Treating Burn Victim Deformities

After a burn, there can be several burn-related sequelae.  There can be hypertrophic or overgrown scars, contracture of the scars and deformities of various body areas that occurred due to the burn. Now that doctors know the key to higher survival is surgically removing the burn and replacing it with a graft, this is the preferred treatment.  Ironically, however, this leads to more deformities and the need to offset the aggressiveness of these procedures.

Scar tissue and contractions are normal parts of healing.  Wounds that are allowed to be infected by letting them heal without surgery result in thicker scars and this is addressed by making sure the wounds don’t have burned tissue on them to become infected.    The infection causes more collagen to be produced and it is produced in whorls and nodules, both of which can lead to unsightly scarring.  These things happen within 3-4 weeks of the injury.

Treating the deformities generally doesn’t occur until the wound has healed completely.  This can take several weeks or more.  Doctors must first address the contractures around the mobile body parts in order to make sure that the elbow bends, the eyelids close, the knees straighten, etc.  The treatment of deformities as a result of contractures needs daily exercise and physiotherapy in order to prevent the joints from getting stuck in an abnormal and non-functioning position.
 
Assessing Burn Deformities
 
Burn deformities cannot be addressed right away because many changes take place from the time of the burn to the time of the healed burn.  Assessing the deformity has to take in the physiological processes that are going on in the burned area as well as the psychological needs of the patient.  The depth and the extent of the burn plays a role in what type of disfigurement the burn victim will have.

Deciding exactly when to surgically-treat the deformity is not easy.  Functional goals take precedence (at least in the beginning) over cosmetic goals.  Earlier treatments are directed at covering an open area of the skull, fixing contracted eyelids, treating urethral or anal blockages because of burns in the perineum, and contracted major joints as these are priorities.  Later treatments, such as treating deformed ears and noses really can’t be done in children, for example, until the growth processes of these body parts has completed.
 
Scars don’t really mature for about 2 years following a severe burn.  Until that happens, splints and pressure dressings are recommended in order to minimize contractures and help the scar mature.    The splints and dressings need to be worn faithfully and there needs to be daily exercise of affected joints in order to keep contractures to a minimum.
 
Techniques for Reconstruction

There are several techniques available for reconstructing burn deformities.  These include the following:
  • Excising the scar and applying a graft over it
  • Excising the scar and closing the remaining skin primarily
  • Using a nearby skin flap
  • Using a technique that transfers skin and underlying tissue
  • Using a technique that transfers skin, underlying tissue, and muscle
  • A distant skin or underlying tissue graft
  • Transferring muscle and skin using microsurgery
The simplest technique is to take out the offending scar and closing the skin around it.  Sometimes it is necessary to leave a rim of the existing scar so that the wound won’t pucker or pull too much on the normal skin.   If the wound can’t be closed primarily, it is excised and covered with a skin graft from a donor site.   The thinner the skin graft is, the better it will adhere to the wound bed and the less contracture it will have.

Doctors have created and used artificial skin dermis to cover the underlying tissues.  The artificial dermis is applied and a thin skin graft is added to the top of it.  It takes more than one surgery to accomplish this but it can be more cosmetically appealing.

A special z-plasty technique can be used in order to have thicker layers of skin and soft tissue placed over the defect with the area the skin is cut from attached by a supplying artery.  The donor site is closed just like ordinary stitches.  In some cases, a tissue expander is temporarily placed underneath the skin and the skin is allowed to stretch over time to cover adjacent defects made by cutting out unsightly scars.

The exact timing of using these techniques is not completely clear.  Scar tissues that are still active may not be good candidates for repair.  Certain things, such as repairing eyelid deformities can conceivably be used as soon as 4-6 months after the initial injury.

Advancements in microsurgery will be the next step in allowing for excellent adherence of grafts and better cosmetic outcomes from serious burns.   
 
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