may also be used from the nasolabial region to release a contracture of the ala. The oral commissure is another area that is commonly injured in burns, resulting in scar contracture, which can greatly limit mouth opening (Fig.  22.2). Thermal circumoral burns commonly produce contracture at the commissure, and electrical burns, especially

H. Hyakusoku et al. (eds.), Color Atlas of Burn Reconstructive Surgery, DOI: 10.1007/978-3-642-05070-1_22, © Springer-Verlag Berlin Heidelberg 2010

Local Flaps for Burned Face

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⊡ Fig. 22.1  A middle-aged woman suffered thermal burns to the right side of her face. She had superficial burns to the majority of her forehead, right cheek, dorsum of the nose, nasal tip, upper and lower eyelids, and chin. The burn injury to her nasal alas was full-thickness, leading to full defect of her entire right ala and almost 90% defect of her left ala (a). Burn scarring and contracture also lead to loss of projection and abnormal contour of her nasal tip. Tissue expansion of

right forehead skin was performed for reconstruction of her nasal alar defects and also to resurface her nasal dorsum and tip (b). She also has local turn-over flaps of healed burn scar on distal end of the nose for nasal lining, and cartilage grafts were used for support of alar rim and tip projection (c). Appearance of the patient after reconstruction (d–f). Superficial burn scars of nasal dorsum and nasal tip had been excised and resurfaced with the forehead flap

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⊡ Fig.  22.2  This middle-aged man suffered acid burns to his eyes, nasal tip, nasal alas, cutaneous upper lip, as well as oral mucosa on the right side (a). He developed blindness, and upper lip incompetence due to scar contracture of the cutaneous upper lip. In addition, the contracture of his oral mucosal scarring on the right side limited his mouth opening on that side. Submental flap was designed based on the submental artery, which is a branch of the facial artery, to resur-

face the intraoral defect created after release of oral mucosal contracture on the right side (b). To store the hair-bearing cutaneous upper lip after burn scar excision, a bipedicled hair-bearing scalp flap, based on the superficial temporal arteries on both sides, was used (c, d). The scalp flap was rotated down like a “bucket handle” and inset. The pedicles were divided a few weeks later. Appearance of the patient 1 year after reconstruction (e)

Local Flaps for Burned Face

in children who place live wires in their mouth, can produce extensive scarring. In electrical injuries the prolonged use of commissure splints can minimize the contracture. In both types of burns, once the contracture occurs, the reconstruction involves the release of the external skin contractures and resurfacing of the defect with a local intraoral mucosal flap into the crux of the defect, with vermilion advancement flap to restore the adjacent lip vermilion. If more bulk is needed, a facial artery musculomucosal flap from the buccal area or the tongue flap is a good alternative [8]. The superior surface of the tongue may have a texture that is too rough in comparison to the normal lip. This can be avoided in lower lip reconstruction by using the smoother undersurface of the tongue [5]. Ectropion of the lip vermilion is generally repaired with a full thickness skin graft rather than a local flap (Fig. 22.3).

Contour Restoration Burn injuries on the face can cause a loss of protruding facial features, such as the nose and its subunits, the ears, and the lips. Scarring of adjacent regions can further distort these structures and alter the contour of the cheek, the nasolabial fold, the lower lip, the chin, and the supramental crease area. Neck contractures can often cause extrinsic pull on the lips and even the eyelids. The neck contractures should be addressed before one proceeds with lip or eyelid reconstruction [6, 7]. Lower lip contractures can also lead to upper lip distortion, and should be released before the upper lip [7]. One of the axioms in reconstructive surgery is that contour restoration is more important than minimizing scars, which in time can lose its redness and tightness [4]. Scars can also be better camouflaged with make-up, whereas contour problems need to be reconstructed with rearrangement of surrounding tissues. Even if the surrounding tissues have suffered in the burn injury, the deeper blood supply is generally undisturbed, and thus local fasciocutaneous flaps can be raised and utilized to restore the contour lost from protruding structures, especially the nose. Thus, the forehead flap and nasolabial flaps are often used to reconstruct the nose. Often in facial burns there is a paucity of adequate tissue for reconstruction. As a result, one should consider the utility of any tissue before discarding it, in case it can be used for reconstruction. Even scar tissues can be utilized. One should keep this in mind before excising tissues to complete an aesthetic subunit [1]. A good

Chapter 22

example is concomitant burn to the upper lip and the nasal base, especially when there is also extensive facial and forehead burn injury. If the upper lip needs resurfacing, the disposable scar in the upper lip area may be transposed to augment the nose [2, 3]. The small scar flaps will usually survive if handled gently and cut thickly with some fat on their undersurface to preserve the subdermal blood supply. One can even delay these scar flaps 1–2 weeks before their actual use [3]. A combination of local flap rearrangement and sheet skin grafting of subunit areas is also a commonly used technique. In these cases after the burn scar is excised and contractures are released, the underlying tissue can be raised as small local flaps and transposed locally to restore the contour and then the entire area covered with a sheet of thick skin graft. One area that this technique is commonly used is the lower lip/supramental crease/chin region, where local turn-over flaps of tissue is moved from the region of the supramental crease, where an indentation is desired, to the area immediately above (in the lower lip), and immediately below (the chin prominence) (Fig. 22.3).

Restoration of Hair-Bearing Tissue Deeper facial burns often injure the hair follicles in hairbearing areas. In both sexes the scalp hairline, eyebrows, and sideburn may be involved, and in men, the bearded areas around the mouth and in the neck may be partially or totally lost. The use of hair-bearing local flaps to restore these regions is a very effective method of significantly enhancing a more normal appearance in burned patients. Tissue expanders are commonly used in the scalp, and this is discussed in detail in other chapters. Scalp flaps are also useful for restoring the sideburns. Eyebrow reconstruction works particularly well for those with extensive burn scarring of the face. The presence of hair can make the facial appearance more aesthetically pleasing by breaking up the uninterrupted area of scars. An island hair-bearing scalp flap based on the superficial temporal artery can be raised and tunneled through the temporal skin to reconstruct the eyebrow. For optimal result, one must ensure that the reconstructed eyebrow be symmetrical to the contralateral normal eyebrow and that the hair follicle direction mimics that of the normal brow [1]. In the beard area, if there are small areas of alopecia, advancement flaps (especially V-Y flaps) of adjacent hair-bearing tissue can be used effectively (Fig.  22.4).

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⊡ Fig. 22.3  This middle-aged woman suffered circumferential oral burns, as well as burns to her bilateral cheeks and nasal alas. Scar contractures of her cutaneous lower lip and chin area produced lower lip ectropion, oral incompetence, and limitation of mouth opening (a). The contour of her lower lip and chin area was also abnormal due to the absence of a supramental crease (b). The burn scar was first excised to release the contracture. To give her lower lip and chin area a more normal contour, local turn-over flaps of subcutaneous tissue was moved from the region of the supramental crease, where an indentation is desired, to the area immediately above (in the lower lip), and immediately below (the chin prominence) (c). Note the supramental indentation after flap transposition (d). A full thickness skin graft from the lower abdomen was used to resurface the cutaneous defect and bilateral commissuroplasties were performed (e). Appearance of the patient after reconstruction. Note the increased mouth opening and also the more natural contour of the lower lip and chin, imparted by the supramental crease and chin prominence (f–h)

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⊡ Fig. 22.4  This middle-aged man suffered thermal burns to his face, leaving him with a full-thickness defect of the lower third of his nose, scar contractures of his right central cheek and malar region, as well as a nonhealing ulcer over his right zygomatic prominence (a). His underwent a prelaminated free radial forearm flap for reconstruction of the lower third of his nose and to resurface his right central cheek and malar region (b). The area reconstructed by the prelaminated free flap lacked natural contours, with no clear boundary between the right cheek and the nasal sidewall, as well as an absent right nasolabial fold. The flap was sculpted to create these natural landmarks. Incisions were made along where the cheek is expected to border on the nasal sidewall and the nasal ala. The expected location of the nasolabial fold was also incised (c, d). Underlying soft tissue was trimmed and the incisional edges tacked down to deep fascial layer to further enhance the definition of the subunit borders. More natural contour of patient’s right face, with more defined cheek-nasal sidewall-ala borders and nasolabial fold (e). This patient also had a V-Y advancement of left upper lip hair-bearing tissue to reconstruct an area of burn alopecia centrally (f–h)

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For larger areas, staged pedicle or bipedicle island flaps from the scalp based on the superficial temporal artery can be used – or if uninjured, the hair-bearing submental region is another source of local flaps to restore the beard area, though donor site scarring may be more prominent [3] (Fig. 22.2).

Secondary Sculpting of Free Tissue Transfer with Local Flaps Free flaps to resurface a burned face are seldom used, but when they are required, the initial result is suboptimal, as the reconstruction is flat and lacks the natural contours. The result in these patients can be significantly improved if at secondary revision, the free flap is sculpted according to the subunits. This can be achieved by placing scars

Local Flaps for Burned Face

within the free flap in the nasolabial region, the supramental crease, and the philtrum, as well as by a combination of selective trimming and deeper subcutaneous flap rearrangement (Fig.  22.4). This way, the more natural contours of the face can be achieved. The scars that are left are a worthy trade-off to the improvement in contour. Local flaps provide the ideal tissue for facial burn reconstruction in terms of tissue color and texture match. Despite the challenges posed by facial burn reconstruction, the following general principles can be applied to optimize outcomes: (1) delay of reconstruction until after scar maturation, (2) release of contractures and extrinsic sources of distortion, (3) the primacy of contour restoration over scarring, (4) conservation of tissues, even those scarred, for reconstruction, and (5) use of hair-bearing flap to restore normal hairline in hair-bearing areas.

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The Square Flap Method hiko hyakusoku and masataka akimoto

Background of the Technique The square flap method was presented in 1985 [1] in Japanese and in 1987 [2] in English. This method consists of a square advancement flap and two triangle transposition flaps (45° and right angle, respectively) (Fig.  23.1). It was devised as an extension method of length between two points similar to Z-plasty. Initially, the method was applied to repair the cleft case such as the earlobe cleft (Fig.  23.2a). On the other hand, the method has superior lengthening effect to Z-plasty (Fig. 23.2b); this method can be applied to reconstruct scar contracture (Fig. 23.3).

Characteristics and Indication of the Method This is one of the methods for repairing scar contractures such as Z-plasty or the method derived from it. In particular, three-dimensional (3D) reconstruction of axilla, cubital fossa, neck, and digital space should be indicated when the scar band is narrow (Fig. 23.4). Moreover, we insist that an advantage of this method is that the square flap does not divide hairy areas of the axilla.

Specific Skills of the Method 1. The angle of the triangular flaps should not be acute to prevent necrosis. Sometimes triangular flaps include scars; thus, we should try to design the angle such that it is as blunt as possible.

2. Square and triangular flaps should be elevated to a conventional thickness of skin flap. 3. The marginal length of the square flap is determined based on the possibility of the flaps joining, that is to say, it depends on the tension of the vertical direction to the elongation course.

Mathematical Theory Geometrical Theory Geometrically, the lengthening rate of the method is +180% [2]. This rate is the longest of all the methods derived from Z-plasty.

Computer-Aided Analysis Here, a computer-aided analysis using the finite element method (FEA) is shown (Figs.  23.5a–c and 23.6). The superiority of the square flap method in repairing scar contracture seems to have been proven. The calculated elongation ratio of the square flap method is 1.9 (90%) by FEA, and 2.8 (180%) by simple geometrical analysis. The smaller elongation ratio is due to the consideration of elasticity and 3D deformation. Among other highpowered local flaps, such as 90° Z-plasty or four-flap Z-plasty, the square flap method shows a higher elongation effect (Fig. 23.6).

M. Akimoto, MD, PhD (*) Plastic and Reconstructive Surgery, Nippon Medical School, Chiba Hokusoh Hospital, Chiba, Japan e-mail: [email protected] H. Hyakusoku, MD, PhD Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School Hospital, Tokyo, Japan e-mail: [email protected] H. Hyakusoku et al. (eds.), Color Atlas of Burn Reconstructive Surgery, DOI: 10.1007/978-3-642-05070-1_23, © Springer-Verlag Berlin Heidelberg 2010

The Square Flap Method

Chapter 23

⊡ Fig.  23.1  The square flap method. A square advancement flap, 90° and 45° triangular transposition flaps are joined

a T S

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⊡ Fig.  23.2  (a) Application of the square flap method to repair a cleft. (b) The longest lengthening effect of the square flap method

⊡ Fig. 23.3  Application of the square flap for scar contracture releasing. Wider scar band can be divided by the square flap method

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⊡ Fig.  23.4  Postoperative view of the square flap method calculated using finite element analysis (FEA) program. Pink–red area indicates higher z-axis displacement. (a) Ninety

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The Square Flap Method

degree Z-plasty. (b) The square flap method. (c) Forty-five degree four flaps Z-plasty

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⊡ Fig. 23.5  Computer simulation model analysis by FEA. Postoperative shape of each method is shown in bird’s eye view

3 2.5 2 FEA geometric

1.5 1 0.5 0 Z-plasty (90deg.)

Square flap method Four flaps Z-plasty

⊡ Fig. 23.6  Calculated elongation ratio of each method by FEA and simple geometrical analysis

The Square Flap Method

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The Square Flap Method

Clinical Cases + Case 1 (Fig. 23.7): Axillary Reconstruction A 9-year-old girl had a scar contracture in her left axilla after burns (a). The square flap method was used to correct it (b). The region where axillary hair will grow in the future was included in the square flap to avoid dividing it after the flap had been transposed (c).

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The Square Flap Method

+ Case 2 (Fig. 23.8): Anterior Neck Reconstruction A 34-year-old man had a severe scar contracture on his neck after burns (a). As the scar was linear from the chest to the jaw, two square flap methods were used to release the contracture (b). The scar contracture was removed without any free skin grafts (c).

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The Square Flap Method

+ Case 3 (Fig. 23.9): Elbow Joint Reconstruction A 9-year-old boy had a scar contracture of the right elbow joint due to burns (a). The square flap method was applied to reconstruct it (b, c). The length of the square flap was determined by skin tension in the vertical direction to the course of elongation.

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+ Case 4 (Fig. 23.10): Digital Web Reconstruction A 3-year-old boy had scar contractures of the right digital web space due to primary skin grafting caused by burns (a). The square flap method was applied (b, c, d).

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Propeller Flap and Central Axis Flap Methods hiko hyakusoku and masahiro murakami

Background of the Technique Extensively burned patients often lack ample healthy skin for skin grafts. We have developed a method for using several novel flaps composed of healthy skin left around recipient sites. In 1991, Hyakusoku et al. [1] presented a propeller flap with a subcutaneous pedicle. The original propeller flap has been used in intact fossa to reconstruct the axilla or cubitus. The flaps are designed in the center of the fossa and were elevated as island flaps. Hyakusoku et al. indicated that perforating vessels are often constant in their pedicles [1]. After this report, some improvements that were made on the methods have been reported such as the multilobed propeller flap [2], and scar band rotation flap [3]. A subcutaneous pedicle is under the center of every flap; thus, these methods were categorized as “central axis flap methods” [4]. Nowadays, subcutaneous pedicle has been refined and vascular (perforator) pedicle propeller (PPP) flaps [5] are in wide-spread use. This PPP flap is introduced in another chapter of this book.

Characteristics and Specific Skills of the Method Propeller Flap Method (Fig. 24.1a)

perforators using Doppler. We then released scar contractures by flap rotation. The flaps were easily rotated, and two scar bands could be released simultaneously. However, covering the donor sites was sometimes difficult, and small skin grafts may be needed when doing such covering.

Multilobed Propeller Flap Method (Fig. 24.1b) The “multilobed propeller flap method” [2] was recently developed in an attempt to overcome disadvantages of the original “propeller flap method.” Small lobules attached to the sides of the propeller flaps reduce the need for free skin grafts. We have applied the method to produce various shapes according to the shape of the scar. When using intact axilla, we ensure that the flap does not run off any hairy region over the edge of the fossa. Flaps are designed as bilobes, trilobes, or quadrilobes and the pedicle is as thick as possible to maintain the rotation angle and minimize tension. Flap rotation can be in the clockwise or counterclockwise direction. The larger lobe of the nonsymmetrical flaps should be used to divide the contracture. The donor site can generally be closed primarily after flap elevation and rotation at an angle of 90°. The lobes are ideally used on normal skin, but may be designed for scars.

Flaps were vascularized from the subcutaneous pedicle in the central portion. We generally need not identify

H. Hyakusoku, MD, PhD (*) Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School Hospital, Tokyo, Japan e-mail: [email protected] M. Murakami, MD, PhD Department of Plastic and Reconstructive Surgery Nippon Medical School, Musashi Kosugi Hospital, Kanagawa, Japan e-mail: [email protected] H. Hyakusoku et al. (eds.), Color Atlas of Burn Reconstructive Surgery, DOI: 10.1007/978-3-642-05070-1_24, © Springer-Verlag Berlin Heidelberg 2010

Propeller Flap and Central Axis Flap Methods

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Chapter 24

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⊡ Fig. 24.1  Original propeller (a). Multiloped propeller flap method (b)

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Clinical Cases + Case 1 (Fig. 24.2)

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A 17-year-old boy had scar contractures at the left elbow after severe flame burns in a traffic accident (a). Thus, we planned a propeller flap to release the scar contracture. After 90° rotation of the flap, the skin defects that resulted from the flap rotation were not covered with skin grafts, but were epithelialized within a month. After a year, functional recovery of the elbow joint region was perfect (b).

Propeller Flap and Central Axis Flap Methods

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Chapter 24

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⊡ Fig. 24.2  Properative view (a). 6 months postoperative view (b)

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Propeller Flap and Central Axis Flap Methods

+ Case 2 (Fig. 24.3) A 25-year-old man had scar contractures on his left axilla after an extensive burn. An operation was performed to release the contracture. A quadrilobed propeller flap method was used (a, b). The flap was rotated almost 90° and the contracture was released completely (c). The result was excellent not only functionally but also cosmetically; the axillary hair area was not divided (d).

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Chapter 24

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⊡ Fig. 24.3  Preperative view (a). intraoparative view (b). 6 months postperative view (c)

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+ Case 3 (Fig. 24.4)

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A 13-year-old boy suffered from an extensive flame burn. After emergency skin grafting, severe contractures occurred in the cubital fossa of both upper limbs. In the right limb, some normal skin remained in the cubital fossa. Therefore, a quadrilobed propeller flap was designed (a, b). A scar on the ulnar side was also included in the flap. The flap was elevated, and clockwise rotation was performed to release the contracture (c). The flap donor site was primarily closed without problems (d). In this case, release of the contracture proved insufficient soon after the operation because the remaining normal skin was little and the flap was too small. However, 3 years after the operation, full extension of the elbow joint was achieved as a result of an expansion effect in the flap, including normal skin (e).

Propeller Flap and Central Axis Flap Methods

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Chapter 24

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⊡ Fig. 24.4  (a) Preoperative view. (b, c) Flap elevation. (d) Postoperative view. (e) Three year postoperative view flap survived completely, including in the scarred area (arrow)

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Propeller Flap and Central Axis Flap Methods

+ Case 4 (Fig. 24.5)

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A 17-year-old boy suffered from extensive burns. A right axillary scar contracture occurred after a life-saving skin graft was performed. Healthy skin remained in the center of the right axilla between the scar band in the anterior and posterior axillary lines. The scar contracture was reconstructed using the “multilobed propeller flap method.” The range of motion (ROM) of the right shoulder joint improved from 60 to 120°.  The contracture has not recurred during the past 3 years since the operation.

Propeller Flap and Central Axis Flap Methods

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⊡ Fig. 24.5  Preperative view (a). Flap elevation (b, c). After flap rotation (d). Three months postoperative view (e)

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Facial Reconstruction pejman aflaki and bohdan pomahac

Introduction Facial burn reconstruction is one of the most challenging problems a plastic surgeon encounters. As much as 80% of the morbidity of burn injuries results from burns to the face and hands. Head and neck burns affect approximately 50% of the patients admitted to a burn center, the majority of which are partial-thickness, and they heal well without surgical intervention [1, 2]. Facial reconstruction should be an integral part of the acute management of facial burns and continued throughout the patient stay in hospital and the rehabilitation process.

Principles of Burn Facial Reconstruction Accurate assessment of the burn depth and extent is the key step in the treatment of facial burns and will largely dictate the subsequent management decisions. The goals of reconstruction are the protection of function, restoration and maintenance of the contour and shape of individual facial structures, and achieving good color and texture match, whenever possible. Except for unique circumstances, no skin graft will ever look as natural as preserved facial skin. The quality of reconstruction (aesthetics, mobility, and late complications) seems to correlate to the thickness of preserved or added dermis by the thickness of the graft. Preservation of dermis is therefore critical. We have adopted an aggressive removal of the superficial debris in mid to deep dermal burns to minimize inflammation and

B. Pomahac, MD (*) Division of Plastic Surgery, Harvard Medical School, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115, USA e-mail: [email protected] P. Aflaki, MD Division of Plastic Surgery, Harvard Medical School, Brigham and Women’s Hospital, Boston, MA 02115, USA

chance of superficial infection. Extensive third-degree burns should be excised early after injury, while small third-degree burns can occasionally be managed following the principles of facial reconstruction similar to cancer or trauma defects. Wherever possible, aesthetic units of the face must be respected to guide both excision and grafting or other reconstructive procedures [3]. The grafts and flaps should be designed in such a way that scars are located within the lines of facial expression (e.g., nasolabial fold) or lines of contour (e.g., mandibular margin). It is imperative that thick skin grafts are used, as thin skin grafts frequently lead to the development of contractures. In resurfacing only part of the face, the graft should be taken from an area with appropriate colormatch with the unburned areas, usually form the scalp, neck, or supraclavicular area. In resurfacing the entire face, the issue of color match becomes irrelevant.

Management of Superficial to Mid-Dermal Burns In light of the dynamic nature of the burn wound, management of the facial burn wound should be directed at prevention of progression to deeper injuries and achieving early closure. Adequate fluid resuscitation, prevention of wound sepsis and providing a wet/moist environment are key elements to minimize the conversion of areas of partial-thickness burn injuries that would heal spontaneously, to areas of deep dermal to full-thickness injuries that would require surgical intervention. Attempts must be made to accelerate skin regeneration by providing an optimal environment where keratinocytes can proliferate, migrate, and subsequently reepithelialize the burn wound. Such an environment can be provided by frequent hydrotherapy, topical antimicrobial agents, and occlusive dressing. Alternatively, in superficial and mid-dermal facial burns, use of Biobrane, a biosynthetic dressing, offers a number of advantages [4]. It adheres to the wound bed, prevents

H. Hyakusoku et al. (eds.), Color Atlas of Burn Reconstructive Surgery, DOI: 10.1007/978-3-642-05070-1_25, © Springer-Verlag Berlin Heidelberg 2010

Facial Reconstruction

evaporative water loss and desiccation, and serves as a barrier against invasion of microorganisms. In the facial region, it is particularly useful as it obviates the need for frequent painful debridement and hydrotherapy after the initial application and minimizes patient discomfort. It allows for frequent inspection without the need for being removed.

Management of Deep Dermal and Full-Thickness Burns Superficial to mid-dermal burns would typically heal within 2–3 weeks. Healing that takes longer than 3 weeks is indicator of a deep dermal or full-thickness injury. The distinction between these two groups of patients may not always be clear, necessitating a period of expectant management, in which the indeterminate burn injuries are given the opportunity to declare their true depth and regenerative capacity. Wound following 3 weeks is associated with ongoing inflammation, proliferation of granulation tissue, and scar formation prone to hypertrophy [5, 6]. Depending on location, scars can lead to contractures and secondary deformities. In small burns and certain locations, for example, where the concavities

Chapter 25

and flexion creases of face are not crossed, this process favoring healing by contraction and epithelial migration from the wound periphery may lead to superior results to grafting (forehead, dorsum of the nose). Mid to deep dermal burns develop by the end of tenth day a thin, superficial debris typically of a white shiny appearance that is avascular and prone to bacterial contamination and infection. We find surgical debridement of this debris highly valuable in our management of facial burns. Using dermabrasion or hydrocision (Versajet™, Smith and Nephew), this necrotic debris is removed in a very controlled fashion to punctuate diffuse dermal bleeding. Occlusive dressings can often be applied afterwards. Tangential excision of the facial burns is reserved for extensive, full-thickness injuries. It may not be easily applicable in particular in the complex central facial regions. Lack of delicate control over the level of excision makes it less than ideal when it comes to dealing with facial burns, where it is absolutely vital to avoid overexcision of the burned skin. In addition, it may cause excessive blood loss when used in the wellperfused facial skin threatening the take of autografts. For this reason, we have often staged the excision of facial full-thickness burns, and covered excised bed with allografts, followed by autografts several days later.

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Clinical Cases + Case 1: Superficial burn with Biobrane

25

A 38-year-old male who sustained second degree burns including facial burn in a house fire. He underwent fluid resuscitation and mid-dermal burns were managed with Biobrane™ on admission (Fig.  25.1a). Two weeks later, the Biobrane completely came off the patient’s face that healed without further complications (Fig. 25.1b).

Facial Reconstruction

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⊡ Fig. 25.1 (a, b)

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+ Case 2: Deep Dermal Burn – Dermabrasion

and Biobrane

25

A 53-year-old woman with history of depression suffered from extensive facial burns following a cooking accident when pot of oil caught on fire (Fig. 25.2a, b). Due to her past medical problems, facial burns were managed with conservative moisturization protocol until day 10 when she was taken to the operating room for dermabrasion and application of biobrane. Same patient 4 months following her accident (Fig. 25.2c, d).

Facial Reconstruction

Chapter 25

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⊡ Fig. 25.2 (a–d)

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+ Case 3: Full-Thickness Small Area Burn

25

A 41-years-old female suffering from epilepsy fell on a heat radiator during a seizure attack and sustained a contact burn to right side of her face while unconscious. The resulting contact burn was managed in an outside institution for 3 weeks prior to her presentation to our clinic (Fig. 25.3a, b). She was taken to the operating room and underwent local tissue undermining, rearrangement and neck advancement flap. Small skin graft was used behind the ear from a supraclavicular location. Healed face 3 months postoperatively is shown (Fig. 25.3c, d).

Facial Reconstruction

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a

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⊡ Fig. 25.3 (a–d)

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+ Case 4: Full-Thickness Extensive Burn

25

A 47-year-old male was involved in a motor vehicle accident. Car caught on fire and caused deep head and neck and other deep third-degree burns; 35% total body surface area. Facial, scalp, and neck burns were clearly deep third degree (Fig. 25.4a, b) and sequentially excised once patient’s overall condition allowed. The grafting continued with autografts and ultimately the exposed calvarium and nasal structures were reconstructed with two free tissue transfers, latissimus dorsi and radial forearm flap, respectively (Fig. 25.4c–e).

Facial Reconstruction

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⊡ Fig. 25.4 (a–e)

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C H A P T E R 26

The Expanded Transposition Flap for Face and Neck Reconstruction robert j. spence

Background of the Technique

Characteristics and Indication for the Technique

Resurfacing of the face and neck in burn survivors is best accomplished using skin from the “blush areas” of the upper body including the neck, shoulders, and upper chest. This gives the best color and texture match to the remaining normal skin of the face and neck. However, the amount of remaining normal blush area skin is frequently limited because of burn scarring in the area. Even when there is a normal amount of unscarred skin in the blush area, very large donor site deformities are left when large areas of the face and neck have to be replaced. Twenty-five years ago, I started using tissue expanders to expand the amount of normal skin particularly in the blush areas for resurfacing of the face and neck yielding enough normal skin to provide resurfacing with expanded full thickness skin grafts. The expansion also allowed the primary closure of the donor sites. From this, the use of the expanded skin as expanded transposition flaps for face and neck resurfacing evolved. Further experience and evolution led to the use of the redundant expanded pedicle skin as full thickness skin graft for resurfacing the central portion of the face where the thinner skin did not obscure the fine facial features of the central portion of the face as thicker flaps would. With time, an entire algorithm for resurfacing large facial deformities was developed with the expanded transposition flap as the central tool in the algorithm [1, 2].

1. When properly designed and executed, this technique provides the following: (a) Relatively thin, large expanded transposition flaps of well-matched color and texture for resurfacing of the entire large aesthetic units of the cheeks and neck. (b) Expanded full thickness skin graft for resurfacing of the aesthetic units of the central portion of the face allowing expression of the fine contours and subtle features of those aesthetic units. (c) Expanded skin remaining at the donor site for primary closure of the donor site. 2.  The indications include: (a) The requirement for replacing the skin of one or more of the large aesthetic units of the cheeks or neck because of contracture, excess hypertrophic scarring, or severe differences in pigmentation from normal surrounding skin. (b) The requirement for a reproducible, reliable way of providing symmetrical reconstruction of both sides of the face with well-matched skin. (c) The desire to close the donor site pri­marily. (d) The requirement to resurface the entire neck with normal skin in a reproducible and reliable way.

R. J. Spence, MD, FACS National Burn Reconstruction Center, Good Samaritan Hospital, 5601 Loch Raven Blvd, Baltimore, MD 21239, USA e-mail: [email protected]

Specific Skills of the Method [3] 1. Tissue expander placement and inflation: (a) A rectangular tissue expander is placed under the normal skin of the shoulders parallel to the line between the base of the neck and the tip of the shoulder approximately 3 months before the planned use of the expanded transposition flap. (b) The incision for the insertion of the tissue expander should be parallel to this long axis of

H. Hyakusoku et al. (eds.), Color Atlas of Burn Reconstructive Surgery, DOI: 10.1007/978-3-642-05070-1_26, © Springer-Verlag Berlin Heidelberg 2010

The Expanded Transpositor Flap

the shoulder as it will become the anterior border of the expanded transposition flap. (c) The amount of skin available is measured by subtracting the anterior–posterior distance across the base of the tissue expander from the anterior–posterior distance over the dome of the ­tissue expander (Fig.  26.1) This leaves enough expanded skin to close the donor site once the flap has been transposed. The tissue expander is expanded until the amount of skin available is in excess of the area that requires resurfacing. (d) Once adequate skin is available, transposition of the expanded flap is scheduled 2 weeks after the last injection. 2. Expanded flap transposition: (a) A final measurement of the amount of skin available is measured and marked as a widened, D = DOME

CHAPTER 26





F.W. = D–B



B = BASE

­ -shaped pattern on the lateral two-thirds of the V expanded skin with the scar from the insertion of the tissue expander as the anterior margin of the marking (Fig. 26.2). (b) The area of abnormal skin to be excised is marked, usually as an aesthetic unit, and excised. Normal eyelid skin is preserved. (c) A pattern of the excision wound is made and checked to make sure that the amount of skin necessary fits within the widened V-shaped pattern marked above. Ideally, the flap is somewhat larger than the pattern. The pattern is used to help in the final orientation and modification of the original V-shaped pattern (Fig. 26.3). (d) The lateral portion of the flap is incised along the V-shaped lines and raised as half of a lenticular pattern (Fig. 26.4a). (e) The tissue expander is removed and the medial portion of the expanded skin is examined for the presence of substantial blood vessels which will become the pedicle of the flap. The position of these blood vessels is marked on the skin (Fig. 26.4b, c). (f) The remainder of the flap is incised roughly along a lenticular-shaped pattern preserving as much skin as possible in the pedicle around the medial blood vessels and still allowing transposition of the flap on to the recipient site.

Flap Width Determination

⊡ Fig. 26.1  The available width of the transposition flap is measured by subtracting the distance across the base of the tissue expander from the distance measured over the dome. This leaves on an expanded skin for donor site closure (previously published in The Journal of Burns and Wounds [3])

⊡ Fig. 26.2  A widened, V-shaped pattern of available skin is marked on the lateral two-thirds of the expanded skin with the tissue expander insertion scar as its anterior margin (previously published in The Journal of Burns and Wounds [3])

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⊡ Fig. 26.3  With proper preoperative judgment and measurement, the pattern of the excision wound should easily fit within the V-shaped lines. If it does not, the pattern becomes the shape of the distal flap with the best fit with the lines (previously published in The Journal of Burns and Wounds [3])

(g) The flap is transposed often turning it 180° causing the pedicle to tube on itself allowing the pedicle to be closed along a spiral line as the flap is inset. The donor site is closed over a drain (Fig. 26.5). (h) Important points: • Ideally, the flap that has been raised is larger than the amount of skin required for the recipient site. These small amount of excess flap margin allows flexibility while insetting the flap. Once inset, the flap conforms anatomically to the recipient defect with contraction in areas of least tension. • The flap margins are gently curved but are made to lie straight along the marionette lines and straight across the lower eyelids of the cheek aesthetic units. This forces the normal lower eyelid up and is redundant often

a

b

c

d

⊡ Fig. 26.4  (a) The lateral two-thirds of the flap are raised off the tissue expander. (b) The vessels in the medial base of the expanded skin are observed through the capsule.

(c) A mark is placed just anterior and posterior to these vessels, and (d) the line of incision is extended up to these marks (previously published in The Journal of Burns and Wounds [3])

The Expanded Transpositior Flap

⊡ Fig. 26.5  The flap is transposed and inset. (a) In the face, the flap is turned 180° causing the pedicle to tube itself. (b) In the neck, the flap is turned 90°, and the pedicle can often be included in the closure

CHAPTER 26

causing temporary closure of the patient’s eyelids postoperatively. However, this is important subsequently as the cheek flap descends somewhat by gravity causing the lower eyelid skin to unfurl without causing an ectropion. • In resurfacing the cheek aesthetic unit, the tip of the flap and that portion of the flap over the lateral orbital rim are sutured to the periosteum of the medial and lateral orbital rims, respectively, with 4-0 clear nylon sutures to suspend the flap against the force of gravity. 3.  Division and insetting of the flap: (a) Division and insetting of the flap is routinely scheduled for 14 days after initial transposition of the flap. (b) The pedicle is divided at its base and the base wound is closed. (c) The spiral wound closure created by the tubing of the flap is reopened and the pedicle is unfurled. The pedicle is then re-draped over the margin of the recipient defect and marked. (d) The pedicle is then transected and inset along the margin of the recipient wound. (e) The residual, unscarred, expanded skin from the pedicle is frequently used as full thickness skin graft to resurface another aesthetic unit of the central portion of the face. (Please note that a more detailed description of this technique is found in ref. [1])

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Clinical Cases + Case 1

26

A 61-year-old woman sustained a 20% total body surface area burn off her face, neck, and bilateral arms in a house fire. She developed severe scarring of the right side of her face and a burn scar contracture of her neck (Fig. 26.6) Bilateral 13 × 7 cm rectangular shoulder tissue expanders were placed 1 year after her burn injury. Three months later, her neck burn scar contracture was released and a left shoulder expanded transposition flap was inset to resurface the release wound. One month later, the neck expanded transposition flap was divided and inset in the same operation with the excision of the scarred right cheek aesthetic unit and resurfacing with the right shoulder expanded transposition flap. Two weeks later, the right cheek expanded transposition flap was divided and inset and the full thickness skin graft from the pedicle was used to resurface the patient’s chin after the excision of hypertrophic burn scar contracture. Subsequently, residual hypertrophic scarring of the submental area was excised and resurfaced with a full thickness skin graft from the groin. The patient had two final operations to remove excess tissue bulk of first the lower half of the right cheek flap, and subsequently, the upper half of the right cheek flap. Five years after the surgery, she has had substantial improvement in the appearance and function of her face and neck, with excellent ability to show facial expression (Fig. 26.7).

The Expanded Transpositior Flap

CHAPTER 26

⊡ Fig. 26.6  Preoperative photos showing facial deformity and neck contracture

⊡ Fig. 26.7  Pre- and postoperative photos. Note the excellent ability to show expression through the right facial expanded transposition flap

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+ Case 2

26

A 38-year-old woman presented several years after a total anterior neck dermabrasion that resulted in intolerable scarring of her neck (Fig. 26.8). She requested total resurfacing of her rather long neck. Bilateral shoulder tissue expanders were placed and inflated. Three months later, the right expanded transposition flap was raised at its maximum dimension (Fig. 26.1) and transposed onto the neck to determine how much neck skin could be excised. That amount of neck skin was excised and the transposition flap was inset. Two weeks later, the first flap was ready for division and inset (Fig. 26.9). Its pedicle was divided at the base of the neck, and the left shoulder expanded transposition flap was elevated, and both were inset after excising the rest of the scarred right lateral neck skin (Fig.  26.10). Two weeks after that, the left expanded transposition flap pedicle was divided and inset after the final excision of the scarred neck skin completing the resurfacing of the neck (Fig.  26.11). Postoperatively, the patient did well and was pleased with her results 6 months after her surgery (Fig. 26.12).

The Expanded Transpositior Flap

⊡ Fig. 26.8  Preoperative photos showing extensive anterior neck scarring

CHAPTER 26

⊡ Fig.  26.9  Two weeks after transposition of the right expanded transposition flap

⊡ Fig.  26.10  Transposition and insetting of the left expanded transposition flap along with dividing and insetting the previously placed right expanded transposition flap pedicle

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+ Case 2 (continued)

26

The Expanded Transpositior Flap

The Expanded Transpositior Flap

CHAPTER 26

⊡ Fig. 26.11  Two weeks later, the left expanded transposition flap pedicle is divided and inset after final excision of the remaining scarred neck skin to complete the resurfacing

⊡ Fig. 26.12  Postoperative photographs 6 months after resurfacing

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C h a p t e r 27

Expanded Thin Flap chunmei wang, junyi zhang, and qian luo

Background of the Technique Extremely large and thin flaps are the first choice for reconstructing postburn scars in wide contour-sensitive areas such as the facial, cervical parts, and extremities. In 1996, Colson [1] initially repaired dorsal of hands with the thinned flap, which is now called “the graft flap.” After 1980, thin flaps with very narrow pedicel were developed in China [2], and Koshima [3] developed the free super-thin flap in Japan. In 1994, Hyakusoku [4] reported the perforator-supercharged subdermal vascular network (SVN) flap, which is the so-called perforator-supercharged super-thin flap. Thereafter, perforator-supercharged flaps were made much larger and that made thinner flaps possible [5–7]. Thus, on those antecedent models, we have used expanded randompattern flaps, perforator flaps, and prefabricated flaps to repair large areas of postburn scars, severe jaw and neck contractures, and scars in the dorsal area of hands that is highly required for the shape and function of the hand. As a result, problems like limitation of the donor site, difficulty in closure and operating have now been overcome.

Characteristics and Indication of the Method 1. Tissue expansion is a common way to harvest extra skin, especially for patients who have small amounts of normal skin around scars. 2. Tissue expansion has been applied to many kinds of flaps, such as random-pattern flaps, free flaps, perforator flaps, and prefabricated flaps.

C. Wang, MD, PhD (*) Dongguan Kanghua Hospital, Dongguan, China e-mail: [email protected] J. Zhang, MD and Q. Luo, MD Dongguan Kanghua Hospital, Dongguan, China

3. Expansion includes a delay procedure and a “passbridge” effect [8]. After implanting the expander, the flap loses connection with the bed. This effect stimulates the neogenesis of vessels and facilitates the formation of vessel network. From the animal experiments, we found the “pass-bridge” effect, because during the expansion, the skin perforator connected with others through neogenetic vessels to supply more areas (Fig. 27.1a) compared to control side (Fig. 27.1b). 4. In the early stage, the blood supply of the expanded and prefabricated thin flaps depends on the pedicle. Later, it quickly connects to the bed by the new-formed vessels. After being cut off from the pedicle, the flap depends on the blood supply from the bed. It is suggested that there is no ischemic phase during the time the flap is transferred to the recipient site. Moreover, the flap becomes thinner.

Specific Skills of the Methods 1. To expand the random-pattern flap, the expander is usually placed above the superficial fascia of the adjacent normal skin. To expand the perforator flap, the perforator artery should be detected by Doppler such as the superficial abdominal artery, intercostal artery, and descending branch of transverse cervical artery [9], after which the expander is put in the area dominated by the perforator at 2 cm away from the perforating point. 2. Design the flap according to the wound surface. After removing the expander, the flap will become thinner, and some parts of the capsule should be cut off. The SVN must then be preserved. 3. The perforator arteries should be detected by Doppler again in the expanded perforator flap. A narrow skin pedicle is also available. Venous drainage through the skin pedicle is strong, and will therefore facilitate safer harvesting of thin or large flaps. 4. After 9–14 days, the pedicles can be cut off.

H. Hyakusoku et al. (eds.), Color Atlas of Burn Reconstructive Surgery, DOI: 10.1007/978-3-642-05070-1_27, © Springer-Verlag Berlin Heidelberg 2010

Expanded Thin Flap

a

Chapter 27

b

⊡ Fig.  27.1  Angiograms of Expanded Swine Skin. (a) Expanded skin. (b) Non-expanded skin. The area between two large cutaneous perforators (red and blue arrows) were

expanded two-weeks. In the results, the neoangiogenesis of vessels were significant in the expanded skin

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Expanded Thin Flap

Clinical Cases + Case 1: Expanded Random-Pattern Flap

27

A 6-year-old boy suffered from flame burns (Fig. 27.2a). An expanded randompattern mandible skin flap and chest flap were designed to reconstruct the face (Fig. 27.2b). The expanded mandibular skin flap was advanced to cover the maxillary wound surface of the same side and the expanded chest skin was grafted to resurface the forehead and nose (Fig. 27.2c). In the follow-up after 3 years, the contour was clear and no hypertrophic scar was observed (Fig. 27.2d).

Expanded Thin Flap

a

Chapter 27

b

d

c

⊡ Fig. 27.2 (a–d)

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Expanded Thin Flap

+ Case 2: Expanded Perforator Flap

27

A 29-year-old male patient developed severe cervical contracture after extensive burns to the neck, shoulder, chest, and upper limbs (Fig.  27.3a).We designed an expanded superthin flap that was transferred from the back with the help of two perforators by “pass-bridge” (the descending branch of the transverse cervical artery and the circumflex scapular artery) (Fig. 27.3b). We rotated the left back flap (3 × 16 cm) with a 4-cm-wide pedicle to cover the neck wound surface and advanced the right back flap to the front to cover the shoulder wound surface. The flap is thin enough to visualize the contour clearly (Fig. 27.3c–f ). The closure of the back donor site was free of tension and no hypertrophic scar was left (Fig. 27.3g). No shrinking of the flap was observed after 2 years (Fig. 27.3h).

Expanded Thin Flap

Chapter 27

a

c

b

d

e

g

⊡ Fig. 27.3 (a–h)

f

h

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Expanded Thin Flap

+ Case 3: Expanded Prefabricated Flap

27

A 4-year-old girl suffering from fire burn had hypertrophic scars on the dorsal side of the hands (Fig. 27.4a). We prefabricated an abdominal perforator passbridge super-thin flap by expansion (Fig. 27.4b). The procedure included three steps. The first was to implant the expander (Fig. 27.4c).The next was to remove the scar and take out the expander forming the bipedicle flap to resurface the wound (Fig. 27.4d). The last was to cut off the pedicles and form the finger webs (Fig. 27.4e). The result after 1 month is shown in Fig. 27.4f. The donor site had no hypertrophic scar left (Fig. 27.4g). In the follow-up after 3 years, both the contour and the function of hand were satisfactory (Fig. 27.4h).

Expanded Thin Flap

a

c

d

⊡ Fig. 27.4 (a–d)

Chapter 27

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Expanded Thin Flap

Expanded Thin Flap

e

Chapter 27

f

g g

⊡ Fig. 27.4 (e–f)

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C h a p t e r 28

Tissue Expansion for Burn Reconstruction huseyin borman and a. cagri uysal

Background The first published clinical report of tissue expansion was by Neumann in 1957 [1]. Neumann used a subcutaneous rubber balloon to achieve the expansion of an area of the scalp for ear reconstruction. Later, Radovan [2] used a sophisticated silicone implant for breast reconstruction. Following some clinical and experimental studies [3, 4], tissue expansion has been accepted as one of the routine procedures in reconstructive surgery.

Basic Principles of Tissue Expansion in Burn Reconstruction Reconstructive ladder in burn reconstruction includes direct closure, adjacent tissue transfer, skin grafts, flaps, and tissue expansion [5–9]. Tissue expansion besides all other remedies facilitates burn reconstruction. The expansion of the skin peripheral to the scar can provide sufficient skin of ideal color, texture, thickness, and sensation with very low donor site morbidity [10–16]. The main disadvantage of the technique is the necessity to have at least two surgical procedures. The complications are exposure or infection of the tissue expander, pain, and long time needed for the total expansion. Basic principles of tissue expansion in burn reconstruction can be listed as follows:

A. C. Uysal, MD (*) Department of Plastic and Reconstructive Surgery, Nippon Medical School, 1 – 1 – 5 Sendagi, Bunkyo-ku, Tokyo 113-8603, Japan e-mail: [email protected] H. Borman, MD Department of Plastic and Reconstructive Surgery, Baskent University, Ankara, Turkey

• The technique should be used after all burns have thoroughly healed and scars have matured. • Preoperative planning is crucial so that once flaps are rotated suture lines are not parallel to previous scars. All planning should be made depending on the localization. Head and neck, trunk, and extremities are the three main localizations where the planning and procedure might change. • All the incisions should be vertical to the expansion plane. • Incision can be placed in previous scars, but the scar should be mature and relatively thick so that the extrusion does not occur. • The placement of multiple tissue expanders of smaller volume is better than one large tissue expander. • Perioperative antibiotics are always used as the incidence of infection is higher in these patients. • The amount of expansion should be monitored to prevent the necrosis of the expanded tissue and exposure of the expander. • The planning of the expansion should be considered depending on the localization: –– Head and neck: Caution should be used in advancing expanded neck skin beyond the border of the mandible. The risk of scar widening, possible lip or eyelid ectropion need to be considered. The expanded skin flap could be used to replace the burned areas, but unburned facial aesthetic units should not be violated. The gravity should be taken into consideration especially when the expander is placed to the cheek region. Thus, multiple and serial small expanders are better than one large expander. The flap adaptation should be performed with the head in extension or turned away. Multiple expanders depending on the curvature of the cranial bones should be planned. Caution should be used for pediatric patients for the deformations of the cranial bones. Expansion should be continued as much as possible as the

H. Hyakusoku et al. (eds.), Color Atlas of Burn Reconstructive Surgery, DOI: 10.1007/978-3-642-05070-1_28, © Springer-Verlag Berlin Heidelberg 2010

Tissue Expansion for Burn Reconstruction

expanded scalp flaps are still immobile when compared to any other skin flap. –– Trunk: Abdominal region posses differences when compared to dorsal and costal region. The expanders should be placed accordingly so that the pressure would not hinder any visceral functions. Abdominal expansion might not be feasible and predictable as the pressure would not expand the tissue thoroughly. Multiple small expanders might help to overcome the gravity problem in long term expansions at the trunk region. –– Extremities: Small, serial and multiple expansions should be planned. The pressure over the expander

Chapter 28

could be high because of the mobility of the extremities, and so, injections should be small in amount and more frequent. An alternative method to decrease the complication ratio has been performed in our clinic, followed by the experimental studies [17]. A silicone sheet with a size equal to the base of the expander has been used in all of the tissue expanders to decrease the amount of pressure over the expanded tissue. The silicone sheet is placed over the tissue expander during the tissue expander insertion. Thus the exposure of the tissue expander is not encountered at all.

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Clinical Cases + Case 1

28

A 10-year-old female was consulted with the complaints of scar tissue on her scalp and face due to flame burn. The left part of the frontal and parietal regions of the scalp were grafted as the acute treatment after burn. The scar was 8 × 17 cm. Preoperative planning was done for the reconstruction of the alopecia region of the scalp before the scar of the face (Fig. 28.1). Three expanders with dimensions of 150, 240, and 500 ml were placed on the right frontoparietal, right temporaparietal, and left temporoparietal region. As described above, a silicone sheet was inserted over each silicone expander to distribute the pressure evenly to the expanded skin (Fig. 28.2). Following the first operation, 1 week later, expansion was started and the expanders were injected with saline twice a week through the ports (Fig. 28.3). After 10 weeks, the second operation was performed. The scar tissue was excised and repaired with the expanded flaps. There were no complications during the expansion and after the flap adaptations (Fig. 28.4).

Tissue Expansion for Burn Reconstruction

⊡ Fig. 28.1  The preoperative view of the patient. On the left lateral view (left), the scar with dimensions of 8 × 17 cm at the left frontal and parietal regions of the scalp was visible. On

⊡ Fig. 28.2  A silicone sheet was inserted over each silicone expander to distribute the pressure evenly to the expanded skin in every expander procedure to decrease any complication depending on our experimental data

Chapter 28

the right lateral view (right), the scar on the right temporal region and face was visible

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Tissue Expansion for Burn Reconstruction

28

⊡ Fig. 28.3  Anterior (left) and left lateral (right) view of the patient on the postoperative second week during the expansion. External port utilization was preferred depending on the case

Tissue Expansion for Burn Reconstruction

⊡ Fig. 28.4  Postoperative 6 months of the patient, cranial view (left above) and posterior view (right above). Postoperative 1 year of the same patient, anterior view (left

Chapter 28

below) posterior view (right below). The alopecia was treated successfully and uneventfully

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Tissue Expansion for Burn Reconstruction

+ Case 2

28

A 7-year-old female patient was seen at the outpatient clinic with the scar tissue at the scalp region. The scald burn at the biparietal regions with a size of 7 × 10 cm was grafted 4 years ago as the acute burn treatment (Fig. 28.5). Two silicone expanders of 240 and 225 ml were placed at the frontal and the occipital region. The expansion was accomplished with weekly saline injections. After 7 weeks, the expanders were taken out, the scar tissue was excised, and the expanded flaps were adapted. There were no complications throughout the treatment except minor pain during expansion (Fig. 28.6).

Tissue Expansion for Burn Reconstruction

Chapter 28

⊡ Fig.  28.6  The postoperative sixth month view of the patient with a minimal acceptable scar

⊡ Fig. 28.5  The preoperative view of the patient with burn scar localized at the biparietal regions with a size of 7 × 10 cm. Two silicone expanders of 240 and 225 ml were planned to be placed at the frontal and the occipital region

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Tissue Expansion for Burn Reconstruction

+ Case 3

28

A 17-year-old female was admitted to our hospital with the complaint of scar tissue due to scald burn on her right forearm and right leg. There was a 8 × 16-cm scar tissue on the radial side of the right forearm. The scar tissue at the proximal part of the right anterolateral leg was 5 × 12 cm. Two expanders with sizes of 225 and 90 ml were inserted to the proximal and distal part of the scar tissue at the forearm, and simultaneously, two other expanders with sizes of 150 ml each were placed to the lateral and medial parts of the scar tissue at the leg. Two expanders were injected twice a week. After 8 weeks, the expanders were taken out and the scar tissues were reconstructed with the expanded flaps. There were no complications (Figs. 28.7 and 28.8).

Tissue Expansion for Burn Reconstruction

Chapter 28

⊡ Fig. 28.8  The scar tissue at the proximal part of the right anterolateral leg was 5 × 12 cm (above). Two expanders with sizes of 150  ml each were placed to the lateral and medial parts of the scar tissue at the leg. The postoperative sixth month view of the patient with minimal scar (below)

⊡ Fig.  28.7  The preoperative view of the patient with a 8 × 16-cm scar tissue on the radial side of the right forearm. Two expanders with sizes of 225 and 90 ml were inserted to the proximal and distal part of the scar tissue at the forearm with external port localization. (above). The postoperative sixth month view of the patient with minimal scar. Dorsal view (middle) volar view (below)

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Scalp Alopecia Reconstruction jincai fan, liqiang liu and jia tian

Background Scalp alopecia reconstruction usually requires fullthickness soft tissue coverage for functional purpose and hair restoration for aesthetical purpose. Since the hairbearing scalp is fixed in number after birth, the ideal solution for scalp alopecia is redistribution of the remaining hair-bearing scalp. Although a small alopecia defect can be repaired by wound closure or numerous types of local scalp flaps [1], a defect of up to 3–5 cm in width is commonly difficult to correct with traditional techniques due to the great tension on the wound closure and “stretch-back” that occurs later on [2–4]. When the scalp flap is not sufficient to repair the scalp lesion, numerous distant flaps are traditionally applied to improve the functional demands. Moreover, hair grafting may be another option to treat scalp alopecia only for cosmetic purposes [5]. However, if a lesion has the problem of unstable scar or thin skin grafting on the skull bone that often breaks down, bleeds, or infects, the hair grafting does not usually work well due to the high risk of lack of hair growth. The advent of tissue expansion started a new era to aesthetically reconstruct scalp alopecia, as it provides a natural hair-bearing scalp with acceptable hair density [2, 5–10]. Currently, it is believed that an alopecia area of up to 50% or more of the total scalp surface can be repaired by using tissue expansion (multistaged tissue expansion or serial tissue expansion) [11]. However, when the scalp defect is such that the hair direction of

the adjacent donor is not parallel to the recipient site, like “sideburns” or hemi-scalp defect, the traditional advancement flap does not usually match the aesthetical demand of the recipient site. On basis of the achievement of the advancement flap and rotation flap, an expanded “flying-wings” scalp flap was developed in our unit to properly manage large sideburn and hemi-scalp defects (Fig. 29.1) [8, 12]. Tissue expansion is usually not indicated to repair acutely injured wounds due to the disadvantages of a high risk of infection and the long time required for any result. In such a case, the tissue expansion should be

J. Fan, MD, PhD (*) Ninth Department of Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences, No. 33 Ba-Da-Chu Road, Beijing 100144, China e-mail: [email protected] L. Liu, MD, PhD and J. Tian, MD Ninth Department of Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences, No. 33 Ba-Da-Chu Road, Beijing 100144, China

⊡ Fig. 29.1  A flying-wings flap is designed by following the principles of an advancement flap and a rotation flap

H. Hyakusoku et al. (eds.), Color Atlas of Burn Reconstructive Surgery, DOI: 10.1007/978-3-642-05070-1_29, © Springer-Verlag Berlin Heidelberg 2010

Scalp Alopecia Reconstruction

carried out secondarily after the wound is completely healed by using traditional techniques (case 4).

Scalp Anatomical Characteristics The layers of the scalp, from the superficial to the deep, are the skin, subcutaneous tissue, galea aponeurosis, loose areolar tissue, and pericranium. The special characteristics are as follows:

1. Between the skin and galea, there are rich connective tissue fibers that make the structures connect firmly. It also allows the scalp flap become less elastic. 2. The scalp is nourished with five pairs of arteries: the supratrochlear artery, supraorbital artery, superficial temporal artery, posterior auricular artery, and occipital artery. The scalp flap can survive in a large size with a narrow and long pedicle. 3. The scalp is mainly innervated from the surrounding to the top with pairs of supratrochlear nerves, supraorbital nerves, auriculotemporal nerves, great auriculars, lesser occipital nerves, greater occipital nerves, and third occipital nerves. Nerve blockade can be easily achieved with good anesthetic results. 4. The subgaleal layer consists of loose areolar tissue and is easily elevated with less bleeding. 5. The direction of the scalp hair growth is angulated to the scalp surface.

Chapter 29

Specific Skill of the Methods 1. The donor site exposed to a tissue expander was usually selected depending on the position of the defect to be corrected, the hair direction required in the recipient site, the convenience to the patient, and the area of hair that will last long. 2. One or two tissue expanders are placed under the subgaleal pocket on one or two sides of the lesion, usually through a small incision in the lesion scalp. 3. The expander is then serially inflated with normal saline at an interval of 5–7 days until the desired volume is attained. 4. An expanded hair-bearing scalp flap should usually be designed with the combination of an advancement flap and a rotation flap, based at least on one nominated vascular system as the pedicle. A flying-wings flap is often used to correct hemi-scalp alopecia, where the wings often work to correct the distant side-part of the lesion with a great change in hair direction. 5. The expanded hair-bearing flap is elevated in the subgaleal layer when the expander is removed. The incision should always be carried out alongside the direction of the hair growth. 6. The scalp flap is then advanced and rotated to the recipient site when the lesion is excised.

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Clinical Cases + Case 1

29

A 6-year-old boy suffered from scalp alopecia after a scald in his infant period. About half of the scalp was coronally covered with about a 14 × 18-cm weak scar (Fig. 29.2a). A 600-mL rectangular tissue expander was placed into a subgaleal pocket of the posterior scalp of the head (Fig. 29.2b) and serially inflated to reach about 680  mL in volume with normal saline for about 4 months (Fig. 29.2c). Thereafter, a flying-wings hair-bearing flap was coronally designed and raised from the expanded scalp, based on the posterior pedicle including the vascular supply of the occipital arteries (Fig. 29.2d). The wing-parts of the flap were rotated to repair the sideburn defects, while the central part for coverage of the frontal defect was done with an advancement movement technique (Fig. 29.2e). Excellent results were achieved (Fig. 29.2f ).

Scalp Alopecia Reconstruction

a

d

b

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c

e

⊡ Fig.  29.2  An anterior hemi-scalp defect was repaired with a coronary design of a flying-wings hair-bearing flap. (a) Preoperative view. (b) View of selecting a desired ­tissue

f

expander. (c) View of the full-expanded hair-bearing scalp. (d, e) Intraoperative views. (f) Postoperative view after 2 weeks

Chapter 29

254

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+ Case 2

29

A 5-year-old boy had scalp alopecia with right hemi-scalp loss after burns when he was young (Fig.  29.3a). Two 400  mL rectangular tissue expanders were inserted in a subgaleal pocket of the left head and serially inflated to reach about 900  mL in volume with normal saline for about 4.5 months (Fig. 29.3b). Thereafter, a flying-wings hair-bearing flap was sagittally designed and raised from the expanded scalp, based on the lateral pedicle including the vascular supply of the superficial temporal artery and postauricular artery. The wing-parts of the flap were rotated to repair the defects of the right pre and postauricular lesions, while the central part for coverage of the top defect of the head was done with an advancement technique (Fig. 29.3c). Excellent results were achieved (Fig. 29.3d).

Scalp Alopecia Reconstruction

Chapter 29

a

b

c

d

⊡ Fig.  29.3  A right hemi-scalp defect was repaired with a sagittal design of a flying-wings hair-bearing flap. (a) Preoperative view. (b) View of full-expanded hair-bearing scalp.

(c) Illustration of transferring the flying-wings expanded scalp flap. (d) Postoperative view

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29

An 18-year-old young man suffered from posterior large scalp alopecia after a neurofibromatosis was excised. A 600-mL rectangular tissue expander was placed into a subgaleal pocket of the anterior scalp of the head and serially inflated to reach about 650  mL in volume with normal saline for about 4 months (Fig. 29.4a). Thereafter, a flying-wings hair-bearing flap was designed and raised from the expanded scalp, based on the anterior pedicle mainly including the vascular supply of the left superficial temporal artery (Fig. 29.4b). The flap was transferred into the posterior defect by the principles of the advancement flap and rotation flap, after the lesion was prepared (Fig. 29.4c). Good results were achieved with less change in the direction of the growing hair (Fig. 29.4d).

Scalp Alopecia Reconstruction

a

Chapter 29

b

c d

⊡ Fig. 29.4  A large posterior scalp defect was repaired with a single flying-wing scalp flap. (a) View of the full-expanded hair-bearing scalp. (b, c) Intraoperative views. (d) Postoperative view

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29

A 12-year-old boy had an acute large open wound on the right temporal head in 2 weeks after a car accident, with deep important structural exposure and slight infection (Fig.  29.5a). After surgical debridement, an acute scalp flap was designed with a pedicle including the right occipital vessels for coverage of the defect, while the large scalp donor site was being repaired with a splitthickness skin graft for temporary coverage (Fig. 29.5b, c). After the wound had healed well in 2 weeks, a 200-mL round tissue expander was placed into a subgaleal pocket beside the lesion and serially inflated to reach about 250  mL in volume with normal saline for about 3 months (Fig.  29.5d). An expanded hair-bearing flap was then designed as a rotation flap for the secondary repair of the scalp alopecia (Fig.  29.5e, f ). Very good results were obtained (Fig. 29.5g).

Scalp Alopecia Reconstruction

a

Chapter 29

d

e

b f

c g

⊡ Fig. 29.5  An acute scalp wound defect was repaired with an acute scalp flap and a delayed expanded scalp flap. (a) Preoperative view. (b, c) Primary intraoperative views of the

scalp flap transferring and the skin grafting. (d) View of fullexpanded hair-bearing scalp. (e, f) Secondary intraoperative views of expanded hair-bearing flap. (g) Postoperative view

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Nasal Reconstruction jincai fan, liqiang liu, and cheng gan

Background of Nasal Reconstruction The techniques of nasal reconstruction began with the Indian flap (cheek flap or forehead flap) in approximately 600 bc, which is as early as the history of plastic surgery [1, 2]. In the fifteenth century, the Branca family developed the upper arm flap, well known as the Italian flap, which is used to form a nose [1, 2]. Till now, many techniques of nasal reconstruction originated mainly from the above two techniques but with various degrees of modifications. Nevertheless, the process of nasal reconstruction has to be carried out in many stages. By the 60s of the last century, with the progression of the vascular microsurgical technique, a free flap could be transferred to a distant lesion in one-stage operation by anastomosing the vascular vessels. Thus, the process of nasal reconstruction thereafter shortened down to one stage, where it is carried out by the microsurgical technique. However, each technique has certain drawbacks. Currently, the major techniques of nasal reconstruction are generally considered to be the following: forehead flap, upper arm tube flap, and free flap. To match the high aesthetic demands of the reconstructed nose, the forehead flap, is frequently used as the first candidate, especially with the aid of a tissue expander to decrease donor morbidity. However, the traditional design of the forehead flap is based on the supratrochlear vessels from the midline or paramedian region of the forehead. The remaining donor lesion is still obvious, even with the aid of a tissue expander [3].

J. Fan, MD, PhD (*) Ninth Department of Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences, No. 33, Ba-Da-Chu Road, Beijing 100144, China e-mail: [email protected] L. Li, MD, PhD and C. Gan, MD Ninth Department of Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences, No. 33, Ba-Da-Chu Road, Beijing 100144, China

Based on the better anatomical understanding of the forehead blood supply from the temporal region, a new technique of the expanded forehead flap has been developed in our unit for nasal reconstruction, in which an island flap is designed from the frontal hairline of the lateral forehead with only a one-stage transferring process, based on the lateral pedicle including the frontal branch of the superficial temporal artery [4]. The donor morbidity of the forehead can be diminished to the minimum without showing any visible unsightly scar in the forehead [4–6].

Indications Considered The techniques for nasal reconstruction are diversified tremendously according to the size, depth, and location of the nasal tissue loss. If the lesion is very superficial i.e., in the skin layer only, a full-thickness skin graft may be a good choice. But the results are usually not satisfactory for Orientals, mainly due to the occurrence of high pigmentation after the surgery. For a small skin defect involving less than 50% of the subunit of the nose, a local flap in the nose is usually satisfactory. If over 50% of a nasal subunit is lost, a nasolabial flap is usually considered for the construction of the entire subunit. An auricular composite tissue grafting technique is often a good choice for the repair of a small lesion in the alar or columella. Moreover, for total or subtotal nasal reconstruction, a forehead flap, upper arm tubed flap, or free flap is commonly considered. But, the traditional forehead flap is usually the first choice. This approach is specially appreciated when combined with the technique of tissue expansion, which allows the secondary donor morbidity to decrease down to a linear scar at the midline or paramidline of the forehead. Even then, the remaining vertical scar is still embarrassing to both the patient and the surgeons (Fig. 30.1). Therefore, a new design of the expanded forehead flap has been developed in our unit not only to fulfill the demands of total or subtotal nasal

H. Hyakusoku et al. (eds.), Color Atlas of Burn Reconstructive Surgery, DOI: 10.1007/978-3-642-05070-1_30, © Springer-Verlag Berlin Heidelberg 2010

Nasal Reconstruction

reconstruction, but also to diminish donor morbidity to a minimum without showing visible scarring (case 1, 2, 3). Of course, when a forehead donor is unavailable, the upper arm tubed flap (Fig. 30.2) and the microsurgical free flaps (Fig.  30.3) could usually become the main alternatives.

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261

Characteristics of Nasal Burn 1. The lesion is usually very large, often spreading out to the surroundings of the face. When the design of the nasal reconstruction is carried out, the restoration of the surrounding lesion should be considered as a part of the design. 2. The burn defect is usually not too deep to completely damage the framework tissue and the lining tissue. 3. Often severe scar contraction occurs. A simple Z-plasty often achieves marvelous results. 4. In the Orientals, the nasal framework (bone and cartilage) is usually insufficient compared to the Caucasian, and the overlying skin becomes thick as well. Thus, the restoration of the overlying full-thickness soft tissue becomes more important during the nasal reconstructive process than the frameworks.

Specific Maneuvers of the Methods

⊡ Fig. 30.1  A vertical scar of the forehead after nasal reconstruction with an expanded midline or para-midline forehead flap

a

b

1. A tissue expander (usually 200–300 mL round shape) is first placed into a submuscular pocket of one side of the forehead, by passing it through a small incision in the top scalp. 2. The expander is then serially inflated with normal saline at an interval of 5–7 days until the desired volume is reached. 3. On the full expanded side of the head, a Doppler flowmeter is used to find the course of the superficial

c

⊡ Fig.  30.2  An upper arm tubed flap for nasal reconstruction. (a) Preoperatively. (b) Transferring process of the flap. (c) Postoperatively

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262

a

Nasal Reconstruction

c

30

b

⊡ Fig. 30.3  A free forearm flap for nasal reconstruction. (a) Preoperatively. (b) Intraoperative design. (c) Postoperatively

temporal artery with its frontal branch and to mark it on the surface of the skin. 4. The forehead flap is designed as a “leaf ” shape along the frontal hairline vertically or transversely. 5. When the tissue expander is removed, an island flap is carefully elevated along the frontal hairline, with the pedicle based on the frontal branch of the superficial temporal vessels on the temporal side, just below the scalp follicles. 6. The lesion of the nose is removed and the lining is often repaired with a turnover flap from the adjacent

tissue. The required framework is usually remodeled with a cartilage graft or secondarily implanted with a shaped silicone prosthesis. 7. The island flap is then transferred into the nose, by passing it through a subcutaneous tunnel between the base of the flap and the lesion. 8. The forehead donor site is directly closed into the frontal hairline by using the remaining forehead ­tissue.

Nasal Reconstruction

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Clinical Cases + Case 1

30

A 26-year-old young man suffered from nasal contractive scar after flame burn (Fig. 30.4a, b). A 300-mL tissue expander was placed into a submuscular pocket of the forehead and serially inflated with normal saline for about 2 months. Thereafter, a 5.5 × 7.5  cm island flap with a “leaf” shape was transversely designed along the hairline, based only on the superficial temporal vascular pedicle (Fig.  30.4c). After the dorsal scar of the nose was removed and the lining was repaired with a “turn-down” scar flap pedicled from the lower margin of the lesion (Fig. 30.4d), the island flap was elevated and transferred to the dorsal nose by passing it through a subcutaneous tunnel between the base of the flap and the lesion. The forehead donor site was closed directly into the frontal hairline by using the remaining forehead tissue (Fig. 30.4e, f ). During more than 7 months of follow-ups, an excellent result was achieved with the reconstructed nose (Fig. 30.4g, h).

Nasal Reconstruction

⊡ Fig. 30.4  A total nasal reconstruction was carried out with an expanded forehead flap based on the temporal island pedicle. (a and b) Preoperatively. (c–f ) Intraoperatively. (g and h) Postoperatively

a

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c

d

e

f

g

h

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Nasal Reconstruction

+ Case 2

30

A 24-year-old man had partial nasal defect after an injection of a unknown tissue filler (Fig. 30.5a). A 200-mL tissue expander was placed into a submuscular pocket of the forehead and serially inflated with normal saline for 7 weeks. A 4.5 × 4  cm expanded forehead flap with a “half-leaf” shape was vertically designed from the hairline region, based on the lateral pedicle (Fig. 30.5b). After the dorsal scar of the nose was removed and the lining was repaired with a “turn-down” scar flap pedicled from lower margin of the lesion (Fig. 30.5c), the island flap was elevated and transferred to the nasal lesion by passing it through a subcutaneous tunnel between the base of the flap and the lesion. The forehead donor site was directly closed into the frontal hairline by using the remaining forehead tissue (Fig.  30.5d, e). A good result was achieved in the 2.5 years of follow-ups (Fig. 30.5f ).

Nasal Reconstruction

a

d

b

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c

e

f

⊡ Fig. 30.5  A subtotal nasal reconstruction was carried out with an expanded forehead flap based on the temporal island pedicle. (a) Preoperatively. (b–e) Intraoperatively. (f ) Postoperatively

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268

Nasal Reconstruction

+ Case 3

30

A 16-year-old girl suffered from partial nasal defect and soft tissue loss of the left nasolabial fold area after radiotherapy of hemangioma (Fig.  30.6a). A 200 mL tissue expander was placed into a submuscular pocket of the forehead and serially inflated with normal saline for 7 weeks. A 4.5 × 9 cm expanded forehead flap was transversely designed from the hairline region, based on the lateral pedicle (Fig. 30.6b). After the lesion was prepared, the island flap was elevated and transferred to the nasal lesion by passing it through a subcutaneous tunnel between the base of the flap and the lesion. The forehead donor site was directly closed into the frontal hairline by using the remaining forehead tissue (Fig. 30.6c, d). A good result was achieved with the 9 months of follow-ups (Fig. 30.6e).

Nasal Reconstruction

a

CHAPTER 30

d

e b

c

⊡ Fig.  30.6  A subtotal nasal lesion and its surroundings were repaired with an expanded forehead flap based on the temporal island pedicle. (a) Preoperatively. (b–d) Intraoperatively. (e) Postoperatively

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C H A P T E R 31

Ear Reconstruction chul park

Introduction Reconstruction of burnt ears can be a challenging task. The requisites for a successful ear reconstruction are twofold: one is the construction of a genuine cartilage framework, and the other is the provision of a durable, yet thin coverage. Among the several options available for ear reconstruction, cartilage fabrication by using autogenous costal cartilage followed by draping with a regional skin flap is the most widely-accepted. In most burnt patients, the vicinity of the deformed ears shows dense scarring, and prevents the use of the regional skin flap for draping the new ear framework. In those situations, use of the temporoparietal facial flap is the best choice. The temporoparietal facial flap provides thin and pliable tissue for wrapping the new framework. Tegtmeier and Gooding [1], Brent and Byrd [2], Brent et  al. [3], Brent [4], Nagata [5], Park et al. [6], Park and Roh [7] have all successfully used the temporoparietal facial flap for auricular reconstruction.

Characteristics of Our Technique 1. Our operation is based on a one-stage reconstruction technique, during which an erect and highly convoluted ear is constructed. 2. Construction of a new framework (Fig.  31.1): The remaining, deformed ear cartilage with scarred skin is completely removed. The sixth through the ninth costal cartilages are harvested from the ipsilateral chest wall. A highly convoluted framework should be  constructed, considering the thickness of the draped fascia flap, the grafted skin, and the layer of

C. Park, MD, PhD Department of Plastic and Reconstructive Surgery, Korea University Hospital, 126-1, Anam-Dong 5-Ga, Seongbuk-Gu, Seoul, Korea e-mail: [email protected]

⊡ Fig. 31.1  Above are depictions of the 6th, 7th, 8th and 9th costal cartilages of the chest wall (each numbered by 6, 7, 8 and 9, respectively? they were used for shaping the main body of the auricule, helix and antihelix); the leftover costal cartilage pieces are depicted by 7’ and 8’, respectively (7’ is used for support under the helical crus and for the buttressing of the erect framework, and 8’ is used for shaping the tail of the helix)

future scar tissue between them. In order to make the  same projection of the opposite, normal ear, a piece of cartilage block is added to the undersurface of the framework. 3. Flap design: When conditions at the temporoparietal region of the defective ear side do not allow elevation of a fascia flap due to previous thermal injury of the scalp skin or of the distributed vasculatures, a contralateral temporoparietal fascia flap is used as a free flap. In order to wrap around an erect and highly

H. Hyakusoku et al. (eds.), Color Atlas of Burn Reconstructive Surgery, DOI: 10.1007/978-3-642-05070-1_31, © Springer-Verlag Berlin Heidelberg 2010

Ear Reconstruction

c­ onvoluted framework in one stage, a large flap should be harvested: for total ear reconstruction, a flap measuring 10–14 cm in length and 10 cm in width, from the upper auricular margin, is usually needed. 4. Flap elevation: Thickness of the fascia flap is variable in each individual. In a male or in an adult it is usually thicker than in a female or a child. The superior auricular muscle is contained within the temporoparietal fascia and variably developed in each patient. In a patient with a well-developed superior auricular muscle, the fascia is thick and tough. In order to use a reliable fascia flap, at least one artery and one vein should be included in the flap, and their branches should be distributed to the distal margin of the elevated flap. Patterns of dominant artery and vein distributed to the temporoparietal fascia flap are variable. The fascia flap is distributed by typical vascular patterns of the superficial temporal artery, and superficial temporal veins were observed in 70% of normal individuals. The flaps in others should be elevated based on a combination of the superficial temporal arteries or veins, the posterior arteries or veins, or the occipital arteries or veins. Extensive dissection would cause congestion of the elevated scalp skin. The congested scalp skin should

CHAPTER 31

be salvaged by using medical leech, or by dripping heparin mixed saline when congestion is suspected.

Operative Procedure 1. Preoperatively, the vascular axis is traced by using a Doppler ultrasound probe. The anterior margin of the flap is designed within the hairline. 2. After a straight, vertical incision, the scalp flap is elevated from the underlying temporoparietal fascia. On the cephalic half-region, vessels, especially veins, ­superficially traverse within the fat layer located under the scalp skin. If the vessels are damaged during dissection, they can be repaired by microanastomosis. 3. The template, which is measured over the anterior and posterior surface of the erect auricular framework fabricated with costal cartilage, is then placed over the facial layer. The edges are incised and the flap is elevated, leaving behind the innominate fascia (a loose areolar tissue layer). When an ipsilateral fascia is used, the elevated flap is turned insideout and draped over the framework. Full-thickness skin obtained from the lateral groin or mediumthickness scalp skin is then grafted over the fascia.

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Clinical Cases + Case 1

31

A 14-year-old boy presenting with auricular defect as a result of a chemical burn on the face and neck suffered 2 years before visiting our department (Fig. 31.2a). With the sixth through the ninth costal cartilages harvested from the ipsilateral chest wall, an erect and highly convoluted framework was constructed (Fig. 31.2b). Through a vertical scalp skin incision, the temporoparietal fascia flap, measuring 11 × 9 cm was elevated. The flap, supplied by the superficial temporal artery and the posterior occipital vein (Fig. 31.2c), was turned inside-out and draped over the framework (Fig. 31.2d). In this case, a part of the helical crus was covered with a deep temporal fascia flap (Fig. 31.2e). Full-thickness skin from the lateral groin was grafted over the fascia. Two years after the operation, a well-convoluted and a bilaterally well-balanced reconstructed ear was shown (Fig. 31.2f–i).

Ear Reconstruction

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273

a

b

c

d

e

f

g

h

i

⊡ Fig. 31.2 (a–i)

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274

Ear Reconstruction

+ Case 2

31

A 28-year-old female presented with an auricular defect as a result of a contact burn on the left side of the scalp and face at the age of 4 years (Fig. 31.3a, b). Before visiting our department, the scalp region was reconstructed through an expansion technique. Preoperatively, significant vascular axes were not detectable on the ipsilateral temporal region using a Doppler ultrasound probe. Therefore, we prepared to harvest a contralateral temporoparietal fascia to use as a free flap. With the sixth through the ninth costal cartilages harvested from the ipsilateral chest wall, an erect and highly convoluted framework was constructed (Fig. 31.3c). Through a scalp skin incision, a temporoparietal fascia flap measuring 12 × 10 cm was elevated based on the superficial temporal artery and vein (Fig. 31.3d). After microanastomosis to the recipient superficial temporal artery and vein, the fascia flap was draped over the prepared framework. Full-thickness skin obtained from the lateral groin was grafted over the fascia. Two years after the operation, a well-convoluted and a bilaterally well-balanced reconstructed ear was shown (Fig. 31.3e, f).

Ear Reconstruction

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275

a

b

c

d

e

f

⊡ Fig. 31.2 (a–f)

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C H A P T E R 32

Reconstruction in Pediatric Burns jui-yung yang and fu-chan wei

Introduction The incidence of pediatric burn (<18 years old) in Taiwan according to data from Childhood Burn Foundation Taiwan ROC was about 33.4%. The incidence of reconstruction needed for this age group was also about the same. From the data presented at Singapore in the year 2006, there was an average of 36.3% (patient number: 2,833/7,795) of pediatric burn (<18 years old) in Linkou burn center (LBC), Chang Gung memorial Hospital (CGMH) from 1986 to 2004 [1]. Among these, onethird of the patients needed reconstruction. This is a large reconstruction group and is of concern. Burn scar contracture are common problems in children after deep thermal burn involving head–neck, extremities including axilla, hands, perineum etc. because they are neither easily positioned initially nor easily rehabilitated later [2]. Another consideration about the needs of reconstruction is that the children will face both the functional and developmental problems as well as aesthetic issue if not reconstructed.

transposition, interpolation, and island flaps may be considered as a tool for hair restoration for relatively small, 3–5 cm wide, or isolated area as described in literature and Coleman III’s descriptions [4]. Tissue expander implantation to expand the hair-bearing scalp for the replacement of the cicatricial area is approved to be an effective and safe method for even scars up to 80% of the scalp area [5] or series expansion up to 4 times in pediatric group [6]. Hair graft is an alternative method for hair restoration for spotted scars or residual scars after reconstruction. Sometimes, a combination of the above-mentioned methods is needed for both functional and aesthetic consideration [7]. For example, a girl sustained a scald burn which resulted in cicatricial alopecia in about 80% of the scalp area (Figs. 32.1 and 32.2). Serial hair-bearing scalp expansion (3 times) with tissue expander implantation at the subgaleal plane was done (Fig.  32.3) and most of the scar tissues were replaced

Hair Restoration for Scalp and Eyebrow in Pediatric Burns The children are vulnerable to suffer from loss of hair either from flame or scald burn if the injuries are deep enough to destroy the hair follicles. If the scar area without hairs (cicatricial alopecia) is not so large, less than 15% of the surface area of the scalp, serial excision, sometimes up to six procedures, may solve the problem [3]. Various hair-bearing flaps such as local advancement, J.-Y. Yang, MD (*) Linkou Burn Center, Chang Gung Memorial Hospital and University, Taiwan e-mail: [email protected] F.-C. Wei, MD Linkou Burn Center, Chang Gung Memorial Hospital and University, Taiwan

⊡ Fig.  32.1  Cicatricial alopecia with 80% hair loss over scalp of a young girl after scald burn, anterior view

H. Hyakusoku et al. (eds.), Color Atlas of Burn Reconstructive Surgery, DOI: 10.1007/978-3-642-05070-1_32, © Springer-Verlag Berlin Heidelberg 2010

Reconstruction in Pediatric Burns

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⊡ Fig. 32.4  Results of three times hair-bearing scalp expansion reconstruction

⊡ Fig.  32.2  Cicatricial alopecia with 80% hair loss over scalp of a young girl after scald burn, posterior view

⊡ Fig.  32.5  Residual hairs in excised scar tissue may be used as a donor site of free hair unit graft

with hairy scalp (Fig. 32.4). Free hair follicle unit graft for the residual scar area using excised scar tissue containing hairs as donor site was done (Fig. 32.5). This girl got more than 95% of scalp hair restoration and was very happy to go to school (Figs. 32.6 and 32.7).

Facial Reconstruction in Pediatric Burns

⊡ Fig. 32.3  Series tissue expander reconstruction for major alopecia area

Small kids occasionally pull down the hot soup, tea, or coffee from the table and this results in burn injury to the head and face. Sometimes children like to play with

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Reconstruction in Pediatric Burns

32

⊡ Fig. 32.6  Results of hair restoration courses, over 95% of scalp hairs restored, anterior view ⊡ Fig. 32.8  Persistent hypertrophic scars over both cheeks of a boy after flame burn, right lateral view

⊡ Fig. 32.7  Posterior view

⊡ Fig. 32.9  Left lateral view

Reconstruction in Pediatric Burns

their father’s lighter and this results in ignition of clothes or something else. Isolated scar contracture or deformity of the face such as eyebrow, nose, lips, ear, or part of the cheeks can be corrected by means of scar excision, contracture release, full-thickness skin graft (FTSG), composite graft taken from ear to nasal ala or scalp to eyebrow, local flap [8] or even free flap. If the scar involved the entire or near total face, replacement therapy using a large piece of FTSG may be considered as Feldman did [9]. Tissue expander implantation to healthy skin along the scar tissue is an alternative method for replacement therapy as Achauer did [10]. The example showing in Figs. 32.14–32.22 is a replacement therapy for facial scars involving nearly total face (Figs. 32.8–32.10). A big tissue expander was implanted to the subcutaneous space of the healthy skin in the neck and expanded as much as possible after regular injection of normal saline for a period (Fig. 32.11). The entire scar in both cheeks according to aesthetic units were excised. The defects were covered with upward advancement of the expanded skin flaps after the removal of the tissue expander (Figs. 32.12 and 32.13). Periosteal fixation inbetween the periosteum of the zygoma bone and under surface of the skin flaps with 3-0 PDS was done. The resultant dimpling of the skin flaps after periosteal fixation will disappear about 2 months later. The final results of follow-up for 2 more years revealed good skin function, appearance, and texture (Figs. 32.14–32.16).

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⊡ Fig. 32.10  Anterior view

Axillary Reconstruction in Pediatric Burns Axillary scar contracture is a common complication in burn survivor not only because of the fact that this area is a 3D structure including anterior, posterior folds, and upper dome, but also due to the difficulty to keep the upper limbs stretching out during the rehabilitation stage. In the pediatric burn, the added difficulties with initial positioning and aftercare in physical therapy make this complication quite common. The cooperation of the children should be taken into consideration for the choice of reconstruction modality. The skin graft procedure is not a good choice because this procedure needs about 1 week immobilization for graft taking. The local cutaneous skin flaps such as multiple Z, VY, or 5-flap plasties can be considered as a method for axillary contracture due to anterior and/or posterior scar band. The fasciocutaneous or square flap is a good choice for the reconstruction of the contracture involving axillary dome including or not including the anterior or posterior axillary fold [2, 11]. Flap surgery, although sometimes technically difficult, is easy for aftercare in pediatric group. For example, a small

⊡ Fig. 32.11  A big tissue expander was used for expansion of healthy neck skin

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32

⊡ Fig. 32.12  The scars over both cheeks were all excised and replaced by expanded skin flap. Periosteal fixation using PDS in zygoma area (dimpling area) for fixation of the skin flap

⊡ Fig. 32.14  The late results, right lateral view

kid sustained scald burn which resulted in scar contracture involving the entire axilla (Fig. 32.17). This kid did not cooperate with the physiologic therapist or even her parents. An island pedicle parascapular flap was designed and elevated from the left back (Fig. 32.18) and rotated to the left axilla along with the overlying scar tissues (Fig.  32.19). The donor site was closed primarily (Fig.  32.20). Follow-up for 1 more year showed good functional release (Fig. 32.21). An interesting finding was that not only did the overlying scars on the flap not affect the flap viability but also the surrounding scar tissues matured satisfactorily.

Chest Including Breast Reconstruction in Pediatric Burns

⊡ Fig. 32.13  Illustration of periosteal fixation for expanded skin flap

Deep chest injury in pediatric group whether from scald or flame burn may be a disaster for them. Scar contracture from deep burn will affect not only the straightening function of the trunk but also the development of the breast or/and nipple-areolar complex (NAC) especially in female children. This is the reason why Dr. Foley P. et al.

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CHAPTER 32

⊡ Fig. 32.16  The late results, anterior view

⊡ Fig. 32.15  The late results, left lateral view

said that breast burns are not benign [12]. This is also the reason why most burn doctors make every effort to preserve the breast buds and/or NAC during debridement for the deep breast burn in prepuberty girls. Besides early conservative treatment for breast burns, proper release of the scar contracture, if any, too much scar tissue involvement around axillary region or severe axillary dome contracture. Contracture release sometimes could be achieved simply by local cutaneous Z-plasty, YV advancement flap, or rotation flap. However, in more extensive scar tissue involvement or severe scar contracture, big patch of FTSG, tissue expansion, larger fasciocutaneous flap, or free flap may be considered [13, 14]. If the development of breast was compromised before puberty or breast buds and/or NAC were destroyed during acute stage, then reconstruction of the breast volume and/or NAC should be considered. In some situations, combined reconstruction scar release with aesthetic augmentation mammaplasty may

⊡ Fig. 32.17  Severe scar contracture in left axilla of a girl after scald burn

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⊡ Fig.  32.18  An island pedicle parascapular flap was designed and elevated from left back

⊡ Fig. 32.20  Donor site can be closed primarily

⊡ Fig.  32.19  The flap including overlying scar tissue was used for axillary reconstruction

be finished simultaneously in one stage [15]. The following example is that of a 3-year-old girl who sustained scald burn which resulted in thick scar formation in her chest and rt. axilla (Fig. 32.22). The contracture of the rt. axilla and most of the rt. breast were released before puberty. Under-development of the right breast was noted at the age of 12 years. A big fasciocutaneous flap elevated from right flank was used for releasing tension and replacement of the scar tissues in the right breast (Figs. 32.23 and 32.24). However, the right breast was still was smaller than left side. Reelevation and repositioning of the previous fasciocutaneous flap, release of some residual contracture with Z-plasty, and augmentation mammaplasty with implant simultaneously for her right breast were done at the age of 23 years (Fig. 32.25). Nipple reconstruction with modified star flap was done 1 year

⊡ Fig.  32.21  Results of good functional correction. The scars over the flap do not affect flap viability

Reconstruction in Pediatric Burns

CHAPTER 32

⊡ Fig. 32.22  Severe scar contracture involving right axilla and chest with loss of nipple–areolar complex in a young girl after scald burn ⊡ Fig. 32.25  Flap re-elevation, scar revision, and augmentation mammaplasty with implant were done simultaneously

⊡ Fig. 32.23  Functional correction of right axilla and fasciocutaneous flap reconstruction of right chest were done ⊡ Fig.  32.26  Results of nipple reconstruction with modified star flap for right breast in an another stage

later in her right breast Fig. 32.26. The girl was satisfied with the results and gave up further reconstruction of the areolar component.

Hand Reconstruction in Pediatric Burns

⊡ Fig. 32.24  Hypoplasia of right breast after puberty noted. P.1

Pediatric hand burn is quite common. Most are due to scald burn including hot water, hot drinks such as tea or coffee, hot soup, and instant noodle soup etc. Proper initial and after care including physical therapy may get good results. In some situations, the wounds are very deep especially those from contact thermal burns such as ironer, hot pressure machine etc. Scar

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contracture more or less will occur in those situations because proper physical therapy is very difficult to do for pediatric patients. Reconstruction choice usually depends on the types of hand contractures. Some classification of burn hand scar contractures had been offered by some authors [16, 17]. The classification of contractures includes adduction contracture of the thumb, abduction contracture of the fifth finger, extensor contracture of the wrist and/or dorsal hand especially metacarpal joints (MPs), flexor contracture of fingers especially proximal phalanx joints (PIPs), palm contracture, web space contracture including syndactylism, boutonnière deformity, and digital amputation. Various reconstruction procedures and methods had been mentioned in the literature and textbooks. However one of the methods called hour-glass flap [18] is very effective for burn webs scar contracture including two joints (PIP and MP) in pediatric group. The design of hour-glass flap is shown in Fig. 32.27. Point 1 at PIP and point 2 at MP should be pointed out first. The middle between point 1 and 2 is point 3 which equal to the volar distal edge of the web space. The middle between point 2 and 3 is point 4. This is lumbrical canal where the digital vessels go through and is the bottom of flap dissection. The middle point between point 3 and 4 is point 5 which is the waist of the hour-glass flap. The middle point between point 4 and 5 is point 6 which is the distal

Reconstruction in Pediatric Burns

edge of the flap. Point 7 is the width of the flap between the dorsal central lines of two fingers. Flap is elevated from point 6 to 4 and used to reconstruct the web space after splitting the adhesion between two fingers. There will be donor defects in finger sides and should be grafted. The example is that of a small kid with web space contracture in both hands. Hour-glass flap was designed (Fig. 32.28) and web space was reconstructed (Fig. 32.29).

⊡ Fig. 32.28  Designs of hour-glass flap for correction of scar contracture in hand webs of a boy sustained from flap burn

⊡ Fig.  32.27  Illustration of hour-glass flap, which is very useful for burn web space reconstruction

⊡ Fig.  32.29  Early results of web reconstruction. Flap in web base and skin graft in finger side

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CHAPTER 32

⊡ Fig.  32.30  Late results showed no recurrence of web contracture

Follow-up for more than 1 year showed good web spaces without any recurrence (Fig. 32.30).

Neck Reconstruction in Pediatric Burns Burn neck scar contracture should be corrected as early as possible in pediatric patients. The contracture not only affects rotation and extension function of the head, but also may cause development of the mandible and result in malocclusion and distortion of the lower face. According to the severity of the contracture, it can be classified into several types namely simple scar bands contracture, scar patches contracture occupying more or less 50% of the neck area, and cervicomandibular adhesion. Considerations about the treatment modality depend on the severity. Z-plasty or other cutaneous flaps may be used for release of contracture bands. Fasiocutaneous flap, parascapular flap, etc. may be used for the correction of contracture due to patch scars in which the area ratio is less than 50% of the neck area. Skin graft, large local flap such as latissimus dorsi (LD) flap, or free flap such as anteriorolateral thigh (ALT) flap may be applied if the scar ratio more than 50% of neck area or for cervicomandibular adhesion [19]. Among these methods, the ALT free flap surgery is a good choice for neck reconstruction for children. Although the surgery is technique-demanding,the advantage is big enough. The postoperative care of flap surgery is easier than skin graft for severe neck contracture in children. The durability, extensibility and less recurrence of the flap make the long-term results acceptable. The example shown in Fig. 32.31 is that of a child with neck scar contracture involving the lower face. He received release

⊡ Fig. 32.31  Persistent hypertrophic scars with contracture in left face and neck of a boy after flame burn

contracture with FTSG from another hospital before, but the results were not satisfactory (Fig. 32.31). All the scar tissues in the neck and lower face were excised and the contracture was released as much as possible in our hospital. A big ALT flap was elevated from the patient’s left thigh based on descending branch of lateral femoral artery as vascular pedicle (Fig. 32.32). The flap was split into two components to provide wide distance and fix to the defect using facial artery as recipient vessel (Fig.  32.33). No postoperative neck splint was needed for this child. Follow up nearly 2 years showed good functional (including head extension and rotation) and aesthetic (including cervicomandibular angle) results (Figs. 32 34 and 32.35). The perforator flap, because of easy harvesting, possible spitting and thin out, has been emphasized by Professor Wei etc. [20] and is proved to be an excellent flap for neck scar reconstruction for children by some authors [21].

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⊡ Fig. 32.32  Thin anterior lateral thigh (ALT) flap elevated from left thigh was used for reconstruction. Several perforators can be used as vascular pedicles for flap split

⊡ Fig. 32.34  Early results of split ALT flap reconstruction

⊡ Fig.  32.33  Immediate results of split ALT flap with Z-plasty in flap edge for scar replacement and functional release of scar contracture in face–neck area

Aftercare Including Nursing and Physiological Therapy (PT) in Pediatric Burn Reconstruction Preoperative prevention from scar contracture in pediatric burns including antideformity positioning, proper dressing, adequate splinting, and patient physical therapy are mentioned in the previous introduction and sections in this chapter. If reconstruction is inevitable, postoperative aftercare including nursing and PT is also very important. The nurse should keep an eye and make sure that the dressings and/or postoperative splint is in adequate place. During dressing change, enough man-power is usually needed to keep the proper anatomic position such as hand, neck or axilla etc. especially when there is tie-over dressing, K-pin, or splint in the operative fields.

⊡ Fig. 32.35  Late results and closed-up view. Scars in incision wounds softer day by day

Reconstruction in Pediatric Burns

After wound healing, aggressive and patient PT is also overemphasized to maintain the operation achievement and prevent recurrence. This usually needs education and cooperation of parents. Regular follow-up for those children after reconstruction is advised because of the fact that the results may get changed after the growth of the children especially in hand and breast surgery. Because the development rate in reconstruction area is sometimes not as fast as the normal site, residual contracture may occur after the growth of the child, even if there was adequate reconstruction initially. In this situation, usually simple procedure such as Z-plasty etc. may solve the problem or the minor contracture will result in major complication such as scar bands in fingers or breast. Sometimes, long-term follow-up until full growth of the children with burn injuries is needed.

CHAPTER 32

Summary Children are not small sized adults. This is also true in the reconstruction of pediatric burns. Although the treatment principles are almost the same as adults, the key points are different. The cooperation from children and their parents, development problems of the children, proper treatment modality for easy aftercare, possibility of postoperative follow-up, and PT etc. need to be taken into consideration. These are the key points for successful reconstruction in pediatric burns.

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Secondary Vascularized Flap hiko hyakusoku and hiroshi mizuno

Background of the Technique Initially, secondary flap made by vascular implantation was presented by a Chinese burn surgeon named Shen in 1980 [1]. In his paper, he described a procedure in which the vascular bundle was elevated and implanted in the proximal subcutaneous region, and 2 weeks later, the neo-vascularized flap was elevated as a pedicled flap for facial and helical reconstruction. On the other hand, our flap was made by free vascular bundle transfer (Fig. 33.1) and 2 weeks later, a pedicled secondary vascularized flap was elevated for transposition [2]. In particular, secondary hair-bearing flap was useful for reconstructing eye–brows or beards [3]. Here we sometimes use the phrase “prefabricated flap” including secondary vascularized flap. The terminology of the prefabricated flap may include secondary tissue (cartilage, bone, etc.) of grafted flaps [4]. Combination of these methods is also included in prefabricated flaps. Washio [5] and Orticochea [6] reported prefabricated flaps in 1971. These papers must have contributed to the development of the concept of flap prefabrication.

Characteristics and Indication of the Method

first and second operations. The pedicle to pedicle type was presented by Shen [1], the pedicle to free type by Shintomi [7], and the free to pedicle type by Hyakusoku [2, 8].

Indications When a specific tissue is needed for some reconstruction, a secondary vascularized flap is useful. However, another procedure that consists of one stage can be used; the method is not usually indicated. Therefore, its indication must be strictly limited. We applied this method to hairy skin flap transposition because of the flexible choice of thickness or stream of the hairs.

Specific Steps of the Method Selection of Vascular Bundle Until now, we have experienced superficial temporal vessels and deep inferior epigastric vessels. These vessels have sufficient lengths and donor scars are hidden with hairs or underwear. At least major vessels of the extremity should be avoided when harvesting vascular bundles.

Characteristics Three procedures for making secondary vascularized flaps are reported. The methods are classified by free vascular bundle transfer or pedicled vascular bundle transposition in

Wrapping Method of the Vascular Bundle It is often said that elevation of buried vascular bundles in a second operation is very difficult. Our device is such

H. Hyakusoku, MD, PhD (*) Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School, Tokyo, Japan e-mail: [email protected] H. Mizuno, MD, PhD Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School, Tokyo, Japan e-mail: [email protected] H. Hyakusoku et al. (eds.), Color Atlas of Burn Reconstructive Surgery, DOI: 10.1007/978-3-642-05070-1_33, © Springer-Verlag Berlin Heidelberg 2010

Secondary Vascularized Flap

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a

b

⊡ Fig. 33.1  Free vascular bundle transfer. (a) Vascular bundle of the deep inferior epigastric vessels is shown. Small muscle was attached in the distal portion. About 15 cm length of the bundle can be harvested. (b) Harvested vascular ­bundle

of superficial temporal artery and vein. A length of about 12 cm can be harvested but sometimes the arteries and veins are separated, thus superficial fascia between the vessels must be attached in order to preserve the shunt circulation

that vascular bundle wrapping is achieved with a penrose drain like a Norimaki (roll) in Sushi. By this method, re-elevation of the bundle is made easier.

or 3 weeks from the first operation is needed. So, allogeneic vascular bundle may be used to avoid making a donor scar [9]. Moreover, free vascular bundles may be useful in the transplantation of engineered tissues in the future [10].

Application of Free Vascular Bundle Transfer to Engineered Tissue Transplantation The role of the vascular bundle is temporal. Thus it is not necessary to maintain a permanent blood flow. Only 2

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Clinical Cases + Case 1 : Bilateral Eyebrow

Reconstruction (Fig. 33.2)

33

A 33-year-old man had one flame burn in his face. After free skin graft to the full face the patient wanted bilateral eyebrows (a). Thus we planned simultaneous reconstruction of the eye-brow using a secondary vascularized tandem island hair-bearing flap 3 weeks after the primary operation (b). As the flap needed to be 20 cm long, deep inferior epigastric vessels were harvested as a free vascular bundle and transplanted in the primary operation (c).

Secondary Vascularized Flap

a

c

⊡ Fig. 33.2 

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b

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+ Case 2 : Upper Lip Reconstruction

in Male (Fig. 33.3)

33

A 32-year-old man had an electrical burn on his face caused by 400 V of electricity at his work. After 3 months, his skin ulcer persisted and needed to be reconstructed cosmetically (a). Thus we planned to reconstruct a bearded lip with hairy skin of the chin. We implanted a superficial temporal vascular bundle with microvascular anastomoses, facial arteries and veins. Two weeks later, the hairy skin was elevated as a skin flap and transposed to a reconstructive upper lip and left cheek (b). In Fig. 33.3, the illustration of this reconstruction is shown (c).

Secondary Vascularized Flap

a ⊡ Fig. 33.3 

b

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c

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+ Case 3 : Hemilateral Eyebrow

Reconstruction in Female (Fig. 33.4)

33

A 40-year-old woman with flame burn scar wanted to correct the eyebrow defect of the right eyelid (a). The secondary vascularized flap method was selected for a safe transplantation of ipsilateral retroauricular hair. The hair in this area possessed the necessary qualities and density suitable to repair female eyebrows. In a preliminary operation, the left deep inferior epigastric vessels were taken at a length of 13 cm to make a free vascular bundle. The bundle was anastomosed with superficial temporal arteries and veins. The bundle was buried in the subcutaneous tissue along the retroauricular hair border. Two weeks later, the bundle was elevated with the hairy skin island attached to the tip of the buried bundle (b). The island flap was transposed to reconstruct the right eyebrow.The flap survived perfectly with growing hairs (c).

Secondary Vascularized Flap

a

c

⊡ Fig. 33.4 

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b

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+ Case 4 : Upper Lip Reconstruction

in Male (Fig. 33.5)

33

A 45-year-old man with scar contracture of the upper lip caused by a flame burn due to a fire hoped for upper lip reconstruction (a). Thus we planned secondary vascularized flap transposition from chin (b). A deep inferior vascular bundle was harvested and implanted in the subcutaneous portion of the chin with microvascular anastomoses. Two weeks later, hair-bearing skin island flap was elevated secondarily and transposed to the upper lip (c). The flap survived completely and a bearded upper lip was reconstructed (d).

Secondary Vascularized Flap

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a

b

⊡ Fig. 33.5 

c

d

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+ Case 5 : Contralateral Eyebrow

Reconstruction in Male (Fig. 33.6)

33

This is a 27-year-old male whose left scalp, hemiface and upper extremity had been subjected to an acid injury at his workspace. Although the entire injured area was repaired by skin grafting, the patient eventually suffered severe scar contracture around his neck and wrist joint that affected the functions of these areas. He also suffered mesh scarring, external auricular loss, and eyebrow hair loss (a). After the functional repair of the neck and wrist joint with a cervico-pectoral flap and an intercostal perforator “super-thin” flap, respectively, eyebrow reconstruction was scheduled in response to his request. His DIEA and V, which were 12 cm in length, were harvested and anastomosed respectively to the contralateral side of his STA and V since his ipsilatral STA & V seemed to be damaged or absent due to the initial injury or the subsequent skin grafting. The distal part of the DIEA & V was buried beneath the temporal galea along the retroauricular hair border (b). Three weeks later, the secondary vascularized hairy flap was elevated as an island flap, transferred through the subcutaneous tunnel, and placed above the supraorbital rim. All wounds were closed primarily. The whole flap subsequently exhibited congestion, especially in the distal area. However, the congestion improved gradually within a few weeks. During this time, a topical steroid ointment was administered to avoid necrosis of the hair follicles. The secondary vascularized hairy flap survived in its entirety with little hair losses. An almost symmetrical appearance was achieved (c).

Secondary Vascularized Flap

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b

c

⊡ Fig. 33.6 

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Prefabricated and Prelaminated Flaps brian m. parrett and julian j. pribaz

Background of the Technique Flap prefabrication and prelamination are complex procedures reserved for cases in which conventional, simpler flaps will not achieve the desired goal or are unavailable [3, 6, 8, 9, 11]. The term prefabrication was first introduced by Shen [14] in 1982 and describes the implantation of a vascular pedicle into a new territory, followed by a period of maturation and neovascularization, and then the subsequent transfer of tissue based on its implanted pedicle [11]. Prefabrication allows any defined tissue volume to be transferred to any specified recipient site, greatly expanding the armamentarium of reconstructive options. Flap prelamination, first coined by Pribaz and Fine in 1994 [8], describes a process in which tissues or other devices are implanted into a vascular territory before it is transferred; the blood supply is not manipulated [9, 12]. Prelamination transforms a native axial flap into a multilayered flap by adding the appropriate support and lining structures for composite reconstruction.

Indications In head and neck burn reconstruction, it is desirable to use flaps that are thin with good color match or to use specialized flaps such as hair-bearing flaps. Although there may be suitable tissues with these special characteristics, they may not have a reliable axial blood supply. Flap prefabrication provides this by implanting an axial blood supply into the desired donor tissue thus rendering it transferable

J. J. Pribaz, MD (*) Division of Plastic Surgery, Harvard Medical School, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115, USA e-mail: [email protected] B. M. Parrett, MD Division of Plastic Surgery and Microsurgery, The Buncke clinic, California Pacific Medical Center, 45 Castro Street, San Francisco, CA 94114, USA

once neovascularization has occurred. Prefabricated flaps allow the transfer of moderate-sized units of thinner tissue from unconventional sites. These are useful in patients with limited donor sites, especially severely burned patients with significant facial disfigurement or diffuse neck contractures that require release and coverage [6]. The goal of prelamination is to compose multilayered composite flaps for reconstruction of complex, multilayered facial defects. Prelamination is particularly useful for patients with central facial defects, especially of the nose, lips, and palate that have layers of skin, cartilage, and mucosa that need to be reconstructed. This can occur in patients with severe facial electric burns.

Operative Technique for Prefabrication Stage 1: Implantation of Vascular Pedicle First, define the defect, requirements for reconstruction, and available donor sites. Form a plan and timeline for reconstruction as the prefabrication process takes at least 8 weeks and involves two stages. A vascular pedicle (which includes at least the artery and its venae comitantes surrounded by adventitial tissue, and may also include fascia or a cuff of muscle) is dissected out, transferred to a new area of tissue, and implanted. The distal end is ligated and no vascular anastomoses are performed (Fig.  34.1a, b). Vascular connections occur spontaneously between the implanted pedicle and surrounding tissue to create a new vascular territory (Fig. 34.1c). We wrap Gore-Tex® (polytetrafluoroethylene tubing) (W.L. Gore & Associates, Flagstaff, AZ) or silicone sheeting around the pedicle to facilitate later flap harvest and pedicle dissection (Fig. 34.1b). Flaps may be prefabricated at a distant site in cases where there is no local tissue available, with the aim of creating a thin flap for head and neck reconstruction by transferring the pedicle superficially (Table 34.1). After the maturation period, the flap is transferred as a free

H. Hyakusoku et al. (eds.), Color Atlas of Burn Reconstructive Surgery, DOI: 10.1007/978-3-642-05070-1_34, © Springer-Verlag Berlin Heidelberg 2010

Prefabricated and Prelaminated Flaps

a

Desired skin Flap

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b Tissue Expander

Cortex

Muscle

Deep vascular pedicle

c

d

Prefabricated Flap

⊡ Fig. 34.1  Technique of flap prefabrication. (a) A deep vascular pedicle is shown and will be dissected out with a cuff of fascia or muscle around it. (b) The vascular pedicle is placed between the underside of the skin flap to be prefabricated and a tissue expander. Gore-Tex® tubing is placed

around the proximal pedicle to facilitate later flap harvest. (c) Tissue expansion starts in 1 week. (d) After at least 8 weeks, the prefabricated flap is raised off the tissue expander (the capsule is included within the flap) and then transferred to the recipient site

flap. This is useful in neck resurfacing after burn scar excision using prefabricated thigh flaps; the descending branch of the lateral femoral circumflex vascular pedicle is transferred from deep to the vastus lateralis muscle to the subcutaneous plane to make a thin, supple flap. We preferentially perform prefabrication locally in patients who have nonburned areas adjacent to the face; regions near the recipient site provide excellent color and texture match. Common donor sites are the anterior and posterior neck, supraclavicular region, postauricular area,

and scalp (Table 34.1). In these cases where a local pedicle is used, no microsurgery is involved. During the first stage, a local vascular pedicle is rerouted into a new area, and this neovascularized tissue is transferred locally into the defect in the second stage. Most commonly, the superficial temporal vascular pedicle is dissected, ligated distally, and transferred into the upper neck usually above a tissue expander, allowing prefabrication of the neck for later transfer to the face. This is useful for cheek or jaw reconstruction. Another benefit of prefabrication near

Table 34.1  Common anatomic locations for flap prefabrication in head and neck reconstruction Anatomic location

Vascular pedicle

Technical points

Medial thigh

Descending branch of lateral femoral circumflex vessels

Incorporate greater saphenous vein for drainage

Lateral thigh

Descending branch of lateral femoral circumflex vessels

Place tissue expander below pedicle to thin flap and increase flap size

Inner upper arm

Thoracodorsal vessels to latissimus and serratus muscles

Distal site

Near recipient site Upper cervical

Superficial temporal vessels

Include temporoparietal fascia in pedicle

Retroauricular or mastoid region

Superficial temporal vessels

Include temporoparietal fascia in pedicle

Supraclavicular

Thoracoacromial vessels

Transfer pedicle over the clavicle and above a tissue expander

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34

the recipient site is the possibility of using multiple sequential prefabricated flaps for reconstructions of multiple facial subunits, transferred sequentially by the same vascular pedicle in a process called the “vascular crane” principle [10]. Occasionally, the native pedicles are too short to reach the area to be vascularized. In these cases, a vascular pedicle can be transferred as a mini-free flap from a distant area to the neck or another chosen area. Any long pedicle is suitable but most commonly, the descending branch of the lateral femoral circumflex vascular pedicle or the radial forearm vascular pedicle with surrounding fascia is used. The base of the pedicle is anastomosed and the distal ligated end is tunneled beneath the area to be prefabricated. Assure that the vascular pedicle is long enough and appropriately based to allow second stage transfer without detaching the anastamosis. Tissue expansion is often used in conjunction with prefabrication as it stimulates angiogenesis and neovascularization, thins the flap, and allows primary closure of the future donor site. The implanted pedicle is placed directly underneath the skin and on top of the expander (Fig.  34.1b, c). Expansion is begun approximately 1–2 weeks postoperatively and lasts until flap transfer. A hand-held Doppler may be used to assure patency of the pedicle at the time of expander fill. If a signal disappears, removing the fluid from the expander will restore flow.

Stage 2: Transfer of Flap After maturation, the neovascularized tissue is harvested and transferred based on the implanted pedicle after at least 8 weeks of maturation (Fig.  34.1d). The flap is transferred as a local or free flap. The flap after transfer usually has some degree of transient venous congestion that can last as long as 48 h. Including a native subcutaneous vein in the flap and performing an additional anastamosis or waiting longer before flap transfer is effective in decreasing congestion. It is mandatory that the flap not be folded as prefabricated flaps cannot tolerate manipulation and folding as well as axial flaps. The donor site, especially if tissue expansion has been used, can usually be closed primarily. Flap size can be rather large, but in clinical cases, we commonly use a conservative 2:1 ratio (length of flap vs. extent of pedicle length within the flap) [5, 15]. Flap delay may also be used to enhance neovascularization and increase the size of the transferred flap. Delay is accomplished by progressively raising the flap off its axial blood supply [5]. Tissue expansion also increases the size of flap that can be transferred.

Prefabricated and Prelaminated Flaps

Operative Technique for Prelamination Stage 1: Introduction of Tissue Prelamination involves a two-stage procedure and begins by defining the defect and the layers that need to be reconstructed. Stage 1 involves introducing the appropriate graft material, such as cartilage, bone, mucosa, or bioengineered materials [1, 2, 4, 7, 12, 13]. Skin or mucosal grafts can provide lining and costochondral, auricular, or septal cartilage can provide structural support. Prelamination is most often employed at a distant site as reconstruction in a remote unscarred territory will allow the best chance for healing and graft incorporation. The forearm provides abundant and thin tissue for nasal, cheek, and upper lip reconstruction. The radial artery territory is most commonly used for prelamination as it has a reliable vascularity that facilitates incorporation of skin, mucosal, and cartilage grafts to construct a complex, three-dimensional flap. Generally, the fasciocutaneous flap is partially raised, the grafts sutured onto the forearm fascia, and the flap reinset. With mucosa, the graft is meshed or cut into small pieces, sutured onto the fascia, and then a 1 mm Silastic sheet is placed over the grafts to avoid adhesions and promote spreading. A tissue expander can be placed under the lining and allows the grafts to better about the flap tissue. Flaps may also be prelaminated in close proximity to the facial defect, such as a prelaminated forehead flap for nasal reconstruction. We have used the submental flap, based on the facial artery submental branch, as a prelaminated flap for full-thickness lip and cheek reconstruction.

Stage 2: Flap Transfer After a period of 3–4 weeks to allow graft incorporation into the flap, the composite flap is transferred to the face. This can be performed as a free-tissue transfer if prelamination occurs distally or as a pedicle flap transfer if prelamination occurs in the head and neck.

Later Stages-Secondary Refinements With this two-stage procedure, edema, scarring, and contraction may result at the donor site before transfer and at the recipient site after transfer. Revisions are necessary to achieve an aesthetically pleasing result. For instance, in complex cheek and nasal reconstruction, prelaminated flaps may need to be debulked, sculptured, and nasal anatomic subunits separated to enhance the full aesthetic result.

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Clinical Cases + Case 1

34

A 32-year-old man sustained extensive burns to his head, neck, and torso and presented with a diffuse burn scar contracture of his neck (Fig.  34.2a). The usual flap donor sites were unavailable because of the burn injury. Thus, a flap was prefabricated over the anterolateral thigh (Fig.  34.2b). The descending branch of the lateral femoral circumflex vessel with some surrounding muscle and fascia was dissected and transferred subcutaneously, where it was placed directly underneath the skin (Fig. 34.2c). Gore-Tex® tubing was placed around the base of the pedicle. Eight weeks later, the thin prefabricated flap was ready for transfer (Fig. 34.2d, e). The neck burn scar contracture was released and the prefabricated flap was microsurgically transferred to the neck (Fig. 34.2f ). The flap survived completely, and 3 months later a minimal debulking was performed. The patient now has excellent neck extension (Fig. 34.2g).

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g

⊡ Fig. 34.2  Patient photographs for case 1 showing the prefabrication of a thigh flap with the lateral femoral circumflex pedicle for neck burn contracture release and flap coverage

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+ Case 2

34

A 45-year-old man with 80% total body surface area burns with extensive facial burns resulting in an absent nose (Fig. 34.3a). A prefabricated flap was designed using a section of unburned skin in the left neck region (Fig. 34.3b). A free transfer of lateral femoral circumflex vessels to the superficial temporal vessels was performed and this vascular pedicle was rotated into the nonburned neck area (Fig.  34.3c). Nine weeks later, nasal reconstruction proceeded with nasal turn-down flaps from local scarred tissues for lining and cartilage grafts for support. Simultaneously, the newly prefabricated flap was transferred as a pedicled flap to the nose (Fig. 34.3d). Six weeks later, using the “vascular crane” principle, the same pedicle was transferred to the hair-bearing scalp region to prefabricate a hair-bearing flap (Fig. 34.3e). Eight weeks later, his upper lip was reconstructed with the prefabricated scalp flap, again using the lateral femoral circumflex pedicle (Fig. 34.3f ). He is shown 1 year postoperatively after two nasal revisions (Fig. 34.3g).

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d

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f

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⊡ Fig. 34.3  Patient photographs for case 2 showing prefabrication near the recipient site for facial burns. The “vascular crane” principle is demonstrated using a single pedicle to

prefabricate two separate flaps for nasal reconstruction and for the formation of a hair-bearing flap for mustache reconstruction

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+ Case 3: Prelamination

34

A 62-year-old man sustained full-thickness facial burns, and debridement resulted in loss of the distal subunits of his nose and full-thickness cutaneous loss of the nasal dorsum, right cheek, and upper lip, with exposed bone and cartilage (Fig. 34.4a). During the first stage of reconstruction, skin and cartilage grafts were placed beneath a radial forearm flap to serve as nasal vestibular lining and nostril rim support, respectively (Fig. 34.4b). After 3 weeks, the grafts had taken and the prelaminated flap was transferred as a single unit for reconstruction of the nose, cheek, and upper lip (Fig. 34.4c, d). One month later, a revision was performed to define the lip, nasal subunits, and cheek (Fig. 34.4e).

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⊡ Fig. 34.4  Patient photographs for case 3 showing a severe central facial burn reconstructed with a radial forearm flap prelaminated with cartilage grafts for nasal support and skin grafts for nasal lining

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Prefabricated Facial Flaps luc téot

Introduction Prefabrication was proposed in 1998 by Khouri et al. [1] as a solution for the neodevelopment of flaps when anatomy could not provide an adapted tissue for a specific surgical procedure, after seminal works done by Erol [2] and Pribaz [3]. The author developed a technique [4] using a vascular carrier placed above a large skin expansion device. This system induces an important angiogenetic process, allowing the expanded skin surface to be progressively vascularized by newly formed capillaries developed from the carrier. This technique may be used anywhere on the body, in particular for extensive scars of the face, to provide aesthetic improvement and a better quality of life.

Technique We have designed a technique for the prefabrication of large flaps to cover whole face reconstruction for cervicocephalic postburns scarring. This technique, based on modifications of the normal skin flap vascular anatomy, is called prefabrication and aims to provide the surgeon with larger flaps than normal anatomy would allow.

This two-stage procedure creates, after skin expansion, a cutaneous axial flap large enough to cover the whole face. During the first stage, an antebrachial fascial flap, including the radial artery and vein, is harvested and connected to the facial pedicle artery and vein. The fascia is then inserted under the supraclavicular skin, and a supralarge skin expander is placed below the fascia. Skin expansion is then carried out, creating a very large flap, with a surface area large enough to cover a 22 × 23-cm skin defect. The second stage is realized 3 months later, when skin expansion is completed. Once the total facial scar is excised, the flap is drawn over the expanded skin surface to the size of the defect. This flap is dissected along the carrier pedicle until the previously realized microvascular anastomosis is visualized. The flap is then turned around its axial flap. Dissection should continue until the facial vessels are exposed and show the microanastomoses previously realized.

Results Seven patients presenting extensive facial scars after burns were offered this technique. Burns sequellae extended over the neck, cheeks, nose, and mandibular area.

L. Téot, MD, PhD Monpellier University, France e-mail: [email protected]

H. Hyakusoku et al. (eds.), Color Atlas of Burn Reconstructive Surgery, DOI: 10.1007/978-3-642-05070-1_35, © Springer-Verlag Berlin Heidelberg 2010

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Clinical Cases + Case 1

35

A 27-year-old female presented with a complete facial scar with retracted eyelids, destruction of the cartilaginous portion of the nose, retraction of the mouth commissures, and scars over the front and the neck (Fig. 35.1a, b). The antebrachial fascia was harvested prior to dissection of the facial artery and vein, and a large undermining of the supraclavicular area was achieved. The antebrachial fascial flap was inserted under the skin, and microanastomosed to the facial vessels. A 2000 cc skin expander was inserted deep into the antebrachial fascia. After a period of 3 months of expansion using saline, an angiogram of the facial vessels was performed (Fig.  35.1c). It showed new vessels extending largely around the skin expande, and coming from the vascular carrier. The radiologist’s evaluation was that an intense neoangiogenesis was induced. During the second operative stage, the facial scars are completely removed. As usual in these types of postburn lesions, a few underlying structures are severed. Underlying muscles and nerves of the scars are atrophied but present. In order to reconstruct the face, a 25 × 25-cm flap was designed over the expanded area, on the left shoulder. Vessels of the carrier pedicle are retrodissected until the previously done microanastomoses could be exposed. The flap is turned over its axial pedicle in order to fill the surgical defect. The opening of the mouth and realization of the commissures are performed, as well as the adaptation of the flap to reconstruct the lower eyebrows. The postoperative period was marked by a progressive reappearance of facial mimics, due to the remodeling of the transplanted skin (folds around the commissure). The patient could then have a normal social life, be married, and have children (Fig. 35.1d).

Prefabricated Facial Flaps

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c

⊡ Fig. 35.1 (a–d)

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+ Case 2 A 5-year-old boy was involved in a domestic accident resulting in burns of 85%. The face was involved. After resuscitation, skin grafts, and rehabilitation, the face presented extensive scars over the cheeks, the neck, and the mandibular areas. The chin was severely scarred with hypertrophic zones, as well as the commissures of the mouth (Fig. 35.2a).

35

The patient underwent the two-step procedure, similar to case 1. The total scarred area was removed and the prefabricated supraclavicular axial flap was dissected and rotated to cover the skin defect. The size of the flap was 20 × 17 cm. The mouth had to be reopened in the middle of the rotated flap (Fig. 35.2b). No postoperative problem was noted, except a transient edema of the face. During the following years, as the child grew, a defatting procedure had to be done on the lateral part of the flap, on the side of the pedicle, without damaging the flap viability (Fig. 35.2c).

Prefabricated Facial Flaps

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⊡ Fig. 35.2 (a–c)

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Prefabricated Facial Flaps

+ Case 3 A 17-year-old boy presented an extensive postburn scar over the lower portion of the face, the chin, and the anterior part of the neck, with a variety of hypertrophic scars and wrinkles. Irregularities were visible, despite a trial of resurfacing using a skin graft (Fig. 35.3a, b)

35

The flap was designed over the left shoulder, which presented a less scarred surface than the right one. However, some scarred areas were present over the expanded skin (Fig. 35.3c). After flap rotation, the oval of the face could be restored. Results at 6 months showed a good remodeling of the contour. The skin was flat, and did not present the commonly encountered bulky aspect. This was probably due to the extensive mechanical stress during the expansion period, where the fat is somehow crushed between the skin and the expander, preventing fat edema after the second surgical procedure (Fig. 35.3d, e).

Prefabricated Facial Flaps

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a

b

c

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⊡ Fig. 35.3 (a–e)

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C H A P T E R 36

Scarred Flap hiko hyakusoku

Background of the Technique For functional reconstruction in extensively burned patients, reconstruction using flaps is necessary, but sometimes healthy skin is missing. However, scars due to epidermal burn (EB), superficial dermal burn (SDB), and deep dermal burn (DDB) can be used as local flaps or regional flaps. There are two concerns about scarred flaps: (1) vascularity of the flap and (2) elasticity of the flap. However, appropriate design and careful preoperative and intraoperative assessment of scars make this procedure successful. In 1981, the present author reported the effectiveness of scarred flaps including the musculocutaneous vascular system [1], after which some cases were experienced [2–4].

2. Skin grafted scars can also be used as scarred flaps. However, assessment of scar thickness is more difficult than primary scars. 3. Intraoperatively, careful observation of bleeding from the edge of the flap and evaluation of scar thickness are necessary. 4. Flap types should be selected on a case-by-case basis; (1) scarred random pattern flap, (2) scarred axial pattern flap, (3) scarred musculocutaneous flap, and (4) scarred fasciocutaneous flap. The vascularity of (3) is the most reliable.

Characteristics and Specific Skills of the Method 1. Theoretically, scars due to SDB and DDB can be used as flaps with normal vascularity. Vascularity of scars due to DB is limited, but these scars can also be used under appropriate preoperative assessment with Doppler ultrasound, color Doppler ultrasound, or MD-CT. Sometimes we can find adequate collateral circulation in the flap.

H. Hyakusoku MD, PhD Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School Hospital, Tokyo, Japan e-mail: [email protected]

H. Hyakusoku et al. (eds.), Color Atlas of Burn Reconstructive Surgery, DOI: 10.1007/978-3-642-05070-1_36, © Springer-Verlag Berlin Heidelberg 2010

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Scarred Flap

Clincal Cases + Case 1 (Fig. 36.1): Axillary Reconstruction A 60-year-old woman had flame burns of DDB and DB in her upper extremity. After lifesaving treatments including early skin graft, the patient had a scar contracture in her right axilla. Thus, a latissimus dorsi musculocutaneous flap was designed in the scarred lesion.

36

This scarred musculocutaneous flap has survived completely and the scar contracture was released.

Scarred Flap

a

b

⊡ Fig. 36.1  (a) Flap design. (b, c) 6 months Post-operation

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Scarred Flap

+ Case 2 (Fig. 36.2): Axillary Reconstruction A 38-year-old man had flame burns covering 42% of the TBSA. The scar contracture affecting the right axillar region was reconstructed with a scarred fasciocutaneous flap (24 × 8 cm), designed in the dorsal area similar to a bilobed flap in order to decrease the raw surface area after transposing the flap.

36

Scarred Flap

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b

⊡ Fig. 36.2  (a) Pre-operative view. (b) Flap design. (c) 6 months post-operative view

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c

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Scarred Flap

+ Case 3 (Fig. 36.3): Ankle Joint Reconstruction

36

A 46-year-old woman had extensive flame burn over 70% TBSA due to a suicide attempt. After lifesaving therapy, the patient suffered from scar contracture of the left foot. Thus, free rectus abdominis musculocutaneous flap was applied to reconstruct the tissue defect after removing the scar. Unfortunately, fascial excision and patch grafts were performed on the abdominal area as lifesaving procedures; however, a free RAM flap was designed as a scarred or skin grafted flap. Of course, we thought that the survival area of the flap must be smaller than a flap in the healthy skin area, thus the design of the flap was limited to the muscle area. The flap survived perfectly and scar contracture was released.

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d

c

⊡ Fig. 36.3 (a–d)

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Scarred Flap

+ Case 4 (Fig. 36.4): Ankle Joint Reconstruction

36

A 23-year-old man had flame burn in his lower extremities and mesh skin grafts were performed. However, the Achilles tendon of the right leg was exposed. A free flap was planned but the patient was admitted in a local hospital, and so we could not perform microsurgery. Thus, the cross-leg distallybased scarred fasciocutaneous sural flap method was used for reconstructing the exposed tendon. The flap size was 20 × 8  cm, and the flap division was performed 14  days after the first operation; hence, the reconstructive purpose was completed.

Scarred Flap

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c

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d

⊡ Fig. 36.4  (a) Pre-operative view. (b) intra-operative view (elevation of the distally-based sural flap). (c) 14 days after primary operation. (d) 6 months post-operation

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C H A P T E R 37

Use of Previously Burnt Skin in Local Fasciocutaneous Flaps rodney chan and julian pribaz

Background of the Technique Reconstruction of severe burns in patients remains a challenge. This is particularly problematic in wounds that require durable flap coverage such as exposed bony prominences, tendons, and joints due to the paucity of normal adjacent skin donor sites. Reluctance in using local or regional flaps previously burned or skin-grafted is based on the erroneous assumption of inferior blood supply in the burned skin from prior thermal damage. The initial thermal injury is generally limited to the skin and subcutaneous fat; the underlying fascia and its vasculature are usually spared. Several authors have published on the feasibility of using previously burned skin in local fasciocutaneous flaps with good success. Tolhurst was the first to observe that small areas of grafted skin remained viable when included in various parts of fasciocutaneous flaps in the trunk [1]. Cherup describes the use of a radial forearm skin graft-fascial flap for hand reconstruction [2]. Pribaz published the first large series of 40 fasciocutaneous flaps using previously burned skin for upper extremity reconstruction [3]. Since then, Barret compared 238 previously burned skin flaps with 115 controls in the pediatric population and concluded no significant differences in the rate of flap necrosis [4].

Characteristic and Indication of the Method We have most experience using this method in the upper extremities, although the same principle can be applied

J. Pribaz, MD (*) Department of Surgery, Division of Plastic Surgery, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115, USA e-mail: [email protected] R. Chan, MD Department of Surgery, Division of Plastic Surgery, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115, USA

elsewhere. In the reconstruction of the upper extremities, flaps are used to cover nongraftable wounds such as exposed tendon, bone, joints, and to release webspace contractures. One area especially prone to breakdown and requiring flap coverage is the elbow, both in the area of the olecranon, its underlying olecranon bursa, as well as the antecubital fossa where contractures are also common. Bony prominences and aponeurotic origins of the extrinsic forearm muscles predispose the elbow area to frequent need for well-vascularized tissue. Local options for coverage include taking tissue from either the arm (distally-based) or the forearm (proximally-based). The most commonly used flap in our experience is the reverse lateral arm flap, which is based on the anterior or posterior radial recurrent arteries. The use of ulnar recurrent upper arm flap is also possible but not ideal, based on the proximity to the ulnar nerve. Posterior interosseous flap, radial forearm, or the ulnar forearm flaps have also been used, but these might be required to act as distally-based flaps to surface the hand and wrist in the multiply burned patient. Careful planning is required so that “no bridges are burned.” The wrist and hand is another potential area requiring flap coverage. This area is particularly prone to exposed bone, joints, and tendon due to the thin skin covering. In addition, contracture of the first webspace is particularly problematic and the use of the reverse posterior interosseous flap has been met with good success in our experience. Coverage over the dorsum of the hand with exposed tendon can be achieved with either reverse radial forearm or reverse ulnar forearm flaps. For smaller defects, use of the proximally-based metacarpal and axial digital flaps can also be helpful. Digital reconstruction requiring flaps is also common and mainly involves coverage of dorsal surface of the PIP joint or PIP joint contracture release, which can either be extensor or flexor-based. Local flaps either based proximally or distally from the metacarpal or digital areas have been used for reconstruction. While our experience has been mostly focused on the upper extremities, the use of previously burned adjacent

H. Hyakusoku et al. (eds.), Color Atlas of Burn Reconstructive Surgery, DOI: 10.1007/978-3-642-05070-1_37, © Springer-Verlag Berlin Heidelberg 2010

Use of Previously Burnt Skin in Local Fasciocutaneous Flaps

skin as fasciocutaneous flaps can be applied throughout the body. Haddock has used previously burnt tissue in the reconstruction of the upper lip and nasal tip [5]. In Barret’s series, while the majority of their flaps were in the upper extremities, 11% were used in the lower extremities, 13% in the face, and 5.5% in the neck and trunk each [4].

Specific Skill of the Methods In our experience, the vascularity was assessed with Doppler ultrasound to mark out the underlying axial artery and perforators and to verify adequate collateral circulation. When using a radial forearm flap, an Allen’s test was performed. The flaps can be based either proximally (orthograde flow) or distally (retrograde flow). The resulting donor site defects often have to be skin-grafted. However, one inherent advantage of this technique is that there is little

CHAPTER 37

added morbidity. The new donor defect, consisting of skin graft on muscle, has very little perceptible change from the previous skin-grafted donor site. The multiply burned patients often have several areas that require flap coverage, and a total treatment plan is needed prior to the commencement of any reconstruction, so as not to compromise future reconstructive options. When raising the flap, it is imperative to raise the skin-grafted fascia, together with the underlying vessels. Rough handling of these flaps, elevation at the wrong level, indiscriminate use of coagulation, and tension during closure can cause overlying skin necrosis. Some authors have also emphasized the need to maximize the time interval between the acute grafting procedure and the raising of the flap for reconstruction. With time, the quality of the skin raised is better, with improved pliability and improved “contourability;” however, this may not always be possible because of the more urgent need for tissue coverage.

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Use of Previously Burnt Skin in Local Fasciocutaneous Flaps

Clinical Cases + Case 1

37

Elbow – 23-year-old man with extensive contracture of his left elbow with radiograph showing ossification of the posterior joint capsule (Fig. 37.1a). After release of soft tissue and bony ankylosis, a reversed lateral arm flap was marked on the skin-grafted upper arm (Fig. 37.1b). The flap is well-perfused and inset over elbow release, and a skin graft was placed on lateral arm donor site (Fig. 37.1c). At 3 months, there is excellent coverage and healed donor site (Fig.  37.1d). The patient is able to flex elbow and bring his hand up to his mouth (Fig. 37.1e).

Use of Previously Burnt Skin in Local Fasciocutaneous Flaps

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e b

c

⊡ Fig. 37.1 (a–e)

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Use of Previously Burnt Skin in Local Fasciocutaneous Flaps

+ Case 2

37

Wrist and hand – 23-year-old man with multilevel injuries of his upper extremity with contracture of his first webspace (Fig. 37.2a). The first webspace has been released and the subluxed phalanx has been repositioned. A defect encompassing the first webspace and dorsum of his hand is now present (Fig. 37.2b). Reverse posterior interrroseous flap was raised from skin-grafted forearm with intraoperative picture depicting a well-perfused flap (Fig. 37.2c). This was inset into the defect over a penrose drain (Fig. 37.2d). He has a satisfactory long-term outcome with a functioning webspace (Fig. 37.2e).

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a

b

c

d

e

⊡ Fig. 37.2 (a–e)

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+ Case 3

37

Digital – 34-year-old man with full-thickness dorsal burns to the thumb and index stumps, without a functional webspace (Fig. 37.3a). “Spare part” pollicization of the injured index stump was performed based on the digital vessels with the palmar aspect of the index stump being used to reconstruct the dorsal aspect of the thumb. A ray amputation of the proximal ray of the index digit was also performed to open up the webspace (Fig. 37.3b), with its accompanying radiograph (Fig. 37.3c). This resulted in a functional webspace. The thumb is shown in both abduction and adduction. An anterolateral thigh flap was eventually performed to resurface his dorsum as well (Fig. 37.3d, e).

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d

b

e

c

⊡ Fig. 37.3 (a–e)

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C H A P T E R 38

Supraclavicular Flap vu quang vinh and tran van anh

Background of the Technique In 1979, Lamberty [1] described the supraclavicular flap on the basis of illustrations taken from Toldt’s anatomical atlas, which was published in 1903 [2]. The author showed a vessel which emerged between the sternomastoid and trapezius in the lower part of the posterior triangle and passed over the acromion. After that, Pallua et  al. [3] reported in 1997 that they had used this flap successfully in eight cases of neck contracture reconstruction. Since then, the supraclavicular flap has been employed widely. Of the various flap techniques that are available, the supraclavicular flap is excellent in terms of its match with the color and texture of the recipient area and the simplicity of the operative procedure [4–12]. The author has also successfully applied this flap in the clinic in numerous cases. The flaps that we employed clinically included not only conventional supraclavicular flaps but also tunnel island flaps, bilateral supraclavicular flaps, and supercharged flaps (Fig. 38.1).

Anatomical Characteristics and Indication 1. Ninety percent of the supraclavicular artery can be found from the middle third of the clavicle (Type I) [13]. Ten percent of that can be found from the lateral third of the clavicle (Type II) [13]. 2. The supraclavicular artery is usually derived from the transverse cervical artery [13]. Ninety five percent of the transverse cervical artery arises from the thyrocervical trunk and 5% from the subclavian artery [13].

V. Q. Vinh, MD, PhD (*) National Institute of Burn, Vietnam e-mail: [email protected] T. V. Anh, MD, PhD National Instituite of Burn, Vietnam

3. On the body surface, the transverse cervical artery can be identified under the skin as being on average 3.77 cm (3–4.5 cm) from the sternoclavicle joint [13]. The external diameter of the transverse cervical artery is on average 2.9 mm, while the external diameter of the supraclavicular artery is on average 1.17 mm [13]. 4. Supraclavicular is indicated for postburn scar contracture in neck, where a large and thin flap is required and also needs to be pliable and match the color for the reconstruction of contour-sensitive areas. Perforator supercharging can be employed if a much larger flap is needed (Fig. 38.1).

Specific Skill of the Method 1. Flap size is determined according to the size of the recipient site and the flap is designed on the patient’s shoulder (Fig. 38.2). We generally prefer fusiform designs as they allow the donor site to be closed primarily. The flap can be employed as a conventional rotation flap, tunneled flap, or supercharged flap, and the flap pedicle selected can be vascular or skin pedicle. 2. Landmarks of the flap should include anterior, posterior, and distal edges that reach the inferior border of the clavicle, the upper area of the trapezius muscle, and the upper arm, respectively. Doppler flowmetry, angiography, and MDCT are usually useful for identifying the supraclavicular artery preoperatively. 3. In the operation, recipient site scars are debrided to the depth of the deep fascia to release the contractures completely. The harvested flap includes skin, subcutaneous tissue, and the fascia of the deltoid muscle. In the medial part of the flap, the supraclavicular artery, which arises from the transverse cervical artery, can be identified. In some cases, we refine the transverse cervical artery and its bifurcation from the thyrocervical trunk to enable harvesting of an island flap with a longer pedicle. 4. The donor site can be closed primarily when the flap width is smaller than 10  cm. When the flap width exceeds 10 cm, split thickness skin grafts or bilobed flaps harvested from the dorsal region are needed.

H. Hyakusoku et al. (eds.), Color Atlas of Burn Reconstructive Surgery, DOI: 10.1007/978-3-642-05070-1_38, © Springer-Verlag Berlin Heidelberg 2010

Supraclavicular Flap

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a

b

⊡ Fig. 38.1  Depiction of the supraclavicular flap and its sup­ ercharged versions. A: supraclavicular flap. A + B: supraclavicular flap supercharged with the posterior circumflex humeral vessel. A + C: supraclavicular flap supercharged with the anteriorcircumflex humeral vessel. A + D: supraclavicular flap supercharged with the thoracoacromial artery perforator (TAAP). A + E: supraclavicular flap supercharged with the lateral thoracic artery perforator (LTAP). a: supraclavicular artery. b: posterior circumflex humeral artery. c: anterior circumflex humeral artery. d: TAAP. e: LTAP. By using the supraclavicular flap displayed by A, it is possible to harvest flaps that are up to 11 cm wide and 21 cm long and whose anterior edges, posterior edges, and distal edges reach the inferior border of the clavicle, the upper area of the trapezius muscle, and the upper arm, respectively. Moreover, if the vessels indicated by b–e are used for supercharging, much larger flaps can be harvested

⊡ Fig. 38.2  The schema of the supraclavicular flap. (a) The supraclavicular artery and the flap. (b) Flap elevation as an island flap. The arrow shows the point that refined the transverse cervical artery and its bifurcation of supraclavicular artery to harvest an island flap with longer pedicle

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Supraclavicular Flap

Clinical Cases + Case 1 (Fig. 38.3)

38

A 42-year-old man suffered from severe scald burns on the neck and shoulder, but did not receive any treatment and subsequently developed contractu­ res. The right shoulder had sufficient good healthy skin for neck reconstruction with a unilateral supraclavicular island flap that measured 25 × 15 cm. The flap was elevated as an island flap and was transferred to cover the defect after removing the scars. The flap survived completely. The neck movement of the patient recovered to the extent that he did not have any problems in daily life, although slight hypertrophic scars did develop on the flap margin. The donor site was closed by using a split thickness skin graft.

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e

b

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c

f

d

g

⊡ Fig. 38.3  (a, b) Preoperative view. (c) Flap design (a 25 × 15-cm supraclavicular flap). (d) Flap elevation. (e) View immediately after the operation. (f, g) View 1 year after the operation

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Supraclavicular Flap

+ Case 2 (Fig. 38.4)

38

A 48-year-old female suffered from a flame burn and developed hypertrophic scars and scar contractures on the chin and neck a year after the wounds had healed. Since the patient has a history of diabetes, angiography was performed preoperatively to identify the supraclavicular artery. To reconstruct her neck, a unilateral supraclavicular island flap (25 × 14  cm) was planned. After removing the scars, the flap was elevated as an island flap. To increase the rotation arc of the vascular pedicle, the transverse cervical artery was ligated above its bifurcation with the supraclavicular artery, and a pivot point on the thyrocervical trunk was created. The flap was rotated 180° to cover the defect. The flap survived completely. The donor site was closed by using a split thickness skin graft. The texture and color matches of the flap were good and the patient was satisfied with the cosmetic and functional outcomes.

Supraclavicular Flap

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c

e

⊡ Fig. 38.4  (a) Preoperative view. (b) Flap design (25 × 14 cm supraclavicular flap). (c) View immediately after the ­operation. (d, e) View 1 year after the operation

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C H A P T E R 39

Superficial Cervical Artery Perforator (SCAP) Flap rei ogawa, shimpei ono and hiko hyakusoku

Introduction The superficial cervical artery (SCA) fasciocutaneous flap was first reported by Nakajima et  al. in 1984 [1]. Hyakusoku developed it for use as a skin flap in 1990 [2], and in 1993, we succeeded in harvesting it as a free flap [3]. The SCA is now considered to be a “transverse cervical perforator” or “trapezius perforator” (Fig.  39.1); thus this flap is widely known as “superficial cervical artery perforator (SCAP) flap” [4]. The cranial part of the trapezius muscle is thought to contain the SCA (superficial branch of the transverse cervical artery), and the middle part the dorsal scapular artery (DSA; deep branch of the transverse cervical artery) [4]. With its wide arc of rotation, the SCAP flap is large enough to cover large defects after removal of neck scar contractures.

Characteristics of the SCAP Flap 1. Flap shapes can be classified roughly into two types. One is a longitudinal shape from the nape to the medial dorsal region, and the other is an oblique shape from the nape to the scapular area. Maximum length of the flap is around 30 cm. The areas between Th1 and Th6 are considered to be the minimal survival areas for SCAP flaps according to an anatomical study

R. Ogawa, MD, PhD (*) Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School Hospital, Tokyo, Japan e-mail: [email protected] S. Ono, MD, PhD Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School Hospital, Tokyo, Japan e-mail: [email protected] H. Hyakusoku, MD, PhD Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School Hospital, Tokyo, Japan e-mail: [email protected]

[4]. However, we have actually used very large flaps between Th1 and Th8 that have survived completely with blood flow supplied only from the SCAP. 2. The pedicle types can be classified into three types: (1) musculocutaneous pedicled flaps, (2) muscle pedicled island flaps, and (3) vascular pedicled island flaps. 3. Pedicle diameter is over 0.7 mm [4]; thus a SCAP free flap transfer is possible in almost all cases. 4. Perforator supercharging is a good option when much larger flaps are needed. In such cases, the dorsal intercostal perforator (DICP, D-ICAP) and the circumflex scapular vessel (CSV) can be employed as supercharged (augmented) vessels. 5. Primary flap thinning can be performed, except the vascular pedicle area, as “super-thin flaps” [5]. Flaps can be thinned down primarily to the layer where the subdermal vascular network can be seen through the minimal fat layer.

Tips for Harvesting Flaps 1. The SCA can be identified on the cranial region of the trapezius muscle on the nape. When the pedicle is employed as a vascular pedicle, the SCA should be identified both on and under the muscle. Pedicle is employed as a musculocutaneous pedicle or muscle pedicle; identification of the SCA on the muscle is not necessary. 2. In the operation, we should pay attention not to injure the accessory nerve. 3. When a muscle or musculocutaneous pedicle is employed, the flap can be elevated with a small amount of muscle. The advantages of musculocutaneous and muscle pedicled flaps are that they are easy to harvest and have reliable venous return. On the other hand, pedicled flaps do have a disadvantage: their rotation arc is limited. 4. The donor site should be covered with a splitthickness skin graft or sutured primarily.

H. Hyakusoku et al. (eds.), Color Atlas of Burn Reconstructive Surgery, DOI: 10.1007/978-3-642-05070-1_39, © Springer-Verlag Berlin Heidelberg 2010

Superficial Cervical Artery Perforator (SCAP) Flap

⊡ Fig. 39.1  The schema of the SCAP flap

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+ Case 1 (Fig. 39.2): Vascular Pedicled SCAP Flap A 28-year-old man suffered from post-burn scar contractures of his neck (a). A 30 x 9 cm of SCAP flap was harvested (b, c). The flap donor site was closed primarily and the flap survived completely (d).

39

Superficial Cervical Artery Perforator (SCAP) Flap

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b

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d

⊡ Fig.  39.2  Anterior neck reconstruction using vascular pedicled SCAP flap. Preoperative view (a). Flap design (b). Immediately postoperative view (c). Three months postoperative view (d)

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+ Case 2 (Fig. 39.3): Cutaneous Pedicled SCAP Flap A 7-year-old female suffered from right axillary contracture, and the contracture was released by cutaneous pedicled SCAP skin flaps. Shoulder motion could recover completely after rehabilitation. After several years, her right breast developed normally without any contractures.

39

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b

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c

⊡ Fig. 39.3  Axillary reconstruction using a pedicled SCAP flap (a). Flap design (b). 3 months after surgery (c). 5 years after surgery

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Superficial Cervical Artery Perforator (SCAP) Flap

+ Case 3 (Fig. 39.4): Musculocutaneous Pedicled

SCAP Flap

A 22-year-old man with a severe postburn neck contracture. Bilateral symmetrical musculocutaneous pedicled SCAP skin flaps measuring 32 × 12 cm were used for reconstruction. After flap transposition, the donor sites were closed with meshed skin grafts. The flaps survived completely, the scar contracture was removed, and there has been no subsequent complication.

39

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⊡ Fig.  39.4  Anterior neck reconstruction using bilateral pedicled SCAP flap. (a) Pre-operative a view. (b) Flap design. (c) 1 year post-operative view

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+ Case 4 (Fig. 39.5): Circumflex Scapular Vessels

Supercharged SCAP Flap

39

A 37-year-old woman had a flame burn due to a suicide attempt. Free splitthickness skin sheets had been grafted onto her neck in the Critical Care Medicine Center. However, she developed a severe neck contracture (a). We applied a left SCAP flap supercharged with the contralateral CSVs measuring 28 × 20 cm to the area where the contracture had been removed (b). The flap was harvested as “super-thin flap,” and the CSVs were anastomosed with the right facial vessels (c). The flap survived and the contracture was released (d, e).

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b

c

d

e

⊡ Fig. 39.5  (a) Pre-operative view. (b) Flap design. (c) Elevated flap. (d, e) A year post-operative view

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Clinical Cases + Case 5 (Fig. 39.6): Dorsal Intercostal Perforator

Supercharged SCAP Flap

39

This case is of a 19-year-old male. After extensive burn on the upper body, neck contracture releasing and reconstruction were performed during childhood. But, the remaining lower neck contracture became tight with growth, and thus, we planned another reconstruction (a). Dorsal intercostal perforator (DICP, D-ICAP) supercharged SCAP propeller flap was designed on his left back (b). The seventh DICP was anastomosed with the right facial vessels, and the flap survived completely (d). The flap size was 30 × 8 cm. The seventh DICP was attached on the distal portion of the flap (c), and the flap was harvested with a vascular pedicle of SCAP.

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⊡ Fig. 39.6   (a) Design of the recipient size. (b) Flap design. (c) Flap elevation. (d) 3 months post-operative view

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Super-Thin Flap hiko hyakusoku, rei ogawa and hiroshi mizuno

Background of the Technique Along with the recent development of “perforator flaps,” thin flaps are now coming into widespread use. However, over the past 20 years, the authors have focused on flap thinning techniques which have allowed us to harvest extremely thin but large flaps. These techniques have been primarily used to reconstruct large areas in burn reconstruction. Historically, thin flaps were initially pioneered by Colson in 1966 [1], and further developed by Thomas in 1980 [2]. Thereafter, an antecedent model to our “super-thin flaps” was devised in China around 1982. The first report of “super-thin flaps” was made by Situ in 1986 [3]. His flap seems to have been influenced by Tsukada’s preserved subdermal vascular network full-thickness skin graft (PSVN) [4]. Some vascular pedicles were attached to the grafted skin in China, but many Chinese plastic surgeons experienced distal epithelial necrosis. Gao, who visited Nippon Medical School in Tokyo in 1990 as a foreign student, held discussions with Hyakusoku that were based on their clinical experiences (Fig. 40.1), and they attempted to develop much safer procedures by animal experiments. After that, the authors have been developing these thin flaps for clinical use (Fig.  40.1), and our “super-thin flap” was first reported in 1994 [5, 6]. Gao et al. [7, 8] also reported their animal experiments in 1999 and 2000 in Japanese, and their experiments were introduced in 2004 with new anatomical findings in English by the authors [9]. R. Ogawa, MD, PhD (*) Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School Hospital, Tokyo, Japan e-mail: [email protected] H. Hyakusoku, MD, PhD Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School Hospital, Tokyo, Japan e-mail: [email protected] H. Mizuno, MD, PhD Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School Hospital, Tokyo, Japan e-mail: [email protected]

a

b

⊡ Fig.  40.1  A case in China. (a) Preoperative design. (b) Postoperative view. This case was presented by Gao. The case was operated upon by Zhiyi Yang around 1990 at 401 PLA’s hospital in China. The flap pedicle seems to have perforators coming from the occipital artery; thus, this flap is considered to be an “occipito-cervico-pectral (OCP) flap [5].” Complete survival of the flap with a complicated shape was amazing, and this picture stimulated Hyakusoku to develop the current sophisticated “super-thin flaps”

H. Hyakusoku et al. (eds.), Color Atlas of Burn Reconstructive Surgery, DOI: 10.1007/978-3-642-05070-1_40, © Springer-Verlag Berlin Heidelberg 2010

Super-Thin Flap

CHAPTER 40

Characteristics of the Method 1. The “super-thin flap” is a generic name; however, it is more anatomically precise to call it the subdermal vascular network (SVN) flap. A discriminating feature of the flap is its extremely thin form. It is primarily thinned to the layer where the SVN (subdermal plexus) can be seen through the minimal fat layer (Fig. 40.2). 2. Theoretically, “super-thin flaps” can be harvested from anywhere in the body. However, most of our reconstructions have been extensive postburn scar contracture cases, for which we need extremely large but thin flaps to reconstruct wide, contour-sensitive areas such as the face, neck, and hands. For this reason, our flaps have been harvested mainly from the back and chest (Fig. 40.3). 3. Primary flap thinning can be considered effective to prevent blood perfusion stealing to adipose tissues, and flap survival area will be extended [10, 11]. 4. With the help of supercharging vessels attached to the distal area of the flap, extremely large and long flaps can be harvested [12]. These flaps can be termed perforator-supercharged “super-thin flaps.” This type of flap has been introduced in another chapter of this book.

Specific Skill of the Methods 1. Before operation, each flap is designed to match the shape of the recipient site, and a judgment is made on whether there is any requirement for perforator supercharging. The judgment should be based on the results

⊡ Fig. 40.2  Primary flap thinning

of anatomical studies [9, 13]. Basically, the 1:2:4 (pedicle width: flap width: flap length) theory suggests a limit to the size in “super-thin flap” without any supercharging. 2. The flap is elevated from the periphery. After the flap is completely elevated, thinning of the flap is performed. The flap is thinned down with curved scissors to the layer in which the SVN can be seen through the minimal fat layer. 3. After debulking, we also sometimes place a suction drain under the flap and apply slight pressure to prevent subdermal hematoma formation. 4. After the donor site is covered with a split-thickness skin graft or primary suture, the thinned flap is rotated and applied to the recipient site.

⊡ Fig. 40.3  Schema of “super-thin flaps.” (a) Occipito-Cervico-pectral (OCP) flap (b). Occipito-Cervico-shoulder (OCS) flap (c). Occipito-Cervico-dorsal (OCD) flap

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Clinical Cases + Case 1 (Fig. 40.4) A 45-year-old man had extensive flame burns on the right cheek. Hypertrophic scars were resected and reconstructed with a small “super-thin flap.” The donor site was closed primarily.

40

Super-Thin Flap

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c

⊡ Fig. 40.4  Preoperative design (a). Transposition of the flap with tension reduction using sutures like shoe strings (b). One-year postoperative view (c)

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+ Case 2 (Fig. 40.5)

40

This patient is a 72-year-old woman who suffered a third-degree burn on the neck, and a second-degree burn on the face and the right hand. The typical cervico-pectral (CP) “super-thin flap” with transverse cervical perforator was designed to reconstruct. The size of the CP flap was determined by the size of the skin defect (20 × 10 cm2). The bottom of the flap was on the fourth rib. The donor site of the anterior chest was partially closed with a skin graft. Flap viability was never in question.

Super-Thin Flap

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c

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b

d

⊡ Fig. 40.5  Postoperative flap design (a). Flap thickness (b). one-year ­postoperative view (b, c)

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+ Case 3 (Fig. 40.6) A 30-year-old man suffered from postburn scar contractures of his lower lip and chin. A 31 × 10-cm of occipito-cervico-dorsal (OCD) “super-thin flap” was harvested. The flap donor site was closed with a small flap designed to the next of main flap. Distal epithelial necrosis was observed but epithelialized completely without any salvage skin grafting.

40

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⊡ Fig. 40.6  Preoperative design (a). Three months postoperative view of the flap applied to the lowerlip and chin (b)

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+ Case 4 (Fig. 40.7) A 14-year-old boy developed hypertrophic scars on his chin after facial burn. An occipito-cerviao-pectoral (OCP) “super-thin flap” was designed and used for reconstruction. The flap donor site was closed primarily.

40

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b

⊡ Fig. 40.7  Preoperative view (a). Flap design (b). One-year postoperative view (c)

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+ Case 5 (Fig. 40.8)

40

A 38-year-old man had a heat press injury on his left hand. The burn ulcer was deep with tendon exposure after debridement. An ipsilateral intercostal perforator (ICP, ICAP) pedicled “super-thin flap” measuring 20 × 13 cm was harvested to cover the dorsum of the hand. The eighth PICP was included in the skin pedicle, and the flap was employed as a distant flap. Thirteen days after the primary operation, the flap was resected from the body and the donor site was closed primarily.

Super-Thin Flap

b

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c

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d

e

⊡ Fig. 40.8 (a–e)  Preoperative view (a). Flap design (b). 6 months postoperative view (c, d, e)

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Super-Thin Flaps jianhua gao and feng lu

Background of the Technique The concept of thin flaps vascularized by subdermal vascular network was first described by Situ [1] in 1986; since then, various types of super-thin flaps have been applied successfully in China and Japan. Basic researches were also performed to better explain the excessive survival mechanism [2–5]. The authors have developed these thin flaps that are called “super-thin flaps,” which was first reported in 1994 [6]. Based on these successful clinical uses, supercharged super-thin flaps [7] and preexpanded super-thin flaps [8] were also reported and are widely used. Our ultimate goal, namely, the development of “thin and reliable flaps” is a unifying principle between “super-thin flaps” and perforator flaps.

Classification In general, super-thin flaps can be classified into three types based on their blood supply (Fig. 41.1). 1.  Random pattern super-thin flap Length: width ratio should be restricted within around 1:1.5; no excessive survival can be achieved. 2.  Axial pattern super-thin flap For example, free ALT super-thin flap and free DIEP super-thin flap are classified into this type. 3.  Super-thin perforator flap It was first introduced in 1994 by the authors. Since then, various types of “super-thin perforator flaps” have been

applied successfully. Preoperative Doppler or multidetector low-CT (MDCT) examinations are very helpful for identifying perforators. This type includes supercharged super-thin perforator flaps and preexpanded super-thin perforator flaps. Theoretically, all distant parts of perforator flaps can be super-thinned, and can be harvested from anywhere in the body.

Special Skills of the Method 1. Super-thinning is a microdissection technique for flaps where fatty tissue is removed and thinned to a level where the subdermal vascular network can be seen in the 2/3 distant part of the flap. Only a minimal (less than 5 mm) fat layer is obtained. It is better to thin the flap gradually from the distant area to the pedicle (Fig. 41.2). 2. Soft tissue around the pedicle (2–3 cm) should be kept intact to avoid any damage to the perforator. 3. Regarding preexpanded super-thin flap, it can be prefabricated to the thinnest perforator flap. Tissue expanders should be carefully inserted under the perforator flaps in advance. After expansion for 2  months, any adherent capsule should be completely excised and then further thinning of the flaps is performed until the subdermal vascular network can be clearly seen.

J. Gao, MD, PhD (*) Department of Plastic and Reconstructive Surgery, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China e-mail: [email protected] F. Lu, MD, PhD Department of Plastic and Reconstructive Surgery, Southern Medical University, Guangzhou, China H. Hyakusoku et al. (eds.), Color Atlas of Burn Reconstructive Surgery, DOI: 10.1007/978-3-642-05070-1_41, © Springer-Verlag Berlin Heidelberg 2010

Super-Thin Flaps

CHAPTER 41

⊡ Fig. 41.1  Various super-thin flaps. (1) Random pattern super-thin flap. (2) Axial pattern super-thin flap. (3a) Regular superthin perforator flap . (3b) Supercharged super-thin perforator flap (3c) Pre-expanded super-thin perforator flap

⊡ Fig. 41.2  Flap trimming technique

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Clinical Cases + Case 1 (Fig. 41.3)

41

A 34-year-old male patient suffered from flame burns 2 years ago, which caused second- and third-degree burns of the back of the right hand. He was admitted for replacement of disfiguring scars in the right hand (Fig. 41.3a). We designed the pectoral intercostal artery perforator (P-ICAP, PICP) flap with a pedicle that includes the seventh intercostal perforator. This flap was 19 cm long, 13 cm wide with a narrow 3.5 cm wide pedicle (Fig. 41.3b). In the first stage, we elevated the distant part of the flap and fatty tissue was removed, and the flap was thinned to a level where the subdermal vascular network could be seen (Fig. 41.3c). Scars on the right hand were surgically removed; the distant part of the P-ICAP flap was transferred (Fig. 41.3d). The pedicle was sutured to a tube and the right hand was kept at a specific posture until division of the pedicle (Fig. 41.3e, f ). Ten days later, the pedicle was cut down and the pedicle flap (3.5 × 5 cm) was transferred to the wrist (Fig. 41.3h). The flap survived well and satisfactory aesthetic improvement was achieved (Fig. 41.3g). The donor site was closed primarily with a linear scar.

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c

b

d

e

g

h

⊡ Fig. 41.3  Super-thin perforator flap (a) Disfiguring scars in the right hand (b) Designed pectoral intercostal artery perforator (P-ICAP, PICP) flap. (c) The flap was thinned to a level where the subdermal vascular network could be seen. (d) P-ICAP flap was transferred. (e, f) The pedicle was sutured

f

to a tube and the right hand was kept at a specific posture until division of the pedicle (g) Satisfactory aesthetic improve­ ment was achieved the pedicle was cut down and (h) The pedicle flap (3.5 × 5 cm) was transferred to the wrist

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+ Case 2 (Fig. 41.4)

41

A 29-year-old male patient presented with severe neck contractures and hypertrophic scars 8 months after a neck vitriol injury. The patient complained of an ugly appearance of the hypertrophic scars and restricted neck mobility (Fig. 41.4a, b). We designed a 21 × 3.5 ~ 7 cm occipito-cervico-shoulder (OCS) super-thin perforator flap in the right side of the patient (Fig. 41.4c). A descending perforator of the occipital artery was included in the pedicle. The flap was elevated and transferred to replace the hypertrophic scars and release neck contractures. After 8 months of follow-up, a satisfactory appearance (symmetry, contour, and color and texture match) and function (mobility and sensation) were achieved (Fig. 41.4d, e).

Super-Thin Flaps

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d

b

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c

e

⊡ Fig.  41.4  (a, b) Hypertrophic scars and restricted neck mobility. (c) Designed occipito-cervico-shoulder (OCS) superthin perforator flap. (d, e) Satisfactory appearance (symmetry,

contour, and color and texturematch) and function (mobility and sensation) were chieved after 8 months of follow-up

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+ Case 3 (Fig. 41.5)

41

A 22-year-old male presented with severe neck contractures 2 years after extensive head and neck vitriol injuries. He was admitted for replacement of disfiguring hypertrophic scars in the anterior neck and to improve the mobility (Fig. 41.5a). A typical design of the acromial-pectoral flap with a transverse cervical perforator was made on the axis that connects the root of the perforator of the superficial branch of the transverse cervical artery and the root of the perforator of the second internal thoracic artery. We created two pockets to insert two kidney-shaped tissue expanders just under the acromial-pectoral flap. During the elevation of the flaps, the occipital triangle was kept intact to avoid damaging the perforators that come from the transverse cervical artery. Over 2 months of serial saline injection in the clinic, a maximum expansion volume of 1200 mL was reached in the left side and 600 mL in the right side (Fig. 41.5b). In a second operation, hypertrophic scars on the left recipient site was surgically removed and the expander was explanted out the donor site. A 15 × 10 cm flap was elevated and thinned. During the elevation of the flaps, the occipital triangle was kept intact to avoid damaging the perforators coming from the transverse cervical artery (Fig. 41.5c). The flap then was thinned and transferred to the neck (Fig. 41.5d). Two weeks later, the pedicle of left flap was cut down. At the same time, the same super-thin perforator flap (13 × 10 cm at the right side) was formed and transferred to right side neck. Also the pedicle of right flap was divided ten days later. After 8 months of follow-up, a satisfactory appearance (symmetry, contour, and color and texture match) and function (mobility and sensation) were achieved (Fig. 41.5e). The donor sites were closed primarily with linear scars (Fig. 41.5f).

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d

b

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c

e

⊡ Fig. 41.5  (a) Disfiguring hypertrophic scars in the anterior neck. (b) A two tissue expanders were used to under the acromial-pectoral flap with the transverse cervical

f

­ erforators. (c) The flap was elevated and then thinned. p (e) Satisfactory appearance and function were achieved. (f)The donor site’s linear scar

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C h a p t e r 42

Anterolateral Thigh Flap for Reconstruction of Soft-Tissue Defects jianhua gao and feng lu

Background of the Technique The anterolateral thigh (ALT) flap was originally described as a septocutaneous artery flap by Song et al. [1]. Almost at the same time, the detailed anatomy of this flap and clinical application were reported by two other Chinese doctors in a Chinese journal [2, 3]. The locations of the perforators on the skin were first reported by the author [4]. After that, the anatomy of this flap was further presented from cadaver dissections or clinical experiences [4–6]. It was found that the blood supply of the anterolateral thigh flap was based on the septocutaneous or musculocutaneous perforators or both, the vascular variations of which were also reported by Koshima et al. [7]. The large skin territory, reliability, and versatility of the ALT flap have made it one of the best choices for soft-tissue defect reconstruction. So this flap has been widely used for head and neck, extremity, and trunk defect reconstruction.

Anatomy and Location of Perforators The ALT flap is based on either the septocutaneous or the musculocutaneous perforators with a diameter around 0.6–1.0 mm from the descending branches of the lateral circumflex femoral artery (LCFA). An average of 8–12 cm vascular pedicle can be obtained and the arterial diameter of the vascular pedicle is approximately 2.0–2.5 mm at

the harvest point, which is always accompanied by two veins with a diameter around 1.8–3.0 mm. LCFA sends perforators through the septum between the vastus lateralis and the rectus femoris or through the vastus lateralis muscle, and supplies a large skin flap on the anterolateral aspect of the thigh. If a visible septocutaneous perforator is found, the flap can be harvested as a septocutaneous flap. However, if septocutaneous perforators are absent, the flap can then be harvested as a musculocutaneous flap, with a small vastus lateralis muscle cuff for added bulk, or as a perforator flap with intramuscular dissection of the musculocutaneous perforators. In anatomic studies, most authors found the blood supply of the ALT flap to be from the musculocutaneous perforators rather than septocutaneous perforators. In the current series we found the major blood supply of the ALT flap to be from the musculocutaneous perforators (59.8%) followed by the septocutaneous perforators (40.2%) (Fig. 42.1). Either the septocutaneous or musculocutaneous perforators are always present at the anterolateral aspect of the thigh, and will allow this flap to be elevated safely. In our clinical experience, the ultrasonic Doppler flow meter is useful in determining the locations of the perforators preoperatively. Almost all perforators are located in an approximate 5-cm radius (92% perforator within 3-cm radius, 80% perforator points concentration in inferiorlateral quadrant region) from the midpoint of the line between the anterior–superior iliac spine and the lateral border of the patella on the donor thigh (Fig. 42.2).

Surgical Techniques J. Gao, MD, PhD (*) Department of Plastic and Reconstructive Surgery, Nanfang Hospital, Southern Medical University, 510515, Guangzhou, China e-mail: [email protected] F. Lu, MD, PhD Department of Plastic and Reconstructive Surgery, Nanfang Hospital, Southern Medical University, 510515, Guangzhou, China

1. Preoperative ultrasonic Doppler flowmeter is used to determine the locations of the perforators, the flap can be designed around these perforators. In general, the flap size should be controlled within 15 × 28 cm. An “S” pattern skin incision is made directly above the rectus femoris muscle. The descending branch of the LCFA can be easily seen within the intermuscular septum of the rectus femoris and vastus lateralis muscles.

H. Hyakusoku et al. (eds.), Color Atlas of Burn Reconstructive Surgery, DOI: 10.1007/978-3-642-05070-1_42, © Springer-Verlag Berlin Heidelberg 2010

Anterolateral Thigh Flap for Reconstruction

Chapter 42

⊡ Fig. 42.2  The location of perforator point on skin surface. Almost all perforators are located in an approximate 5-cm radius from the midpoint of the line between the ­anterior–superior iliac spine and the lateral border of the patella on the donor thigh. 80% perforator points ­concentra­tion in inferior-lateral quadrant region

⊡ Fig.  42.1  1 Lateral circumflex femoral vessel, 2 ascending branch, 3 transverse branch, 4 descending branch, 5 perforators

2. The thigh skin is then raised and retracted laterally by a subfacial plane dissection, which will expose the septocutaneous or musculocutaneous perforators. If the septocutaneous perforator exists, it always lies superficially on the vastus lateralis muscle and traverses in the intermuscular septum of the rectus femoris and vastus lateralis muscles proximally. The dissection becomes easier if it is from the distal to proximal. 3. If no septocutaneous perforator exists, we could always identify two to three musculocutaneous perforators emerging from the vastus lateralis muscle. The most proximal one was a preferable choice because of the relatively larger diameter of the perforator. The intermuscular septum of the rectus femoris and vastus lateralis muscle is dissected to explore the descending branch of the LCFA. The intramuscular dissection of the musculocutaneous perforator is then begun, also

from distal to proximal. The musculocutaneous perforator is then elevated with a 0.5-cm cuff of vastus lateralis muscle attached after careful division and ligation of several muscular branches. 4. The descending branch of the LCFA is isolated after division and ligation of several muscular branches to the rectus femoris and vastus lateralis muscles.

Advantages and Disadvantages Compared with other free flaps, the ALT flap has numerous advantages, including: (1) the large skin paddle can be harvested even when only a single major cutaneous perforator is available (the largest one is 20 × 30 cm in Koshima’s comment), (2) the flap may be thinned and is suitable for reconstruction of extremity or intraoral defects, (3) a long vascular pedicle can be obtained, (4) sensory flaps using the lateral femoral cutaneous nerve can also be obtained, (5) there is minimal morbidity at the donor site, and (6) part of the vastus lateralis muscle can be used to fill dead space in the neck and floor of the mouth floor or bony defects of the extremity to avoid infection after surgery.

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There are some disadvantages to this flap. The donor site scars associated with use of skin grafts in a large defect may preclude its use, particularly in female patients. Another disadvantage is that the anatomy of the perforator supplying the ALT flap is variable. In sum, the ALT flap, harvested as a septocutaneous flap, a perforator flap with intramuscular dissection, or

Anterolateral Thigh Flap for Reconstruction

as a musculocutaneous flap is versatile and useful for a variety of reconstructive problems. It can be harvested easily and safely to reconstruct large, complicated softtissue defects with minimal donor site morbidity.

Anterolateral Thigh Flap for Reconstruction

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Case Reports + Case 1 (Fig. 42.3)

42

A 47-year-old man presented with a diabetic ulcer on his left foot. A right free ALT septocutaneous flap was used to reconstruct the soft-tissue defect (Fig. 42.3a). The size of the flap was 22 × 12 cm (Fig. 42.3b), and the septocutaneous perforator was supplied from the LCFA descending branch (Fig. 42.3c, d). Complete flap survival was achieved without daily ambulating difficulty after 5 years of follow-ups (Fig. 42.3e, f ).

Anterolateral Thigh Flap for Reconstruction

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f c

⊡ Fig. 42.3  (a) Diabetic ulcer on his left foot. (b) A right free ALT (22 × 12 cm) septocutaneous flap was designed (c, d) Septocutaneous perforator was supplied from the LCFA

descending branch. (e, f ) Complete flap survival was achieved without daily ambulating difficulty

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Anterolateral Thigh Flap for Reconstruction

+ Case 2 (Fig. 42.4) A 27-year-old male patient suffered with severe left malleolar soft-tissue defect after being involved in an electric burn (Fig. 42.4a). An ALT flap measuring 20 × 14 cm was harvested from the left thigh for reconstruction (Fig. 42.4b, d). The vascular pedicle was anastomosed to the posterior tibial vessels, and the wound healed satisfactorily at the 3-year follow-up (Fig. 42.4c).

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Chapter 42

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⊡ Fig. 42.4  (a) Left malleolar soft-tissue defect. (b, d) An ALT flap measuring 20 × 14 cm was harvested from the left thigh. (c) The wound healed satisfactorily at the 3-year follow-up

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Anterolateral Thigh Flap for Reconstruction

+ Case 3 (Fig. 42.5)

42

A 20-year-old female presented with neck contractures 5 years after extensive neck and anterior flame burn. She asked for help to replace the disfiguring scars in the anterior neck and improve the mobility (Fig. 42.5a). A typical ALT flap (15 × 10 cm) was designed on the right thigh (Fig. 42.3b). Later, the hypertrophic scars on the neck were surgically removed, and the elevated and thinned ALT flap was transferred and anastomosed with the right facial vessels on the recipient. The donor site was closed with split skin graft. After 6 months of follow-ups, Satisfactory appearance (symmetry, contour, and color and texture match) and function (mobility and sensation) were achieved (Fig. 42.5c).

Anterolateral Thigh Flap for Reconstruction

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⊡ Fig. 42.5  (a) A 20-year-old female with neck contractures. (b) A typical ALT flap (15 × 10 cm) was designed on the right thigh. (c) Satisfactory appearance and function (mobility and sensation) were achieved

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Free Muscle Flaps for Lower Extremity Burn Reconstruction huseyin borman and a. cagri uysal

Background The concept of immediate excision and coverage of early burn wounds has been controversial in certain circumstances because of the clinical concept of the progressive necrosis [1]. However, radical debridement followed by early coverage with grafts and/or flaps has been performed. The main principle about the burn treatment and reconstruction is to jeopardise neither the patient nor any flap that might be lost because of the general status of the acute burn victim [2]. The surgical principles of burn care are preservation of life, prevention and control of infection, conservation of all viable tissue, maintenance of function and timely closure of burn wounds [3–5]. Thus, the timing of any reconstruction and closure of burn wounds should be considered after all other vital issues [6–8].

Free Muscle Flaps for Lower Extremity Burn Reconstruction The identification of muscle as a potential source of tissue as a flap offered tremendous possibilities for wound coverage and defect reconstruction [9–12]. Further investigations of the muscle perforators led to the utilisation of perforator flaps with low donor site morbidity. However, the high vascularity supplied by the microcirculation of any muscle flap still persists to be effective in

A. Cagri Uysal, MD (*) Department of Plastic and Reconstructive Surgery, Nippon Medical School, Tokyo, Japan Department of Plastic and Reconstructive Surgery, Baskent University Faculty of Medicine, Ankara, Turkey e-mail: [email protected] H. Borman, MD Department of Plastic and Reconstructive Surgery, Baskent University Faculty of Medicine, Ankara, Turkey

high infection localisations, such as the burn patient [13, 14]. In addition, the microsurgical transfer of any muscle flap enables high success rates with the large flap pedicles and low variation rates [15, 16]. In selected cases, we propose the utilisation of free muscle flaps for lower extremity burn reconstruction.

• The reconstruction ladder for burn reconstruction should be followed in any case: direct closure, adjacent tissue transfer, skin grafts, flaps and tissue expansion. • For any microsurgical procedure, including the free muscle flap transfer, the operation should be postponed until the general status of the patient is stable enough. • The free muscle flaps should be planned where there is high risk of infection and the radical debridement is not feasible, such as exposed bone, tendon, nerve or joint. • In any case of bone fracture at the lower extremity, external fixation by orthopaedicians would decrease the possibility of infection of the burned area. The pre-operative planning should start with the decision of the localisation of the external fixation. • The muscle flaps should be preferred at the localisations where pressure will be exposed, such as heel or sacrum. Osteomyelitis or any exposed bone tissue should be covered with muscle flaps. • If free-flap is mandatory for the reconstruction, the muscle flaps with larger diameter and longer pedicles should be the first choice in electrical burns. The free rectus abdominis muscle flap has been the first choice in our cases because of its large diameter, ease to harvest and the short operating time. It can be performed even in severe burn cases without jeopardising the flap or the patient’s general status. • The free muscle flap could be preferred instead of myocutaneous flap as free muscle flap decreases the time of operation and there will be a necessity for grafting of other burn areas at the lower extremity.

H. Hyakusoku et al. (eds.), Color Atlas of Burn Reconstructive Surgery, DOI: 10.1007/978-3-642-05070-1_43, © Springer-Verlag Berlin Heidelberg 2010

Free Muscle Flaps for Lower Extremity Burn Reconstruction

Thus, the aesthetic purpose should not be taken into consideration and simultaneous grafting of the burn areas and the free muscle flap can be performed. • The pre-operative evaluation of the recipient arteries must be done. The distal circulation should be preserved with end-to-side anastomosis. Intra-operative

Chapter 43

evaluation of the damage at the vessels is the gold standard. So the anastomosis should be performed at the safest level. Thus, a longer pedicle might be necessary intra-operatively. Free rectus abdominis muscle often serves as a good flap source.

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Clinical Cases + Case 1

43

A 52-year-old male patient was seen at the emergency clinic of our university. He had a widespread black eschar on his right leg starting from the knee joint extending till the ankle joint circumferentially. There were multiple fractures of the tibia that were stabilised with external fixation (Fig. 43.1). After debridement and grafting, there were exposed bone and tendon at the lateral malleolar region (Fig. 43.2). A rectus abdominis free muscle flap was planned. The deep inferior epigastric artery and concomitant veins were dissected (Fig. 43.3). The posterior tibial artery and vein were used as the recipient. End-to-side anastomosis was done to the posterior tibial artery and end-to-end anastomosis was accomplished for the two concomitant veins (Fig. 43.4). The muscle flap was grafted after adaptation. There were no complications on the postoperative first year (Fig. 43.5).

Free Muscle Flaps for Lower Extremity Burn Reconstruction

Chapter 43

⊡ Fig. 43.1  Pre-operative medial (above) and lateral (below) views of the patient with an occupational injury on his right leg starting from the knee joint extending till the ankle joint circumferentially. There were multiple fractures of the tibia that were stabilised with external fixation. Early debridement and skin grafting were performed

⊡ Fig. 43.2  After the debridement and grafting, there were exposed bone and tendon at the lateral malleolar region

⊡ Fig. 43.3  Rectus abdominis free muscle flap was planned (above). The muscle was exposed (middle). The deep inferior epigastric artery and concomitant veins were dissected (below)

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+ Case 1 (continued)

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Free Muscle Flaps for Lower Extremity Burn Reconstruction

Free Muscle Flaps for Lower Extremity Burn Reconstruction

Chapter 43

⊡ Fig. 43.4  The posterior tibial artery and vein were used as the recipient (left). End-to-side anastomosis was done to the posterior tibial artery and end-to-end anastomosis was accomplished for the two concomitant veins (right)

⊡ Fig. 43.5  Lateral (above) and posterior (below) views of the same patient at post-operative 1 year

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+ Case 2

43

A 43-year-old male patient was consulted at the burn centre of our university. The patient had a 5 × 5 cm of defect at the left medial malleolar region with exposed bone, tendon and joint due to electrical burn injury (Fig.  43.6). Following the necessary debridement, a partial rectus abdominis free muscle flap was planned. The deep inferior epigastric artery and concomitant veins were exposed and the posterior tibial artery and vein were used as the recipient. The muscle flap was grafted with meshed split thickness skin graft after the adaptation. There were no complications. The ankle joint was stable and the range of motion was normal (Figs. 43.7 and 43.8).

Free Muscle Flaps for Lower Extremity Burn Reconstruction

Chapter 43

⊡ Fig. 43.6  Pre-operative view of the patient with a 5 × 5 cm of defect at the left medial malleolar region with exposed bone, tendon and joint due to electrical burn injury ⊡ Fig.  43.7  Intra-operative view of the patient, the free muscle flap was grafted

⊡ Fig.  43.8  Post-operative sixth month view of the same patient after free partial rectus abdominis muscle flap and skin grafting

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+ Case 3

43

A 47-year-old patient was consulted at the emergency ward of our university. The patient had an occupational injury to his left leg resulting in tibial fracture and patchy skin loss. Following the debridement of the necrotic tissue and fixation of the tibia, there were exposed bone and tendon (Fig. 43.9). Thus, free rectus abdominis muscle flap was planned for the defect. The deep inferior epigastric artery and concomitant veins were exposed and the anterior tibial artery and vein were used as the recipient. End-to-side anastomosis was done to the anterior tibial artery and end-to-end anastomosis was accomplished for the two concomitant veins. The muscle flap was grafted after adaptation. There were no complications on the post-operative sixth month (Figs. 43.10 and 43.11).

Free Muscle Flaps for Lower Extremity Burn Reconstruction

⊡ Fig.  43.9  The patient had an occupational injury to his left leg resulting in tibial fracture and patchy skin loss. Following the debridement of the necrotic tissue and fixation of the tibia, there were exposed bone and tendon on the anterior and lateral parts of the leg

⊡ Fig. 43.10  Medial view of the leg on the post-operative sixth month

Chapter 43

⊡ Fig. 43.11  Lateral view of the same patient

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Prepatterned, Sculpted Free Flaps for Facial Burns elliott h. rose

Background The demands of the twenty-first century dictate aesthetic excellence as well as functional correction in complex burn reconstructions. The severely disfigured burned face is marred by corrugated external scarring, distortion of facial features, and restricted facial movement. Z-plasties, local flaps, and full thickness skin grafts are useful in addressing more limited functional needs of ectropion release, nasal stenosis, perioral contractures, exposed ear cartilage, etc. [1]. However, in burns involving large surface areas of the face, these more limited applications are inadequate. Feldman has suggested “megaunits” of thick split-thickness skin grafts to cover large “aesthetic units” (initially described by GonzalesUlloa) [2] (Fig. 44.1). Even in the most optimal circumstance, these will never simulate normal skin perfectly [3]. In my experience, large sheet grafts generate “flat facies” lacking texture, distinct facial planes, and facial expression, not to mention gross color mismatches.

Advantages of Prepatterned, Sculpted Free Flaps The author prefers prepatterned free flaps for large surface area facial defects [4, 5]. Flap design mimicking “aesthetic subunits” hides the scars at the junction of facial planes. In 1995, the author described aggressive intraoperative sculpting both prior to and during transfer to immediately restore the contours and planes of the facial geometry and preclude extensive debulking at E. H. Rose, MD Division of Plastic and Reconstructive Surgery, The Mount Sinai Medical Center, 895 Park Avenue, New York, NY, 10075, USA e-mail: [email protected]

⊡ Fig. 44.1  “Aesthetic Subunits” of the face. Scars of flap transfers are hidden at the “seams” of the junction of facial planes

a later stage [6]. Other authors have advocated “superthin” microvascular free flaps for contour sensitive areas [7–13]. The soft skin texture provided by composite flap transfer has the look and feel of normal facial skin and provides the “palette” for camouflage makeup. Movement of the facial muscles is unhindered by deep adhesions.

H. Hyakusoku et al. (eds.), Color Atlas of Burn Reconstructive Surgery, DOI: 10.1007/978-3-642-05070-1_44, © Springer-Verlag Berlin Heidelberg 2010

Prepatterned, Sculpted Free Flaps for Facial Burns

Steps in Aesthetic Restoration of the Burned Face 1. Rebuild facial architecture/restore deep structural support 2. Segmental replacement of “aesthetic” facial units with prepatterned microsurgical tissue transfers 3. Aggressive intraoperative sculpting 4. Seams hidden at junction of facial planes 5. Secondary contouring/SAL to achieve facial definition 6. Laser resurfacing 7. Cosmetic camouflage

Technique 1. Indelible felt marker is used to outline the peripheral margins of the facial subunit to be excised (Fig. 44.2). 2. The external carotid/facial artery system is auscultated with the Doppler probe and marked in red. The external jugular vessel is marked with blue ink (Fig. 44.2).

⊡ Fig. 44.2   Design of the scarred facial subunit to be excised. The recipient external carotid/ facial artery system and external jugular vein are mapped by Doppler auscultation and marked with red and blue ink respectively

Chapter 44

3. A transparent film (10/10 steri-drape) is placed over the face and the entire subunit is traced (Fig. 44.6d). Note: additional vertical height should be allowed in the neck region near the anastomotic site to allow for postsurgical swelling. Modifications in flap design should also be incorporated to allow for the release of scar contracture (e.g., neck, upper/ lower lip, eyelids, etc.) 4. Donor sites are chosen based on comparable thickness, color match, hair density, texture, etc. My preferences are scapula for cheek, malar, forehead and hemi-face; forearm or scapula for neck; forehead for nose; temporoparietal for ear or scalp. 5. With proper positioning of the patient, the donor vessels are Doppler auscultated and marked with indelible red ink (Fig.  44.3). The cut transparent pattern of the recipient site is positioned over the donor vessel to optimize the axial orientation of the vessels and to allow for maximum subcutaneous “sculpting” during elevation of the flap. The flap

⊡ Fig. 44.3  Design of the pre patterned scapular flap. The superficial circumflex scapular artery is Doppler auscultated and marked with red ink. Axial donor vessels are positioned within the center of the flap. Note that the hash marks at the periphery represent the “areas of maximum thinning” (AMT)

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design is circumscribed with a green marker. The “areas of maximum thinning” (AMT’s) are defined by hash marks to correspond to anticipated locations at the recipient site (i.e., preauricular, neck, lip, jawline, infraorbital, etc.) (Fig. 44.4). 6. Incisions through the dermis are made at the margins of the flap. Aggressive undermining is carried out at the subcutaneous level with a #10 scalpel corresponding to the hash marks. Central to the hash

⊡ Fig. 44.4  Graphic representation of the prepatterned, sculpted free flap. Shaded areas denote the areas of maximum thinning (AMT)

Prepatterned, Sculpted Free Flaps for Facial Burns

marks, the flap is elevated at the subfascial level to protect the vascular pedicle. Intraoperative Doppler monitoring is used to assess position and depth of the vascular pedicle. 7. The prepatterned, sculpted flap is transposed to the recipient site. Key points in the pattern are tacked with “pilot” sutures of 3–0 silk in the exact anatomical orientation while the arterio-venous anastamoses are completed. 8. The proximal third of the keloid is elevated while the microvascular anastamoses are carried out. Generally, the facial keloid at the recipient site is not resected in its entirety until the anastamoses are completed and patency is assured. If deep fascial suspension is required, the slings are inset prior to the flap closure (Fig. 44.5). 9. The flap is carefully inset like a “piece of a jigsaw puzzle” into the freshly excised recipient defect. Aggressive “intraoperative sculpting” is initiated to simulate normal facial planes and contours. 10. If flap design and inset have been successfully planned, minimal trimming is required and the only residual fullness is in the neck overlying the vascular pedicle near the anastamoses. Seams of the flap usually correspond to natural borders of the facial aesthetic subunits. 11. The edges of the donor site are widely undermined and advanced. The residual defect is covered with

⊡ Fig. 44.5  Fascia lata sling for deep structural support and lip suspension. Fascial slings, anchored proximally to the zygomatic arch and distally to the lateral lip commissure, are inset after scar removal and prior to flap placement

Prepatterned, Sculpted Free Flaps for Facial Burns

a STSG (later excised 6 months later and closed as a single curvilinear scar). 12. Additional refinement surgery at 4–6 months often includes limited debulking and suction-assisted lipectomy, laser resurfacing of scars, scar revision, etc.

Chapter 44

13. After final restoration of facial contour is achieved, the patient is taught application camouflage makeup by a professional aesthetician.

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Clinical Cases + Case 1

44

A 36-year-old female sustained third-degree burns to lower face and neck in a house fire at age 10. A dense contracting scar of the lower face and neck measuring 30 × 25 cm extended to the sternocervical junction (Fig. 44.6a, b). Neck extension was limited by 30° from the restrictive vertical scar band. The neck aesthetic subunit was circumscribed and the facial artery and external jugular vein defined by Doppler auscultation (Fig.  44.6c). A pattern of the recipient defect crafted from thin, transparent sheeting was cut (Fig. 44.6d). Note: additional vertical height was allowed near the vascular pedicle to allow for postsurgical swelling. The cut pattern was placed over the scapular donor site for orientation and marking. The harvested prepatterned sculpted scapular flap was transposed to the recipient defect in the neck. Anastamoses between the superficial circumflex scapular vessels and facial artery/external jugular vein were successfully completed and the flap survived 100%. Refinement surgery 6 months later included modest debulking and SAL of neck, osteoplasty implant augmentation of the chin, and laser resurfacing of the facial and scapular scars. One and a half years postoperatively, excellent neck contour is apparent with sharp definition of the cervicomental angle (Fig. 44.6e, f). The soft texture of the flap is ideal for light make-up application. Neck extension is unrestricted.

Prepatterned, Sculpted Free Flaps for Facial Burns

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⊡ Fig. 44.6  Case 1. 36 y.o. female sustained third-degree burns to lower face and neck in house fire at age 10. (a). 30 X 25 cm corrugated, thick burn scar of lower face and neck. (b) On profile, contracting scar extends from chin to sternocervical junction (c) Design of excised aesthetic subunit of the neck. Facial artery and jugular vein defined by Doppler auscultation and marked. (d) Template of recipient defect cut

Chapter 44

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c

f

from thin, transparent sheeting used for design of patterned scapular flap (e, f) Frontal and profile appearance following transfer of a prepatterned, sculpted scapular flap. Refinement surgery at 6 months post transfer included modest debulking and SAL of neck, osteoplasty implant augmentation of chin, and laser resurfacing of the facial scars

Chapter 44

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+ Case 2

44

A 12-year-old Irish boy sustained 30% burns to the face/neck, arms, and legs as a toddler when his Halloween costume caught fire. Eleven prior surgeries for eyelid ectropion, chin, and lip correction were marginally successful. At initial evaluation, dense keloid scars were present over the entire face, including both temporal regions, buccal and infraorbital cheeks, neck, and jawline (Fig. 44.7a). On profile, dense bands of contracting scar extended obliquely across the cervicomental angle (Fig.  44.7b). The lower lip was substantially foreshortened and evaginated with exposure of lower dentition and dental alveolar ridge. Multistage facial resurfacing was accomplished by microvascualar free flap transfer of a patterned radial forearm flap for neck reconstruction (Fig. 44.7c, d), followed by sequential patterned scapular flaps to the right and left hemi-facial/cheeks, respectively (Figs. 44.2 and 44.3). A bimalar fascia lata sling was used during the neck reconstruction to elevate the lower lip. Fascial lata slings from the malar arch to the lateral lip modioli were placed beneath each of the scapular free flaps for lateral lip support (Fig. 44.5). Free flaps were 100% successful. Additional refinement surgeries included modest debulking of cheeks and neck, Porex chin implant, bilateral lower lid canthoplasty, dermal plication of the nasolabial creases, and laser resurfacing of the scars. Six months after the final surgery, facial contours are restored with sculpted soft tissue conforming to facial geometry (Fig. 44.7e). Seams are hidden at the junctions of the aesthetic subunits. On profile, acuteness of the cervicomental angle is well defined with good chin projection (Fig.  44.7f ). Apposition of the lower to upper lip is functionally normal.

Prepatterned, Sculpted Free Flaps for Facial Burns

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⊡ Fig. 44.7  Case 2. 12 year old Irish boy with 30% burns to face/neck, arms and legs as toddler when his Halloween costume caught fire. (a) Dense keloid facial scarring over both temporal regions, buccal and infraorbital cheeks, neck and jawline. (b) Dense contracting scar across cervicomental angle. Chin is hypoplastic and lower lip is foreshortened and evaginated, exposing lower dentition. (c) Marking of 1st stage excision of neck aesthetic subunit (d) Design of patterned radial forearm flap. Bimalar fascia lata sling was inserted for

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lower lip suspension. Neck reconstruction was followed by sequential patterned scapular flaps to right and left hemi-face/ cheeks respectively (Figures 44.2, 44.3, 44.5). (e, f) Frontal and profile, following multi-stage free flap reconstruction. Additional refinement surgeries included modest debulking of cheeks and neck, Porex chin implant, bilateral lower lid canthoplasties, dermal placation of nasolabial creases, and laser resurfacing of scars

Chapter 44

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A 16-year-old was involved in a motor vehicle accident in which she was ejected from the car, lost consciousness, and was pinned under the muffler of the car, compressing her neck and left face for over an hour. Prior ­split-thickness “megaunit” sheet grafting left her with a dense plaque of keloid scar measuring 25 × 20 cm over the left midface and neck (Fig. 44.8a, b). The “woody,” corrugated scar extended from the zygomatic arch obliquely across the buccal cheek and inferiorly across left mandible and cervicomental sulcus to the lower neck (Fig. 44.8b). The lower lip was distracted in a downward vector by the scar contracture of the labiomental sulcus. Blunting was noted at the lateral lip commissure. Lateral neck rotation as limited by 20° and extension by 30°. At surgery, the keloid scar of the face/neck was excised as an aesthetic unit defined at its inferior border by the cervicomental junction (Fig. 44.8c). The face and neck were reconstructed with a large prepatterned, sculpted scapular flap utilizing both the transverse and oblique branches of the superficial circumflex scapular system. Extensive intraoperative sculpting provided definition to the infraorbital, preaurcicular, nasolabial, and mandibular planes. A fascia lata sling to support the lateral lip commissure was placed prior to inset of the scapular flap. Flap survival was 100%. Additional refinement surgery included modest debulking of the scapular flap, multiple scar revisions and Z-plasties, contour threads to the lower lip vermilion, and laser resurfacing of the residual scars. A year and a half after the initial surgery, the flap conforms to the “natural” contours of the face and allows for symmetrical facial expression (Fig. 44.8d, e). The soft texture provides a “palette” for light camouflage make-up. Neck rotation and extension are unrestricted.

Prepatterned, Sculpted Free Flaps for Facial Burns

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⊡ Fig. 44.8  Case 3. 16 year old female involved in motor vehicle accident in which she was ejected from car, lost consciousness, and her face was pinned under muffler of car for over an hour. (a,b) 25 X 20 cm dense plaque of keloid scar as a residual of “megaunit” sheet grafting. Thick, corrugated scar extended from zygomatic arch to lower neck, distracting lower lip elements and distorting smile. (c) Scar of lower

Chapter 44

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c

face/ neck excised as aesthetic subunit defined at its inferior border by cervicomental junction (d,e) Frontal and profile, following large prepatterned, sculpted scapular flap. Fascia lata sling was inserted to support lateral lip commissure. Additional refinement surgery included modest debulking of scapular flap, scar revisions and Z-plasties, contour threads to lower lip vermilion, and laser resurfacing of facial scars

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C h a p t e r 45

The Deltopectoral Free Skin Flap: Refinement in Flap Thinning, Pedicle Lengthening, and Donor Closure kenji sasaki, motohiro nozaki, and ted t. huang

Background of the Technique The deltopectoral skin flap described by Bakamjian [1] is an axial flap, and therefore it can be harvested as a free skin flap for distant transfer via microsurgical technique [2–4]. This skin flap is useful for facial resurfacing because of excellent color and texture match, the feature particularly suitable for people with dark skin complexion. Shortness of the vascular pedicle and smallness of the vessel caliber, on the other hand, render flap revascularization technically difficult. The method is, furthermore, plagued with problems attributable to the bulkiness of skin flap and morbidities associated with the donor site deformity. These problems can be ameliorated by including a segment of the internal mammary vessel in flap pedicle, immediate defatting/thinning of the skin flap at the time of flap formation (Fig.  45.1), and using of a V-to-Y advancement flap closure technique to manage the donor site defect (Fig. 45.2) [5].

Characteristics and Indication of the Method 1. A segment of the internal mammary artery and vein incorporated in the flap vascular pedicle increases the vessel size and the vascular pedicle length more

K. Sasaki, MD, PhD (*) Department of Plastic & Reconstructive Surgery, Nihon University School of Medicine, Tokyo, 173-8610, Japan e-mail: [email protected] M. Nozaki, MD, PhD Department of Plastic & Reconstructive Surgery, Tokyo Women's Medical University, Tokyo, Japan T. T. Huang, MD, PhD Division of Plastic & Reconstructive Surgery, Zuoying Amed Forces Hospital, Kaohsiung, Taiwan

⊡ Fig. 45.1  A schematic drawing to show the technique to thin the flap at the time of flap harvesting and to fabricate a vascular pedicle by incorporating a segment of the internal mammary vessels

than twofold, and it makes the flap revascularization technically much easier. 2. Frequency of secondary flap thinning is reduced by incorporating the maneuver of thinning of the skin flap before transfer. 3. The use of V-to-Y technique of wound closure simplifies the closure of the flap donor defect. The outcome was considered to be much better than conventional technique of primary closure with concomitant skin grafting.

Special Skill of the Methods 1. Flap design: Before operation, the course of intercostal vessels supplying the deltopectoral area over the second and the third intercostal space is ascertained using

H. Hyakusoku et al. (eds.), Color Atlas of Burn Reconstructive Surgery, DOI: 10.1007/978-3-642-05070-1_45, © Springer-Verlag Berlin Heidelberg 2010

The Deltopectoral Free Skin Flap

⊡ Fig. 45.2  A schematic drawing to show the V-to-Y technique of flap donor site closure. Vascular supply to the flap is based upon the underlying adipo-fascial tissues (AF) and/or the lateral segment of the pectoral major musculature (PMM)

a Doppler device. The lateral edge of the flap is bound by a line 2–3 cm beyond the deltopectoral sulcus. Medial boundary of the flap can be expanded by 3–4 cm beyond the ipsilateral parasternal. Lengthening of the vascular pedicle can be achieved by moving the medial edge of the flap 1–2 cm to the lateral side [6]. 2. Flap harvesting and thinning: Dissection of the flap is started from the lateral margin. The dissection is carried out subcutaneously 4–5 mm thickness of the flap and continued two finger breath lateral to the sternal border, and dissection level is changed into the fascia of pectoralis major muscle medially not to injure the anterior perforating branches of the internal mammary vessel as they usually emerge through the pectoralis major muscle, one finger breath lateral to the sternal border. The origin of the pectoralis major muscle may be divided and retracted laterally to facilitate the dissection of the anterior perforat-

Chapter 45

Donor closure

ing branches of the internal mammary vessel and to expose the costal cartilage 1.5–2  cm from the sternal border. A small segment of the costal cartilage is removed with a rongeur to facilitate exposing the internal mammary vessel. 3. Closure of the donor defect: The soft tissue defect resulted from costal cartilage resection is obliterated by suturing the muscle. In instance, where a complete closure of the defect is not feasible and would distort the nipple-areolar configuration, a V-to-Y advancement flap technique is useful, especially in closing the central defect. This skin flap is dissected out either as a subdermal adipofascial flap or as a pectoralis major musculocutaneous flap (Fig. 45.2). 4. Flap transfer: Flap revascularization is accomplished by coating the flap vessels with the facial artery/vein or the superficial temporal artery/vein under magnification.

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+ Clinical Cases + Case 1

45

A 34-year-old female received a 30% TBSA flame burn. After emergent skin grafting, she suffered from severe scarring of her submento-mento-oral region. The lower lip was severely pulled down, resulting in poor oral hygiene and excessive exposure of lip mucosa (Fig. 45.3a). After excision of hypertrophic scar, the resultant defect extended from submental to upper lip, and the DP free flap measuring 16 × 10  cm was designed on the second and third intercostals area (Fig.  45.3b, c). Dissection of the flap was carried out as described as above. Flap thinning was performed intraoperatively. Thickness of the flap harvested was approximately 4–5 mm. A segment of the internal mammary artery and vein was included in the flap vascular pedicle. The arterial size and venous size were 1.6 and 2.4 mm, respectively. The vascular pedicle was 3 cm in length (Fig. 45.3d, e). The flap was transferred to the face via a microvascular technique. The facial vessels were used as the recipient vessels. The donor defect was closed with a V-Y advancement technique (Fig. 45.3f ). The postoperative course was uneventful. Secondary defatting surgery of the flap was unnecessary (Fig. 45.3g). The deformity around the chest was minimal (Fig. 45.3h).

The Deltopectoral Free Skin Flap

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b

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g

⊡ Fig.  45.3  (a) A 34-year-old female suffered from burn scarring. (b) After excision of scar, the resultant defect extended from submental to upper lip. (c) The DP free flap measuring 16 × 10 cm was designed. A triangular skin marking denotes the flap that was used to close the flap donor defect. (d) A segment of the internal mammary artery and

f

h

vein was included in the flap pedicle (arrow). (e) Intraoperative thinning was performed. Thickness was approximately 4–6  mm. (f) Immediate postoperative findings. (g) The results at 5 months after the surgery. (h) The deformity around the chest was minimal

Chapter 45

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The Deltopectoral Free Skin Flap

+ Case 2 This 11-year-old girl received a scald burn involving her face and neck at the age of 3 years. In the subacute phase she underwent split thickness skin graft in a local hospital. She had long been suffering from scar in the right half of her face accompanying with pigmentation, depigmentation, and lip deformities (Fig. 45.4a).

45

Scar was excised following esthetic unit, resulting in defect of 11 × 8 cm. The facial artery and vein, shown with an arrow, were isolated for vascular anastomosis (Fig. 45.4b). The DP free flap was designed on the pecto-clavicular area based on the second and third intercostals vessels. The medial edge of the flap was located 1.5 cm lateral to the sternal margin in order to lengthen the vascular pedicle (Fig. 45.4c). The flap fabricated was thin. The vascular pedicle was 5 cm in length (Fig. 45.4d). The flap was transferred via a microvascular technique (Fig. 45.4e). The donor defect, in this case, was closed with STSG. Contour, color, and texture were considered to be cosmetically satisfactory (Fig. 45.4f ). Secondary defatting surgery of the flap was unnecessary.

The Deltopectoral Free Skin Flap

a

Chapter 45

b

d

⊡ Fig.  45.4  (a) A 11-year-old girl received a scald burn involving her face and neck at the age of 3 years. (b) Scar was excised following esthetic unit. The arrow shows the facial artery and vein for recipient vessels. (c) The DP free flap was designed on the pecto-clavicular area. The medial edge of the

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f

flap was located lateral in order to lengthen the vascular pedicle. (d) The flap harvested was thin and had long pedicle, the internal mammary vessels (shown with arrow). (e) The appearance of the flap at the end of procedure. (f) The grafted area 3 years later

Chapter 45

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The Deltopectoral Free Skin Flap

+ Case 3

45

A 48-year-old male sustained a 65% TBSA burn in a gasoline explosion 2 years ago. He had undergone multiple skin grafting for emergent wound closure. He was eager to have restored the contracture and shrinkage of the graft skin of his neck, cheek, and chin areas. Blunting mento-cervical angle and mentolabial angle resulted in cosmetically poor (Fig.  45.5a). After excision of the shrinkage skin, the resultant defect extended to lower cheek, chin, and lower lip (Fig. 45.5b). The DP free flap measuring 16 × 13 cm was designed on the second and third intercostals area. Medial boundary of the flap was expanded 4 cm beyond the ipsilateral parasternal (Fig. 45.5c). Dissection of the flap was carried out as described above. Not only intraoperative thinning, but also lengthening of pedicle was performed (Fig. 45.5d). The flap was transferred by a microvascular technique. The donor defect was closed with a V-Y advancement technique. The appearance of reconstructed site is cosmetically satisfactory. The donor site deformity around the chest was minimal (Fig. 45.5e, f ).

The Deltopectoral Free Skin Flap

Chapter 45

a

c

e

⊡ Fig. 45.5  (a) A 48-year-old male suffered from burn contracture of his neck and chin areas. (b) The resultant defect extended to lower cheek, chin, and lower lip after excision of the scar. (c) A large size of DP free flap was designed on the

b

d

f

second and third intercostals area. (d) The flap harvested. (e, f ) The grafted area 12 years later. Texture and color match are excellent

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C h a p t e r 46

Shape-Modified Radial Artery Perforator (SM-RAP) Flap for Burned Hand Reconstruction musa a. mateev and rei ogawa

Background of the Methods Radial forearm flaps were first reported by Yang et al. [1] in 1978 and are one of the most reliable conventional types of flaps. To overcome the donor-site morbidity associated with this flap, which includes problems due to major artery sacrifice, numbness of the dorsal hand, and the development of unfavorable scars, many modifications of the radial forearm flap method have been reported. These modifications have resulted in the expanded flap [2], the distally based flap [3], and the perforator-based flap/perforator flap [4–6] methods. In a further modification, we developed the “shape-modified radial artery perforator flap (SM-RAP flap) method” [7–9]. We focused this chapter on this SM-RAP flap. This is a thin radial forearm flap that is divided into sections on the basis of separate perforators in order to facilitate the inset. Thus, the flap has a huge advantage over other types of flaps in that its thin-form and changeable shape can be altered to match the shape of the recipient site. Meanwhile, the use of a long and narrow flap means the donor site can be closed primarily without any complications because of the low skin tension present (Fig. 46.1). We speculate that radial artery sacrifice may not result in any serious deleterious short- or long-term outcomes. However, it is important to carefully observe patients over a long-term follow-up period.

Specific Skill of the Methods

2. Depending on the size and shape of the recipient site, an elliptically shaped flap on the radial forearm was designed such that the donor site could be closed primarily. The maximum width of the flap was defined by the simple capture of the skin on the forearm. In our case series [9], the maximum width ranged from 3 to 7 cm, with an average of 5.12 cm. 3. The average number of perforators from the radial artery is approximately 12 [10], each section can be designed comparatively free. 4. The flap dissection should be performed on a tourniquet. 5. Flap elevation was initiated from the lateral margin to identify perforators in the septocutaneous components. The medial border of the flap was then incised and the flap was islanded completely. 6. After careful dissection of the perforator vessels along their course to the radial artery in the lateral intermuscular septum, followed by retraction of the flexor carpi radialis muscle medially and the brachioradialis muscle laterally, the perforator vessels are isolated from each other. 7. After elevation of the flap, the donor site should be closed primarily while a tourniquet was applied. 8. The flap is then divided into two or three components according to the course of the perforators to fit the recipient site shape. 9. The proximal portions of the radial vessels are ligated and cut for distally based pedicled flap transfer for ipsilateral hand reconstruction.

1. The flaps should be designed after debridement or complete release of scar contractures. M. A. Mateev (*) Department of Plastic, Reconstructive Microsurgery and Hand Surgery, National Hospital of Kyrgyzstan, Bishkek, Kyrgyzstan e-mail: [email protected] R. Ogawa, MD, PhD Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School Hospital, Tokyo, Japan e-mail: [email protected] H. Hyakusoku et al. (eds.), Color Atlas of Burn Reconstructive Surgery, DOI: 10.1007/978-3-642-05070-1_46, © Springer-Verlag Berlin Heidelberg 2010

Shape-Modified Radial Artery Perforator

⊡ Fig. 46.1  Depiction of the shape-modified radial forearm perforator flap (three components). This figure shows three separated perforator flaps. The second flap is rotated 90°,

Chapter 46

while the third flap can be rotated 180°. Thus, the narrowly shaped flap can be subdivided and reorganized to fit a wide range of differently shaped recipient sites

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Shape-Modified Radial Artery Perforator

Clinical Cases + Case 1 (Fig. 46.2)

46

A 23-year-old male was involved in a car accident and scar contractures developed on his left hand during 1 year (a). After removal of the scars (b), tendons were exposed, and SM-RAP flap was performed (c). The flap was divided into two parts by perforators, and the first part covered the index finger, and the second part was rotated 180° to cover the middle and ring fingers. The flap survived completely and functions of fingers were recovered (d, e).

Shape-Modified Radial Artery Perforator

a

d

⊡ Fig. 46.2 

Chapter 46

b

c

e

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Shape-Modified Radial Artery Perforator

+ Case 2 (Fig. 46.3)

46

A 23-year-old male suffered a left dorsal hand burn that left him with scar contractures (a). The tendons were exposed after completely releasing the contractures and the wounds were covered with a 19 × 6 cm SM-RAP flap. The flap was rotated 180° (propeller flap) and divided into two components by radial artery perforators (b). The proximal component was rotated 90° and applied to the ulnar side of the dorsal hand (c). As a result, the metacarpophalangeal joints recovered their full range of motion. There were no complications, including numbness of the dorsal hand (d, e).

Shape-Modified Radial Artery Perforator

a

Chapter 46

d

e b

c

⊡ Fig. 46.3 

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Chapter 46

Shape-Modified Radial Artery Perforator

+ Case 3 (Fig. 46.4) A 5-year-old girl suffered from scald burn on the right palm by hot water (a, b). Scar contractures were released and reconstructed by SM-RAP flap. The flap was divided into two parts, and the first part was slightly incised to change the shape to fit the donor shape on the finger. The second part was advanced and put next to the first part (c). The flap survived completely, and there has been no dysfunction of the hand for 4 years now (d).

46

Shape-Modified Radial Artery Perforator

a

c

⊡ Fig. 46.4 

Chapter 46

b

d

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Chapter 46

Shape-Modified Radial Artery Perforator

+ Case 4 (Fig. 46.5) A 21-year-old female suffered from burn on the left hand dorsum and developed scar contractures (a, b). The contractures were released and reconstructed by SM-RAP flap (c). The flap was divided into two parts and folded on the center of the flap (d, e). The flap could cover the recipient site. Aesthetic and functional improvements were observed (f , g).

46

Shape-Modified Radial Artery Perforator

a

d

f

⊡ Fig. 46.5 

Chapter 46

b

425

c

e

g

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Chapter 46

Shape-Modified Radial Artery Perforator

+ Case 5 (Fig. 46.6) A 1.5-year-old female suffered from severe burn on the right palm (a). The contractures were released and reconstructed by SM-RAP flap. The flap was divided into two parts and folded in the center of the flap (b, c). The flap could cover the recipient site. Aesthetic and functional improvements were observed. We did not observe any blood circulation and functional problems over 5 years after the operation (d, e).

46

Shape-Modified Radial Artery Perforator

a

Chapter 46

d

b e

c

⊡ Fig. 46.6 

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C h a p t e r 47

The Radial Artery PerforatorBased Adipofascial Flap for Coverage of the Dorsal Hand isao koshima, mitsunaga narushima, and makoto mihara

Introduction

Anatomical Considerations

Although the coverage of deep burn defects on the dorsal hand is quite complex and time-consuming, it can be accomplished by several techniques. Introduction of reverse flow island flaps obtained from the ipsilateral forearm or hand [1–4] has made the reconstruction easier, but even with the use of those flaps, the following serious problems often arise: (1) the sacrifice of major vessels of the arm and hand [5], (2) an unacceptable donor scar on the forearm or dorsal hand, and (3) the need for careful and complex dissection of vascular pedicles of small caliber. I believe these are the disadvantages of the reverse flow flaps. To overcome these disadvantages of the reverse flow skin flaps, adipofascial flap, which is fascial flap with overlying fatty tissue, is preferable to simple fascial flap because adiposal tissue acts as an effective gliding surface of extensor tendons of the hand. We developed a radial artery perforator-based adipofascial flap for the repair of defects on the hand dorsum with minimal surgery [6]. In this chapter, we describe two cases in which radial artery perforatorbased adipofascial flaps were successfully used.

Anterior Aspect of the Forearm

I. Koshima, MD (*) Departments of Plastic and Reconstructive Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan e-mail: [email protected] M. Mihara, MD M. Narushima, MD Departments of Plastic and Reconstructive Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan

Most of the fasciocutaneous perforators emerge from the gaps between the muscles and tendons of the forearm. Several upper and lower branches of the radial artery supply the forearm skin. The upper branches supply the brachioradialis and the flexor carpi radialis muscles (musculocutaneous arteries), while the lower branches penetrate through the fascia between the brachioradialis and the extensor carpi radialis longus muscles to supply the skin over the flexor aspect of the lower third of the forearm, and take a gently ascending direction. At the distal one-third of the lateral border of the forearm, the radial artery gives off a few dorsal branches. After giving off the feeding capillary of the superficial radial nerve, one of the dorsal branches (the dorsal superficial branch of the radial artery) runs posteriorly under or over the brachioradialis tendon and penetrates through the intertendinous space between the brachioradialis and the abductor pollicis longus tendons to supply the fascia on the lateral and the posterior aspects of the forearm (Fig. 47.1).

⊡ Fig. 47.1  Schematic drawing of the location of perforators on the posterior aspect of the forearm. v radial artery; R perforator of the radial artery; A perforator of the anterior interosseous artery; P perforator of the posterior interosseous artery; n superficial radial nerve; a abductor pollicis longus; e extensor pollitis longus; b extensor carpi radialis brevis; L extensor carpi radialis longus; r brachioradialis; d exten­­ sor digitorum; m extensor digiti minimi; u extensor carpi ulnaris

H. Hyakusoku et al. (eds.), Color Atlas of Burn Reconstructive Surgery, DOI: 10.1007/978-3-642-05070-1_47, © Springer-Verlag Berlin Heidelberg 2010

The Radial Artery Perforator-Based Adipofascial Flap

The suprafascial capillaries of the radial artery perforators run transversely in the lower two-thirds of the anterior aspect of the forearm. Only those radial perforators that follow the cutaneous nerves run in a direction parallel to the long axis of the forearm. On the lateral aspect of the forearm, the capillary network is tightly packed.

Posterior Aspect of the Forearm The most important fasciocutaneous arteries arise from the posterior and anterior interosseous arteries. The descending branch of the posterior interosseous artery runs downwards toward the wrist through the intermuscular septum between the extensor carpi ulnaris and the extensor digiti minimi muscles. After perforating the fascia at the distal one-third of the forearm, the descending branch divides into medial and lateral branches that ramify in the skin covering the flexor carpi ulnaris and the superficial extensor muscles. The anterior interosseous artery has two main perforating arteries of the forearm (superior and inferior branches). The superior branch passes through the space between the abductor pollicis longus and the radius and perforates the fascia at four fingerbreadths from the radial styloid process. It vascularizes the skin over the lower third of the posterior surface and the lateral border of the forearm. The inferior perforating artery supplies most of the deep muscles of the posterior compartment.

Operating Technique Prior to the flap transfer, Doppler audiometry and/or stereoscopic arteriograms of the affected arm are examined

Chapter 47

and a few fasciocutaneous perforators, arising from the radial vessels within 10 cm proximal to the radial styloid process, are detected in the lateral aspect of the distal forearm (Figs. 47.1 and 47.3a). As for the flap transfer, after resection of the scar around the defect, an S-shaped incision through the posterolateral aspect of the forearm is made. Through this incision, a few fasciocutaneous perforators, including the dorsal superficial branch of the radial vessels can be found in the distal one-third of the lateral aspect of the forearm. They arise through the intertendinous septum between the brachioradialis, the abductor pollicis longus, and the flexor carpi radialis tendons, and enter the forearm adipofascia. After the proximal end of the adipofascial flap is transected, a distally based adipofascial flap with the dorsal superficial branch is elevated from the posterior aspect of the forearm. The proximal base of the flap is preserved widely, involving fascia and adiposal tissue, around the fasciocutaneous perforator because skeletonization of the perforator often damages the blood circulation of the flap. The lateral forearm cutaneous veins and nerves (including the superficial radial nerve) can be dissected and freed from the flap. They should be left on the forearm muscles. The flap is then turned distally to cover the defect on the dorsal hand, and a small amount of bleeding from the capillary vessels in the flap can be seen. Finally, after the donor forearm defect is closed directly, the transferred flap is covered with a split thickness or full thickness skin graft. Postoperatively, a bandage with slight pressure and without a tie-over is employed.

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The Radial Artery Perforator-Based Adipofascial Flap

Clinical Cases + Case 1

47

A 38-year-old man suffered from a deep dermal burn on the left distal forearm and dorsal hand caused by a traffic accident. Two months after the burn, the resulting defect was covered with a split thickness skin graft. However, the extensor tendons had been exposed on the skin defect of the dorsal aspect of the hand (Fig. 47.2a). Prior to secondary repair, stereoscopic arteriograms of the affected arm were examined and a few fasciocutaneous perforators arising from the radial vessels were detected in the lateral aspect of the distal forearm, 6–9 cm proximal to the styloid process. Half a year after the burn, secondary operation was performed. After debridement around the defect, the dorsal superficial branch of the radial vessels was found in the distal one-third of the forearm. A distally based adipofascial flap was then elevated from the distal two-thirds of the posterior aspect of the forearm. Only the distal fasciocutaneous perforator was left as a vascular pedicle, and the flap was turned to cover the defect. Finally, the flap was covered with a split thickness skin graft. The postoperative course was uneventful, and there was no necrosis of the skin graft, or forearm herniation. Active motion of the hand was allowed 3 weeks after surgery and the patient complained of forearm muscle dysfunction due to adhesion. One year after the flap transfer, the patient could use the affected hand without difficulty (Fig. 47.2b).

The Radial Artery Perforator-Based Adipofascial Flap

Chapter 47

a

c

⊡ Fig. 47.2  A 38-year-old man with a deep dermal burn on the dorsal hand. (a) Even with a split thickness skin graft, tendon-exposing defects still remain. (b) Radial artery perfo-

b

d

rator adipofascial flap was elevated. (c) The flap turned over tendon, and split graft covered the flap. (d) Half a year after the surgery

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The Radial Artery Perforator-Based Adipofascial Flap

+ Case 2

47

A 26-year-old female suffered from an avulsive injury of the dorsal hand and transection of the extensor tendon caused by a press machine. Although initial repair with the tendon suture and wound closure was performed, the avulsed skin became necrotized, resulting in a deep defect with exposure of the tendons (Fig.  47.3a). Preoperative stereoscopic arteriograms showed a fasciocutaneous perforator arising from the radial vessels in the lateral aspect of the distal forearm, 4 cm proximal to the styloid process. Two months after the injury, following debridement of the necrotized skin, the perforator was found through an S-shaped longitudinal incision on the forearm. Then, a distally based adipofascial flap was raised from the entire posterior aspect of the forearm. The elevated flap with a perforator was passed through a subcutaneous tunnel in the lateral aspect of the wrist and turned to cover the defect on the hand (Fig.  47.3b). Finally, a full thickness skin graft with very thin fatty tissue from the groin region was placed over the transferred flap. Postoperatively, active motion of the hand was started 3 weeks after surgery. One year after the flap transfer, the reconstructed hand had no problems with minimal scarring and no sensory disturbance due to damage of the superficial radial nerve (Fig. 47.3c & d).

The Radial Artery Perforator-Based Adipofascial Flap

a

c

Chapter 47

b

d

⊡ Fig. 47.3  (a) A 26-year-old female with dorsal skin necrosis. (b) A distally based adipofascial flap with a perforator (arrowhead) is elevated and turned to cover the defect. (c)

Full thickness skin graft from the groin region covered the fascia. (d) One year after the surgery

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C H A P T E R 48

Microdissected Thin Flaps in Burn Reconstruction naohiro kimura

Background of the Technique Generally, the perforators give off several thick branches in the adipose layer after penetrating the hiatus of the deep fascia, and then finally run into the subdermal plexus. The blood circulation of the flap mostly depends on these perforators and their branches, which means that the adipose tissue of the flap can be thoroughly removed while preserving an adequate circulation in the flap. A thin flap is prepared conventionally by the removal of nearly the entire adipose tissue of the elevated flap, with a small amount around the perforator and branches retained intact [1, 2]. However, since the distribution of the perforator and branches cannot be detected completely during the thinning procedure, it is not easy to decide on the optimal amount and position of the residual adipose tissue. Moreover, in the worst case, the procedure may sever the essential branch supplying the blood circulation of the flap, thereby leading to partial necrosis of the thin flap. Moreover, it is impossible to prepare an evenly thin flap because of the residual adipose tissue. The microdissection procedure was developed to resolve these drawbacks which inevitably accompany the conventional thinning method. It consists of the dissection of the intraadipose perforator and its branches and the removal of the adipose tissue around them under operative microscopic magnification. This procedure enables the entire anatomical structure of the vessels between the deep fascia and subdermal plexus to be exposed. Therefore, the elevation of the thin flap after microdissection does not jeopardize the vessels in the adipose layer, and an evenly thin flap can be prepared regardless of the anatomical variations of the perforators and their branches [3]. Although the procedure appears to be risky for the delicate circulation of the thin vessels, these can be easily N. Kimura, MD Showa University, 1-30, Fujigaoka, Aoba-ku, Yokohama, Kanagawa, Japan e-mail: [email protected]

and safely manipulated under a microfield, as they are wrapped by the connective tissue in the adipose layer. Theoretically, microdissection can be applied to any part of the body where a free flap can be elevated, but the author recommends the use of the following five flaps for the convenience of reconstruction: anterolateral thigh perforator (ALTP) flap, tensor fasciae latae perforator (TFLP) flap, deep inferior epigastric artery perforator (DIEAP) flap, thoracodorsal artery perforator (TDAP) flap [4], and groin flap [5, 6].

Operative Procedure At the first step of the operation, the location of the perforator should be detected using a Doppler probe or high resolution CT, although preoperative detection of the perforator is not always possible. The first incision is made at a distance of approximately half the width of the required flap from the point of detection. Suprafascial dissection should be carried out through this incision to find the perforator penetrating the deep fascia. Once the perforator is detected, Gelpi retractors are then inserted between the deep fascia and the elevated skin to make an appropriate field for microdissection. In microdissection, loose connective tissue covering the adipose tissue of the flap can be observed first, and then should be removed sharply around the perforator to expose the layer of relatively large fat lobules. Next, these fat lobules should be removed bluntly using microforceps to expose the intraadipose branches of the perforators. Since the subcutaneous adipose layer is composed of a thin fascia and a fat lobule layer, similar to a sandwich, microdissection should be performed both sharply and bluntly in accordance with these layers. Continuing with this procedure, the size of the fat lobule layer immediately is reduced, which is the sign of completion of microdissection (Fig.  48.1). At this stage, a small hollow is formed around the branches of the perforator, and the thickness of the flap can be estimated by pinching this hollow with the fingers. After completing

H. Hyakusoku et al. (eds.), Color Atlas of Burn Reconstructive Surgery, DOI: 10.1007/978-3-642-05070-1_48, © Springer-Verlag Berlin Heidelberg 2010

Microdissected Thin Flaps in Burn Reconstruction

CHAPTER 48

⊡ Fig. 48.1  1: Before microdissection (left), and after microdissection (right). 2: schematic description of the elevation of the microdissected thin flap. Before detection of the perforator (left). After microdissection (center). After elevation of the flap (right)

microdissection of the intraadipose perforator, subfascial dissection is carried out to expose the proximal vessel of the perforator. After microdissection and pedicle dissection, the point of inserting the perforator into the subdermal plexus should be marked from the skin side. This point should be positioned at the center of the flap design. Elevation of the thin flap from the surrounding area to this small hollow should be performed sharply using electrocautery (Fig. 48.1).

Developments and Indications of the Method Through this procedure, an evenly thin, large flap measuring approximately 20 cm along the long axis can be

easily prepared for reconstruction of the dorsum of the hand, a half side of the cheek and the neck, the axilla, the Achilles tendon, and the knee fossa. If a larger flap is required, combination of two individual areas of the flap allows the preparation of an extremely large flap that is approximately 35 cm along the long axis [7, 8]. On the contrary, an extremely small flap also can be elevated on the basis of knowing the correct inflow point of the perforator to the subdermal plexus [9]. Moreover, information of the vessel anatomy in the adipose layer, such as the thickness, distribution, and direction, has enabled the development of a new processing method of the flap, termed the “microdissected tailoring procedure” [10].

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Clinical Cases + Case 1

48

A 24-year-old man suffered flame burn to 60% of his total body surface area. After early stage treatment of the general burn injury, he had severe scar contractures of both palmer and dorsal side of the right hand (Fig. 48.2a, b). An intrinsic minus contracture of the five fingers was corrected, and skin defects on the palmer side of the proximal phalanxes and dorsal side over the proximal and distal interphalangeal joint of each four fingers are resulted. Additionally, both sides of the first web space created a deep tissue defect (Fig. 48.2c, d). A 14 × 15 cm irregular-shaped microdissected thin deep inferior epigastric artery perforator (DIEAP) flap was transferred to the dorsum of the fingers and the first web space with the vascular anastomoses at the anatomical snuff box. The defects of the palmer surface of each finger were covered by the full thickness skin graft (Fig. 48.2e, f ). One month after transfer of the DIEAP flap, contracture of the palmer side of the hand was released to create a deep skin defect exposing the flexor tendons and the nerves (Fig. 48.3a, b). A microdissected thin anterolateral thigh perforator (ALTP) flap measuring 10 × 15  cm was transferred to the defect with the vascular anastomoses to the radial artery and the cutaneous veins (Fig. 48.3c, d). The flap survived completely and an acceptable hand function was restored for the patients 3 years postoperatively (Fig. 48.3e, f ).

Microdissected Thin Flaps in Burn Reconstruction

a

b

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e

⊡ Fig. 48.2 (a–f)

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CHAPTER 48

+ Case 1 (continued)

48

Microdissected Thin Flaps in Burn Reconstruction

Microdissected Thin Flaps in Burn Reconstruction

CHAPTER 48

439

a

b

c

d

e

f

⊡ Fig. 48.3 (a–f)

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Microdissected Thin Flaps in Burn Reconstruction

+ Case 2

48

An 18-year-old man had a large skin defect on the right lower extremity after having had a general burn. Most part of the leg and foot defect were covered by the meshed split-thickness skin graft, and the area of the Achilles tendon was planned to be covered by the free flap to prevent secondary contracture (Fig.  48.4a, b). A microdissected thin groin flap measuring approximately 20 × 10 cm (Fig. 48.4d) was elevated based on the deep branch of the superficial circumflex iliac artery (Fig. 48.4c: green ribbon). The pedicle of the flap was anastomosed to the posterior tibial artery and vein. The postoperative course was uneventful, and the patient recovers almost full range of motion of the ankle with no trouble of gait (Fig. 48.4e, f ).

Microdissected Thin Flaps in Burn Reconstruction

a

c

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e

⊡ Fig. 48.4 (a–f)

CHAPTER 48

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C H A P T E R 49

Perforator Pedicled Propeller Flaps hiko hyakusoku, musa a. mateev, and t. c. teo

Background of the Technique

Subcutaneous Pedicled Propeller (SPP) Flap

Hyakusoku et al. [1] presented a propeller flap for reconstruction of axilla and cubitus in 1991. The original propeller flap has been used for intact fossa and was elevated as a subcutaneous pedicled island flap. Nowadays, this propeller flap has been refined and various types of propeller flaps have been reported [2–11]. The represented one is the perforator pedicled propeller (PPP) flap [5], and this procedure is now considered to be another option for use of perforator flaps. Acentric perforator pedicle (Fig. 49.1a) enables the flap to rotate 180° [6, 7], and this flap can cover a long-distance defect (Fig. 49.1b).

If subcutaneous pedicle has some perforators, refinement of the perforators is not necessary, but a 180° rotation may be difficult because pedicle kinking will be a problem compared to the perforator pedicle.

Definitions and Classifications of the Propeller Flap

Muscle Pedicled Propeller (MPP) Flap

Definition Every skin island flap can become a propeller flap. However, the advancement flap, transposition flap, and nonisland rotation flap should be excluded. Thus, “island flap with axial rotation” is the definition of the propeller flap.

Classification (Fig. 49.2)

Perforator Pedicled Propeller (PPP) Flap Refined perforator makes the flap easy to rotate 180°; thus, the coverage area is wider than that of the SPP flap.

If some musculocutaneous perforators exist, refinement of the perforators is not necessary. In this case, a small amount of muscle can be attached to the skin island, and can be harvested as a MPP flap.

Perforator-Supercharged (PS) Propeller Flap If a long propeller flap is needed, perforator supercharging would be useful.

Propeller flaps can be classified by types of pedicles. H. Hyakusoku, MD, PhD (*) Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School Hospital, Tokyo, Japan e-mail: [email protected] M. A. Mateev, MD Department of Plastic, Reconstructive and Microsurgery and Hand Surgery, National Hospital of Kyrgyz Republic, Kyrgystan e-mail: [email protected] T. C. Teo, MD Department of Plastic and Reconstructive Surgery, Queen Victoria Hospital, East Grinstead, UK e-mail: [email protected]

Specific Steps of the Method Theoretically, the survival area of pedicled propeller flaps is the same as that of the free perforator flap. The course and territory of perforators are different in each region, so careful preoperative assessment using Doppler ultrasound, color Doppler ultrasonography, or multidetector low computed tomography (MD-CT) is necessary. We can roughly estimate the survival area of pedicled propeller flap according to the random pattern flap theory. It is believed that 1:2 (width:length) random pattern flaps can survive anywhere in the body, so 1:4 flaps may be safe when a vascular axis exists in the central portion of the

H. Hyakusoku et al. (eds.), Color Atlas of Burn Reconstructive Surgery, DOI: 10.1007/978-3-642-05070-1_49, © Springer-Verlag Berlin Heidelberg 2010

Perforator Pedicled Propeller Flaps

a

CHAPTER 49

b

A

B ⊡ Fig. 49.1  (a) Location of the pedicle. (b) Rotation of the propeller flap

⊡ Fig. 49.2  Classification of the propeller flap

443

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444

Perforator Pedicled Propeller Flaps

flap.

Clinical Cases + Case 1: Posterior Tibial PPP Flap (Fig. 49.3)

49

A 62-year-old male presented with an unstable burn scar on the medial aspect of his left ankle. He sustained contact burns due to hot ashes 50 years ago and the original wound was skin grafted, but it failed to take over the medial malleolus and Achilles tendon regions. This subsequently healed by secondary intention giving rise to an area of unstable scarring which broke down intermittently (a). Preoperative investigation with a hand-held Doppler ultrasound machine located a good signal from a perforator artery located 12 cm from the distal edge of the unstable scar. An island fascio-cutaneous flap, based on that single perforator arising from the posterior tibial artery, was planned. This flap was 21 cm long and 5 cm wide (a). At surgery, the unstable scar was excised and this resulted in a 4 × 7-cm defect. Through a generous posterior incision and a subfascial approach (b), the perforator was located (c). Other perforator vessels (d) were identified and all were ligated, except for the one that was selected (e). The flap was then rotated 180° around the perforator to cover the defect. The secondary defect on the proximal calf was closed directly (f ). Healing was uncomplicated, and at final review 8 months later (g), the flap had successfully replaced the unstable area with no breakdown.

Perforator Pedicled Propeller Flaps

CHAPTER 49

a

b

c

d

e

f

g

⊡ Fig. 49.3  Posterior tibial PPP flap

445

446

CHAPTER 49

Perforator Pedicled Propeller Flaps

+ Case 2: Facial Artery PPP Flap (Fig. 49.4)

49

A 31-year-old female patient who had epilepsy suffered from deep dermal burn by hot water during an epileptic attack 2 years ago (a, b). A 12 × 7-cm defects occurred after scar debridement; thus, a facial artery PPP flap was designed on her left neck (c). The flap was elevated and transferred to the recipient site through a skin tunnel (d, e). Another flap was made using cheek skin and the defect was covered by rotation. The flaps survived completely and the disfigurement of her left face improved (f ).

Perforator Pedicled Propeller Flaps

a

c

CHAPTER 49

447

e

d

b f

⊡ Fig. 49.4  Facial artery PPP flap

448

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Perforator Pedicled Propeller Flaps

+ Case 3: Radial Artery PPP Flap (Fig. 49.5)

49

A 23-year-old male patient suffered from deep burn 2 months before the operation (a). An 8 × 4-cm defect on his right forearm was reconstructed with a radial artery PPP flap (b). The flap dissection was started from the medial side of the marked line. The flap was dissected above the deep fascia. The perforator came from the radial artery, which was found 2 cm from the distal part of the flap, and the length of the perforator was 2 cm and the diameter was 1.5 mm (c). Then, we dissected the flap on the lateral side from the proximal to distal side. The flap size was 11 × 5 cm. The flap was elevated and rotated 135°. The flaps survived completely (d–f ).

Perforator Pedicled Propeller Flaps

a

CHAPTER 49

d

b e

c

f

⊡ Fig. 49.5  Radial artery PPP flap

449

CHAPTER 49

450

Perforator Pedicled Propeller Flaps

+ Case 4: Dorsal Pedis Artery PPP Flap

(Fig. 49.6)

49

A 14-year-old male patient suffered from extensive scald burn on his left foot 5 years ago, and contracture and deformity of the first toe developed (a). After scar contracture releasing, a defect on the plantar surface was 6 × 3 cm (b). An interphalangial longitudinal Kirshner-wire was inserted to fix the joints. Elevation of the dorsal pedis artery PPP flap was started from the medial border of the flap under the fascia and reached the distal part of the dorsalis pedis artery (c–e). The perforator was located 3 cm distally from the proximal part of the flap. The length of the perforator was 2 cm and the diameter was 1 mm. Then the flap was rotated 110°, and the donor site was closed primarily (f, g). The K-wire was removed 2 weeks later. The flap survived completely (h).

Perforator Pedicled Propeller Flaps

a

CHAPTER 49

451

b

d

e

g

h

⊡ Fig. 49.6  Dorsalis pedis artery PPP flap

c

f

452

C H A P T E R 50

Perforator Supercharged Super-Thin Flap hiko hyakusoku and rei ogawa

Background of the Technique Most of our reconstructions have been extensive postburn scar contracture cases, for which we need extremely large but thin flaps to reconstruct wide, contour-sensitive areas such as the face and neck [1–9]. For this reason, our flaps have been harvested mainly from the back and chest as “super-thin flaps”, with the help of perforator supercharging (Fig. 50.1). A discriminating feature of the flap is its extremely thin and large form. It is primarily thinned to the layer where the subdermal vascular network (subdermal plexus) can be seen through the minimal fat layer. Moreover, longer and larger flaps can be harvested according to the selection of the perforators attached to the flaps. Thus, these flaps can be considered as “madeto-order flaps”.

Characteristics and Indications of the Method 1. Free style long and large flaps can be harvested according to the selection of the perforators attached to the flaps (Fig. 50.1). 2. We can attach some perforators to the flap, and can harvest various types such as free flaps, vascular pedicled flaps and skin pedicled flaps. However, the skin pedicled type is the most reliable one. Since venous drainage is a common problem of extremely

thin flaps, the reliability will increase if we can retain a skin pedicle.

Specific Skill of the Methods 1. Before operation, each flap is designed to match the shape of the recipient site, and a judgment is made on whether there is any requirement for perforator supercharging. The judgment should be based on the results of anatomical studies [6–8]. The existence of proposed perforators used for supercharging and recipient vessels should be confirmed by Doppler flowmetry [3]. Multi-detector CT (MD-CT) is also useful for the detection of these vessels [10]. 2. The flap is elevated from the periphery. Then, the proposed perforators for anastomosis are confirmed macroscopically and attached to the flap. 3. After the flap is completely elevated, thinning of the flap is performed. The flap is thinned down with curved scissors to the layer in which the subdermal vascular network can be seen through the minimal fat layer. 4. After debulking, we sometimes place a suction drain under the flap and apply slight pressure to prevent subdermal haematoma formation. 5. After the donor site is covered with a split-thickness skin graft or primary suture, the thinned flap is rotated and applied to the recipient site. The vessels are anastomosed under microscope. Finally, the flap is sutured.

R. Ogawa, MD, PhD (*) Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School Hospital, Tokyo, Japan. e-mail: [email protected] H. Hyakusoku, MD, PhD Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School Hospital, Tokyo, Japan. e-mail: [email protected] H. Hyakusoku et al. (eds.), Color Atlas of Burn Reconstructive Surgery, DOI: 10.1007/978-3-642-05070-1_50, © Springer-Verlag Berlin Heidelberg 2010

Perforator Supercharged Super-Thin Flap

CHAPTER 50

⊡ Fig. 50.1  The schema of perforator supercharged “super-thin flaps”

453

CHAPTER 50

454

Perforator Supercharged Super-Thin Flap

Clinical Cases + Case 1: Super-thin Flap using dorsal

intercostal perforator and circumflex scapular vessels

50

A 35-year-old female suffered flame burns to 25% of her total body surface area (Fig. 50.2a). After emergent skin grafting, she suffered severe scar contracture of the anterior neck. The circumflex scapular vessels (CSV) and dorsal intercostal perforator (D-ICAP, DICP) supercharged “super-thin flap” transfer was performed to reconstruct the area from the chest to chin, including the anterior neck (Fig. 50.2b–d). The area was very large, and we estimated a flap size of 35 × 19 cm. The CSV were anastomosed with the facial vessels, and the D-ICAP was anastomosed with the transverse cervical vessels. The cervicomental angle was clear. Three years after the operation, no recurrence of scar contracture or shrinking of the flap was observed (Fig. 50.2e, f ).

Perforator Supercharged Super-Thin Flap

a

c

CHAPTER 50

455

e

b

f d

⊡ Fig. 50.2 (a–f)

456

CHAPTER 50

Perforator Supercharged Super-Thin Flap

+ Case 2: Super-thin Flap using Circumflex

Scapular Vessels

50

A 33-year-old female developed a cervical scar contracture after a split-thickness skin graft was used in another hospital to treat an extensive burn (Fig.  50.3a). We planned a CSV supercharged “super-thin flap” transfer from the left back (Fig. 50.3b). The flap measured 30 × 15 cm, with a narrow skin pedicle of 4 × 4 cm (Fig. 50.3b). The CSV were supercharged and anastomosed with the right facial vessels on the recipient site (Fig. 50.3c, d). The donor site was closed with a meshed skin graft. No shrinking of the flap was observed after 6 months (Fig. 50.3e, f ).

Perforator Supercharged Super-Thin Flap

a

c

CHAPTER 50

457

e

b f

d

⊡ Fig. 50.3 (a–f) 

458

CHAPTER 50

Perforator Supercharged Super-Thin Flap

+ Case 3: Super-thin Flap using Dorsal

I­ ntercostal ­Perforator and Circumflex Scapular Vessels

50

A 43-year-old female suffered from severe flame burns to 30% of her total body surface area following an accident. After emergent skin grafting, the patient suffered from severe scar contractures of the anterior neck and chest (Fig. 50.4a). A perforator supercharged “super-thin flap” transfer was employed to reconstruct the anterior neck and chest (Fig. 50.4b). The flap was elevated with the CSV and D-ICAP, DICP (Fig. 50.4c). These vessels were anastomosed with facial vessels and transverse cervical vessels under a microscope, respectively. The patency of the artery of the D-ICAP could not be maintained due to technical problems during the case. The flap was sutured with nylon and the operation was concluded (Fig. 50.4d). Retrospectively, supercharging of the D-ICAP artery was not needed in this case. The D-ICAP vein might be useful for the drainage of blood flow in the distal area of the flap. The donor site was closed with a meshed skin graft. No shrinking of the flap was observed after 8 months (Figs. 50.4e, f ).

Perforator Supercharged Super-Thin Flap

a

d

⊡ Fig. 50.4 (a–f) 

CHAPTER 50

459

b

c

e

f

460

CHAPTER 50

Perforator Supercharged Super-Thin Flap

+ Case 4: Super-thin Flap using Pectoral

­Intercostal Perforator

50

A 37-year-old male developed a cervical scar contracture after a split-thickness skin graft for an extensive burn (Fig. 50.5a). We planned a pectral intercostal perforator (P-ICAP, PICP) supercharged “super-thin flap” transfer from the left chest (Fig. 50.5a). The flap measured 25 × 7 cm (Fig. 50.5a). After primary defatting (super-thinning: Fig. 50.5b), the P-ICAP was anastomosed with the right superficial temporal vessels (STV) on the recipient site (Fig. 50.5c, d). The donor site was closed directly. No shrinking of the flap and no ­re-contracture were observed after 3 months (Fig. 50.5e).

Perforator Supercharged Super-Thin Flap

a

d

⊡ Fig. 50.5 (a–e) 

b

e

CHAPTER 50

461

c

462

C H A P T E R 51

Perforator Supercharged Super-Thin Flap vu quang vinh

Background

Technique

Introduced in 1994 by Hyakusoku and Gao [1] Hyakusoku et al. [2], the “super-thin flap” is a distinctively thin flap primarily thinned to the layer where the subdermal vascular network (subdermal plexus) can be seen through minimal fat layer (primary defatting). Moreover, Hyakusoku et  al. [3] developed various types of long, large super-thin flaps. These flaps can be harvested mainly on the back and chest by selecting flaps with attached perforators (perforator supercharging). For the reconstruction of severely disfigured neck and face, large and thin flaps such as the ­occipito-cervico-dorsal (OCD) “super-thin flap” should be harvested from the dorsal region with supercharging of the circumflex scapular vessels (CSV). The flap obtained is thin, pliable, and reliable, with an acceptable skin color match. With the anatomical study and many clinical cases involving super-thin flaps for reconstruction of the face, chin, and neck scar contracture, we have confirmed that the OCD “super-thin flap” is sufficiently useful [4–9]. Moreover, bilateral reconstruction using this flap may be useful for total face reconstruction.

a. The flap is designed to match the shape of the recipient site. b. Mapping of the observed perforators on the skin surface of the proposed flap territory is performed. c. In the operation, the recipient site is debrided and the recipient vessels (in most instances, the facial artery and veins, and/or transverse cervical artery and veins, or superficial temporal artery) are exposed and identified in the supine position. d. The position is changed from supine to prone, and the flap is elevated from the periphery. The perforators proposed to be used for anastomosis are confirmed macroscopically. Dorsal intercostal perforators and circumflex scapular artery and veins can be attached to the flaps of approximately 4 cm length. e. After the flap is completely elevated, thinning of the flap is performed. The flap is thinned by scissors to the layer in which the subdermal vascular network could be seen through the minimal fat layer. f. Check and stop bleeding in the flap using a bipolar or electrical knife. g. The donor site is covered with a split-thickness skin graft or primary suture, the position is changed again from prone to supine, and the thinned flap is rotated and applied to the recipient site. h. The vessels are anastomosed under microscopy in microvascular augmented cases. Finally, the flap is fixed with sutures.

Supercharged Occipito-Cervico-Dorsal (OCD) “Super-Thin Flap” Indication The present OCD “super-thin flap” goes far beyond the conventional concept of other flaps. It is very thin and extremely large, and is useful for the reconstruction of contour-sensitive areas such as the total face, chin, and neck. It can be designed to match the shape of recipient sites by perforator supercharging in the distal area of the flap.

V. Q. Vinh National Institute of Burn, Vietnam e-mail: [email protected]

Tips a. The flap is thin, pliable, and reliable, with an acceptable skin color match. Flap territory is large enough for a total neck unit or half face unit using only a cutaneous perforator of circumflex scapular artery. b. If the flap is designed such that it is over 15 cm wide, dorsal intercostal perforators (D-ICAP, DICP) can also be attached to the flap.

H. Hyakusoku et al. (eds.), Color Atlas of Burn Reconstructive Surgery, DOI: 10.1007/978-3-642-05070-1_51, © Springer-Verlag Berlin Heidelberg 2010

Perforator Supercharged Super-Thin Flap

c. For face reconstruction, vessel recipient is a unilateral superficial temporal artery. d. This flap can be used safely in children.

CHAPTER 51

e. The flap width varies from 10 to 13  cm; a primary suture can be performed on the donor site after undermining surrounding tissue.

463

CHAPTER 51

464

Perforator Supercharged Super-Thin Flap

Clinical Cases + Case 1

51

A 42-year-old woman suffered from acid injury to the face, chin, neck, and chest. A year after primary skin grafting, hypertrophic scarring and contracture developed from the neck to the cheek. We used CSV supercharged OCD “super-thin flap” to reconstruct the upper lip, chin, cheek, and neck on the left side. The flap was 25 × 15  cm, and the narrow skin pedicle was 5  cm wide (Fig. 51.1a). Most of the flap, except for the narrow skin pedicle and CSV augmented area, was thinned radically, leaving only the subdermal vascular plexus and a minimal layer of fat tissue. After elevation of the flap, it was rotated and the CSV was anastomosed with the left superficial temporal vessels. The donor site of the flap was covered with meshed skin grafts harvested from her left lateral thigh. The flap survived completely, and the patient was satisfied with the functional and cosmetic results (Fig. 51.1b). Hypertrophic scars (4 × 15 cm) were still present on the right side of her face on the cheek, and so we reconstructed the area with an expanded flap from the right submental region.

Perforator Supercharged Super-Thin Flap

a

b

⊡ Fig. 51.1 (a, b)

CHAPTER 51

465

CHAPTER 51

466

Perforator Supercharged Super-Thin Flap

+ Case 2

51

A 34-year male suffered extensive flame burns to the neck and chest. Split full-thickness skin grafts to neck and chest were performed. However, scar contracture developed. A supercharged OCD flap measuring 26 × 10 cm, with narrow skin pedicle measuring 4 × 4 cm was elevated with the left CSV. The flap was rotated to cover the defect after removing scar contractures. The flap survived completely, and functional and cosmetic results were good after 6 months postoperation. The donor site was primary closed.

Perforator Supercharged Super-Thin Flap

⊡ Fig. 51.2

CHAPTER 51

467

CHAPTER 51

468

Perforator Supercharged Super-Thin Flap

+ Case 3

51

A 13-year-old male suffered extensive flame burns to the neck and chest. Split full-thickness skin grafts to the neck and chest were performed. However, scar contracture developed. Bilateral supracalvicular island flap was used to cover the defect after the scar contracture was removed at another hospital. Unfortunately, the flap experienced partial necrosis. The necrotized area was debrided and covered with split full-thickness skin graft. After 3 months of the surgery, we planned a CSV supercharged OCD super-thin flap that measured 35 × 13 cm; the narrow skin pedicle was 5 cm wide. The flap was thinned primarily, leaving only the subdermal vascular plexus and a minimal layer of fat tissue. Right CSV was anastomosed with the left facial artery. The donor site was closed with split full-thickness skin graft. The flap survived completely; good function and cosmetic results were obtained after 1 year postoperation.

Perforator Supercharged Super-Thin Flap

⊡ Fig. 51.3

CHAPTER 51

469

470

C H A P T E R 52

Extended Scapular Free Flap for Anterior Neck Reconstruction claudio angrigiani, joaquin pefaure, and marcelo mackfarlane

Background of the Technique Free flaps have been traditionally used for the repair of burn sequelae since the beginning of microsurgery era. Over the past 20 years, the senior author has focused on the use of the back as a donor site for flaps to resurface the anterior neck burn sequelae. The combination of the scapular and parascapular flaps provides a large area capable to resurface the entire aesthetic unit. Almost the complete hemiback may be harvested and irrigated by the circumflex scapular vessels. Scapular and parascapular flaps have been originally described by Dos Santos and Nassif [1–2] Koshima [3] first utilized the combination of the scapular and parascapular flaps to resurface a difficult defect in the lower limb. The use of the extended scapular flap for anterior neck resurfacing has been initially published in 1990 [4–5]. Anatomical studies have shown that the superficial circumflex scapular artery arborizes in the subcutaneous tissue when it reaches this level from the quadrangular space. The vascular pedicle does not pierce any septum and is placed above the deep fascia; therefore, there is no need to incorporate the deep fascia for better flap vascularization or to denominate the flap as “septofasciocutaneous”.

Characteristics and Indication of the Method 1. A 28 × 16-cm flap can be safely harvested on this pedicle (Fig. 52.1). 2. The flap is used for resurfacing the anterior neck aesthetic unit, which extends from the mandible to the clavicle and the sternal notch. The lateral limit is C. Angrigiani, MD (*) Hospital General Francisco Santojanni, Argentina e-mail: [email protected] J. Pefaure, MD M. MackFarlane, MD Hospital General Francisco Santojanni, Argentina

⊡ Fig. 52.1  Diagrm of the flap

placed at the level of the posterior border of the sternocleidomastoid muscle. 3. The aesthetic unit is reconstructed completely even if it is not completely involved by the lesion. Unfavourably placed scars produce not only a poor aesthetic result, but also a poor functional result. 4. There are not so many donor sites that provide a uniform large flap with a single vascular pedicle. 5. Partial anterior neck aesthetic unit reconstruction produces a poor aesthetic result, which is almost

H. Hyakusoku et al. (eds.), Color Atlas of Burn Reconstructive Surgery, DOI: 10.1007/978-3-642-05070-1_52, © Springer-Verlag Berlin Heidelberg 2010

Extended Scapular Free Flap

i­ mpossible to solve; if complete unit reconstruction is not indicated, partial reconstruction must be done according to subunit principle: the neck may be subdivided into floor of the mouth and vertical neck. Aesthetic result is always minor in quality, though. 6. Reconstruction beyond the limits of the neck unit with this flap is not a good idea. There will be loss of cervicomental angle which is extremely aesthetically important. 7. Expansion of local or vicinity tissues is not a good option for neck reconstruction; recidivant contracture will eventually occur.

Specific Skills of the Methods The flap is designed to resurface the anterior neck aesthetic unit; not the size of the defect. Therefore, the dimension of the flap is constant. In an average adult male, a 28 × 16-flap is used; in females 26 × 14.

CHAPTER 52

If the burn lesion extends to the cheek area or the lower lip, the flap is placed at the limit of the neck unit. Further treatments will be necessary to solve the remaining areas. Sectioning of the soft tissues is performed up to the level of the hyoid bone even if they are not involved by the lesion or retracted. The dissection is performed above the deep fascia and the fat can be safely trimmed up to the superficial fascia. No attempt is made to raise a super thin flap initially. Complementary defatting procedures are required to obtain a better aesthetic result. Better aesthetic results are obtained when the flap reaches the capillary line at the lateral part of the neck. The flap must be immobilized at the level of the hyoid cartilage with non absorbable 3-0 nylon monofilament to avoid loss of cervico mental angle. Suction drainages are left in place for 5 days. Adaptative dressing is applied for 5 days. Intermittent soft dressing immobilization with a neck collar is placed for 1 month.

471

CHAPTER 52

472

Extended Scapular Free Flap

Clinical Cases + Case 1

52

A 21-year-old female suffered flame burns to 15% of her total body surface area involving the cheek, neck and upper thorax (Fig. 52.2). After initial skin grafting, she suffered moderate scar contracture of the anterior neck. A 26 × 14 extended scapular flap was used to resurface the anterior neck aesthetic unit. The flap vessels (circumflex scapular artery and vein) were anastomosed to the facial artery and vein. The donor area was closed directly. Eventually, complementary procedures were done to ameliorate the aesthetic appearance of the cheek (Fig. 52.3–52.8).

Extended Scapular Free Flap

473

b

a

c

e

CHAPTER 52

d

f

g

⊡ Fig. 52.2  (a) Preop view. (b) Flap design on the right side back. (c) Flap elevation plane superficial to the deep fascia. (d) Flap elevated pedicle view. (e) Donor area direct closure. (f–g) Two months postop view

CHAPTER 52

474

Extended Scapular Free Flap

+ Case 2

52

A 28-year-old female developed a moderate cervical scar contracture after intermediate flame burn to her neck. Moderate functional impairment occurred with neck extension. The main complaint was aesthetic deficit. An extended scapular flap was used to resurface the entire anterior neck aesthetic unit. The flap measured 26 × 14 cm and was anastomosed with the facial vessels on the recipient site. The donor site was closed with a meshed skin graft. No shrinking of the flap was observed after 6 months (Fig. 52.3 a–d).

Extended Scapular Free Flap

CHAPTER 52

a

b

c

d

⊡ Fig. 52.3  (a-c) Preop view clinical case 2. (b–d) 90 day-postop view complmentary esthetic rhinoplasty was performed

475

CHAPTER 52

476

Extended Scapular Free Flap

+ Case 3 A 57-year-old-female developed a cervical scar contracture after a split-thickness skin graft was used in another hospital to treat an extensive burn. Complete release of the anterior neck unit and immediate resurfacing with an extended scapular flap was planned to solve a severe impairment in neck flexion extension as well as rotation movement. A 10-year follow up showed complete neck function and permanent, good aesthetic result (Fig. 52.4 a–d).

52

Extended Scapular Free Flap

CHAPTER 52

a

b

c

d

⊡ Fig. 52.4  (a-c) Preop view clinical case 3. (b–d) Four year postop view. The inferior limit of the flap has been pulled i­ nferiorly by the remaining anterior thoracic scar

477

478

References

Chapter 1   1. Jackson DM (1953) The diagnosis of the depth of burning. Br J Surg 40:588–596   2. Kim DE, Phillips TM, Jeng JC, Rizzo AG, Roth RT, Stanford JL, Jablonski KA, Jordan MH (2001) Microvascular assessment of burn depth conversion during varying resuscitation conditions. J Burn Care Rehabil 22(6):406–416

Chapter 2   1. Van Zuijlen PP, Vloemans JF, van Trier AJ, Suijker MH, van Unen E, Groenevelt F, Kreis RW, Middlekoop E (2001) Dermal substitution in acute burns and reconstructive surgery: a subjective and objective long-term follow-up. Plast Reconstr Surg 108(7):1938–1946   2. Boyce ST, Kagan RJ, Yabukoff KP, Meyer NA, Rieman MT, Greenhalg DG, Warden GD (2002) Cultured skin substitutes reduce donor skin harvesting for closure of excised, fullthickness burns. Ann Surg 235(2):269–279   3. Purdue GF, Hunt JL, Still JM (1997) A multicenter clinical trial of a biosynthetic skin replacement, Dermagraft-TC, compared with cryopreserved human cadaver skin for temporary coverage of excised burn wounds. J Burn Care Rehabil 18:52–57   4. Demling RH, DeSanti L (1999) Management of partial thickness facial burns (comparison of topical antibiotics and bio-engineered skin substitutes). Burns 25(3):256–261   5. Sheridan R, Choucair R, Donelan M, Lydon M, Petras L, Tompkins R (1998) Acellular allodermis in burn surgery: a 1-year results of a pilot trial. J Burn Care Rehabil 19:528–530   6. Heimbach D, Luterman A, Burke J, Cram E, Herndon D, Hunt J, Jordan M, McManus W, Solim L, Warden G et al (1988) Artificial dermis for major burns. A multicenter randomized clinical trial. Ann Surg 208:313–320   7. Rheinwald JG, Green H (1975) Serial cultivation of strains of human epidermal keratinocytes: the formation of keratinizing colonies from single cells. Cell 6:448–451   8. Gallico GG, O’Connor NE, Compton CC, Kehind O, Green H (1984) Permanent coverage of large burn wounds with autologous cultured human epithelium. N Engl J Med 311:448–451   9. Compton CC, Hickerson W, Nadire K, Press W (1993) Acceleration of skin regeneration from cultured epithelial autografts by transplantation to homograft dermis. J Burn Care Rehabil 14:653–662

10. Wassermann D, Schlotterer M, Lebreton F, Levy J, Guelfi MC (1989) Use of topically applied silversulfadiazine plus cerium nitrate in major burns. Burns 15:257–260 11. Chang KP, Tsaii CC, Lin TM, Lai CS, Lin SD (2001) An alternative dressing for skin graft immobilization: negative pressure dressing. Burns 27(8):839–842 12. Tredget EE, Shankowsky HA, Groenveld A, Burell R (1998) A matched-pair, randomized study evaluating the efficacy and safety of Acticoat® silver-coated dressing for the treatment of burn wounds. J Burn Care Rehabil 19: 532–537 13. Janzekovic Z (1970) A new concept in the early excision and immediate grafting of burns. J Trauma 10:1103–1108

Chapter 3   1. Steed DL, Donohoe D, Webster MW, Lindsley L (1996) Effect of extensive debridement and treatment on the healing of diabetic foot ulcers. Diabetic Ulcer Study Group. J Am Coll Surg 183:61–64   2. Hansbrough JF, Zapata-Sirvent RL, Peterson VM, Bender E, Claman H, Boswick JA (1984) Characterization of the immunosuppressive effect of burned tissue in an animal model. J Surg Res 37:383–393   3. Robson MC, Heggers JP (1970) Delayed wound closure based on bacterial counts. J Surg Oncol 2:379–383   4. Davis SC, Mertz PM, Bilevich ED et al (1996) Early debridement of second degree burn wounds enhances the rate of reepithelialization – an animal model to evaluate burn wound therapies. J Burn Care Rehabil 17:558–561   5. Deitch EA, Wheelahan TM, Rose MP, Clothier J, Cotter J (1983) Hypertrophic burn scars: analysis of variables. J Trauma 23:895–898   6. Sargent RL (2006) Management of blisters in the partialthickness burn: an integrative research review. J Burn Care Res 27:66–81   7. Janzekovic Z (1970) A new concept in the early excision and immediate grafting of burns. J Trauma 10:1103–1108   8. Herndon DN, Barrow RE, Rutan RL, Rutan TC, Desai MH, Abston S (1989) A comparison of conservative versus early excision. Therapies in severely burned patients. Ann Surg 209:547–552; discussion 552–553   9. Sorensen B, Fisker NP, Steensen JP, Kalaja E (1984) Acute excision or exposure treatment? Scand J Plast Reconstr Surg 18:87–93

H. Hyakusoku et al. (eds.), Color Atlas of Burn Reconstructive Surgery, DOI: 10.1007/978-3-642-05070-1_BM, © Springer-Verlag Berlin Heidelberg 2010

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10. Thompson P, Herndon DN, Abston S, Rutan T (1987) Effect of early excision on patients with major thermal injury. J Trauma 27:205–207 11. Caldwell FT Jr, Wallace BH, Cone JB (1996) Sequential excision and grafting of the burn injuries of 1507 patients treated between 1967 and 1986: end results and the determinants of death. J Burn Care Rehabil 17:137–146 12. Xiao-Wu W, Herndon DN, Spies M, Sanford AP, Wolf SE (2002) Effects of delayed wound excision and grafting in severely burned children. Arch Surg 137:1049–1054 13. Palmieri TL, Greenhalgh DG (2002) Topical treatment of pediatric patients with burns: a practical Guide. Am J Clin Dermatol 3:529–534 14. Cuttle L, Naidu S, Mill J, Hoskins W, Das K, Kimble R (2007) A retrospective cohort study of Acticoat® versus Silvazine in pediatric population. Burns 33:701–707 15. Jeffrey SLA (2007) Debridement of pediatric burns. In: Granick MS, Gamelli RL (eds) Surgical wound healing and management. Informa Health Care, USA, pp 53–56 16. Bishop JF (2004) Burn wound assessment and surgical management. Crit Care Nurs Clin North Am 16:145–177 17. Steadman PB, Pegg SP (1992) A quantitative assessment of blood loss in burn wound excision and grafting. Burns 18: 490–491 18. Cole JK, Engrav LH, Heimbach DM, Gibran NS, Costa BA, Nakamura DY, Moore ML, Blayney CB, Hoover CL (2002) Early excision and grafting of face and neck burns in patients over 20 years. Plast Reconstr Surg 109:1266–1273 19. Klein MB, Moore LM, Costa B, Engrav LH (2005) Primer on the management of face burns at the University of Washington. J Burn Care Rehabil 26:2–6 20. Rennekampff HO, Schaller HE, Wisser D, Tenenhaus M (2006) Debridement of burn wounds with a water jet surgical tool. Burns 32:64–69

Chapter 4   1. Jackson DM (1953) The diagnosis of the depth of burning. Br J Surg 40:588–596   2. Jackson DM (1969) Second thoughts on the burn wound. J Trauma 9:839–862   3. Gibran NS, Heimbach DM (2000) Current status of burn wound pathophysiology. Clin Plast Surg 27:11–22   4. Branemark PI, Breine U, Joshi M et  al (1968) Part I. Pathophysiology of thermal burns. Microvascular pathophysiology of burned tissue. Ann N Y Acad Sci 150:474–494   5. Arturson MG (1985) The pathophysiology of severe thermal injury. J Burn Care Rehabil 6:129–146   6. Melikan V, Laverson S, Zawacki B (1987) Oxygen-derived free radical inhibition in the healing of experimental zoneof-stasis burns. J Trauma 27:151–154   7. Nozaki M, Guest MM, Bond TP et al (1979) Permeability of blood vessels after thermal injury. Burns 6:213–221   8. Molnar JA (2004) The role of topical negative pressure in burns. In: Banwell P, Teot L (eds) Topical negative pressure therapy. TXP Communications, UK, pp 150–158   9. Morykwas MJ, Argenta LC, Shelton-Brown EI et al (1997) Vacuum-assisted closure: a new method for wound control



and treatment: animal studies and basic foundation. Ann Plast Surg 38:553–562 10. Argenta LC, Morykwas MJ, Marks MW, DeFranzo AJ, Molnar JA, David LR (2006) Vacuum assisted closure; state of the clinical art. Plast Reconstr Surg 117(7 Suppl):127S–142S 11. Greene AK, Puder M, Roy R, Arsenault D, Kwei S, Moses MA, Orgill DP (2006) Microdeformational wound therapy: effects on angiogenesis and matrix metalloproteinases in chronic wounds of 3 debilitated patients. Ann Plast Surg 56(4):418–422 12. Scherer SS, Pietramaggiori G, Mathews JC, Prsa MJ, Huang S, Orgill DP (2008) The mechanism of action of the vacuum-assisted closure device. Plast Reconstr Surg 122(3): 786–797 13. Morykwas MJ, David LR, Schnieder AM et al (1999) Use of subatmospheric pressure to prevent progression of partialthickness burns in a swine model. J Burn Care Rehabil 20: 15–21 14. Molnar JA, Simpson JL, Voignier DM et  al (2005) Management of an acute thermal injury with subatmospheric pressure. J Burns Wounds 4:108–118 15. Molnar JA (1997) The use of a hypobaric device in acute human burns. 10th Annual Regional Burn Seminar, Chapel Hill, North Carolina. December 6 16. Molnar JA, Heimbach D, Gibran N, Tredgett E, Mozingo D, Bauling P, Kemalyan N, Still J, Lennox P, Lozano D (2005) Evaluation of subatmospheric pressure treatment of acute burn injury in a prospective, randomized, controlled, blinded, multicenter trial. Australian and New Zealand Burn Association Annual Scientific Meeting 2005, Sydney, Australia. September 15 17. Molnar JA, Lew WK, Rapp DA, Gordon ES, Voignier D, Rushing S, Willner W (2009) Use of standardized, quantitative digital photography in a multicenter web-based study. Eplasty 9:19–26 18. Schrank C, Mayr M, Overesch M et  al (2004) Ergebnisse der Vakuumtherapie (V.A.C.®-Therapie) von oberflächlich und tiefdermalen Verbrennungen. Zentralbl Chir 129: 51–53 19. Kamolz LP, Willy C (2006) Vacuum therapy in the treatment of acute burns – an overview. In: Willy C (ed) The theory and practice of vacuum therapy. Lindquist Book, Ulm

Chapter 5   1. Yannas IV, Burke JF (1980) Design of an artificial skin. I. Basic design principles. J Biomed Mater Res 14(1):65–81   2. Yannas IV, Burke JF, Warpehoski M, Stasikelis P, Skrabut EM, Orgill D, Giard DJ (1981) Prompt, long-term functional replacement of skin. Trans Am Soc Artif Intern Organs 27:19–23   3. Burke JF, Yannas IV, Quinby WC et al (1981) Successful use of a physiologically acceptable artificial skin in the treatment of extensive burn injury. Ann Surg 194(4):413–428   4. Orgill DP, Straus FH II, Lee RC (1999) The use of collagenGAG membranes in reconstructive surgery. Ann NY Acad Sci 888:233–248

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  5. Moiemen NS, Staiano JJ, Ojeh NO et al (2001) Reconstructive surgery with a dermal regeneration template: clinical and histologic study. Plast Reconstr Surg 108(1):93–103   6. Clayton MC, Bishop JF (1998) Perioperative and postoperative dressing techniques for Integra artificial skin: views from two medical centers. J Burn Care Rehabil 19(4): 358–363   7. Machens HG, Berger AC, Mailaender P (2000) Bioartificial skin. Cells Tissues Organs 167(2–3):88–94   8. Morykwas MJ, Argenta LC, Shelton-Brown EI et al (1997) Vacuum-assisted closure: a new method for wound control and treatment: animal studies and basic foundation. Ann Plast Surg 38(6):553–562   9. Argenta LC, Morykwas MJ (1997) Vacuum-assisted closure: a new method for wound control and treatment: clinical experience. Ann Plast Surg 38(6):563–576 10. Argenta LC, Morykwas MJ, Marks MW, DeFranzo AJ, Molnar JA, Daivd LR (2006) Vacuum-assisted closure: state of clinic art. Plast Reconstr Surg 117(7 suppl):127S–142S 11. Saxena V, Hwang CW, Huang S, Eichbaum Q, Ingber D, Orgill DP (2004) Vacuum-assisted closure: microdeformations of wounds and cell proliferation. Plast Reconstr Surg 114(5):1086–96 12. Orgill DP, Manders EK, Sumpio BE, Lee RC, Attinger CE, Gurtner GC, Ehrlich, HP (2009) The mechanisms of vacuum assisted closure: More to learn. Surgery 146(1): 40–47. 13. Schneider AM, Morykwas MJ, Argenta LC (1998) A new and reliable method of securing skin grafts to the difficult recipient bed. Plast Reconstr Surg 102(4):1195–1198 14. Molnar JA, Shrimanker N, Morykwas MJ, Argenta LC (2002) Improved skin graft adherence and vascularizaton of Integra® using subatmospheric pressure – a laboratory study. American Burn Association 34th Annual Meeting, April 24–27. Chicago, Illinois. 15. Molnar JA, Defranzo AJ, Hadaegh A et al (2005) Acceleration of integra incorporation in complex tissue defects with subatmospheric pressure. Plast Reconstr Surg 113(5):1339–1346 16. Park CA, Defranzo AJ, Marks MW, Molnar JA (2009) Outpatient reconstruction using Integra and subatmospheric pressure. Ann Plast Surg 62:164–169 17. Newman CE, Morykwas M, Park CA, Gordon S, Simpson J, DeRoberts D, Molnar JA (2005) Immediate skin grafting on an engineered dermal substitute. J Burn Care Rehabil 26 (2 suppl):S89

Chapter 6   1. Wood FM (2002) Clinical potential of cellular autologous epithelial suspension. Wounds 15:16–22   2. Marchisio PC (1991) Polarized Expression of Integrin Receptors (ά6 β4, ά2 βά, and άvβ5) and their Relationships with the Cytoskeleton and Basement Membrane matrix in Cultured Human Keratinocytes. J. Cell Bio 112: 761–773   3. Martin P (1997) Wound healing - aiming for perfect skin regeneration. Science 276:75–81   4. Brown TL, Muller MJ (2003) Parsimony simplicity and survival in burn care. Burns 29:197–198   5. Herndon DN, Barrow RE, Rutan RL, Ritan DC, Desai MH (1987) A comparison of conservative versus early exci-

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Chapter 7   1. Weeks B (2008) Brief introduction to the history of burns medical science. In: Burns regenerative medicine and therapy. S. Karger AG, Switzerland, pp 1–3   2. Ioannovich J, Gravvanis A, Tsoutsos D (2004) The treatment of burn disease in the Hippocratic era. Plast Reconstr Surg 114:1664–1665   3. Nicoli N, Fini M, Giardino R (2008) From Hippocrates to tissue engineering: surgical strategies in wound treatment. World J Surg 32:2114–2121   4. Kandela P (1999) Sketches from The Lancet. Antisepsis. Lancet 353:937

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28. Stoff A, Rivera AA, Mathis JM et al (2007) Effect of adenoviral mediated overexpression of fibromodulin on human dermal fibroblasts and scar formation in full-thickness incisional wounds. J Mol Med 85:481–496 29. Katsu M, Koyama H, Maekawa H et al (2009) Ex vivo gene delivery of ephrin-B2 induces development of functional collateral vessels in a rabbit model of hind limb ischemia. J Vasc Surg 49:192–198 30. Egana JT, Fierro FA, Kruger S, et al (2009) Use of human mesenchymal cells to improve vascularization in a mouse model for scaffold-based dermal regeneration. Tissue Eng Part A 15(5):1191–1200. doi:10.1089/ten.tea. 2008.0097 31. Atiyeh BS, Costagliola M (2007) Cultured epithelial autograft (CEA) in burn treatment: three decades later. Burns 33:405–413 32. Wood FM, Kolybaba ML, Allen P (2006) The use of ­cultured epithelial autograft in the treatment of major burn injuries: a critical review of the literature. Burns 32: 395–401 33. Liu P, Deng Z, Han S et  al (2008) Tissue-engineered skin containing mesenchymal stem cells improves burn wounds. Artif Organs 32:925–931 34. Yan X, Owens DM (2008) The skin: a home to multiple classes of epithelial progenitor cells. Stem Cell Rev 4: 113–118 35. Branski LK, Gauglitz GG, Herndon DN et  al (2009) A review of gene and stem cell therapy in cutaneous wound healing. Burns 35:171–180 36. Braun KM, Prowse DM (2006) Distinct epidermal stem cell compartments are maintained by independent niche microenvironments. Stem Cell Rev 2:221–231 37. Fuchs E, Nowak JA (2008) Building epithelial tissues from skin stem cells. Cold Spring Harb Symp Quant Biol 73: 333–350 38. Li H, Fu X, Ouyang Y et al (2006) Adult bone-marrow-derived mesenchymal stem cells contribute to wound healing of skin appendages. Cell Tissue Res 326:725–736 39. Kamolz LP, Kolbus A, Wick N et al (2006) Cultured human epithelium: human umbilical cord blood stem cells differentiate into keratinocytes under in vitro conditions. Burns 32: 16–19 40. Ceradini DJ, Kulkarni AR, Callaghan MJ et  al (2004) Progenitor cell trafficking is regulated by hypoxic gradients through HIF-1 induction of SDF-1. Nat Med 10:858–864 41. Altman AM, Matthias N, Yan Y et al (2008) Dermal matrix as a carrier for in  vivo delivery of human adipose-derived stem cells. Biomaterials 29:1431–1442 42. Trottier VR, Marceau-Fortier G, Germain L et  al (2008) IFATS collection: using human adipose-derived stem/ stromal cells for the production of new skin substitutes. Stem Cells 26:2713–2723

Chapter 8   1. Mandrekas AD, Zambacos GJ, Anastasopoulos A (2002) Treatment of bilateral severe eyelid burns with skin grafts: an odyssey. Burns 28:80–86   2. Gonzarez-Ulloa M, Castillo A, Stevens E, Alvarez FG, Leonelli F, Ubaldo F (1954) Preliminary study of the total

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restoration of the facial skin. Plast Reconstr Surg 13: 151–161   3. Gonzarez-Ulloa M (1956) Restoration of the face covering by means of selected skin in regional aesthetic units. Br J Plast Surg 9:212–221   4. Gonzarez-Ulloa M, Stevens E (1961) Reconstruction of the nose and forehead by means of regional aesthetic units. Br J Plast Surg 13:305–309   5. Gonzalez-Ulloa M (1987) Regional aesthetic units of the face. Plast Reconstr Surg 79:489–490   6. Ogawa R, Ono S, Hyakusoku H, Rennekampff HO (2008) A case of upper lip and moustache reconstruction using a submental artery perforator (SMAP) flap. Euro J Plast Surg 31:33–35   7. Ogawa R, Hyakusoku H, Murakami M (2003) Color Doppler ultrasonography in the planning of microvascular augmented “super-thin” flaps. Plast Reconstr Surg 112(3): 822–828   8. Vinh VQ, Ogawa R, Van Anh T, Hyakusoku H (2007) Reconstruction of neck scar contractures using supraclavicular flaps: retrospective study of 30 cases. Plast Reconstr Surg 119(1):130–135   9. Winspur I (1985) Distant flaps. Hand Clin 1(4):729–739 10. Hyakusoku H, Fumiiri M (1987) The square flap method. Br J Plast Surg 40(1):40–46 11. Hyakusoku H, Yamamoto T, Fumiiri M (1991) The propeller flap method. Br J Plast Surg 44(1):53–54 12. Hyakusoku H, Ogawa R (2003) The small-wave incision for long keloids. Plast Reconstr Surg 111(2):964–965

Chapter 9   1. Edgar D, Brereton M (2004) Rehabilitation after burn injury. BMJ 329:343–345   2. Fujii T (1990) Local treatment for extensive deep dermal thickness burn and follow-up study. Acta Chir Plast 32: 46–56   3. Kibe Y, Takenaka H, Kishimoto S (2000) Spatial and temporal expression of basic fibroblast growth factor protein during wound healing of rat skin. Br J Dermatol 143:720–727   4. Nissen NN, Gamelli RL, Polverini PJ, DiPietro LA (2003) Differential angiogenic and proliferative activity of surgical and burn wound fluids. J Trauma 54:1205–1210   5. Fu X, Shen Z, Chen Y, Xie J, Guo Z, Zhang M, Sheng Z (1998) Randomised placebo-controlled trial of use of topical recombinant bovine basic fibroblast growth factor for ­second-degree burns. Lancet 352:1661–1664   6. Akita S, Akino K, Imaizumi T, Hirano A (2005) A basic fibroblast growth factor improved the quality of skin grafting in burn patients. Burns 31:855–858   7. Akita S, Akino K, Imaizumi T, Tanaka K, Anraku K, Yano H, Hirnao A (2006) The quality of pediatric burn scars is improved by early administration of basic fibroblast growth factor. J Burn Care Res 27:333–338   8. Gibran NS, Isik FF, Heimbach DM, Gordon D (1994) Basic fibroblast growth factor in the early human burn wound. J Surg Res 56:226–234

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15. Bandyopadhyay B, Fan J, Guan S et al (2006) A “traffic control” role for TGFbeta3: Orchestrating dermal and epidermal cell motility during wound healing. J Cell Biol 172:1093–1105



  5. Kazki R (2001) Rehabilitation make-up and plastic surgery (Japanese). Keiseigeka 44:1029–1036   6. Koike S, Ogawa R, Aoki R, Kazki R (2007) Consideration of scar plasty made by self-injury (Japanese). J Jap Soc Aest Plast Surg 29(3):155–159

Chapter 11   1. Ogawa R. Current algorithms for the treatment and prevention of hypertrophic scars and keloids   2. Chang P, Laubenthal KN, Lewis RW 2nd, Rosenquist MD, Lindley-Smith P, Kealey GP (1995) Prospective, randomized study of the efficacy of pressure garment therapy in patients with burns. J Burn Care Rehabil 16:473   3. Van den Kerckhove E, Stappaerts K, Fieuws S, Laperre J, Massage P, Flour M, Boeckx W (2005) The assessment of erythema and thickness on burn related scars during pressure garment therapy as a preventive measure for hypertrophic scarring. Burns 31:696   4. O’Brien L, Pandit A (2006) Silicon gel sheeting for preventing and treating hypertrophic and keloid scars. Cochrane Database Syst Rev (1):CD003826   5. Akaishi S, Akimoto M, Hyakusoku H, Ogawa R (2009) Visual analysis for the effect of silicone gel sheet with the finite element study. Plast Recostr Surg   6. So K, Umraw N, Scott J, Campbell K, Musgrave M, Cartotto R (2003) Effects of enhanced patient education on compliance with silicone gel sheeting and burn scar outcome: a randomized prospective study. J Burn Care Rehabil 24:411   7. Wittenberg GP, Fabian BG, Bogomilsky JL, Schultz LR, Rudner EJ, Chaffins ML, Saed GM, Burns RL, Fivenson DP (1999) Prospective, single-blind, randomized, controlled study to assess the efficacy of the 585-nm flashlamp-pumped pulsed-dye laser and silicone gel sheeting in hypertrophic scar treatment. Arch Dermatol 135:1049   8. Alster T (2003) Laser scar revision: comparison study of 585-nm pulsed dye laser with and without intralesional corticosteroids. Dermatol Surg 29:25   9. Ogawa R, Hyakusoku H, Ogawa K, Nakao C (2008) Effectiveness of mugwort lotion for the treatment of post-burn hypertrophic scars. J Plast Reconstr Aesthet Surg 61:210 10. Suzawa H, Ichikawa K, Kikuchi S, Yamada K, Tsuchiya O, Hamano S, Komatsu H, Miyata H (1992) Effect of tranilast, an anti-allergic drug, on the human keloid tissues. Nippon Yakurigaku Zasshi 99:231 11. Kazuki R (2001) The role of rehabilitation makeup in modern medical care. Jpn J Plast Reconstr Surg 44:1029

Chapter 12   1. Aoki R (1994) Social prognosis of post-burn survival patients (Japanese). Nessho 20(2):64–71   2. Downie M (1984) Camouflage therapy. Aust J Derm 25: 89–91   3. Rayner VL (1990) Assessing camouflage therapy for the disfigured patient; a personal perspective. Dermatol Nurs 2(2): 101–104   4. Rayner VL (1995) Camouflage therapy. Cosmet Derm 13(2): 467–472

Chapter 13   1. Dantzer E, Braye FM (2001) Reconstructive surgery using an artificial dermis (Integra): results with 39 grafts. Br J Plast Surg 54(8):659–664   2. Sibbald RG, Zuker R, Coutts P, Coelho S, Williamson D, Queen D (2005) Using a dermal skin substitute in the treatment of chronic wounds secondary to recessive dystrophic epidermolysis bullosa: a case series. Ostomy Wound Manage 51(11):22–46   3. Ophof R, Maltha JC, Kuijpers-Jagtman AM, Von Den Hoff JW (2007) Evaluation of a collagen-glycosaminoglycan ­dermal substitute in the dog palate. Tissue Eng 13(11): 2689–2698   4. Tufaro AP, Buck DW 2nd, Fischer AC (2007) The use of artificial dermis in the reconstruction of oncologic surgical defects. Plast Reconstr Surg 120(3):638–646   5. Tsoutsos D, Stratigos A, Gravvanis A, Zapandioti P, Kakagia D (2007) Burned breast reconstruction by expanded artificial dermal substitute. J Burn Care Res 28(3):530–532   6. Herlin C, Louhaem D, Bigorre M, Dimeglio A, Captier G (2007) Use of Integra in a paediatric upper extremity degloving injury. J Hand Surg Eur 32(2):179–184. Epub 2007 Jan 16   7. Jeng JC, Fidler PE, Sokolich JC, Jaskille AD, Khan S, White PM, Street JH 3rd, Light TD, Jordan MH (2007) Seven years’ experience with Integra as a reconstructive tool. J Burn Care Res 28(1):120–126   8. Haslik W, Kamolz LP, Nathschläger G, Andel H, Meissl G, Frey M (2007) First experiences with thecollagen-elastin matrix Matriderm™ as a dermal substitute in severe burn injuries of the hand. Burns 33(3):364–368. Epub 2007 Jan 22   9. Ryssel H, Gazyakan E, Germann G, Ohlbauer M (2008) The use of MatriDerm™ in early excision and simultaneous autologous skin grafting in burns–a pilot study. Burns 34(1):93–97. Epub 2007 Jul 17 10. Gravante G, Delogu D, Giordan N, Morano G, Montone A, Esposito G (2007) The use of Hyalomatrix PA in the treatment of deep partial-thickness burns. J Burn Care Res 28(2):269–274 11. Shevchenko RV, Sibbons PD, Sharpe JR, James SE (2008) Use of a novel porcine collagen paste as a dermal substitute in full-thickness wounds. Wound Repair Regen 16(2): 198–207 12. Scuderi N, Onesti MG, Bistoni G, Ceccarelli S, Rotolo S, Angeloni A, Marchese C (2008) The clinical application of autologous bioengineered skin based on a hyaluronic acid scaffold. Biomaterials 29(11):1620–1629. Epub 2008 Jan 16

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  1. Livesey SA, Herndon DN, Hollyyoak MA, Atkinson YH, Nag A (1995) Transplanted acellular allograft dermal matrix. Potential as a template for the reconstruction of viable dermis. Transplantation 60:1–9   2. Takami Y, Matsuda T, Yoshitake M, Hanumadass M, Walter RJ (1996) Dispase/detergent treated dermal matrix as a dermal substitute. Burns 22:182–190   3. Takami Y, Tanaka H, Wada T, Takeda T, Kubota J, Ogo K, Shimazaki S (2000) Characterization of an acellular allogenic dermal matrix and its clinical application. Jpn J Burn Injuries 26:261–267   4. Takami Y, Shimazaki S, Yamaguchi R, Tanaka H, Harii S (2004) Transplantation of tissue-engineered skin composed of autologous cells and acellular allogeneic dermal matrix. Jpn J Plast Reconstr Surg 47:867–873   5. Takami Y, Yamaguchi R, Shimazaki S (2006) Successful transplantation of tissue-engineered skin equivalent based on autologous transformation of allograft skin. Am J Transplant 6 (Suppl 2) and Transplantation 82 (issue 1) (Suppl 3):746   6. Sahota PS, Burn JL, Heaton M, Freedlander E, Suvarna SK, Brown NJ, MacNeil S (2003) Development of a ­reconstructed human skin model for angiogenesis. Wound Rep Reg 11:275–284   7. Hernon CA, Harrison CA, Thornton DJA, Sheila MacNeil (2007) Enhancement of keratinocyte performance in the production of tissue-engineered skin using a low calcium medium. Wound Rep Reg 15:718–726

  1. Atiyeh BS, Costagliola M (2007) Cultured epithelial autograft (CEA) in burn treatment: three decades later. Burns 33(4):405–413. Epub 2007 Apr 2   2. Frame JD, Still J, Lakhel-LeCoadou A, Carstens MH, Lorenz C, Orlet H, Spence R, Berger AC, Dantzer E, Burd A (2004) Use of dermal regeneration template in contracture release procedures: a multicenter evaluation. Plast Reconstr Surg 113(5):1330–1338   3. Hickerson WL, Compton C, Fletchall S, Smith LR (1994) Cultured epidermal autografts and allodermis combination for permanent burn wound coverage. Burns 20(Suppl 1): S52–S55; discussion S55–S56   4. Lee LF, Porch JV, Spenler W, Garner WL (2008) Integra in lower extremity reconstruction after burn injury. Plast Reconstr Surg 121(4):1256–1262   5. Petersen MJ, Lessane B, Woodley DT (1990) Characterization of cellular elements in healed cultured keratinocyte auto­ grafts used to cover burn wounds. Arch Dermatol 126(2): 175–180   6. Phillips TJ, Gilchrest BA (1992) Clinical applications of cultured epithelium. Epithelial Cell Biol 1(1):39–46   7. Prem Shukla C, Robert Sheridan L (2008) Initial Evaluation and Management of the Burn Patient, HYPERLINK http:// www.emedicine.com www.emedicine.com; 7 Feb 2008   8. Robert Sheridan L. Burns, Rehabilitation and Reconstruction, HYPERLINK http://www.e-medicine.com www.emedicine. com; 28 Aug 2008   9. Silvio Podda, Christopher Chia T, Wayne Stadelmann (2008) Skin, Tissue Expansion, HYPERLINK http://www.emedicine.com www.emedicine.com; 2 Sep 2008

Chapter 15   1. Abai B, Thayer D, Glat PM (2004) The use of a dermal regeneration template (Integra) for acute resurfacing and reconstruction of defects created by excision of giant hairy nevi. Plast Reconstr Surg 114(1):162–168   2. Dantzer E, Braye FM (2001) Reconstructive surgery using artificial dermis (Integra): results with 39 grafts. Br J Plast Surg 54:659   3. Moiemen NS, Staiano JJ, Ojeh NO et al (2001) Reconstructive surgery with a dermal regeneration template: clinical and histologic study. Plast Reconstr Surg 108:93   4. Yannas IV, Burke JF, Orgill DP, Skrabut EM (1982) Wound tissue can utilize a polymeric template to synthesize a functional extension of skin. Science 215:174   5. Yannas IV, Lee E, Orgill DP, Skrabut EM, Murphy GF (1989) Synthesis and characterization of a model extracellular matrix that induces partial regeneration of adult mammalian skin. Proc Natl Acad Sci USA 86:993   6. Integra Brochure (2003) Integra Life Science Corporation   7. Michaeli D, McPherson M (1990) Immunologic study of artificial skin used in the treatment thermal injuries. J Burn Care Rehabil 11:21

Chapter 17   1. Davis J (1941) The story of plastic surgery. Ann Surg 113:641–656   2. Pollock G (1871) Cases of skin grafting and skin transplantation. Trans Clin Soc Lond 4:37   3. Blair V, Brown J (1929) The use and uses of large split grafts of intermediate thickness. Surg Gynecol Obstet 49:82   4. Brown J, McDowell F (1949) Skin grafting. JB Lippincott, Philadelphia   5. Lee LF, Proch JV, Spenler W, Garner WL (2008) Integra in lower extremity reconstruction after burn injury. Plast Reconstr Surg 121:1256–1262   6. Figus A, Leon-Villapalos J, Philip B, Dziewulski P (2007) Severe multiple extensive postburn contractures: a simultaneous approach with total scar tissue excision and resurfacing with dermal regeneration template. J Burn Care Res 28: 913–917   7. Grube BJ, Engrav LH, Heimbach DM (1994) Early ambulation and discharge in 100 patients with burns of the foot treated by grafts. J Trauma 33:662–664

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Chapter 18

Chapter 20

  1. Luce EA (2000) The acute and subacute management of the burned hand. Clin Plast Surg 27(1):49–63   2. David Herandon N (2007) Total burn care, 3rd edn. Saunders Elsevier, London   3. Heimbach DM, Logsetty S (2000) Modern techniques for wound coverage of the thermally injured upper extremity. Hand Clin 16(2):205–214   4. Berger MM, Baines M, Raffoul W, Benathan M, Chiolero RL, Reeves C, Revelly JP, Cayeux MC, Senechaud I, Shenkin A (2007) Trace element supplementation after major burns modulates antioxidant status and clinical course by way of increased tissue trace element concentrations. Am J Clin Nutr 85(5):1293–1300   5. Berger MM, Raffoul W, Shenkin A (2008) ‘Practical guidelines for nutritional management of burn injury and recovery’ – a guideline based on expert opinion but not including RCTs. Burns 34:141–143   6. Dantzer E, Braye FM (2001) Reconstruction surgery using artificial dermis: results with 39 grafts. Br J Plast Surg 54:659–664   7. Dantzer E, Queruel P, Salinier L et al (2003) Dermal regeneration template for deep hand burns: clinical utility for early grafting and reconstructive surgery. Br J Surg 56:764–774   8. Vernez M, Raffoul W, Benathan M (2003) Treatment of burns with biological defined epidermal autograft. An ­experimental and clinical evaluation. Int J Atrif Organs 26(9):793–803   9. Betsi E, Benathan M, Raffoul W (2007) Autologus cell cultures in the surgical management of the hand in dystrophic epidermolysis bullosa. J Hand Surg 32 pp. 6 (Supp 1)

  1. Alexander JW, MacMillan BG, Martel L (1982) Correction of postburn syndactyly: an analysis of children with introduction of the VM-plasty and postoperative pressure inserts. Plast Reconstr Surg 70:345–352   2. Hirshowitz B, Karev A, Rousso M (1975) Combined double Z-plasty and Y-V advancement for thumb web contracture. Hand 7:291–293   3. Karacaoglan N, Uysal A (1994) The seven flap-plasty. Br J Plast Surg 47:372–374   4. Koyama H, Fujimori R (1982) V-W plasty. Ann Plast Surg 9:216–219   5. Suzuki S, Matsuda K, Nishimura Y (1996) Proposal for a new comprehensive classification of V-Y plasty and its analogues: The pros and cons of inverted versus ordinary Burow’s triangle excision. Plast Reconstr Surg 98: 1016–1022   6. Suzuki S, Um SC, Kim BM et al (1998) Versatility of modified planimetric Z-plasties in the treatment of scar with contracture. Br J Plast Surg 51:363–369   7. Roggendorf E (1982) Planimetric elongation of skin by Z-plasty. Plast Reconstr Surg 69:306–316   8. Roggendorf E (1983) The planimetric Z-plasty. Plast Reconstr Surg 71:834–842

Chapter 19   1. Wang XQ, Kempf M, Liu PY, Cuttle L, Chang HE, Kravchuk O, Mill J, Phillips GE, Kimble RM (2008) Conservative surgical debridement as a burn treatment: supporting evidence from a porcine burn model. Wound Repair Regen 16(6): 774–783   2. Rennekampff HO, Schaller HE, Wisser D, Tenenhaus M (2006) Debridement of burn wounds with a water jet surgical tool. Burns 32(1):64–69   3. Summers JB, Kaminski J (2003) Maggot debridement therapy (MDT) for burn wounds. Burns 29(5):501–502   4. Ozcan C, Ergün O, Celik A, Cördük N, Ozok G (2002) Enzymatic debridement of burn wound with collagenase in children with partial-thickness burns. Burns 28(8): 791–794   5. Hirai T, Hyakusoku H, Fumiiri M (1991) The use of a wire frame to fix grafts externally. Br J Plast Surg 44:69–70   6. Murakami M, Hyakusoku H, Ishimaru S (2003) External wire frame fixation of eyelid graft. Br J Plast Surg 56: 312–313   7. Ogawa R, Aoki S, Aoki M, Oki K, Hyakusoku H (2007) Three-dimensional external skin graft fixation of digital skin graft. Plast Reconstr Surg 119(1):440–442

Chapter 21   1. Mulliken JB, Martina-Perez D Churchill Livingstone (1999) The principle of rotation advancement for repair of unilateral complete cleft lip and nasal deformity. Plast Reconstr Surg 104(5):1247–1260   2. Macgregor AD (2000) Fundamental techniques of plastic surgery, 10th edn   3. Davis JS (1931) The relaxation of scar contracture by means of z-, or reversed z-type incision: stressing the use of scar infiltrated tissue. Ann Surg 94:871–884   4. Longacre JJ, Berry HK, Basom CR, Townsend SF (1976) The effects of Z-plasty on hypertrophic scars. Scand J Plast Reconstr Surg 10(2):113–128

Chapter 22   1. Achauer B (1991) Burn reconstruction, 1st edn. Thieme, Stuttgart, NY   2. Achauer B (1992) Reconstructing the burned face. Clin Plast Surg 19:623–636   3. Feldman J (1987) Secondary repair of the burned upper lip. Perspectives Plast Surg 1:31–72   4. Guo L, Pribaz JR, Pribaz JJ (2008) Nasal reconstruction with local flaps: a simple algorithm for management of small defects. Plast Reconstr Surg 122:130e–139e   5. Jackson I (2007) Local flaps in head and neck reconstruction, 2nd edn. Quality Medical, St. Louis   6. MacLennan SE, Corcoran JF, Neale HW (2000) Tissue expansion in head and neck burn reconstruction. Clin Plast Surg 27:121–132

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  7. Neale HW, Billmire DA, Carey JP (1986) Reconstruction following head and neck burns. Clin Plast Surg 13:119–136   8. Pribaz JJ, Meara JG, Wright S, Smith JD, Stephens W, Breuing KH (2000) Lip and vermilion reconstrucxtion with the facial artery musculomucosal flap. Plast Reconstr Surg 105:864–872

Chapter 23   1. Hyakusoku H, Shirai H, Umeda T, Fumiiri M (1985) Reconstruction of axillary scar contracture using the square flap method. Jpn J Plast Reconstr Surg 28:548–554   2. Hyakusoku H, Fumiiri M (1987) The square flap method. Br J Plast Surg 40:40–46   3. Ogawa R, Hyakusoku H, Murakami M, Koike S (2003) Reconstruction of axillary scar contractures-retrospective study on 124 cases during 25 years. Br J Plast Surg 56:100–105

Chapter 24   1. Hyakusoku H, Yamamoto T, Fumiiri M (1991) The propeller flap method. Br J Plast Surg 44:53–54   2. Murakami M, Hyakusoku H, Ogawa R (2005) The multilobed propeller flap method. Plast Reconstr Surg 116: 599–604   3. Murakami M, Hyakusoku H, Ogawa R (2005) The scar band rotation flap. Burns 31:220–222   4. Hyakusoku H, Iwakiri I, Murakami M, Ogawa R (2006) Central axis flap methods. Burns 32:891–896   5. Hyakusoku H, Ogawa R, Oki K, Ishii N (2007) The perforator pedicled propeller (PPP) flap method: a report of two cases. J Nippon Med Sch 74:367–371

Chapter 25   1. Fraulin F, Illmayaer S, Tredget E (1996) Assessment of cosmetic and functional results of conservative versus surgical management of facial burns. J Burn Care Rehabil 17:19–29   2. Cole JK, Engrav LH, Heimbach DM et al (2002) Early excision and grafting of face and neck burns in patients over 20 years. Plast Reconstr Surg 109:1266–1273   3. Gonzales-Ulloa (1957) Restoration of the face covering by means of selected skin in regional aesthetic units. Plast Recontr Surg 19:350   4. Hansbrough JF, Zapata-Sirvent R, Carroll WJ et  al (1984) Clinical experience with Biobrane biosynthetic dressing in the treatment of partial-thickness burns. Burns 10:415–419   5. Deitch EA, Wheelahan TM, Rose MP et  al (1983) Hypertrophic burn scars: analysis of variables. J Trauma 23:895–898   6. Ghahary A, Shen YJ, Scott PG et al (1993) Enhanced expression of mRNA for transforming growth factor alpha 1, type I and type III procollagen in human post-burn hypertrophic scar tissues. J Lab Clin Med 122:465–473

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Chapter 26   1. Spence RJ (2008) An algorithm for total and subtotal facial reconstruction using an expanded transposition flap: a twenty year experience. Plast Recon Surg 121(3):795–805   2. Spence RJ (2008) The challenge of reconstruction for severe facial burn deformity. Plast Surg Nurs 28(2):71–76; quiz 77–78   3. Spence RJ (2007) Expanded transposition flap technique for total and subtotal resurfacing of the face and neck. J. Burns Wounds 6:100–114. http://www.journalofburnsandwounds. com/volume06/jobw06e8.pdf

Chapter 27   1. Colson P, Janvier H (1966) Le degraissage primaire et total des lambeaux d’autoplastic a distance. Ann Chir Plast 11:11–20   2. Situ P (1986) Pedicled flap with subdermal vascular network. Acad J First Medical Coll PLA(Chinese) 6: 60   3. Koshima I, Higaki H, Kyou J, Yamasaki M (1989) Free or pedicled rectus abdominis muscle perforating artery flap. Jpn J Plast Reconstr Surg 32:715–719   4. Hyakusoku H, Pennington DG, Gao JH (1994) Microvascular augmentation of the super-thin occipito-cervico-dorsal lap. Br J Plast Surg 47:465–469   5. Ogawa R, Hyakusoku H, Murakami M, Aoki R, Tanuma K, Pennington DG (2002) An anatomical and clini-cal study of the dorsal intercostal cutaneous perforators – Its application to free microvascular augmented subdermal vascular network (ma-SVN) laps-. Br J Plast Surg 55: 396–401   6. Ogawa R, Hyakusoku H, Murakami M, Gao JH (2004) Clinical and basic research on occipito-cervico-dorsal flaps including a study of the anatomical territories of dorsal trunk vessels. Plast Reconstr Surg 113:1923–1933   7. Chin T, Ogawa R, Murakami M, Hyakusoku H (2005) An anatomical study and clinical cases of “super-thin laps” with transverse cervical perforator. Br J Plast Surg 58: 550–555   8. Zhang J, Wang C, Gui L et al (2008) The effect of expansion prefabrication on crossing area supply axial pattern flap: an experimental study on pigs. J Rep Reconstr Surg (Chinese) 5:554–557   9. Ogawa R, Hyakusoku H (2003) Color doppler ultrasonography in the planning of microvascular augmented super-thin (SVN: subdermal vascular network) flaps. Plast Reconstr Surg 112:822–828 10. Gao JH, Hyakusoku H, Inoue S et al (1994) Usefulness of narrow pedicled intercostal perforator flap for coverage of the burned hand. Burns 20:65–70

Chapter 28   1. Neumann CG (1957) The expansion of an area of skin by progressive distention of a subcutaneous balloon. Plast Reconstr Surg 19:124

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  2. Radovan C (1982) Breast reconstruction after mastectomy using the temporary expander. Plast Reconstr Surg 69:195   3. Radovan C (1984) Tissue expansion in soft tissue reconstruction. Plast Reconstr Surg 74:482   4. Argenta LC, Marks MW, Pasyk KA (1985) Advances in tissue expansion. Clin Plast Surg 12:159   5. Chun JT, Rodrich RJ (1998) Versatility of tissue expansion in head and neck reconstruction. Ann Plast Surg 40:226   6. Spence RJ (1992) Experience with novel uses of tissue expanders in burn reconstruction of the face and neck. Ann Plast Surg 28:453   7. Hallock GG (1987) Tissue expansion techniques in burn reconstruction. Ann Plast Surg 81:274   8. Borman H, Maral T, Demirhan B, Haberal M (1999) Skin flap survival after superficial and deep partial-thickness burn injury. Ann Plast Surg 43(5):513   9. Borman H, Maral T, Demirhan B, Haberal M (2000) Reliability of island flaps raised after superficial and deep burn injury. Ann Plast Surg 45(4):395 10. Spence RJ (2008) An algorithm for total and subtotal facial reconstruction using an expanded transposition flap: a 20-year experience. Plast Reconstr Surg 121(3):795 11. Gao JH, Ogawa R, Hyakusoku H, Lu F, Hu ZQ, Jiang P, Yang L, Feng C (2007) Reconstruction of the face and neck scar contractures using staged transfer of expanded “Superthin flaps”. Burns 33(6):760 12. Lu F, Gao JH, Ogawa R, Hykusoku H (2006) Preexpanded distant “super-thin” intercostal perforator flaps for facial reconstruction without the need for microsurgery. J Plast Reconstr Aesthet Surg 59(11):1203 13. Unlu RE, Sensöz O, Uysal AC (2001) Re: The use of serial tissue expansion in pediatric plastic surgery. Ann Plast Surg 47(6):679 14. Lozano S, Drucker M (2000) Use of tissue expanders with external ports. Ann Plast Surg 44(1):14 15. Hudson DA, Grob M (2005) Optimising results with tissue expansion: 10 simple rules for successful tissue expander insertion. Burns 31(1):1 16. Acarturk TO, Glaser DP, Newton ED (2004) Reconstruction of difficult wounds with tissue-expanded free flaps. Ann Plast Surg 52(5):493 17. Borman H, Deniz M, Bahar T et  al (2009) An alternative method of using an interpositional silicone sheet in tissue expansion. J Craniofac Surg 20(3):905

Chapter 29   1. Wells MD (2006) Scalp reconstruction. In: Mathes SJ (ed) Plastic surgery, 2nd edn. WB Saunders, Philadelphia   2. Nordström REA (1996) Tissue expansion. Butterworth Heinemann, Boston   3. Nordström REA (1984) “Stretch-back” in scalp reductions for male pattern baldness. Plast Reconstr Surg 73:422   4. Nordström REA, Devine JW (1985) Scalp stretching with a tissue expander for closure of scalp defects. Plast Reconstr Surg 75:578   5. Unger W, Nordtrom R (1988) Hair transplantation, 2nd edn. Marcel Dekker, New York



  6. Radovan C (1984) Tissue expansion in soft-tissue reconstruction. Plast Reconstr Surg 74:482   7. Argenta LC, Watanabe JJ, Grabb WC (1983) The use of tissue expansion in head and neck reconstruction. Ann Plast Surg 11:31   8. Fan J (1991) Tissue expansion. Ph.D. Thesis. Beijing Union Medical University, Beijing   9. McCauley RL, Oliphant JR, Robson MC (1990) Tissue expansion in the correction of burn alopecia: classification and methods of correction. Ann Plast Surg 25:103 10. Anderson RD (1993) The expanded “BAT” flap for treatment of male pattern baldness. Ann Plast Surg 31: 385–391 11. Wieslander JB (1991) Tissue expansion in the head and neck. A 6-year review. Scand J Plast Reconstr Surg Hand Surg 25(1):47–56 12. Fan J, Yang P (1997) Aesthetic reconstruction of burn alopecia by using expanded hair-bearing scalp flaps. Aesthetic Plast Surg 21:440–444

Chapter 30   1. Feldman JJ (1990) Facial burns. In: McCarthy JG (ed) Plastic surgery. WB Saunders, Philadelphia   2. Burget GC (2006) Aesthetic reconstruction of the nose. In: Mathes SJ (ed) Plastic surgery, 2nd edn. WB Saunders, Philadelphia   3. Adamson JG (1988) Nasal reconstruction with the expanded forehead flap. Plast Reconstr Surg 81:12–20   4. Fan J (2000) A new technique of scarless expanded forehead flap for reconstructive surgery. Plast Reconstr Surg 106: 777–785   5. Fan J, Liu Y, Liu L, Gan C (2009) Aesthetic pubic reconstruction after electrical burn by using a partial hair-bearing expanded free-forehead flap. Aesthetic Plast Surg 33:643–646   6. Fan J, Yang P (1997) Versatility of expanded forehead flaps for facial reconstruction. Scand J Plast Reconstr Hand Surg 31:357–363

Chapter 31   1. Tegtmeier RE, Gooding RA (1977) The use of a facial flap in ear reconstruction. Plast Reconstr Surg 60:406–411   2. Brent B, Byrd HS (1983) Secondary ear reconstruction with cartilage grafts covered by axial, random, and free flaps of temporoparietal fascia. Plast Reconstr Surg 72:141–151   3. Brent B, Upton J, Acland RD, Shaw WW, Finseth FJ, Rogers C, Pear RM, Hentz VR (1985) Experience with the temporoparietal fascial free flap. Plast Reconstr Surg 76: 177–188   4. Brent B (1992) Auricular repair with autogenous rib cartilage grafts: two decades of experience with 600 cases. Plast Reconstr Surg 90:355–374   5. Nagata S (1994) Secondary reconstruction for unfavorable microtia results utilizing temporoparietal and innominate fascia flaps. Plast Reconstr Surg 94:254–265

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  6. Park C, Lew D, Yoo W (1999) An analysis of 123 temporoparietal fascial flaps: anatomic and clinical considerations in total auricular reconstruction. Plast Reconstr Surg 104:1295–1306   7. Park C, Roh TS (2001) Total ear reconstruction in the devascularized temporoparietal region: I. Use of the contralateral temporoparietal fascial free flap. Plast Reconstr Surg 108: 1145–1153

Chapter 32   1. Yang JY, Chuang SS and Huang CY (2005) Burn epidemiology in Taiwan and Chang Gung Memorial Hospital (CGMH). Present at 3rd meeting of Asian Wound Healing Society, Singapore, Aug   2. Yang JY (2005) Reconstruction of axillary contractures. In: McCauley RL (ed) Functional and aesthetic reconstruction of burned patients, Chapt.27. Taylor & Francis, pp 367–378   3. Huang TT, Larson DL, Lewis SR (1977) Burn alopecia. Plast Reconstr Surg 60:763–767   4. Coleman III JJ, Matthew K (2006) Reconstruction of the burned scalp. In: Sood R (ed) Achauer and Sood’s burn surgery, reconstruction and rehabilitation, Chapt. 9. Saunders, pp 149–167   5. Buhrer DP, Huang TT, Yee HW et  al (1988) Treatment of burn alopecia with tissue expanders in children. Plast Reconstr Surg 81:512–515   6. Hudson DA, Lazarus D, Silfen R (2000) The use of serial tissue expansion in pediatric plastic surgery. Ann Plast Surg 45:589–593   7. Graravito E, McCauley RL (2005) Reconstruction of the burned scalp. In: McCauley RL (ed) Functional and aesthetic reconstruction of burned patients, Chapt.16. Taylor & Francis, pp 217–226   8. Dougherty WR, Spence RJ (2006) Reconstruction of the burned face/neck: acute and delayed. In: Sood R (ed) Achauer and Sood’s burn surgery, reconstruction and rehabilitation, Chapt. 14. Saunders, pp 234–253   9. Feldman J (1984) Reconstruction of the burned face in children. In: Serafin D, Georgiade NG (eds) Pediatric plastic surgery. CV Mosby, St. Louis, pp 552–632 10. Achauer BM (1991) Burn of the face. In: Achauer BM (ed) Burn reconstruction, Chapt. 3. Thieme, pp 23–30 11. Asuku ME, Ibrahim A, Ijekeye FO (2008) Post-burn axillary contractures in pediatric patients: a retrospective survey of management and outcome. Burns 34:412–417 12. Foley P, Jeeves A, Davey RB et al (2008) Breast burns are not benign: Long-term outcomes of burns to the breast in pre-pubertal girls. Burns 34(3):412–417 13. McCauley RL (2007) Reconstruction of the burned breast. In: Herndon DN (ed) Total burn care, 3rd edn, Chapt 57. Saunders, pp 741–748 14. Yang JY (2005) Reconstruction of chest contractures. In: McCauley RL (ed) Functional and aesthetic reconstruction of burned patients, Chapt.29. Taylor & Francis, pp 393–410 15. Huang T (2007) Overview of burn reconstruction. In: Herndon DN (ed) Total burn care, 3rd edn, Chapt. 52. Saunders, pp 674–686

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16. McCauley RL, Asuku ME (2006) Upper extremity burn reconstruction. In: Mathes’s plastic surgery, 2nd edn, Vol VII, Chapt. 186. Saunders, pp 605–646 17. Sood R, Brenner K, Achauer BM (2006) Reconstruction of he burned hand. In: Sood R (ed) Achauer and Sood’s burn surgery, reconstruction and rehabilitation, Chapt. 20. Saunders, pp 307–323 18. Salisbury RE, Bevin AG (1981) Burn syndactyly the “hourglass” procedure. In: Salisburn RE, Bevin AG (eds) Atlas of reconstructiove burn surgery, Chapt. 38. Saunders, pp 180–185 19. Tsai FC, Mardini S, Chen DJ, Yang JY et al (2006) The classification and treatment algorithm for post-burn cervical contractures reconstructed with free flaps. Burns 32:626–633 20. Wei FC, Celik N (2003) Perforator flap entity. Clin Plast Surg (Ed. Wei FC) 30(3):325–329 21. Yang JY, Tsai FC, Jagdeep Chana S, Chuang SS, Chang SY, Huang WC (2002) Use of the free thin anterolateral thigh Flaps combined with cervicoplasty for reconstruction of postburn anterior cervical contractures. Plast Reconstr Surg 110(1):39–46 22. Yang JY. Long-term follow-up of the burn face reconstruction using tissue expander. Presented at

Chapter 33   1. Shen T (1981) Vascular implantation into skin flap: experimental study and clinical application; a preliminary report. Plast Reconstr Surg 68:404–409   2. Hyakusoku H, Okubo M, Umeda T, Fumiiri M (1987) A prefabricated hair-bearing island flap for lip reconstruction. Br J Plast Surg 40:37–39   3. Mizuno H, Akaishi S, Kobe K, Hyakusoku H. Secondary vascularized hairy flap transfer for eyebrow reconstruction. J Plast Reconstr Aesthet Surg (in press)   4. Erol OO, Parsa FD, Spira M (1981) The use of secondary island graft-flap in reconstruction of the burned ear. Br Plast Surg 34:417   5. Wasio H (1971) An intestinal conduit for free transplantation of other tissues. Plast Reconstr Surg 48:48   6. Orticochea M (1971) A new method for total recon­ struction of the nose: the ears as donor areas. Br J Plast Surg 24: 225   7. Shintomi Y, Oura T (1982) The use of muscle vascularized pedicle flaps. Plast Reconstr Surg 70:725–732   8. Hyakusoku H (1993) Secondary vascularized hair-bearing island flaps for eye-braw reconstruction. Br J Plast Surg 46:45–47   9. Hirai T, Manders EK, Huges K, Oki K, Hyakusoku H (1996) Experimental study of allogenically vascularized prefabricated flaps. Ann Plast Surg 37:394–399 10. Ogawa R, Oki K, Hyakusoku H (2007) Vascular tissue engineering and vascularized 3D tissue regeneration. Regen Med 2:831–837

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Chapter 34   1. Costa H, Cunha C, Guimaraes I et al (1993) Prefabricated flaps for the head and neck: a preliminary report. Br J Plast Surg 46:223–227   2. Holle J, Vinzenz K, Wuringer E et al (1996) The prefabricated combined scapula flap for bony and soft-tissue reconstruction in maxillofacial defects–a new method. Plast Reconstr Surg 98:542–552   3. Khouri RK, Upton J, Shaw WW (1992) Principles of flap prefabrication. Clin Plast Surg 19:763–771   4. Lauer G, Schimming R, Gellrich NC et  al (2001) Prelaminating the fascial radial forearm flap by using tissueengineered mucosa: improvement of donor and recipient sites. Plast Reconstr Surg 108:1564–1572   5. Maitz PK, Pribaz JJ, Hergrueter CA (1996) Impact of tissue expansion on flap prefabrication: an experimental study in rabbits. Microsurgery 17:35–40   6. Parrett BM, Pomahac B, Orgill DP et al (2007) The role of free-tissue transfer for head and neck burn reconstruction. Plast Reconstr Surg 120:1871–1878   7. Pribaz JJ, Guo L (2003) Flap prefabrication and prelamination in head and neck reconstruction. Semin Plast Surg 17:351–362   8. Pribaz JJ, Fine N (1994) Prelamination: defining the prefabricated flap–a case report and review. Microsurgery 15: 618–623   9. Pribaz JJ, Fine NA (2001) Prefabricated and prelaminated flaps for head and neck reconstruction. Clin Plast Surg 28:261–272 10. Pribaz JJ, Maitz PK, Fine NA (1994) Flap prefabrication using the “vascular crane” principle: an experimental study and clinical application. Br J Plast Surg 47:250–256 11. Pribaz JJ, Fine N, Orgill DP (1999) Flap prefabrication in the head and neck: a 10-year experience. Plast Reconstr Surg 103:808–820 12. Pribaz JJ, Weiss DD, Mulliken JB et al (1999) Prelaminated free flap reconstruction of complex central facial defects. Plast Reconstr Surg 104:357–365 13. Rath T, Tairych GV, Frey M et  al (1999) Neuromucosal prelaminated flaps for reconstruction of intraoral lining defects after radical tumor resection. Plast Reconstr Surg 103: 821–828 14. Shen TY (1982) Microvascular transplantation of pre­ fabricated free thigh flap (Letter). Plast Reconstr Surg 69:568 15. Tark KC, Shaw WW (1996) The revascularization interface in flap prefabrication: a quantitative and morphologic study of the relationship between carrier size and surviving area. J Reconstr Microsurg 12:325–330

Chapter 35   1. Khouri RK, Ozbeck MR, Hruza GJ, Young VL (1996) Facial reconstruction with prefabricated induced expanded (PIE) supraclavicular skin flaps. Plast Reconstr Surg 95: 1007–1015



  2. Erol OO (1976) The transformation of a free skin graft into a vascularized pedicled flap. Plast Reconstr Surg 58: 470–477   3. Pribaz JJ, Fine N, Orgill DR (1999) Flap prefabrication in the head and neck: a 10 year experience. Plast Reconstr Surg 103:808–820   4. Téot L, Cherenfant E, Otman S, Giovannini UM (2000) Prefabricated vascularised supraclavicular flaps for face resurfacing after postburns scarring. Lancet 355(9216): 1695–1696

Chapter 36   1. Fumiiri M, Ishii K, Hyakusoku H et al (1981) Scarred flapincluding musculocutaneous vascular system. Jpn J PRS 24:470–475   2. Hyakusoku H, Ishii K, Fumiiri M (1983). The use of skin flaps containing scar tissue for extensive burn scar contractures. Transaction of the 8th IPRAS 8, pp 210–212   3. Hyakusoku H, Okubo M, Suenobu J, Fumiiri M (1986) Use of scarred flaps and secondary flaps for reconstructive surgery of extensive burns. Burns 12:470–474   4. Hyakusoku H, Tonegawa H, Fumiiri M (1994) Heel coverage with a T-shaped distally based sural island fasciocutaneous flap. Plast Reconstr Surg 93:872–876

Chapter 37   1. Tolhurst D, Haeseker B, Zeeman R (1983) The development of the fasciocutaneous flap. PRS 71:597–605   2. Cherup L, Zachary L, Gottlieb L, Petti C (1990) The radial forearm skin graft-Fascial Flap. PRS 85:898–902   3. Pribaz J, Pelham J (1994) Use of previously burned skin in local fasciocutaneous flaps for upper extremity reconstruction. Ann Plast Surg 33:272–280   4. Barret J, Herndon D, McCauley R (2002) Use of previously burned skin as random cutaneous local flaps in pediatric burn reconstruction. Burns 28:500–502   5. Hallock GG (1992) The random fasiocutaenous flap for upper extremity coverage. J Hand Surg 17A:93–101

Chapter 38   1. Lamberty BG (1979) The supra-clavicular axial patterned flap. Br J Plast Surg 32:207   2. Toldt C (1903) Anatomischer atlas, 3rd edn. Urban & Schwarzen­ berg, Berlin   3. Pallua N, Machens HG (1997) The fasciocutaneous supraclavicular artery island flap for releasing postburn mentosternal contractures. Plast Reconstr Surg 99:1878   4. Khouri RK, Ozbek MR, Hruza GJ, Young VL (1995) Facial reconstruction with prefabricated induced expanded (PIE) supraclavicular skin flaps. Plast Reconstr Surg 95:1007

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  5. Mizerny BR, Lessard ML, Black MJ (1995) Transverse cervical artery fasciocutaneous free flap for head and neck reconstruction: initial anatomic and dye studies. Otolaryngol Head Neck Surg 113:564   6. Pallua N, Magnus NE (2000) The tunneled supraclavicular island flap: an optimized technique for head and neck reconstruction. Plast Reconstr Surg 105:842   7. Teot L, Cherenfant E, Otman S, Giovannini UM (2000) Prefabricated vascularised supraclavicular flaps for face resurfacing after postburns scarring. Lancet 355:1695   8. Pallua N, von Heimburg D (2005) Pre-expanded ultra-thin supraclavicular flaps for (full-) face reconstruction with reduced donor-site morbidity and without the need for microsurgery. Plast Reconstr Surg 115(7):1837–1844   9. Vinh VQ, Ogawa R, Van Anh T, Hyakusoku H (2007) Reconstruction of neck scar contractures using supraclavicular flaps: retrospective study of 30 cases. Plast Reconstr Surg 119:130 10. Laredo Ortiz C, Valverde Carrasco A, Novo Torres A, Navarro Sempere L, Márquez Mendoza M (2007) Supraclavicular bilobed fasciocutaneous flap for postburn cervical contractures. Burns 33:770 11. Vu QV, Ogawa R, Tran VA, Hyakusoku H (2008) A case of neck scar contracture reconstructed using a pedicled supraclavicular flap. Plast Reconstr Surg 121:350 12. Pallua N, Demir E (2008) Postburn head and neck reconstruction in children with the fasciocutaneous supraclavicular artery island flap. Ann Plast Surg 60:276 13. Vinh VQ, Van Anh T, Ogawa R, Hyakusoku H (2009) Anatomical and clinical studies of the supraclavicular flap: analysis of 103 flaps used to reconstruct neck scar contractures. Plast Reconstr Surg 123(5):1471–1480

Chapter 39   1. Nakajima H, Fujino T (1984) Island fasciocutaneous flaps of the dorsal trunk and their application to myocutaneous flaps. Keio J Med 33:59–82   2. Hyakusoku H, Yoshida H, Okubo M et al (1990) Superficial artery skin flaps. Plast Reconstr Surg 86:33–38   3. Hyakusoku H, Takizawa Y, Murakami M (1993) Versatility of the free or pedicled superficial cervical artery skin flaps in head and neck burns. Burns 19:168–173   4. Ogawa R, Murakami M, Vinh VQ, Hyakusoku H (2006) Clinical and anatomical study of superficial cervical artery flaps: retrospective study of reconstructions with 41 flaps and the feasibility of harvesting them as perforator flaps. Plast Reconstr Surg 118(1):95–101   5. Hyakusoku H, Gao JH (1994) The “super-thin” flap. Br J Plast Surg 47(7):457–464

Chapter 40   1. Colson P, Janvier H (1966) Le degraissage primaire et total des lambeaux d’autoplastic a distance. Ann Chir Plast 11:11–20   2. Thomas CV (1980) Thin flaps. Plast Reconstr Surg 65: 747–752

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  3. Situ P (1986) Pedicled flap with subdermal vascular network. Acad J First Mil Med Coll PLA (Chinese) 6:60   4. Tsukada S (1980) Transfer of free skin grafts with a preserved subcutaneous vascular network. Ann Plast Surg 4:500–506   5. Hyakusoku H, Gao JH (1994) The “super-thin” flap. Br J Plast Surg 47:457–464   6. Hyakusoku H, Pennington DG, Gao JH (1994) Microvascular augmentation of the super-thin occipito-cervico-dorsal flap. Br J Plast Surg 47:465–469   7. Gao JH, Hyakusoku H, Aoki R et al (1999) An experimental study on the survival of random pattern flaps with a narrow skin pedicle in pigs; comparison of survival and blood supply in thick flaps with various pedicle widths. J Jpn Plast Reconstr Surg 19:553–559   8. Gao JH, Hyakusoku H, Aoki R et al (2000) A study of survival on random pattern flaps with narrow pedicle; comparison in the thinned flaps with various pedicle width and between thinned flap and conventional thick flaps. J Jpn Plast Reconstr Surg 20:233–238   9. Ogawa R, Hyakusoku H, Murakami M, Gao JH (2004) Clinical and basic research on occipito-cervico-dorsal flaps: including a study of the anatomical territories of dorsal trunk vessels. Plast Reconstr Surg 113(7):1923–1933 10. Chetboun A, Masquelet AC (2007) Experimental animal model proving the benefit of primary defatting of full-thickness random-pattern skin flaps by suppressing “perfusion steal”. Plast Reconstr Surg 120(6):1496–1502 11. Ogawa R, Hyakusoku H (2008) Flap thinning technique: the effect of primary flap defatting. Plast Reconstr Surg 122(3): 987–988 12. Ogawa R, Hyakusoku H, Murakami M (2003) Color Doppler ultrasonography in the planning of microvascular augmented “super-thin” flaps. Plast Reconstr Surg 112(3):822–828 13. Vinh VQ, Ogawa R, Iwakiri I, Hyakusoku H, Tanuma K (2007) Clinical and anatomical study of cervicopectoral superthin flaps. Plast Reconstr Surg 119(5):1464–1471

Chapter 41   1. Situ P (1986) Pedicled flap with subdermal vascular network. Acad J First Med Coll PLA (in Chinese) 6:60–61   2. Yang ZY, Chen BB, Huong YM et al (1991) The use of the pedicled over-thin flap of the acromiopectoral region in repair of face and neck. J Rep Reconstr Surg (in Chinese) 5:141–142   3. Yuan XB, Chen WP, Yang Y et al (1993) Experimental study of island super thin flap. Chin J Microsurg (in Chinese) 16:188–190   4. Gao JH, Hyakusoku H, Sato M et  al (1994) A analysis of transcutaneous gas and blood flow in narrow pedicled flap with subdermal vascular network. Chin J Microsurg (in Chinese) 17:248–250   5. Gao JH, Hyakusoku H, Akimoto M et al (1992) Experiences in using the super-thin flap. Jpn J Plast Reconstr Surg (in Japanese) 35:1097–1103   6. Hyakusoku H, Gao J-H (1994) The super thin flap. Br J Plast Surg 47:457–464

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  7. Hyakusoku H, Pennington DG, Gao JH (1994) Microvascular augmentation of the super-thin occipito-cervicodorsal flap. Br J Plast Surg 47:465   8. Lu F, Gao JH, Ogawa R, Hykusoku H (2006) Preexpanded distant super-thin intercostals perforator flaps for facial reconstruction without the need for microsurgery. J Plast Reconstr Surg 59:1203–1120

Chapter 42   1. Song YG, Chen GZ, Song YL (1984) The free thigh flap: a new free flap concept based on septocutaneous artery. Br J Plast Surg 37:149   2. Luo LS, Gao JH, Chen LF et al (1984) Clinical application of free anterolateral thigh flap. Di Yi Jun Yi Da Xue Bao 4(1):1–4 (Chinese)   3. Xu DC, Zhong SZ, Liu MZ et  al (1984) Anatomy of the anterolateral thigh flap. Lin Chuang Jie Pou Xue Za Zhi 2(3):158–160 (Chinese)   4. Gao JH, Luo LS, Chen LF et al (1984) The skin locations of the perforators of anterolateral thigh flap. Lin Chuang Jie Pou Xue Za Zhi 2(3):161–163 (Chinese)   5. Xu DC, Zhong SZ, Kong JM et al (1988) Applied anatomy of the anterolateral thigh flap. Plast Reconstr Surg 82:305   6. Zhou G, Qiao Q, Chen GY, Ling YC, Swift R (1991) Clinical experience and surgical anatomy of 32 free anterolateral thigh flap transplantations. Br J Plast Surg 44:91   7. Shimizu T, Fisher DR, Carmichael SW, Bite U (1997) An anatomic comparison of septocutaneous free flaps from the thigh region. Ann Plast Surg 38:604   8. Koshima I, Fukuda H, Utunomiya R, Soeda S (1989) The anterolateral thigh flap: variations in its vascular pedicle. Br J Plast Surg 42:260

Chapter 43   1. Chick RL, Lister GD, Sowder L (1992) Early free-flap coverage of electrical and thermal burns. Plast Reconstr Surg 89(6):1013   2. Shen T, Sun Y, Cao D et al (1988) The use of free-flaps in burn patients: experience with 70 flaps in 65 patients. Plast Reconstr Surg 81(3):352   3. Hunt JL, Purdue GF, Zbar RIS (2000) Burns: acute burns, burn surgery and postburn reconstruction. Sel Read Plast Surg 9(12):5   4. Borman H, Maral T, Demirhan B, Haberal M (1999) Skin flap survival after superficial and deep partial-thickness burn injury. Ann Plast Surg 43(5):513   5. Borman H, Maral T, Demirhan B, Haberal M (2000) Reliability of island flaps raised after superficial and deep burn injury. Ann Plast Surg 45(4):395   6. Sakallioglu AE, Haberal M (2007) Current approach to burn critical care. Minerva Med 98(5):569   7. Haberal M (2006) Guidelines for dealing with disasters involving large numbers of extensive burns. Burns 32(8):933   8. Haberal MA (1995) An eleven-year survey of electrical burn injuries. J Burn Care Rehabil 16(1):43



  9. Mathes SJ, Nahai F (1982) Clinical applications for muscle and musculocutaneous flaps. C Mosby, St Louis 10. Mathes SJ, Vasconez LO, Jurkiewicz MJ (1977) Extensions and further applications of muscle flap transposition. Plast Reconstr Surg 60:6 11. Gonzalez MH, Weinzweig N (2005) Muscle flaps in the treatment of osteomyelitis of the lower extremity. J Trauma 58(5):1019 12. Lai CS, Lin SD, Chou CK, Cheng YM (1991) Use of a cross-leg free muscle flap to reconstruct an extensive burn wound involving a lower extremity. Burns 17(6):510 13. Hagan KF, Buncke HJ, Gonzalez R (1982) Free lattisimus dorsi muscle flap coverage of an electrical burn of the lower extremity. Plast Reconstr Surg 69:125 14. May JW Jr, Lukash FN, Gallico GG 3rd (1981) Latissimus dorsi free muscle flap in lower-extremity reconstruction. Plast Reconstr Surg 68(4):603 15. Yucel A, Senyuva C, Aydin Y, Cinar C, Guzel Z (2000) Softtissue reconstruction of sole and heel defects with free tissue transfers. Ann Plast Surg 44(3):259 16. Bunkis J, Walton RL, Mathes SJ (1983) The rectus abdominis free flap for lower extremity reconstruction. Ann Plast Surg 11(5):373

Chapter 44   1. Achauer BM (1992) Reconstructing the burned face. Clin Plast Surg 19:623–636   2. Gonzalez-Ulloa M (1956) Restoration of the face covering by means of selected skin in regional aesthetic units. Br J Plast Surg 9:212–221   3. Feldman JJ (1987) Facial resurfacing. In: Brent B (ed) The artistry of plastic surgery. Mosby, St Louis   4. Rose EH, Norris MS (1990) The versatile temporoparietal fascial flap: adaptability to a variety of composite defects. Plast Reconstr Surg 85:224–232   5. Rose EH (1998) Prepatterned microsurgical tissue transfers for replacement of aesthetic facial units. In: Rose EH (ed) Aesthetic facial restoration. Lipincott-Raven, Philadelphia, NY   6. Rose EH (1995) Aesthetic restoration of the severely disfigured face in burn victims: a comprehensive strategy. Plast Reconstr Surg 96:1573–1585   7. Hyakusoku H, Pennington DG, Gao JH (1994) Microvascular augmentation of the super-thin occipito-cervico-dorsal flap. Br J Plast Surg 47:465–469   8. Ogawa R, Hyakusoku H, Murakami M, Aoki R, Tanuma K, Pennington DG (2002) An anatomical and clinical study of the dorsal intercostal cutaneous perforators – its application to free microvascular augmented subdermal vascular network (ma-SVN) flaps. Br J Plast Surg 55:396–401   9. Yang JY, Tsai FC, Chana JS, Chuang SS, Chang SY, Huang WC (2002) Use of free thin anterolateral thigh flaps ­combined with cervicoplasty for reconstruction of postburn anterior cervical contractures. Plast Reconstr Surg 110: 39–46 10. Chin T, Ogawa R, Murakami M, Hyakusoku H (2005) An anatomical study and clinical cases of “super-thin flaps” with transverse cervical perforator. Br J Plast Surg 58: 550–555

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492

11. Mun GH, Jeon BJ, Lim SY, Hyon WS, Bang SI, Oh KS (2007) Reconstruction of postburn neck contractures using free thin thoracodorsal artery perforator flaps with cervicoplasty. Plast Reconstr Surg 120:1524–1532 12. Gao JH, Ogawa R, Hyakusoku H, Lu F, Hu ZQ, Jiang P, Yang L, Feng C (2007) Reconstruction of the face and neck scar contractures using staged transfer of expanded “superthin flaps”. Burns 33:760–763 13. Vinh VQ, Ogawa R, Iwakiri I, Hyakusoku H, Tanuma K (2007) Clinical and anatomical study of cervicopectoral superthin flaps. Plast Reconstr Surg 119:1464–1471

Chapter 45   1. Bakamjian VY (1965) A two stage method for pharyngoesophageal reconstruction with a primary pectoral skin flap. Plast Reconstr Surg 36:173–184   2. Harii K, Ohmori K, Ohmori S (1974) Free deltopectoral skin flaps. Brit J Plast Surg 27:231–239   3. Taylor GI, Daniel RK (1975) The anatomy of several free flap donor site. Plast Reconstr Surg 56:243–253   4. Daniel RK, Cuningham DM, Taylor GI (1975) The deltopectoral flap: an anatomical and hemodynamic approach. Plast Reconstr Surg 55:275–282   5. Sasaki K, Nozaki M, Honda T, Morioka K, Kikuchi U, Huang T (2001) The deltopectoral skin flap as a free flap revisited: further refinement in flap designing and fabri­ cation, and in clinical usage. Plast Reconstr Surg 107: 1134–1141   6. Sasaki K, Nozaki M, Honda T, Morioka K, Kikuchi U, Huang T (2009) The deltopectoral skin flap as a free flap revisited: further refinement in flap designing and fabrication, and in clinical usage. In: Berish Strauch, Luis O Vasconez (eds) Grabb’s encyclopedia of flaps, 3rd edn, vol 1 Head and neck, Chapter 125. Wolters Kluwer/Lippincott Wiliams & Wilkins, Philadelphia, pp 354–356

Chapter 46   1. Yang G, Chen B, Gao Y (1981) The forearm free skin flap transplantation. Natl Med J China 61:139   2. Kenney JG, DiMercurio S, Angel M (1990) Tissue-expanded radial forearm free flap in neck burn contracture. J Burn Care Rehabil 11:443   3. Weinzweig N, Chen L, Chen ZW (1994) The distally based radial forearm fasciosubcutaneous flap with preservation of the radial artery: an anatomic and clinical approach. Plast Reconstr Surg 94:675   4. Koshima I, Moriguchi T, Etoh H, Tsuda K, Tanaka H (1995) The radial artery perforator-based adipofascial flap for dorsal hand coverage. Ann Plast Surg 35:474   5. Safak T, Akyürek M (2000) Free transfer of the radial forearm flap with preservation of the radial artery. Ann Plast Surg 45:97   6. Koshima I, Tsutsui T, Nanba Y, Takahashi Y, Akisada K (2002) Free radial forearm osteocutaneous perforator flap

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for reconstruction of total nasal defects. J Reconstr Microsurg 18:585   7. Mateev M, Beermanov K, Subanova L, Novikova T (2004) Reconstruction of soft tissue defects of the hand using the shape-modified radial forearm flap. Scand J Plast Reconstr Surg Hand Surg 38:228   8. Mateev MA, Beermanov KA, Subanova LK, Novikova TV, Shaltakova G (2005) Shape-modified method using the radial forearm perforator flap for reconstruction of soft-tissue defects of the scalp. J Reconstr Microsurg 21:21   9. Mateev MA, Ogawa R, Trunov L, Moldobaeva N, Hyakusoku H (2009) Shape-modified radial artery perforator flap method: analysis of 112 cases. Plast Reconstr Surg 123(5): 1533–1543 10. Yang D, Morris SF (2006) Radial artery perforator flap. In: Blondeel PN, Hallock GG, Morris SF and Neligan PC (eds) Perforator flaps. Quality Medical, St Louis, pp 301–317

Chapter 47   1. Song R, Song Y, Yu Y, Song Y (1982) The upper arm free flap. Clin Plast Surg 9:27–35   2. Soutar DS, Tanner NSB (1984) The radial forearm flap in the management of soft tissue injuries of the hand. Br J Plast Surg 37:18–26   3. Foucher G, Genechten F, Merle N, Michon J (1984) A compound radial artery forearm flap in hand surgery: an original modification of the Chinese forearm flap. Br J Plast Surg 37:139–148   4. Penteado CV, Masquelet AC, Chevrel JP (1986) The anatomic basis of the fasciocutaneous flap of the posterior interosseous artery. Surg Radiol Anat 8:209–215   5. Jones BM, O’Brien CJ (1985) Acute ischaemia of the hand resulting from elevation of a radial forearm flap. Br J Plast Surg 38:396–397   6. Koshima I, Moriguchi T, Etoh H, Tsuda K, Tanaka H (1995) The radial artery perforator-based adipofascial flap for dorsal hand coverage. Ann Plast Surg 35:474–479

Chapter 48   1. Kimura N, Satoh K (1996) Consideration of the thin flap as an entity and clinical applications of the thin anterolateral thigh flap. Plast Reconstr Surg 97:985–992   2. Kimura N, Satoh K, Hasumi T, Otuka T (2001) Clinical application of the free thin anterolateral thigh flap in 31 consecutive patients. Plast Reconstr Surg 108:1197–1208   3. Kimura N (2002) A microdissected thin tensor fasciae latae perforator flap. Plast Reconstr Surg 109:69–77   4. Kimura N, Satoh K, Hosaka Y (2003) Microdissected thin perforator flaps: 46 cases. Plast Reconstr Surg 112: 1875–1885   5. Kimura N, Saitoh M (2006) Free microdissected thin groin flap design with an extended vascular pedicle. Plast Reconstr Surg 117:986–992   6. Kimura N, Saitoh M, Sumiya N, Itoh Y (2009) Clinical application and refinement of the microdissected thin groin

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flap transfer operation. J Plast Reconstr Aesthet Surg 62: 1510-1516   7. Kimura N, Saitoh M, Itoh Y, Sumiya N (2006) Giant combined microdissected thin thigh perforator flap. J Plast Reconstr Aesthet Surg 59:1352–1359   8. Kimura N, Saitoh M, Itoh Y, Sumiya N (2008) A comprehensive protocol of general burn treatment with microdissected thin flaps – a preliminary report. Eur J Plast Surg 31: 213–217   9. Kimura N, Saitoh M, Sumiya N, Itoh Y (2008) Reconstruction of the hand skin defects by microdissected mini anterolateral thigh perforator flaps. J Plast Reconstr Aesthet Surg 61: 1073–1077 10. Kimura N, Saitoh M, Okamura T, Hirata Y, Itoh Y, Sumiya N Concept and anatomical basis of Microdissected tailoring method for free flap transfer-. Plast Reconstr Surg 123: 152-62, 2009.

Chapter 49   1. Hyakusoku H, Yamamoto T, Fumiiri M (1991) The propeller flap method. Br J Plast Surg 44:53–54   2. Hyakusoku H, Iwakiri I, Murakami M, Ogawa R (2006) Central axis flap methods. Burns 32:891–896   3. Hallock GG (2006) The propeller flap version of the adductor muscle perforator flap for coverage of ischial or trochanteric pressure sores. Ann Plast Surg 56(5):540–542   4. Moscatiello F, Masià J, Carrera A, Clavero JA, Larrañaga JR, Pons G (2007) The ‘propeller’ distal anteromedial thigh perforator flap. Anatomic study and clinical applications. J Plast Reconstr Aesthet Surg 60(12):1323–1330   5. Hyakusoku H, Ogawa R, Oki K, Ishii N (2007) The perforator pedicled propeller (PPP) flap method: a report of two cases. J Nippon Med Sch 74:367–371   6. Jakubietz RG, Jakubietz MG, Gruenert JG, Kloss DF (2007) The 180-degree perforator-based propeller flap for soft tissue coverage of the distal, lower extremity: a new method to achieve reliable coverage of the distal lower extremity with a local, fasciocutaneous perforator flap. Ann Plast Surg 59(6):667–671   7. Wong CH, Cui F, Tan BK, Liu Z, Lee HP, Lu C, Foo CL, Song C (2007) Nonlinear finite element simulations to elucidate the determinants of perforator patency in propeller flaps. Ann Plast Surg 59(6):672–678   8. Pignatti M, Pasqualini M, Governa M, Bruti M, Rigotti G (2008) Propeller flaps for leg reconstruction. J Plast Reconstr Aesthet Surg 61(7):777–783   9. Rubino C, Figus A, Mazzocchi M, Dessy LA, Martano A (2008) The propeller flap for chronic osteomyelitis of the lower extremities: a case report. J Plast Reconstr Aesthet Surg 10. Schonauer F, La Rusca I, Di Monta G, Molea G (2008) Choosing the correct sense of rotation in 180 degrees propeller flaps. J Plast Reconstr Aesthet Surg 61(12):1492 11. Rad AN, Singh NK, Rosson GD (2008) Peritoneal artery perforator-based propeller flap reconstruction of the lateral distal lower extremity after tumor extirpation: case report and literature review. Microsurgery 28(8):663–670



Chapter 50   1. Ogawa R, Hyakusoku H, Murakami M, Aoki R, Tanuma K, Pennington DG (2002) An anatomical and clinical study of the dorsal intercostal cutaneous perforators, and application to free microvascular augmented subdermal vascular network (ma-SVN) flaps. Br J Plast Surg 55(5):396–401   2. Hyakusoku H, Gao JH, Pennington DG, Aoki R, Murakami M, Ogawa R (2002) The microvascular augmented subdermal vascular network (ma-SVN) flap: its variations and recent development in using intercostal perforators. Br J Plast Surg 55(5):402–411   3. Ogawa R, Hyakusoku H, Murakami M (2003) Color Doppler ultrasonography in the planning of microvascular augmented “super-thin” flaps. Plast Reconstr Surg 112(3):822–828   4. Ogawa R, Hyakusoku H, Iwakiri I, Akaishi S (2004) Severe neck scar contracture reconstructed with a ninth dorsal intercostal perforator augmented “super-thin flap”. Ann Plast Surg 52(2):216–219   5. Ogawa R, Hyakusoku H (2004) Bipedicled free super-thin flap harvesting from the anterior chest. Plast Reconstr Surg 113(4):1299–1300   6. Ogawa R, Hyakusoku H, Murakami M, Gao JH (2004) Clinical and basic research on occipito-cervico-dorsal flaps: including a study of the anatomical territories of dorsal trunk vessels. Plast Reconstr Surg 113(7):1923–1933   7. Chin T, Ogawa R, Murakami M, Hyakusoku H (2005) An anatomical study and clinical cases of ‘super-thin flaps’ with transverse cervical perforator. Br J Plast Surg 58(4): 550–555   8. Vinh VQ, Ogawa R, Iwakiri I, Hyakusoku H, Tanuma K (2007) Clinical and anatomical study of cervicopectoral superthin flaps. Plast Reconstr Surg 119(5):1464–1471   9. Gao JH, Ogawa R, Hyakusoku H, Lu F, Hu ZQ, Jiang P, Yang L, Feng C (2007) Reconstruction of the face and neck scar contractures using staged transfer of expanded “superthin flaps”. Burns 33(6):760–763 10. Ono S, Hyakusoku H, Ogawa R, Oki K, Hayashi H, Kumita S (2008) Usefulness of multidetector-row computed tomography in the planning and postoperative assessment of perforator flaps. J Nippon Med Sch 75(1):50–52

Chapter 51   1. Hyakusoku H, Gao JH (1994) The “super-thin” flap. Br J Plast Surg 47:457–464   2. Hyakusoku H, Pennington DG, Gao JH (1994) Microvascular augmentation of the super-thin occipito-cervicodorsal flap. Br J Plast Surg 47:465–469   3. Hyakusoku H, Gao JH, Pennington DG, Aoki R, Murakami M, Ogawa R (2002) The microvascular augmented subdermal vascular network (ma-SVN) flap: its variations and recent development in using intercostal perforators. Br J Plast Surg 55(5):402–411   4. Ogawa R, Hyakusoku H, Murakami M, Aoki R, Tanuma K, Pennington DG (2002) An anatomical and clinical study of the dorsal intercostal cutaneous perforators – its application

493

Index

A Acellular matrix, 100–107 Acentric axis, 442 Acentric propeller flap, 442, 443 Acticoat®, 138 Adipofascial flap, 409, 428–433 Adipose tissue, 40, 357, 434 ADM. See Allogeneic dermal matrix Advancement flap, 164, 178, 181, 183, 186, 214, 250, 251, 256, 275, 279, 281, 408, 442 Aesthetic unit, 13, 47, 115, 208, 220–224, 240, 279, 398, 406, 470, 472 Alloderm™, 91 Allogeneic dermal matrix (ADM), 100–107 Allograft, 113 Allotransplantation, 100–103, 106, 107 Alopecia, 118, 181, 183, 242, 245, 250–259, 275, 277 ALT flap. See Anterolateral thigh flap Angiogenesis, 90, 302 Angiography, 338, 342 Ankle joint, 45, 57, 326, 328, 390, 391, 394, 395 Ankylosis, 44, 332, 333 Anterior chest, 45, 53, 80, 360 Anterior interosseous artery, 428, 429 Anterolateral thigh (ALT) flap, 304, 305, 336, 337, 378–387, 434, 436 Antibiotic, 10, 38, 240 Artificial dermis, 7, 8 Autoadhesive rubber, 141 Autograft, 112, 130, 216 Axial pattern flap, 320, 368, 369 Axilla, 25, 45, 52, 128, 137, 186, 190, 198, 202, 206, 280–282, 286, 435, 442 B Bacteria, 10, 11, 17, 22, 23, 106, 108, 146, 209 Band contracture, 285 Bandage, 10, 38, 79, 141, 142, 146, 429 Basic fibroblast growth factor (bFGF), 62, 63 Betadine®, 32 bFGF. See Basic fibroblast growth factor Bilateral contracture, 53 Biobrane™, 12, 13, 34, 208, 210, 212 Biomaterial, 41 Blister, 3–6, 10–13 Bone marrow, 40, 41



Branch, 180, 230, 234, 260, 262, 271, 285, 301, 302, 304, 344, 374, 379, 382, 383, 406, 409, 428–430, 434, 440 Broadband contracture, 51, 52, 54–58 Buttock, 2, 30, 64, 138 C Camoflage, 77, 81, 399, 401 Carbon dioxide (CO2) laser, 72, 74 Carboxymethylcellulose, 6 Cartilage, 44, 46, 154, 179, 262, 270–272, 274, 288, 300, 302, 306, 308, 309, 398, 409, 471 Central axis flap, 198–207 Central contracture, 53 Cervico-pectral (CP) flap, 360 Cheek flap, 223, 224, 260 Chin, 48, 86, 176, 179, 181, 182, 224, 292, 296, 314, 316, 342, 362, 364, 402–405, 414, 415, 454, 462, 464 Circumflex scapular vessel (CSV), 344, 352, 402, 454, 456, 470 Collagen, 22, 64, 65, 72–75, 90, 91, 106–108, 172, 174 Collagenase, Color Doppler ultrasonography, 442 Commissure, 47, 172, 178, 181, 312, 314, 400, 406, 407 Compression, 76, 77, 140–142, 144 Contracture, 5, 12, 25, 26, 38, 44, 76, 94, 108, 119, 132, 150, 160, 172, 178, 186, 198, 209, 220, 230, 276, 296, 300, 322, 330, 338, 344, 357, 372, 386, 398, 414, 416, 436, 450, 452, 462, 472 Corticosteroid, 76–78, 81 CP flap. See Cervico-pectral flap Cream, 6, 75, 82, 140 Cross-leg flap, 328 CSV. See Circumflex scapular vessel CT, 434 Cubital fossa, 51, 186, 204 Cubital joint, 45, 51 D DB. See Deep burn DDB. See Deep dermal burn Debridement, 6, 7, 10–14, 27, 64, 65, 68, 69, 116, 141, 144, 146, 147, 209, 258, 281, 308, 366, 388, 391, 394, 396, 397, 416, 432, 446

495

496 Debris, 10, 13, 23, 27, 146, 208, 209 Debulking, 304, 357, 398, 401–407, 452 Deep burn (DB), 2, 4, 8, 9, 12, 102, 140, 280, 428, 448 Deep dermal burn (DDB), 66, 80, 208, 209, 212, 320, 430, 431, 446 Deep inferior epigastric artery, 390, 394 Deep inferior epigastric artery perforator (DIEAP, DIEP) flap, 368, 434, 436 Defatting, 314, 408, 410, 412, 460, 462, 471 Delayed flap, 259 Deltopectral (DP) flap, 410–415 Depigmentation, 412 Dermabrasion, 32, 36, 72, 73, 209, 212, 226 Dermal substitute (DS), 8, 9, 12, 90–98, 100, 142, 143 Dermis, 3–8, 13, 14, 26–28, 30, 38, 39, 62–64, 68, 69, 72–74, 90, 91, 100, 101, 132, 133, 137, 153, 208, 400 Descending, 230, 234, 285, 301, 302, 304, 378, 379, 382, 383, 429 Diabetes, 63, 342 Digit, 19, 49, 58, 59, 96, 134, 137, 336 Digital joint, 45, 49, 146 Digital web, 45, 49, 196 DIP, 49, 58 Distally-based flap, 329, 330 Distant flap, 49, 50, 84, 250, 366, 368, 370, 408 DMEM. See Dulbecco's modified Eagle's medium Doppler ultrasound, 271, 274, 320, 331, 444 Dorsal intercostal perforator (D-ICAP, DICP), 354, 454, 458, 462 Dorsal pedis artery, 450 DP flap. See Deltopectral flap DS. See Dermal substitute Dulbecco's modified Eagle's medium (DMEM), 101 E Ear, 45, 60, 137, 155, 214, 240, 270–275, 279, 398, 399 EB. See Epidermal burn Edema, 3, 11, 16, 17, 21, 82, 140, 302, 314, 316 EDTA, 100, 101 Embryonic stem cell, 41 End-to-end anastomosis, 390, 393, 396 End-to-side anastomosis, 389, 390, 393, 396 Epidermal burn (EB), 320 Epidermis, 3, 5, 22, 26, 28, 30, 39, 40, 62, 72–74, 92, 100, 101, 106 Epithelial necrosis, 356, 362 Epithelisation, 27 Escarotomy, 34, 140 Eschar, 4, 11, 13, 14, 146, 390 Expanded flap, 76, 79, 178, 220–242, 246, 248, 250, 251, 255–261, 265–269, 279, 280, 368, 416, 464 Extensor carpi radialis, 428 Extensor carpi radialis brevis, 428 Extensor carpi ulnaris, 428, 429 Extensor digiti minimi, 428, 429 Extensor digitorum, 428 Extensor pollitis longus, 428 External agents, 77, 81 External wire-frame, 146–148, 150, 151, 153–155, 157 Eyebrow, 83, 84, 181, 276, 279, 290, 294, 298, 312

Index Eyelid, 14, 46, 82–84, 120, 137, 146, 150, 151, 178, 179, 181, 221–223, 240, 294, 312, 399, 404 F Fascia, 13, 14, 28, 46, 230, 289, 300–302, 304, 331, 338, 400, 404–407, 429, 433, 434, 471, 473 Fascial excision, 12–14, 326 Fascial flap, 143, 270–272, 274, 310, 312, 330, 409, 428, 448, 450, 470 Fat, 12, 64, 73, 141, 156, 181, 271, 316, 330, 344, 357, 368, 428, 432, 434, 452, 462, 464, 468, 471 FEA. See Finite element method Fibroblast, 73 Fibromodulin, 40 Finite element method (FEA), 186, 188 Fixomull®, 32 Flammacerium, 7, 8 Flying-wing, 250 Foam, 7, 22 Forearm, 2, 50, 51, 66, 67, 137, 183, 216, 248, 249, 262, 302, 308, 309, 330, 331, 334, 399, 404, 405, 416, 417, 428–430, 432, 448 Forehead flap, 175, 179, 181, 260–262, 265–269, 302 Foundation, 82–83, 88, 276 Free flap, 113, 398–407, 470–477 Full thickness skin graft, 122, 132–133, 152, 154, 224, 432, 436, 466, 468 G Galea, 251, 252, 298 Gammagraft™, 91 Gauze, 6, 23, 32, 63, 66, 70, 74, 138, 141 Gel sheet, 76, 77, 80 Gelpi retractor, 434 Genital, 2, 45, 60 Gliaderm™, 91 Gore-tex®, 300, 301, 304 Grafting, 7–9, 64, 68, 77, 128, 132–138, 146–157, 174, 196, 204, 216, 298, 362, 388–390, 406, 410, 414, 454, 458, 464, 472 Groin flap, 49, 50, 224, 271, 272, 274, 432–434, 440 H Hair, 5, 52, 133, 178, 190, 202, 250, 276–279, 288, 300, 399 Hair-bearing flap, 181, 184, 251, 252, 253, 254, 255, 256, 258, 259, 278, 290, 292, 302, 308, 309 Hairline, 181, 184, 262, 264, 266, 268, 271 Hairy flap, 288, 292, 298 Hand, 3, 12–13, 17, 27, 76, 83, 90, 116, 118, 133, 140–144, 146, 208, 230, 276, 330, 357, 370, 416–433, 435 Head and neck, 96, 115, 118, 208, 216, 240, 276, 300, 301, 302, 304, 374, 378 Helical crus, 270, 272 Hematoma, 94, 108, 133, 146, 357 Hemilateral contracture, 53 Hormone, 72 Hyalomatrix 3D™, 90 Hyaluronic acid, 40

Index Hydrocision, 209 Hydrofiber, 6, 140, 141 Hyperhydration, 140 Hypertrophic scar, 10, 26, 32, 38, 40, 62, 76–81, 114, 118, 132, 133, 135, 162, 163, 166, 167, 172, 174, 220, 224, 232, 234, 236, 278, 285, 316, 340, 342, 358, 364, 372, 373, 374, 375, 464 I Implant, 41, 108, 230, 236, 240, 262, 276, 279, 282, 283, 288, 292, 296, 300–302, 402, 403, 404, 405 Infection, 5, 10, 16, 22, 23, 27, 62, 63, 68, 90, 94, 98, 105, 118, 138, 208, 209, 240, 250, 258, 346, 379, 388 Inflammatory cell, 38, 62 Inguinal, 45, 55, 79, 134, 137 Integra®, 8, 22–25, 27, 34, 90, 91, 94, 98, 108–116, 119, 124, 126, 128, 130, 137 Intercostal perforator, 298, 344, 354–355, 366, 370, 371, 454–455, 458–159, 460–462 Internal agents, 81 Irrigation, Ischemia, 4, 16, 17, 118 Island flap, 181, 184, 198, 260, 262, 264, 266, 268, 276, 280, 282, 290, 294, 296, 298, 338–340, 342, 344, 428, 442, 468 J Jelonet®, 32 K Keloid, 62, 74, 76, 400, 404–407 Kenzan, 79, 146 Keratinocyte, 8, 12, 14, 26, 38, 39, 62, 73, 101, 103, 144 Kirshner-wire, 154, 450 Knee joint, 45, 56, 390, 391 L Laser, 72, 74, 80–81, 141, 399, 401–407 Lateral circumflex femoral artery (LCFA), 378, 379, 382, 383 Lateral femoral circumflex vessel, 301, 304, 306 Lateral thoracic artery perforator (LTAP), 339 LCFA. See Lateral circumflex femoral artery Linear contracture, 48–51, 54–58 Lining, 179, 261, 262, 266, 300, 302, 306, 308, 309 Lip deformity, 412, 413 Local flap, 46–52, 54–59, 79, 132, 178–184, 186, 250, 260, 279, 285, 302, 320, 330–337, 398 Low computed tomography (MD-CT), 320, 442, 452 Lower leg, 56, 57 LTAP. See Lateral thoracic artery perforator Lumbar, 45, 54 M Macrophages, 62 Make-up therapy, 81–88 Mandible skin flap, 232 Massage, 32, 82, 83, 88 Matriderm™, 8, 12, 90, 91, 92, 96, 98, 143 Mentum, 86

497 Mesenchymal stem cells (MSCs), 41 Mesh graft, 7, 8, 26, 64, 119, 132–137, 328 Meshed graft, 27, 30, 34, 100, 137, 302, 350, 394, 440, 456, 458, 464, 474 Metacarpal joints (MPs), 284 Metal sponge, 146, 147 Microdissected thin flap, 434–441 Microvascular flap, 118, 398, 410, 412, 414 Moisturization, 212 MPP flap. See Muscle pedicled propeller flap MPs. See Metacarpal joints MSCs. See Mesenchymal stem cells MTP, 45, 58 Multi-modal therapy, 76, 78, 81 Multidetector, 442 Multilobed propeller flap, 198–199 Muscle, 13, 44, 96, 272, 301, 312, 326, 330, 338, 344, 378, 388–398, 409, 416, 428, 443, 470 Muscle flap, 344, 388–397 Muscle pedicled propeller (MPP) flap, 442 Muscle perforator, 388 Musculocutaneous flap, 108, 320, 322, 326, 344, 350–351, 378, 380, 409 N Nasolabial flap, 178, 260 Nasolabial fold, 181, 183, 208, 268 Nd: YAG laser, 80 Neck, 11, 48, 70, 94, 118, 135, 176–178, 186, 192–193, 208, 220–230, 240, 272, 276, 299, 300, 311, 332, 339, 344, 360, 372, 378, 399, 412, 435, 446, 452, 462, 470–477 Needling, 72–75 Negative pressure wound therapy (NPWT), 22–23 Neodermis, 22, 90, 108–111, 114, 115, 116 Nerve, 251, 312, 330, 344, 379, 428, 429, 432, 436 Nipple, 53, 280, 282, 283, 409 Non-steroidal antiinflammatory drugs (NSAIDs), 81 Nonmeshed skin graft, 141, 143, 144 Nose, 45, 60, 179, 181, 183, 209, 232, 260, 262, 264, 266, 279, 300, 306, 308, 310, 312, 399 NPWT. See Negative pressure wound therapy NSAIDs. See Non-steroidal antiinflammatory drugs O Occipital artery, 252, 271, 356, 372 Occipito-cervico-dorsal (OCD) flap, 357, 362, 462–464, 466, 468 Occipito-cervico-pectral (OCP) flap, 356, 357, 364 Occipito-cervico-shoulder (OCS) flap, 357, 372, 373 Occlusive dressing, 22, 208, 209 OCD flap. See Occipito-cervico-dorsal flap OCP flap. See Occipito-cervico-pectral flap OCS flap. See Occipito-cervico-shoulder flap Op-Site®, 138 P Pain, 3, 6, 7, 23, 25, 76, 79, 80, 82, 138, 141, 209, 240, 246 Palmar, 3, 12, 45, 49, 50, 147, 170, 336 Parascapular flap, 280, 282, 285, 470

498 PDGF. See Platelet derived growth factor PDL. See Pulsed dye laser Pectral intercostal perforator (P-ICAP, PICP), 370, 371, 460 Pedicled flap, 47, 51, 56, 264, 266, 288, 306, 344, 346–351, 366, 416, 442–452 Perforator, 48, 198, 230, 285, 298, 338, 344, 356, 368, 378, 388, 416, 428, 434, 442, 452, 462 Perforator pedicled propeller (PPP) flap, 442–451 Perforator-based flap, 416, 428–433 Perforator-supercharged (PS) propeller flap, 442 Perioral, 45, 47 Periorbital, 45, 46 Pigmentation, 36, 92, 106, 220, 412 PIPs. See Proximal phalanx joints Planimetric Z-plasty, 160, 166 Plantar, 4, 9, 45, 57, 59, 450 Platelet derived growth factor (PDGF), 73 Platysma, 48 Postauricular artery, 254 Posterior interosseous flap, 330, 428, 429 Posterior occipital vein, 272, 273 PPP flap. See Perforator pedicled propeller Preexpanded flap, 368 Prefabricated flap, 47, 230, 236, 288, 300–317, 368 Prelaminated flap, 300–309 Preserved subdermal vascular network full-thickness skin graft (PSVN), 356 Propeller flap, 51, 56, 198–207, 354, 420, 442–451 Proximal phalanx joints (PIPs), 45, 49, 58, 284, 330 Proximally-based flap, 330 Pulsed dye laser (PDL), 80 R Radial artery, 302, 310, 416–433, 436, 448–449 Radiation, 76, 77 RAM free flap. See Rectus abdominis muscle free flap Random pattern flap, 230, 232–233, 320, 368, 369, 442 Randomized control trial (RCT), 62, 81 Range of motion (ROM), 11, 17, 19, 21, 23, 25, 116, 128, 135, 138, 206, 394, 420, 440 RCT. See Randomized control trial ReCell®, 26–37 Rectus abdominis muscle (RAM) free flap, 326, 388, 389, 395, 396 Regional flap, 47, 52, 118, 270, 320, 330 Rejuvenation, 72 Remodeling, 62, 108, 110, 172, 174, 262, 312, 316 Resurfacing, 8, 27, 36, 72, 74, 178, 179, 181–184, 208, 220, 221, 223, 224, 226, 229, 232, 236, 301, 316, 336, 399, 401–408, 470–472, 474, 476 Retinoic acid, 72, 73 ROM. See Range of motion Rotated flap, 180, 198, 202, 234, 240, 251, 252, 254, 280, 314, 342, 357, 417, 418, 420, 444, 448, 450, 452, 462, 464, 466 Rotational flap, 120, 178, 198, 200, 250, 251, 256, 258, 281, 338, 442, 443, 446 S S-shaped incision, 429 SAP. See Subatmospheric pressure

Index Scaffold, 40, 41, 100–107 Scalp, 5, 118, 133, 146, 180, 208, 240, 250–259, 261, 270, 276–277, 298, 301, 347, 399 Scalp flap, 180, 181, 241, 250, 251, 255, 257–259, 271, 306 SCAP flap. See Superficial cervical artery perforator flap Scapular flap, 280, 282, 285, 399, 402–407, 470–477 Scarred flap, 320–329 Scarring, 14, 23, 38–40, 62, 72, 73, 75, 88, 109, 111, 118, 119, 124, 132, 160, 179–181, 184, 220, 224, 226, 227, 261, 270, 298, 302, 310, 398, 405, 410, 411, 432, 444, 464 SDB. See Superficial dermal burn Secondary vascularized flap, 288–299 Septocutaneous perforator, 378, 379, 383 Septofasciocutaneous flap, 470 Seroma, 22, 94, 133 Shape-modified flap, 416–427 Shape-Modified Radial Artery Perforator (SM-RAP) Flap, 416–427 Sheet graft, 12, 64, 100, 133–138, 178, 398, 406, 407 Shoulder, 206, 220, 221, 224, 226, 234, 312, 316, 338, 340, 348, 357, 372, 373 Silicone, 6, 7, 22, 23, 25, 62, 90, 91, 94, 108, 109, 240–243, 246, 247, 262 Silversulfadiazine, 6, 7, 21 Skin expander, 310, 312 Skin graft, 4, 6, 10, 22, 26, 38, 46, 62, 76, 82, 90, 100, 108, 122, 132–138, 140–144, 146–157, 174, 178, 192, 198, 208, 220, 240, 250, 260, 279, 290, 309, 314, 320, 330, 338, 344, 356, 380, 388, 398, 408, 429, 436, 444, 452, 462, 472 Skull, 7, 91, 94, 96, 250 SM-RAP flap. See Shape-modified radial artery perforator flap Split thickness skin graft (STSG), 7, 13, 14, 22, 23, 25–27, 30, 34, 46, 53–55, 63, 64, 68, 69, 94, 100–103, 114, 124, 126, 128, 132, 133, 135–137, 176, 258, 338, 340, 342, 344, 357, 394, 398, 401, 412, 430, 431, 440, 452, 462, 476 Square flap, 186–197 Stem cell, 12, 38–41 Steroid, 76–81, 298 Stiffness, 44 STSG. See Split thickness skin graft Subatmospheric pressure (SAP), 17–23, 25 Subdermal plexus, 357, 434, 435, 452, 462 Subdermal vascular network, 230, 344, 356, 357, 368, 370, 371, 452, 462 Subdermal vascular network (SVN) flap, 230, 357 Super-thin flap, 48, 230, 298, 344, 356–375, 398, 452–469, 471 Supercharged flap, 230, 338, 352, 354, 357, 368, 369, 442, 452–469 Supercharging, 338, 339, 344, 357, 452, 458, 462 Superficial cervical artery perforator (SCAP) flap, 344–355 Superficial dermal burn (SDB), 66, 80, 320 Superficial radial, 428, 429 Superficial temporary artery, 180, 181, 184, 251 Supraclavicular flap, 338–343 Supraorbital artery, 251 Supratrochlear artery, 251

Index

499

Surfasoft®, 32 SVN flap. See Subdermal vascular network flap

Trypsin, 27, 100, 101 Tubed flap, 260, 261

T TAAP. See Thoracoacromial artery perforator Tangential excision, 11–13, 92, 176, 209 Taping, 77, 79 Tarsorrhaphy, 146, 150 Tattoo, 72 TDAP flap. See Thoracodorsal artery perforator flap Temporoparietal facial flap, 270 Temporoparietal region, 242, 270 Tensor fasciae latae perforator (TFLP) flap, 434 TESE. See Tissue-engineered autologous skin equivalent TEWL. See Transepidermal water loss TFLP flap. See Tensor fasciae latae perforator flap TGF. See Transforming growth factor The internal mammary artery, 408, 410, 411 The internal mammary vessel, 408, 409, 413 Thigh, 2, 7, 8, 55, 56, 64, 79, 80, 102, 104, 105, 285, 286, 301, 304, 305, 336, 378–387, 434, 436, 464 Thinning, 80, 344, 356, 357, 368, 399, 400, 408–415, 434, 452, 460, 462 Thoracoacromial artery perforator (TAAP), 339 Thoracodorsal artery perforator (TDAP) flap, 434 Tissue expansion, 108, 133, 179, 230, 240–251, 260, 281, 301, 302, 388 Tissue undermining, 214 Tissue-engineered autologous skin equivalent (TESE), 100–107 Toe joint, 45, 58 Toe web, 45, 59 Transepidermal water loss (TEWL), 63 Transforming growth factor (TGF), 40, 73 Transposition flap, 164, 220–229 Transverse cervical artery, 234, 338, 342, 344, 374, 462

U Upper arm, 51, 52, 66, 84, 152, 260, 261, 301, 330, 332, 338 V V flap, 164, 170 V-Y flap, 160–171 V-Y plasty, 132, 164 V.A.C.®. See Vacuum assisted closure (VAC)® Vacuum assisted closure (VAC)®, 5, 16–25, 90, 91, 133, 138 Vascular bundle, 8, 288–290, 292, 294, 296 Vermilion, 181, 406, 407 Versajet™, 13, 14, 209 Vitamin A, 72–75 Vitamin C, 73–75 W W-plasty, 50, 51, 54–57, 76 Waterjet, 14 Wraping method, 23, 138, 270, 288–289, 434 Wrist joint, 45, 50, 284, 298 X Xenograft, 8, 113 Y Y-V plasty, 132 YV advancement flap, 281 Z Z-plasty, 48, 49, 52, 59, 76, 113, 132, 133, 160, 161, 166, 172–178, 186, 188, 261, 281, 282, 285–287 Zygomatic arch, 400, 406, 407