In the aftermath of a burn, emerging hypertrophic scars and inadequate skin healing must be treated to prevent or minimize the creation of scars that will otherwise cause substantial functional impediment and disfigurement. A treatment plan may include the use of Z-plasty to release local scar contractures, or skin grafts to further reduce tension and restore structures to their normal positions. Pedicle flaps, tissue expansion, and other flaps and composite tissue allotransplantation may also be considered. Site-specific considerations may guide planning on the face, including the eyelid, nose, ear, and cheeks, as well as the scalp and neck. Ectropion and microstomia may need to be corrected. Contractures of the hand, including the web spaces and eponychial folds, and also the neck and axilla, may be specifically addressed.
Hypertrophic scars (HTSs) and low-quality skin replacement (LQS) both result in long-lasting morbidity after burns. HTSs are the cutaneous manifestation of prolonged skin inflammation characteristic of slow healing, deep partial-thickness burns, or full-thickness burns. LQS results from the use of thin, highly expanded, meshed skin grafts in the setting of a large surface area burn with insufficient donor skin. Both HTS and LQS are aesthetically displeasing and often result in function-limiting burn scar contractures, particularly on the face or around the joints. Normal or as close to normal appearing, soft, pliable, functioning skin is required on the face, especially in the periocular and perioral regions. In the hands, range of motion can be severely limited when HTS and/or LQS is present. This chapter focuses on the general principles of burn reconstruction as well as site-specific surgical interventions for commonly encountered burn scar contractures.
The initial visit to discuss postburn reconstruction necessitates a survey of all scarred areas and available donor sites. Proper treatment of burn scar contractures requires critical analysis of displaced anatomy and the resulting functional limitations. Depending on the depth of the injury, scar contracture can occur at the level of the skin, subcutaneous fat, muscle fascia, and in severe cases, tendon, ligament, joints, and even bone. In cases when deep structures are the cause of the contractures, composite or staged procedures may be required. However, this may not be evident until the skin tightness has first been addressed. For the purpose of this chapter, we will focus on burn scar contractures limited only by skin and subcutaneous tissues.
Burn scars that do not limit the range of motion of a joint are ideal for nonsurgical therapies, including laser, compression, silicone gel sheeting, and rarely, corticosteroid injections. Scars that limit range ...