PLASTIC SURGERY
Late management of burns
Odhran P Shelley FRCSI(Plast)
Peter Dziewulski FRCS(Plast)
Certain sequelae are expected after burn injury. The degree to
which these sequelae affect the individual depends on the type
of the injury, initial treatment and the patient.
The late effects of burn injury are related to the loss of normal
tissue and its replacement with scar tissue. Scars may be itchy,
lumpy, discoloured and unsightly (see ‘Management of scars’, page
18). They exert greater effect if they replace tissues with previous
complex function: scars may limit movement, impair vision, make
mouth opening difficult, cause pain, and otherwise prevent activ-
ity. Many patients have scars involving multiple sites, which affect
many different functions, are aesthetically displeasing, and cause
social embarrassment. The key to post-burn care is scar manage-
ment, affecting improvement with therapy and surgery, in addition
to promoting psychological acceptance and social reintegration.
Burn management takes place within a multidisciplinary
team (surgeon, anaesthetist, nurse, physiotherapist, occupational
therapist, social worker, psychotherapist, dietitian, pharmacist,
paediatrician). On completion of initial treatment, regular review
is required to determine how the patient is managing the activities
of daily life and to determine if he is experiencing problems. The
review process assesses the function and aesthetic appearance of
the burned area, assesses burn scarring and identifies areas to
which treatment should be directed. The review process continues
for many years.
Acute care
The nature of the original injury often predicts future needs. The
size, sites and depth of burn, as well as the mechanism of burn
and associated injuries, exert influence on rehabilitation and
reconstruction needs. Additional factors (e.g. pre-morbid health,
physical, psychological and social well-being) are important. Re-
cognizing the environment in which the patient lives and to which
he will return is equally important. Social support, psychological
stability and patient motivation greatly influence outcome.
The subsequent rehabilitation and reconstruction needs are
largely determined by the initial care. Delays in initial treatment,
delays in definitive skin closure, wound infection, metabolic defi-
ciencies, inadequate therapy, can negatively affect outcome and
significantly increase future needs. Late reconstruction of burns
begins on admission to the Burn Unit.
Odhran P Shelley is a Specialist Registrar at St Andrew’s Centre for
Plastic Surgery, Broomfield Hospital, Essex.
Peter Dziewulski is a Consultant Plastic Surgeon at St Andrew’s Centre for
Plastic Surgery, Broomfield Hospital, Essex.
SURGERY 24:1
Medical management of scars
Scar management begins immediately after the burn. A number
of measures are implemented to optimize scar healing once initial
healing has occurred.
Massage and moisturizing of scarred areas – due to loss of
adnexal structures, the skin cannot produce the natural oils present
in sebum that help maintain the pliability and elasticity of the skin.
Hence, the skin is more liable to fissure and crack, with consequent
pain and infection. Regular moisturizing and massage with simple
aqueous cream or cocoa butter helps to avoid these problems.
Pressure therapy – pressure decreases the partial arterial oxygen
tension of tissue, increases activity of collagenase and promotes
collagen remodelling. Tubigrip™ or custom-made garments (e.g.
Jobst™) can be used. Semi-rigid moulds (e.g. clear Uvex™ mask)
may also be useful in treating facial burns.
Silicone gels are beneficial in some patients. The exact mecha-
nism of action is not completely understood, but a hydrating effect
within the scar has been proposed. Silicone is available as a gel
sheet or a clear gel and must be worn for 24 hours.
Corticosteroid therapy – areas of scarring that are significantly
hypertrophic or keloidal may benefit from intralesional injection of
corticosteroid, which inhibits myofibroblast activity. The size of area
that can be treated is limited by the total dose of corticosteroid that
can be given. Injection may be painful and topical local anaesthetic
is advisable, although some patients require local anaesthesia with
sedation. Lesions are usually treated at intervals of six weeks.
Splints – keeping the joints in a position of function improves
subsequent function in the hand. These splints may be confined
to periods of rest (e.g. at night) as the patient starts mobilizing.
Burn reconstruction
It is not possible to absolutely separate initial surgical treatment
from subsequent reconstruction; burn reconstruction should be
considered in terms of primary and secondary reconstruction. The
effectiveness of initial surgery determines future requirements.
The burn surgeon initially replaces ‘like with like’. Primary
reconstruction usually entails some form of graft technique, where
the injury is limited to the skin. Graft techniques include autograft,
allograft, isograft and xenograft. They can be used as full-thick-
ness or split-thickness skin grafts (see ‘Grafts and flaps’, page 27).
They can also be applied as sheets, fenestrated or meshed. Scar
hypertrophy is directly related to delay in wound healing, and
treatment that expedites healing reduces the requirements of burn
reconstruction. The biological properties of allograft, xenograft,
and isograft make them a useful adjunct in aiding closure of the
burn wound. They are not, however, used for definitive wound
closure. They help avoid excessive scar formation by promoting
healing.
If using the patient’s skin, the donor site should be placed in a
position that is acceptable to him. The skin graft should be selected
to best match the recipient area. Each donor site represents a fur-
ther injury to the patient and no more skin than is required should
be harvested. Attention should be paid to adnexal structures if a
full-thickness skin graft is needed. Blush skin in the head and neck
area is most closely matched by full-thickness skin from above the
clavicles; scalp skin may also be used as a split-thickness graft in
these areas.
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Sheet grafts have a better appearance than meshed graft and
should be used, if possible, in high-value sites (e.g. face, neck,
hands, across joints). If treating facial burns, the wound should
be grafted in aesthetic units, with the seam of the graft along the
edges of the aesthetic unit.
If using meshed graft, the lowest mesh ratio that achieves wound
closure should be used. If mesh is being placed across joints, the
interstices should be close together and the axis of the graft placed
transversely across the joint. Intact dermis has an inhibitory effect
on myofibroblast activity and wound contracture is indirectly
related to the amount of dermis within the graft. Full-thickness skin
grafts undergo less secondary contraction than split-thickness skin
grafts. The latter are mainly used for primary burn reconstruction;
these grafts are reserved for secondary burn reconstruction due to
the limited availability of full-thickness donor sites.
Grafts should be secured to the wound base, and exposed to
allow expression of haematoma or securely dressed to avoid graft
shearing. Skin substitutes may be used if there is a deficiency of
donor sites. Dermal substitutes (e.g. Integra™) require a multiple-
stage reconstruction with subsequent thin split-thickness skin graft.
Keratinocyte cell culture techniques may also be used in the acute
setting.
Patients should be advised that skin grafts may differ from native
skin in terms of texture, pigmentation and hair growth. Appropri-
ate sun blocks should be applied to the grafted area, regardless of
skin type.
Timing of surgery: certain sites tend to be problematic and deserve
urgent attention (Figure 1).
Complex injury: in certain cases where the defect is complex
and future functional deficiency can be predicted, more complex
primary reconstruction may be needed. Such primary reconstruc-
tions may require neurovascular reconstruction, and transfer of
soft tissue in the form of local, regional or distant flap. Ideally,
deficient structures are reconstructed primarily. Rehabilitation
usually progresses in tandem with initial burn surgery and aims
to promote function and minimize disability.
Initial burn care successfully replaces the injured tissue for most
patients. Postoperative care must ensure that preventable meas-
ures are avoided. Successful graft take alone does not guarantee
Timing of surgery
Urgent Compartment syndromes
Breathing difficulties; need for tracheostomy
Corneal exposure with keratitis
Microstomia, inability to feed
Acute entrapment of nerves
Soon Ectropion to eye
Lip ectropion, loss of oral competence
Contracture of web space
Neck contracture
Delayed Subcutaneous band contractures
Areas of hypertrophic scar
Areas of symptomatic scar
1 ant loss of function (e.g. neuropraxia). It may also be associated
SURGERY 24:1
good outcome. Uninjured body parts should not lose function as
a consequence of inappropriate positioning or immobilization.
Joints should be placed in a position of function and receive
passive physiotherapy to ensure preservation of the full range
of movement. Active mobilization is encouraged; resting splints
should be used if appropriate.
Post-burn scarring may be symptomatic and present as hyper-
trophic or keloidal scars of the skin. Scarring may also present in
the form of subcutaneous bands or contracture (Figure 1). Decisions
regarding the time of surgery must be made in conjunction with
a Scar Therapist. Scar maturation may make surgical correction
unnecessary. The medical treatments discussed above are useful
tools in the management of excessive scar response.
Scarring subsequent to burn injury should be considered with
regard to effect on function and aesthetic appearance. Both are
important, but restoration of function has greater priority. Secondary
reconstructive surgery is necessary to address problematic scars.
Function: loss of function after burn injury may result from the
primary effect of the injury or from secondary sequelae. Secondary
effects may occur directly or indirectly (e.g. a hypertrophic scar in
web space with contracture, versus a healed hand with tightness
of the first web). Secondary effects of contracture may result in
permanent and irreversible skeletal distortion.
Contractures (Figure 2) must be considered when assessing burn
scars. There are two types, intrinsic and extrinsic, and both may
result in the same effect e.g. ectropion. Intrinsic contracture implies
integral loss of function; extrinsic contractures require release.
Such contractures require reconstruction. Surgery in these areas
should release all scarring, superficially and deep. If release is not
achieved in theatre, it is unlikely to be achieved with subsequent
therapy. Revision of scarring may be achieved using incisional or
excisional techniques. Subsequent reconstruction may be done
using grafts or flaps, depending on requirements. The authors
prefer excisional techniques because they achieve a greater degree
of release and greater degree of restoration of function.
One must carefully assess the amount and type of tissue
required when planning a reconstruction. This process of tissue
selection is akin to using a ‘reconstructive ladder’, but may also
be viewed as an ‘elevator’ (Figure 3). It is not necessary to move
sequentially from direct closure of wound to skin graft to final
flap. Often a flap-based reconstruction is indicated primarily.
Local flaps: if there is sufficient local skin to affect a release and
reconstruction, such tissue can be imported into the area in which
it is deficient, using principles of advancement or transposition
(pivot). The most commonly used flaps are Z-plasty and Y–V
plasty or combination flaps.
Tissue expansion is a process whereby cyclical loading is used
to achieve stress relaxation and an increase in the area of skin
adjacent to the burn scar. This allows reconstruction with tissue
that closely matches the area to be replaced, in terms of colour,
texture, thickness and sensation. Tissue expansion requires place-
ment of an expander prosthesis in a subcutaneous pocket, with a
port for injection of saline. Tissue expansion may be complicated
by distortion of body image and physical deformities, with result-
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Management of contractures

a Severe contractures of the hand with b Release of burn contractures. c Application of skin graft.
significant functional impairment.

d Application of tie-over dressing. e Release of contracture. f Good function.

Donor sites: like should be replaced with like. Patients should be

Reconstructive ladder (may be used as an elevator)
advised that skin grafts may differ from the native skin in terms
of texture, pigmentation and adnexal structures. Appropriate sun
Direct closure
blocks should be applied to the area grafted regardless of skin type.
Graft technique
Patients should also be advised that they may have delays in wound
Split thickness
healing and a permanent scar at the site of harvest.
Full thickness
Skin substitute
Hypopigmentation: changes in pigmentation due to burn injury may
Composite
result in a variegated appearance of the skin. This is related to initial
Flap technique activation of the melanosome in areas of superficial burn, and is often
Local represented by a pigmented area around the margins of the burn.
Transposition Treatment consists of sun blocks to the area. Hydroquinolones may
Pivot also be effective in controlling hyperpigmentation. The melanocyte
Alphabet-plasty (Z, Y–V, V–M, W) is very vulnerable to injury and permanent loss of this cell causes
Regional hypopigmentation after deeper burns. This is more problematic in
Myocutaneous darker skin types. Hypopigmentation is not always permanent and
Fasciocutaneous repigmentation is possible up to two years after injury.
Neurocutaneous
Distant
Hair-bearing areas: areas of cicatricial alopecia must be assessed
Free tissue transfer
according to the site, total area, and confluence of alopecia.
Reconstruction involves reduction of the area of scar and importa-
Prelamination techniques tion of hair-bearing skin (where possible). This usually requires
Tissue expansion techniques a staged approach, with serial excision of the affected area or
tissue expansion, with subsequent excision of alopecia and flap
3 reconstruction. Variously designed scalp flaps may also be used
to confer a hairline. Follicle transplant and tattooing of scalp may
with pain, implant exposure, extrusion and infection, so patient be of benefit in selected cases.
selection is important. At the time of surgery, incisions should be Keloidal folliculitis is a problematic entity affecting the beard
appropriately positioned, and a pocket of sufficient size should area in men. Although long-term antibiotics may help, reducing
be used with, ideally, the base of the implant(s) being twice the superimposed infection, definitive treatment usually requires exci-
size of the defect to be reconstructed. sion and graft reconstruction. 

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