The Art of Local Tissue Rearrangements in Burn Reconstruction: Z-Plasty and More.

In recent decades, advances in surgical anatomy, burn pathophysiology, surgical techniques, and laser therapy have led to a paradigm shift in how we approach burn scars and contractures. Scar excision and replacement with uninjured tissue, which predominated burn scar treatment for much of the 20th century, is no longer appropriate in many patients. A scar's intrinsic ability to remodel can be induced by reducing tension on the scar using various techniques for local tissue rearrangement.

Evolution of Burn Care: Past, Present, and Future.

Burn care evolved slowly from primitive treatments depicted in cave drawings 3500 years ago to a vibrant medical specialty which has made remarkable progress over the past 200 years. This evolution involved all areas of burn care including superficial dressings, wound assessment, fluid resuscitation, infection control, pathophysiology, nutritional support, burn surgery, and inhalation injury. Major advances that contributed to current standards of care and improved outcomes are highlighted in this article.

Split-thickness skin graft donor-site morbidity: A systematic literature review.

The purpose of this systematic literature review is to critically evaluate split-thickness skin graft (STSG) donor-site morbidities. The search of peer-reviewed articles in three databases from January 2009 to July 2019 identified 4271 English-language publications reporting STSG donor-site clinical outcomes, complications, or quality of life. Of these studies, 77 met inclusion criteria for analysis.

Five Essential Principles for First Web Space Reconstruction in the Burned Hand.

Background: Burn injuries commonly affect the hand, and the development of adduction contractures of the first web space is frequent and deleterious, both functionally and aesthetically. Many corrective techniques and algorithmic approaches have been described to treat this problem, but there is no consensus on the optimal management.

Methods: A retrospective review at a single high-volume pediatric burn center was undertaken to evaluate the clinical course of these patients.

Triangular Fossa Graft for Philtral Reconstruction After Facial Burns: A 34-Year Experience.

Background: Upper lip burns and skin grafts used for the resulting deformities all contract, leading to distortion of regional tissues and producing a flattened upper lip devoid of normal anatomic landmarks. Absence of the philtral contour draws attention to the upper lip and can accentuate other reconstructive inadequacies. Philtral restoration requires a 3-dimensional reconstruction capable of resisting contractile forces to restore and maintain normal relationships between the upper and lower lips.

Laser Modulation of Hypertrophic Scars: Technique and Practice.

In this review, the authors discuss the use of laser photothermolysis and laser resurfacing in the management of hypertrophic burn scars. They provide details regarding preoperative selection, intraoperative decision making, and postoperative care.

Management of trauma and burn scars: the dermatologist's role in expanding patient access to care.

Recent advances in laser surgery and our understanding of wound healing have ushered in a new era of trauma and burn scar management. Traditional therapy has centered around scar excision followed by primary closure or tissue replacement with flaps and grafts. This approach represents a perpetuation of the common fallacy that extensive scar improvement requires extensive surgical intervention.

Vermillion Reconstruction With Anal Verge Transitional Epithelium: Turning Things Upside Down.

Postburn lip deformities pose a significant set of challenges to reconstructive burn surgeons because of the complex anatomy, diverse functions, and specialized nature of the lip tissues. There has been a paucity of literature on restoration of the vermillion to date. The authors report on two patients who suffered burn injuries resulting in significant lip deformities who underwent a novel method of vermillion reconstruction with a full thickness anal verge skin graft.

Reconstruction of the Adult and Pediatric Burned Hand.

Thermal injuries of the hand can have a great impact on function. Initial treatment should focus on the prevention of contracture through the use of tissue-sparing techniques and optimized occupational therapy. Surgical intervention should follow the standard reconstructive ladder and can involve several techniques from simple to complex including minimally invasive techniques, such as laser and steroid injection, contracture release and skin grafting, and local tissue rearrangement and regional flaps as well as distant pedicled and free flaps.

Scar Management in the Pediatric and Adolescent Populations.

For most children and adolescents who have developed symptomatic scars, cosmetic concerns are only a portion of the motivation that drives them and their caregivers to obtain treatment. In addition to the potential for cosmetic disfigurement, scars may be associated with a number of physical comorbidities including hypertrichosis, dyshidrosis, tenderness/pain, pruritus, dysesthesias, and functional impairments such as contractures, all of which may be compounded by psychosocial factors. Although a plethora of options for treating scars exists, specific management guidelines for the pediatric and adolescent populations do not, and evidence must be extrapolated from adult studies.

Biology and principles of scar management and burn reconstruction.

Hypertrophic scarring is extremely common and is the source of most morbidity related to burns. The biology of hypertrophic healing is complex and poorly understood. Multiple host and injury factors contribute, but protracted healing of partial thickness injury is a common theme.

Laser treatment of traumatic scars with an emphasis on ablative fractional laser resurfacing: consensus report.

Importance: Despite expert wound care and assiduous management with traditional therapy, poor cosmetic outcomes, restricted motion, and symptoms such as pain and itch are a pervasive problem of disfiguring and debilitating scars. The advent of ablative fractional photothermolysis within the past decade and its application to the treatment of traumatic scars represents a breakthrough in the restoration of function and cosmetic appearance for injured patients, but the procedure is not widely used.

Objective: To provide a synthesis of our current clinical experience and available literature regarding the laser treatment of traumatic scars with an emphasis on fractional resurfacing.

Pediatric burn-related scalp alopecia treated with tissue expansion and the incidence of associated facial burn injuries.

In the pediatric population, cutis aplasia, scalp avulsion, and burn injuries are the leading causes of scalp alopecia that is evaluated for reconstruction by plastic surgeons. Scalp alopecia is seen in 25% of children who suffer burn injuries of the head and neck. These injuries are rarely isolated to the scalp, and the adjacent structures are often affected.

Pulsed dye laser in burn scars: current concepts and future directions.

Hypertrophic scarring after partial-thickness burns is common, resulting in raised, erythematous, pruritic, and contracted scars. Treatment of hypertrophic scars, especially on the face, is challenging and has high failure rates. Excisional treatment has morbidity and can create iatrogenic deformities.

The phrenic nerve as a motor nerve donor for facial reanimation with the free latissimus dorsi muscle.

Free functional muscle transfer for acquired facial paralysis most often involves two stages. In this report, we describe single-stage free muscle transfer using the phrenic nerve as the donor motor nerve. Six patients with unilateral facial paralysis underwent single-stage facial reanimation using a free latissimus dorsi muscle with the ipsilateral phrenic nerve as the donor nerve.

Nasal reconstruction after severe facial burns using a local turndown flap.

Reconstruction of the nose after severe burn injury is a challenging problem. There are usually associated facial burns, which limits the availability of local flaps. Reconstruction with unburned distant tissue is often not appropriate because of the resulting mismatch in color and texture.

Pulsed dye laser therapy and z-plasty for facial burn scars: the alternative to excision.

Hypertrophic scarring after partial thickness facial burns is common when epithelialization takes longer than 3 weeks. Well-healed areas continue to mature unfavorably, resulting in raised, erythematous, and contracted scars. Excisional treatment of such scars has morbidity and can create iatrogenic deformities.

Purse-string closure of scalp defects following tissue expansion: an effective aesthetic alternative.

Primary closure of scalp defects under tension can be complicated by scar widening and alopecia, and large defects usually require the use of local flaps, skin grafts or free flaps. Tissue expansion facilitates the use of local flaps to cover large defects, but multiple expanders and complex flaps with extensive incisions may cause significant scars and alopecia. We describe a purse-string closure of expanded scalp tissue following excision of a large congenital nevus sebaceous.

Pursestring thigh lift: direct approach for a problematic deformity.

Extreme thigh lipodystrophy localized in a "saddlebag" distribution can be difficult to treat with conventional body-lift approaches. We present a case of extreme thigh lipodystrophy treated with suction lipectomy and direct excision of skin and fat. The circular defects were closed with pursestring sutures and yielded a greatly improved contour and minimal iatrogenic deformity or scarring.

Nailfold reconstruction for correction of burn fingernail deformity.

Background: Fingernail deformities frequently occur after burn injury to the hand. In many cases, the deformity is not the result of injury to the nail bed or germinal matrix but is instead secondary to contracture of soft tissues proximal to the eponychium. The roof of the nailfold peels away from the nail, causing abnormal nail growth and appearance.

Long-term consequences of toxic epidermal necrolysis in children.

Objective: Toxic epidermal necrolysis (TEN) is an acute inflammatory systemic condition that involves injury not just to the skin. Historically, it has been associated with a high mortality but few long-term consequences among survivors. With improved survival, long-term consequences may be becoming more apparent.