Steven E. Wolf, Art Sanford

The following is included as a description of daily tasks that take place in our

burn units. Topics such as the process of daily rounds and caring for wounds will

be discussed. They are intended as guidelines for the care of burn patients.

PATIENT ADMISSION

HISTORY AND PHYSICAL

You have learned how to obtain a medical history and physical assessment

skills in medical school. Be thorough. In burned patients, a couple of points should

be emphasized. Patient evaluation includes an AMPLE history: allergies, medications,

preexisting illness, last meal, and the events of the injury including time,

location, and concomitant results. A history of loss of consciousness is sought.

When, where, and how did the injury occur? With children, stories that do not

match the injuries are suspicious for child abuse. What time did the burn occur?

What was the initial treatment, including any narcotics or sedation that was administered

and resuscitation at an outlying center? What is the immunization status,

particularly for tetanus. For electrical injuries, the voltage that caused the injury

is documented. For chemical injuries, the type of chemical and the duration

from the injury are noted.

WOUND ASSESSMENT

An accurate initial description of the wounds, including depth assessment and

extent of injury is accurately documented, preferably on a cartoon of the body

(see figures in wound management chapter). If forms cannot be found, this may

be drawn in the progress notes. Treatment that has been administered including

the type of dressing and any escharotomies and fasciotomies are recorded. The

wounds are gently debrided under sedation or anesthesia if necessary. Blisters are

removed during this process. After complete evaluation, consultation is made with

the responsible faculty, with a decision for the wound treatment. This is generally

done with either topical antimicrobials, or a biologic/synthetic dressing. If topical

antimicrobials are chosen, silvadine with mycostatin is generally the choice except

for the face, which should have neomycin/mycostatin. Ears are treated with

sulfamyalon to prevent chondritis.

ADMISSION ORDERS

These are tailored for the burn size. In general, this will require a burn size

calculation to guide resuscitation volume. For those with other trauma, x-rays

and CT scans may be needed. All special procedures such as CT scans or

arteriograms require a progress note describing their necessity. Tetanus prophylaxis

is given as appropriate. Major injuries (> 30% TBSA) receive empiric antibiotics

to cover staphylococcus and gram-negative organisms. Hypothermia should

be avoided by limiting body exposure and warming the patient’s room. Comfort

measures including sedatives and analgesics are given after the initial assessment.

Nutritional support is given immediately, either by mouth for minor burns (milk,

Resource®) or via a nasoenteric tube for major burns. For those who are mechanically

ventilated, attention must be made to the ventilator settings, particularly in

the setting of inhalation injury. Serial exams of the vascular and neurologic status

of extremities that are at risk are made. Elevation of injured limbs with topical

collagenases can be used for marginally “tight” limbs that do not clearly require

escharotomy. Labs including a blood count and electrolytes are drawn daily for

the immediate phase of care. Consults for physical and occupational therapy, nutrition,

respiratory therapy, psychiatry, photography, and social work are placed

for all patients at admission. A list of medications and their recommended doses

are included in Table 12.1.

DAILY ROUNDS

Rounds with the burn team are made daily at 7:00 AM. All burn wounds are

inspected unless there was a recent operation. In general, the operative dressings

are removed on postoperative day 3 down to the fine mesh gauze. Clinical circumstances

may dictate that the wounds be inspected earlier at the discretion of

the senior physician. All wounds are completely exposed on postoperative day 4.

Donor sites are exposed on the day of the operation after arrival to the hospital

room or on postoperative day 1, and are available for daily inspection thereafter.

Wounds that are treated conservatively should be seen daily to inspect for signs of

invasive infection. Ominous signs include a surface appearance of fungus or black

spots. Increasing edema and erythema around wounds also increase suspicion. If

there is any question, the wound should be biopsied and sent to pathology and

microbiology. The pathologists do rapid sections to look for organisms invading

into viable tissue. The microbiologists identify the organism, and the quantitative

counts. The wounds are then dressed until the following day.

All personnel who participate in the dressing changes wear gowns and gloves

which are available just outside the room. Other personnel who are only looking

at the wound take care not to touch either the patient or the furniture in the room

Table 12.1. Medication dosage guidelines

Vitamins & Minerals 0-2 Years 2-12 Years > 12 Years

Multi Vitamin Poly Vi Sol 1 ml Poly Vi Sol 1 ml Vi Deylin 5 ml

Or Chewable Tab or Theragran

Ascorbic Acid 250 mg QD 250 mg QD 500 mg QD

Folic Acid 1 mg QMWF 1 mg QMWF 1 mg QMWF

Vitamin A 2500U 5000U 10000U

Zinc Sulfate 55 mg 110 mg 220 mg

Elemental Iron < dose =" 2">

30 kg Dose = 65 mg PO TID or FeSO4 325 mg PO TID

Antifungal Prophylaxis

Mycostatin Oral Suspension 5ml QID 5ml QID 5ml QID

H-2 Blockers

Ranitidine Dose = 2 mg/kg/dose PO or IV q8h.

If gastric pH is less than 4, increase dose by 1 mg/kg up to a maximum of 8 mg/kg/

dose PO or IV q8h

Treatment with Ranitidine is for the entire period of acute burn hospitalization.

If patient has had an endoscopically documented ulcer, Ranitidine should be

prescribed for 6 weeks from the time the ulcer was documented.

Diuretics

Furosemide: IV: 0.25 mg/kg/dose q6h up to 1 mg/kg/dose

PO: 0.5 mg/kg/dose q6h up to 2 mg/kg/dose

Spironolactone: 0-2 yrs 6.25 mg PO q12h

3 yr-12 yr 12.5 mg PO q12h

> 12 yr 25 mg PO q12h

Human Growth Hormone 0.2 mg/kg/dose SQ qd

Beta-Adrenergic Blockers

Propranolol: 0.25 mg-0.5 mg/kg/dose IV q6H, titrate to decrease heart rate by 25%

Metroprolol: 0.75 mg/kg/dose IV q12h, titrate to decrease heart rate by 25%

Antibiotics:

Acyclovir: Mucocutaneous ASV 750 mg/m2/day

8 mg/kg/24h q8h IV x 7 days

Herpes Zoster in Immunocompromised Patients:

7.5 mg/kg/dose q8h IV

250-600/m2/dose 4-6 x day PO

Adult dose 800 mg 4-6 x day PO x 7-10 days

Varicella-Zester: 1500 mg/m2/day q6h or 30 mg/kg/day q8h IV

20 mg/kg/dose (max 800 mg/dose) PO 4-5 x day x 6 days

Begin treatment at earliest sign or symptom

Amikacin: 22.5 mg/kg/day q8h PO

1.5 gm max/day

Amoxicillin: 25-40 mg/kg/day q8hr PO

> 20 kg Use adult dose

Adult dose 250–500 mg PO q8hr

Amphotericin-B: Test dose: 0.1 mg/kg x 1 up to 1 mg

Initial dose: 0.25 mg/kg/day increasing by 0.125-0.25 mg/kg/day until

1 mg/kg/day as tolerated (given QD or QOD. Infuse over 6 h.

Premedicate with Acetaminophen and Diphenhyramine at dosages

based on weight.

Ampicillin: 50-100 mg/kg/day q4h IV Mild to moderate infection

150-200 mg/kg/day q4h IV Severe infection

50-100 mg/kg/day q6h PO Mild to moderate infection

> 20 kg Use adult dose

Adult dose 250-500 mg q6h PO

Augmentin: <>

> 40 kg 250-500 mg/dose q8h PO

Aztreonam: 200 mg/kg/day q6h IV

8 gm max/day

Cefazolin: 25-100 mg/kg/day q8h IV

12 gm max/day

Cefoperazone: 25-100 mg/kg/day q12h IV

16 gm max/day

Cefotaxime: <>

>50 kg 1-2 mg q6-8h IV

12 gm max/day

Cefotetan: 40-60 mg/kg/day q12h IV

Cefoxitin: 80-160 mg/kg/day q6h IV

12 gm max/day

Ceftazidime: 90-150 mg/kg/day q8h IV

6 gm max/day

Ceftriaxone: 50-75 mg/kg/day q12h IV

4 gm max/day

Cefuroxime: 50-100 mg/kg/day q6h IV

Adult dose: 750 mg-1.5 mg/dose q8h IV

Chloramphenicol: 50-100 mg/kg/day q6h IV or PO

Clindamycin: 16-40 mg/kg/day q8h IV

2.7 gm max/day

8.58 mg/kg/day q8h PO

3 gm max/day

cont’d.

Dicloxacillin: 12.5-5.0 mg/kg/day q8h PO (up to 2 gm/day)

> 40 kg should receive adult dose

Adult dose 125-250 mg q8h PO

Erythromycin: 10-20 mg/kg/day q8h IV

30-50 mg/kg/day q8h PO

Fluconazole: 3-6 mg/kg/day IV or PO

Immunocompromised: 12 mg/kg/day IV or PO

Adult doses: 200-400 mg IV or PO on Day 1

Followed by 100-200 mg PO or IV

Gentamicin: <>

> 40 kg 5 mg/kg/day q8h IV

Imipenem/Cilistatin: > 12 yrs 50 mg/kg/day q6h IV

≤ 12 yrs 75 mg/kg/day q6h IV

4 gm max/day

Itraconazole: Adult dose: Loading dose 200 mg PO TID for 3 days, then 200 mg POQD:

If ineffective may increase by 100 mg increments to 400 mg PO QD

Mebendazole: (round, hook or whipworm) 100 mg PO BID x 10 days

Metronidazole: Giardiasis–5 mg/kg/day PO TID x 10 days

Amebiasis–35-50 mg/kg/day PO TID x 10 days

Miconazole: Children > 1 yr 20-40 mg/kg/day q8h IV

Nafcillin: 100-200 mg/kg/day q4h IV

Adult dose: 500 mg-2000 mg q4-6h IV

Penicillin G: 25,000-100,000 units/kg/day q4h IV

Adult dose: 2-24 million units/day q4-6 h IV

Penicillin VK: 25-50 mg/kg/day divided 96h PO

Children ≥ 12 yrs or adult doses: 125-500 mg PO q6-8h

Piperacillin: 200-300 mg/kg/day q4h IV

24 gm max/day

Ticarcillin: 200-300 mg/kg/day q4h IV

24 gm max/day

Tobramycin: <>

> 40 kg 5 mg/kg/day q8h IV

Vancomycin: 40 mg/kg/day q6h IV

CHS infections 60 mg/kg/day

Adults 500 mg q6 h or 1 pm q12h IV

Zosyn: 100 mg/kg/days

IV q6h

in an effort to avoid passing organisms between patients. After removing the gowns

and gloves in the patient room, each participant washes their hands prior to going

to the next room.

During the wound inspection, the events of the previous day and night are

reviewed with the team, including any pertinent changes in vital signs or physical

exam. All laboratory and x-ray results are discussed (see included worksheet on

Table 12.4). After this review, plans for the day are made which should be reflected

in the physician’s orders. After rounds are complete, the operations for the day or

the outpatient schedule are attended to.

In the afternoon, brief rounds are made with the team where the events of the

day are discussed. Potential problems should be identified for the personnel on

call.

OPERATIONS

When patients are admitted, the operating room should be notified to prepare

for the operation the subsequent day. The operating theater is warmed with adequate

supplies garnered, such as multiple electrosurgical units. The burn size

should be calculated in square centimeters to give an estimate of the blood loss.

For example, a 50% TBSA burn in a 2.0 m2 man will be 1.0 m2 burn surface area.

One m2 is equal to 10,000 cm2 (100 cm x 100 cm). Blood loss is generally 0.5-1.0 ml

of blood per cm2 excised. So this man should have 20 units of whole blood or

reconstituted whole blood (one unit of packed red blood cells added to one unit

of fresh frozen plasma) available for the operation. An estimation of the amount

of cadaver skin required is made and ordered as well. For a massive burn (> 80%

TBSA), enough skin to cover the whole wound is ordered, with a decreased amount

for lesser wounds. Fresh cadaver skin is best if it is available, although frozen cadaver

skin can be used.

A preoperative note is prepared for each patient the day before his or her operation.

This note should contain the indication for the operation, the planned

procedure, documentation that appropriate consent has been obtained, NPO orders

if indicated, and that blood and skin have been requested.

On the day of the operation, the airway is secured by the anesthesia staff with

subsequent bronchoscopy and bronchoalveolar lavage specimens obtained. The

dressings are then removed in the operating theater under the supervision of the

surgeons. The entire body surface area is prepared with betadine and sterile drapes

placed under the patient. For most burns, the entire body is prepared in order to

allow for intraoperative decisions about the donor sites that are procured and the

amount of the wound to excise. A Foley catheter is then placed as dictated by the

clinical situation. The operation is then begun and completed, followed by application

of bolsters or bulky dressings to the grafted areas.

After the operation is complete, the postoperative orders are written with all

the tenets described above in the admission orders kept in mind. An operative

note is written describing the date, surgeons, operative findings, wound excised

and grafted in cm2, donor sites, estimated blood loss, intraoperative fluids, and

operative complications. Lastly, the details of the operation are dictated for later

transcription.

All bedside procedures such as central vein cannulation, Swan-Ganz catheter

placement, escharotomy, bedside sharp debridement, and bronchoscopy are documented

with both a procedure note and a dictated note.

Please find included a list of medications commonly used with their recommended

doses (Table 12.1). Also find the target serum levels for some antibiotics

(Table 12.2). Lastly, we have included some recommended medications for

anxiolytics, itching, nausea, and bowel cleansing (Table 12.3).

Table 12.2. Serum level norms

Amikacin Acetaminophen

Trough: 5-8 µg/ml (1h post dose)

Peak: 25-30 µg/ml = or <>µg/ml

Toxic: > 50 µg/ml

Vancomycin Imipramine

Trough: 5-10 µg/ml (8h post dose)

Peak: 30-40 µg/ml 150–300 µg/ml

Toxic: > 500 µg/ml

Do not advance if PR int. > 0.2

Gentamicin

Trough: <>µg/ml Phenytoin

Peak: 5-10 µg/ml neonates: 6-14 µg/ml

peds/adults: 10-20 µg/ml

Tobramycin Phenobarbital

Trough: <>µg/ml pediatric: 15-30 µg/ml

Peak: 4-10 µg/ml adult: 20-40 µg/ml

Table 12.3. Anxiolytic (after pain control)

Criteria: First—Address pain management

Second—Address posttraumatic stress disorder (PTSS) problems and then

Third—Use anxiolytics

Lorazepam dose: 0.03 mg/kg/dose PO or IV q4h

Acute patients: Taper benzodiazepines: reduce dose by 50% every 2nd day

Reconstructive patients: > 15 days on benzodiazepines, taper slowly, reduce dose every 3rd

day (may be tapered post discharge if necessary)

Itch

Step 1: Use moisturizing body shampoo and lotions.

Step 2: Diphenhydramine 1.25 mg/kg/dose PO q4h scheduled

Step 3: Hydroxyzine 0.5 mg/kg.dose PO q6h and

Diphenydramine 1.25 mg/kg/dose PO q6h

Alternate medication so that patient is receiving one itch medicine every 3 hours

while awake.

Step 4: Hydroxyzine 0.5 mg/kg/dose PO q6h

Cyproheptadine 0.1 mg/kg/dose PO q6h and

Alternate medication so that patient is receiving one itch medicine every 2 hours

while awake.

Management of Postoperative Nausea and Vomiting

Droperidol: 0.025-0.05 mg/kg/dose IV q4-6h PRN

Bowel Regimen

Start with 1 and 2 any time narcotics are given

1) Prune juice <>

> 5 yrs-4 oz

> 10 yrs-6 oz

2) (Colace) Diacetyl sodium

Less than 6 yrs of age 10-60 mg/day

Children 6-12 yrs of age 40-120 mg/day

Children more than 12 yrs 100-200 mg/day

Then add one of these if patient becomes constipated:

3) Mineral oil 1-3 oz day

4) Mini-enema (colace-glycerine) if no B.M. by noon

5 SBI enema if no B.M. by 1500 hours.

Table 12.4. Daily rounds worksheet

Date:

Name: _____________________________ Age: _____________ Home: __________

Burn Date: _________________________ Admit Date: ______

Height: ____________________________ Weight ___________ TBSA: __________

% of Burn: _________________________ % 3rd: ____________ SA Burn: ________

PBD#: POD#: for Genitourinary

I/O summary: ( )

Overnight concerns urine output: cc/kg/h

Fluid needs calculated* (% met last 24 hours)

lytes: BUN crt Na K Cl Mg P Ca

Vital Signs foley (yes/no) issues:

T: Tmax: at GU meds:

Respiratory Wounds

RR Grafts

ABG: pH PCO2 pO2 02sat on HCO3 BE Type Location Donor site(s)

Ventilator: mode RR TV 02sat F102 PEEP PIP

CT output:

CXR:

Pulm PE

Pulm meds: Cultures

DateAmt./OrganismLocation

Cardiovascular

P BP CVP

Cor PE State of wounds/

dressings:

Cor meds State of donor sites:

Antimicrobial meds:

Hematology

Blood given: PRBC whole other Neuro/Pain:

Colloid:

Labs: Hgb Hct WBCplt glucose ibili

TP alb AST ALT AlkP GGT osm If OR

blood ordered*:

Gastrointestinal skin ordered:

NCT residuals: NGT guaiac

Stool stool guaiac emesis:

Feeds

Caloric needs calculated*: (% met last 24 hours) Assessment:

Abd PE:

GI meds: Plan:

*use formula card to calculate

A

Acid burn 99, 100

Airway 6-8, 14, 18

Albumin 17, 18, 87

Alkali 98, 99

Alloderm® 43

Allograft split skin graft 27

Amikacin 78, 123, 126

Amphotericin B 78

Anesthesia 24-26, 53, 60, 62, 63

Antibiotics 78, 85, 93, 112, 121, 126

Arachidonic acid 82, 83

ARDS 84, 100

Arginine 67, 84

Autologous split skin graft 25, 28, 38,

39, 46

B

Bacitracin 75, 76

Bactroban 75, 76

Biobrane® 25-27, 40, 41, 49

Biological dressing 9, 23, 26-28, 40

Blisters 9, 22, 23, 25, 26, 55, 120

Bronchoalveolar lavage 77, 78, 125

Burn alopecia 116, 117

Burn depth 22, 25

Burn resuscitation 14

Burn scar 108, 109, 113, 118

Burn size consideration 2

Burn size determination 9

Burn surgery 35, 37

Burn units 3

Burn wound assessment 9, 21, 23

Burn wound infection 72, 73, 75

Burn wound treatment 1, 2, 21,

25-34, 47, 51

Burns 1-3, 5-12, 14, 17

C

Caloric needs 66, 67, 69, 70

Carbon monoxide 6, 54, 59, 90, 91

Ceftazidime 78, 123

Cement (calcium oxide) burn 99

Cervical spine stabilization 7

Chemical burns 6, 59, 97

Cultured epithelial autograft (CEA)

43, 44

Curreri formula 67

Cytokines 56, 82, 83

D

Dermagraft TC® 26, 40, 41

Dermatome 27, 33, 35, 37, 39, 43

Dietary composition 67, 68, 71

Disseminated intravascular coagulation

(DIC) 57, 88

Duoderm® 26

E

Electrocautery 24, 37, 38, 50

Endotracheal intubation 6-8, 55, 63

Enteral feeding 69

Eschar 9, 21, 22, 29, 30, 35, 37, 38, 75,

99

Escharotomy 9, 24, 102, 105, 106, 120,

121, 126

F

Face 1, 3, 7, 21, 26, 28, 29, 33, 35-38,

40, 44, 46, 92, 105, 107,

111, 114, 116, 121

Fasciotomies 102

Flamacerium 28

Fluconazole 78, 124

Fluid resuscitation 7, 9, 10, 12, 14, 18,

19, 81, 84, 93

Formic acid 100

Full-thickness burns 3, 20, 22, 24, 28,

29, 31-33, 35, 37- 42, 44, 45,

49

Fungal infection 38, 73, 78

G

Glutamine 67

Growth hormone 48, 49, 122

H

Hemodialysis 87, 100

Hepatic failure 87

High voltage injury 101

Hydrocarbons 100, 101

Hydrofluoric acid 99, 100

Hypertonic saline 18

I

Ice 6

Immunosuppression 73, 74, 78, 79

Inflammation 76, 81, 82, 84, 85, 92

Inhalation injury 1-3, 5, 10, 11, 18,

54-56, 58, 59, 62

Initial resuscitation 11

Integra® 30, 39-43

Intraoperative monitoring 60

Intubation 55, 62, 63

Itraconazole 78, 124

IV access 7

L

Line sepsis 76

M

Mafenide acetate 75, 76

Mepitel® 26, 27

Mesh graft 31, 32, 35, 44, 45

MODS (multiple organ failure

syndrome) 82

Mycostatin 75, 76, 120-122

Myoglobin 12, 18, 57, 102

N

Nitric oxide 82-84, 95

Nutrition 44, 57, 66, 68, 70

O

Omniderm® 26

Operations 107, 109-111, 125

Oxygen 5, 6, 54, 56, 57, 63, 66, 82-84,

87, 90-92, 94, 95, 98

Oxygen free radicals 82, 83, 84

P

Pain management 55, 63

Partial thickness burns 20, 22, 24, 27,

28, 30, 31, 37, 40, 41, 48

Patient-surgeon relationship 104,

105, 108-110, 112

Peritoneal dialysis 86

Piperacillin 78, 124

Pneumonia 63, 69, 73, 74, 77, 78, 82,

83, 85, 91, 93, 94

Polymyxin B 75, 76

Pre-Hospital care 5, 8, 13

Pulmonary failure 87

R

Reconstruction 104, 105, 108-114,

116-119

Renal failure 86, 100

Resuscitation formula 11

Rounds 120, 121, 125

“Rule of Nines” 9, 14, 15, 22

S

Scar release 118

Sedation 9, 25, 48, 55, 59, 60

Sepsis 27, 29, 30, 32, 39, 51, 56,

69, 73-76, 78-81, 83-85, 88,

90

Silvadene 26, 75, 76

Silver sulfadiazine 26-28, 75, 76

Skin graft 24, 25, 27, 28, 30, 32,

34-39, 43-47, 49, 50, 52

ankle 32, 107, 118

axilla 32, 46, 117

breast 32

buttocks 32, 46

elbow 32, 107, 117

foot 32, 101, 107, 118

genitalia 21, 26, 32, 44

hand 1, 3, 21, 28, 29, 32, 33,

35, 37-39, 44, 46, 55, 101,

105-107, 111, 117, 118

knee 32, 107, 118

lower limb 31, 32

perineum 3, 21, 26, 32

upper limb 31, 32

Skin graft knives 35

Skin substitute 29, 30, 34, 38-41

Smoke inhalation 74, 77, 90, 92

Stapler 35

Systemic inflammatory response

syndrome (SIRS) 81, 82,

84, 88

T

Tegaderm® 26

Tetanus 12, 120, 121

Thrombocytopenia 79, 88

Total parenteral nutrition (TPN) 68, 69

Tracheobronchitis 77, 78

Transportation 5, 8

U

Urinary tract infection 74, 77

V

Vaseline gauze 26, 27

Ventilator management 85, 90, 94

Vivonex TEN® 68, 70, 85

X

Xenograft 26-28, 40

Z

Z-plasty 111, 114

Zones of injury 20

Dedication

We wish to recognize all those who went before us to pave the path of

burn care at UTMB and the Shriners Burns Hospital in Galveston. The

development and growth of these units was begun primarily through the

efforts and support of Truman G. Blocker, Sally Abston, and James C.

Thompson. We dedicate this work to them.

Editors

Contributors

Steven E. Wolf, MD

Assistant Professor

Department of Surgery

Clinical Fellow (1996-1997)

Shriners Burns Hospital and Blocker Burn Unit

University of Texas Medical Branch

Galveston, Texas, USA

Chapters 1, 8, 10, 12

David N. Herndon, MD

Jesse Jones Professor of Surgery

Chief of Staff,

Shriners Burns Hospital and Blocker Burn Unit

University of Texas Medical Branch

Galveston, Texas, USA

Juan P. Barret, MD

Clinical Fellow (1997-1999)

Shriners Burns Hospital

and Blocker Burn Unit

University of Texas Medical Branch

Galveston, Texas, USA

Chapters 4,11

Peter Dziewulski, MD, FRCS (Plast)

Consultant Plastic and Reconstructive

Surgeon

St. Andrews Centre for Plastic Surgery

and Burns

Essex, United Kingdom

Clinical Fellow (1997-1998)

Shriners Burns Hospital

and Blocker Burn Unit

University of Texas Medical Branch

Galveston, Texas, USA

Chapter 4

Doraid Jarrar

Research Fellow

Department of Surgery

Brown University

Providence, Rhode Island

Fellow (1996-1998)

Shriners Burns Hospital

and Blocker Burn Unit

University of Texas Medical Branch

Galveston, Texas, USA

Chapter 8

Marc G. Jeschke, MD

Fellow (1996-1999)

Shriners Burns Hospital

and Blocker Burn Unit

University of Texas Medical Branch

Galveston, Texas, USA

Chapter 9

Ron Mlcak, RT

Director of Respiratory Therapy

and Inter-Hospital Transportation

Shriners Burns Hospital

Galveston, Texas, USA

Chapter 2

Victor M. Perez, MD

Clinical Fellow (1998-1999)

Shriners Burns Hospital

and Blocker Burn Unit

University of Texas Medical Branch

Galveston, Texas, USA

Chapter 6

Edgar J. Pierre, MD

Resident in Anesthesia

University of Miami

Miami, Florida, USA

Fellow (1994-1997)

Shriners Burns Hospital

and Blocker Burn Unit

University of Texas Medical Branch

Galveston, Texas, USA

Chapter 10

Peter I. Ramzy

Fellow (1997-1999)

Shriners Burns Hospital

and Blocker Burn Unit

University of Texas Medical Branch

Galveston, Texas, USA (1997-1999)

Chapter 7

Art Sanford, MD

Clinical Fellow (1998-1999)

Shriners Burns Hospital

and Blocker Burn Unit

University of Texas Medical Branch

Galveston, Texas, USA

Chapters 3,12

Arjav J. Shah, MD

Resident in Anesthesia (1995-1999)

University of Texas Medical Branch

Galveston, Texas, USA

Chapter 5

Acknowledgments

We wish to acknowledge the efforts of several, without which the following

handbook could not have been developed. The burn fellows and

residents shouldered most of this work. The efforts of all the nurses and

therapists should also be recognized. Lastly, the tireless work of our partner,

Dr. Manu Desai cannot go unmentioned. His innumerable contributions

to burn care are described in these pages.

Juan P. Barret

The severity of injury and deformity from burns ranges from relatively minor

to severe. Nevertheless, even minor disfigurements can have severe psychological

and social impact on the victim. The basic concerns are for function, comfort and

appearance. Normal and hypertrophic scarring, scar contracture, loss of parts of

the body and change in color and texture of injured skin are processes common

and unique to all burned patients. The burn surgeon has to prevent and minimize

deformity, fight the loss of function and restore normality when possible.

Plastic surgery patients expect the results of surgical treatment to be aesthetically

pleasing as well as functionally correct. This is also true for burn patients.

More than anyone else, their expectations as to what they want and desire are far

beyond the real possibilities of the state of the art techniques available.

As in the acute phase, a realistic approach solves later disappointments and

misunderstandings. An informed patient can understand the basis of the problem

and ask for reality.

Burn reconstruction starts when the patient is admitted in the acute phase and

lasts until the patient’s expectations have been reached and/or there is nothing

else to offer. However, it is normally a life commitment, and, although there may

be no other possibilities at that point, the patient-surgeon relationship still continues

(see Table 11.1).

ACUTE MANAGEMENT OF BURNS

Preventing of and minimizing scarring in burn patients starts during the acute

phase. Reducing the inflammatory and catabolic response after burn injury by a

team approach and early closure of the wound is paramount to control wound

healing in these patients. Early excision and grafting of deep partial thickness

wounds and full thickness wounds is, generally, the only way to control scarring.

The final result, though, is always unpredictable, as individual factors are difficult

Table 11.1. Characteristics of burn reconstructive plastic surgery

1. Start at acute period

2. Strong patient-surgeon relationship

3. Development of a “master plan”

Table 11.2. Techniques useful in the acute phase to diminish reconstructive needs

1. Use of darts in escharotomies when crossing joints

2. Use sheet grafts when possible

3. Place seams following skin tension lines

4. Place grafts transversely over joints

5. Use aesthetic units to the face and hands with medium thickness split skin grafts

6. Use of splints, face masks and silicone inserts as soon as possible

7. Early pressure therapy

8. Early ambulation and exercise

o predict and control.

It is preferable that the surgeon managing the acute injury will be responsible

for later reconstruction. If this is not the case, the reconstructive surgeon should

be consulted early on so that the needs for reconstruction enter into the plan of

the acute care.

Neck, oral and joint splints can prevent deformities. Good planning of face

grafts, extensive use of sheet grafts in all locations when possible and the presence

of living dermis during burn excision and grafting are of paramount importance.

On the other hand, bearing in mind the future reconstructive needs of the patient

helps to spare important areas for use as donor sites in the acute phase. Having,

for instance, a neck with normal, unscarred skin helps in resurfacing the face with

expanded tissue.

Different procedures are important during the acute phase to minimize later

reconstruction (see Table 11.2). Grafting the face with medium thickness skin

grafts in aesthetic units is of extreme importance to resemble a normal appearance

once mature scars in the area are present. Linear escharotomies should be

avoided, and darts, which help to break the direction of the incision (see Fig. 11.1)

when crossing joints, help to prevent linear hypertrophic scarring. Similarly, only

the dermis has to be incised when performing them. Fat does not produce a tight

compartment syndrome. If excessive pressure is still present after the escharotomy

has been performed, a closed blunt fasciotomy through a small incision should be

considered.

Graft seams should follow skin tension lines so that they resemble normal

wrinkles or folds. They should be longitudinal in the limbs, and grafts on the

joints must be placed transversely, perpendicular to the axis of the limb. This

maneuver avoids linear scars extending over and beyond joints.

Medium split thickness skin grafts give a good appearance on grafted hands. It

is the author’s belief that grafts should be placed following the axis of the limb,

with a seam placed between the second and third metacarpal bones (see Fig. 11.2).

In this way, the grafts extend from the dorsum of the hand to the fingers, and there

is only one longitudinal scar extending to the second web space. Grafting the dorsum

of the hand as a complete unit renders an unsightly and unpleasant scar over

the knuckles.

Splints, face masks, silicone gel sheets, early pressure therapy, ambulation and

skeletal traction and fixation are also of great importance to produce the best result and to avoid future operations.

Burn trauma requires aggressive rehabilitation to prevent debilitating deformities.

Burn distribution as well as burn depth is a good predictor of rehabilitation

outcome. Prevention of burn deformities includes proper positioning with

or without splints, exercise to maintain joint range of motion, maintenance of

muscle strength and muscle tone and early mobilization. All the above is also true

not only for the acute period but also for the reconstructive period.

Burn patients tend to assume the position of comfort, which is many times

responsible for deformities that require reconstructive surgery (see Table 11.3).

Positioning in bed is then one of the most important ways to prevent them (see

Table 11.4). Exercise reduces edema, maintains joint motion and strength, reduces

scars and maintains development. Ambulation can begin as soon as the patient is

deemed medically stable with wounds properly dressed and doubly wrapped.

Positioning and splinting affects many problems in the care of burned patients.

Splints are used for either immobilization or mobilization by using static

and dynamic splints. Initially splints are used at all times except for exercise and

immediately postop during the immobilization period. As active range of motion

increases and is maintained, protocol changes to night-only splinting. Skeletal traction

and fixation are used also on a limited basis to prevent and correct burn scar

contracture formation, always tailored to the patient’s needs.

Table 11.3. Position of comfort after burn trauma (to be avoided)

1. Neck flexion

2. Shoulder protraction

3. Elbow flexion

4. Metacarpal extension

5. Interphalangeal flexion

6. Wrist flexion

7. Hip flexion

8. Knee flexion

9. Ankle plantar flexion

Table 11.4. Prevention of deformity: positioning in bed

1. Maintain straight alignment of the trunk and neck

2. Neck should be in slight extension

3. Arms should be elevated in the neutral plane or in line with the glenoid at approximately

15-20° of horizontal flexion and 80° of abduction

4. Elbow should be in full extension

5. Hand should be in the intrinsic plus position with the thumb in flexion and abduction

6. Hips should be in extension and abduction

7. Knees should be in full extension

8. Foot should be in neutral position and 90° or greater dorsiflexion

IME OF RECONSTRUCTION

It has been proposed that definitive correction of burn scarring should be delayed

for one year or longer after healing. It is certainly true that inaesthetic and

ugly scars mature over time and with the effect of pressure and splints many of

them do not require surgery once the acute phase of scar maturation has taken

place. Patience, many times, is the best tool of the reconstructive surgeon.

Even though the former is in general true, there are certain procedures that

must be addressed before the golden period of scar maturation is over. When

considering burn reconstruction, there are procedures that are urgent, others that

are essential and many that are desirable. It is in the latter that the patient-surgeon

relationship, negotiation with the patient and a good rapport is necessary (see

Table 11.5).

Urgent procedures are those in which the golden period of scar maturation

does not apply, when it is absolutely certain that an operation is needed and noble

structures are exposed or are severely damaged. Urgent procedures are to be

planned to correct function that are not suitable amenable to treatments, often

because time is of the essence. An eyelid release to protect an exposed cornea,

correction of distracted or entrapped neurovascular bundles, severe fourth degree

contractures and severe microstomia fall into this group. Intense rehabilitation,

splinting and pressure therapy are mandatory after correction of these deformities.

Normally, skin grafts are necessary, since scars are very immature and

flaps may be at risk of complications at this time.

Essential procedures are those in which, although they are not urgent and important

structures or the overall health of the patient is not challenged, an early

operation may improve the late appearance and the rehabilitation of the patient.

At first, the deformity should be addressed nonoperatively. If this approach does

not lead to the appropriate results, an operation may be considered. In this section

fall all burn scar contractures that do not respond to rehabilitation and hypertrophic

scarring and contractures that prevent the patient from eating, bathing,

moving, and performing activities of daily living.

Table 11.5. Timing burn reconstructive surgery

1. Urgent procedures

• Exposure of noble structures (e.g., eyelid releases)

• Entrapment or compression of neurovascular bundles

• Fourth degree contractures

• Severe microstomia

2. Essential procedures

• Reconstruction of function (e.g., limited range of motion)

• Progressive deformities not correctable by ordinary methods

3. Desirable procedures

• Reconstruction of passive areas

• Aesthetics

Finally, we have the desirable reconstructive needs. Most of the problems fall

into this category. These are very often aesthetic problems and scar contractures

that, although not prominent, produce great discomfort to the patient. Many of

the problems disappear in the first two years postburn with appropriate care. These

are the problems that benefit most from patience and time. Many important deformities

seen a few months postburn, that would require extensive surgery, improve

with time, and can be treated with simple or less extensive procedures later

on. The author has found that in all desirable reconstructive procedures, it is a

good practice to wait until all red and immature scars have disappeared before

starting any kind of surgery. Many times an early operation is an unnecessary

operation under these circumstances.

Many factors other than scar maturation, however, affect the decision of when

to operate on burn scars. Psychological and socioeconomic factors are very important

when making a decision. The patient’s mood plays an important role,

since an unmotivated or depressed patient will not cooperate. Moreover, operating

on such a patient may produce discomfort and discouragement, which, eventually,

can diminish the patient’s compliance and prevent further reconstruction.

The social status of the patient is also of great relevance. Emotional support received

from friends, family and co-workers are important, as is his economic status.

When making a plan, all these particular circumstances need to be taken into

account.

PATIENT-SURGEON RELATIONSHIP

Burn patients, among all plastic surgery patients, need more care and a good

relationship with their surgeon. The relationship is normally a long lasting one,

many times extending for a lifetime. Patients require a surgeon’s professional expertise,

but also time, a good dose of optimism and compassion. Many times the

patient-surgeon relationship starts in the acute phase when the plastic surgeon

acts as the primary burn surgeon. Other times, the physician, at some point in the

patient’s recovery, refers him/her to the reconstructive surgeon. Nevertheless, in

both situations, the initial meeting is important. At that time, the patient presents

a set of complaints. The reconstructive surgeon will have to evaluate the complaints,

the patient’s motivation for surgery and the psychological status of the

patient. We have to remember, though, that the patient will evaluate the surgeon’s

attitude and conduct also. As with any other kind of surgery, it is very important

to know previous and current medical conditions, allergies, medications, operations

and other health history. If the reconstructive surgeon has not been involved

in the care of the acute injury, a complete record of the inpatient and outpatient

care pertaining to the burn injury should be obtained. Also, direct contact with

the referring burn surgeon is very important. The first meeting should be professional,

private and unhurried. At this time the surgeon has to determine the patient’s

motivation and expectations. This is an extremely important point in burn plastic

surgery. The patient’s expectations are usually unrealistic. They expect to be normal

again, and it is the surgeon’s responsibility at this point to assess the chief

complaints and explain to the patient the real possibilities. The patient has to

understand the limitations of surgery and that first function and then cosmesis

will be addressed. Although many times at the outset deformities or major problems

will be apparent and ready for surgery, it is preferable to have subsequent

visits before surgery, when further inquiries can be addressed and preparation for

surgery can be done unhurriedly. A photographic workup is extremely important

to document the case, assist in definitive preoperative planning and for documentation.

Burn reconstructive surgery is normally an elective procedure; however,

often different approaches may be considered before surgery. When dealing with

long-term scars and burn deformities, different problems may be encountered

intraoperatively that might require a complementary technique. These specific

issues of burn reconstructive surgery have to be explained in detail to the patient,

and the surgeon needs to foresee and include them in the preoperative planning

and the informed consent so that unpleasant surprises are not encountered later.

Patients need to be reassured frequently. The reconstructive surgeon needs to

know the patient’s fears and feelings as the reconstructive plan goes on. Several

times a burn reconstruction project involves more than 10 operations, many clinic

visits and often a long time to make a final assessment. The latter, in the case of a

small child, may be more than 18 years. The patient’s feelings and impressions

must be addressed continuously, and any trouble, minor disappointment or depression

detected early on and treated as needed. The author has found it very

helpful to maintain contact with the psychology team that worked with the patient

in the acute phase. Patients know, then, that they are available any time help

is needed. If this approach is not possible, finding a reliable and affordable source

for psychology support for patients is advisable.

Despite our best efforts, however, some patients ask to stop the reconstructive

process before all treatments and planned operations are performed. Patients become

more realistic as time and surgery go by, and sometimes they decide to cancel

future operations. If a good patient-surgeon relationship has been achieved,

many times this is just a small “honeymoon” for a patient that has been involved

with surgery for the last years. Most of them return to the office to continue the

process and achieve all possible reconstruction when their enthusiasm renews.

BURN RECONSTRUCTIVE VISIT: DEVELOPMENT

OF A MASTER PLAN

As noted before, a complete record of the acute hospitalization should be obtained

when possible. A thorough history and physical examination must be obtained.

Quality and color of the skin in the affected areas must be noted: abnormal

scars, hyper- or hypopigmentation, contractures, atrophy and open wounds.

Function has to be addressed next; all involved joints are examined and range of

motion noted. Any scar contracture extending beyond joints has to be defined

also. Next, skeletal deformities have to be addressed. Many times scar contractures

distort joints and the body maintains an abnormal position to overcome the deformity.

This is particularly true in children; the effect of traction on a growing

joint and bone can create long term deformities. In children, and in all patients

whose injuries were produced in childhood, a complete X-ray workup must be

obtained to examine the status of bones and joints. In severe restriction of function,

an X-ray must be obtained also to rule out heterotopic calcification.

The needs for physiotherapy, occupational therapy and pressure garments have

to be considered at this time. Also, if any of these devices are to be needed after the

operation, the patient has to be referred to the rehabilitation department. Finally,

an inventory of all possible sites for donor tissue is made.

Once patients have expressed all their chief complaints and a thorough examination

of the patient is done, a master plan is developed. All reconstructive possibilities

are discussed with the patient, and timing and order of such procedures is

outlined. Negotiation is the key point during this period. Many times what is most

evident and most unpleasant for a patient is one of the last problems to be addressed

by the master plan. All important points and pitfalls are explained to the

patient. The importance of addressing all urgent, essential and functional problems

first has to be understood by the patient. This is very important, since the

patient can be extremely upset when important cosmetic problems are disregarded

at the beginning and, on the other hand, other not such serious problems (to

them) are addressed first.

On developing a master plan it is important to start the reconstruction with a

“winner” for the first procedure. A small and easy operation, with few possible

complications and evident and quick improvement to the patient’s appearance,

such as an excision of a small hypertrophic scar on the face or a simple Z-plasty of

an unpleasant scar contracture are important procedures that can show the patients

what can be achieved with reconstructive surgery and encourage them to

carry on with the master plan. More complex and difficult operations are started

later, with an enthusiastic patient, since it normally takes longer for these complex

operations to demonstrate definitive benefits.

Finally, it is important to perform as many procedures as possible in the preschool

years in children and offer the patient multiple, simultaneous procedures.

Time, effort and money are thereby best invested. The essentials of burn reconstruction

are summarized in Table 11.6.

PATIENT CARE IN BURN RECONSTRUCTIVE SURGERY

Preoperative, intraoperative and postoperative care of burn reconstructive

patients include all techniques and special treatments of general plastic surgery

and any state of the art special plastic surgery techniques. The scope of procedures

performed in burn reconstructive surgery ranges from split thickness grafts to tissue expansion and microsurgery. The reader is referred to other selected readings

to find more specific plastic surgery techniques.

As stated previously, a good preoperative plan is essential to avoid later surprises.

The plastic surgeon operating on burn patients works most of the time

with scarred and injured skin. It is important to handle with extreme care all tissues

since vascularization in the area is normally altered. Patients are instructed to

stop smoking for at least three weeks before surgery. All meals and drinks containing

active vascular drugs need to be tapered, and any medications noted in order

to stop all unnecessary drugs. The patient is instructed also to avoid medications,

such as aspirin, that may increase intraoperative and postoperative bleeding. Uncontrolled

hypertension, cough, nausea and disorders of coagulation need to be

known by the surgeon and treated as needed, since they increase the risk of hematoma.

It is always advisable that the patients present for surgery with a responsible

adult who will take care of them after surgery.

The evening before surgery the patient is instructed to have the skin cleansed

with bacteria-reducing soaps and a light dinner is advised. Burn patients have

normally hypertrophic scarring, seams and intradermal cysts that are prone to

have a high bacterial load. It is advisable, also, to include in the plan perioperative

use of antistaphylococcal agents. If a skin flap or introduction of alloplastic material

is to be performed, antibiotics should be continued in the postoperative period

for at least two more doses. Intraoperatively, large doses of local anesthetics

are to be avoided, and the extensive use of electrocoagulation is minimized since it

increases the risk of necrosis of the scarred skin. Similarly, the use of subcutaneous

epinephrine is limited because of the same risks. All dermal or scar edge bleeding

is controlled intraoperatively with topical thrombin (1000 units/ml).

Smooth emergence from general anesthesia free of coughing and vomiting is

essential in burn reconstructive surgery, as are controlling high or low blood pressure

episodes, nausea and vomiting. Also, hyperactive and anxious patients may

benefit from anxiolytic medication to avoid sudden and uncontrolled movements

in the immediate postoperative period. Light dressings are applied after surgery,

and any high pressure avoided since it can injure burned tissue. Immobilization is

kept at a minimum, and passive and active range of motion are started as soon as

Table 11.6. Essentials of burn reconstruction

1 Strong patient-surgeon relationship

2 Psychological support

3 Clarify expectations

4 Explain priorities

5 Note all available donor sites

6 Start with a “winner” (easy and quick operation)

7 As many surgeries as possible in the preschool years

8 Offer multiple, simultaneous procedures

9 Reassure and support the patient

possible in the postoperative period. It helps to avoid edema formation, congestion

and recurrence of contractures. Splints, prostheses and pressure garments

have to be used either immediately or early after the operation. Rehabilitation is

normally part of the reconstructive master plan, so that it has to be included and

started after surgery. Silicone inserts to grafted areas have been found helpful to

control the early phase of scar maturation, as they apply gentle and uniform pressure

to the wounds and position joints. It is also very important to have good pain

control, since having a comfortable and cooperative patient helps positioning,

rehabilitation and the success of any operation. Patient-assisted analgesia is the

best option if the patient is able to use it. Other than that, hydrocodone and morphine

are good alternatives. Anxiolytics should be considered as part of the pain

control program, and the addition of anti-itching medications and anti-emetics

such as diphenhydramine and droperidol are very helpful. Finally, providing the

patient and family an environment that is cozy and relaxing helps them and the

burn reconstructive team to cope better with the periodic admissions, decreasing

fear and anxiety before every step in the progress of the reconstructive program.

SURGICAL APPROACH TO THE BURN RECONSTRUCTIVE PATIENT

Some progress has been made in burn reconstructive surgery in the last decades,

although its impact is not as dramatic as in other areas of plastic surgery.

Burn reconstructive surgery for many decades involved incisional or excisional

releases of the affected scars and skin autografting. However, nowadays, the first

approach should involve local or regional flaps. They provide new and vascularized

tissue to the area, they grow in children and render the best functional and

cosmetic result. These flaps can be raised either with normal skin or burn scar.

Even though it is generally true that burned tissue can be congested, ischemic and

necrotic, it can be used as a reliable flap if extreme care is used while raising the

flap and if the injured skin is left attached to the underlying tissues. This expands

burn reconstruction to new territories and techniques.

When considering the surgical approach to a burned patient, the surgeon has

to ask himself what is the patient’s primary complaint, what tissues are left, what

parts are missing and what sort of donor sites are available. The techniques available

for burn reconstruction are summarized in Table 11.7.

The chief complaint or complaints need to be carefully evaluated. If immature

scars or an increasing deformity is present and there is not an urgent or essential

procedure to be performed, pressure garments and occupational and physical

therapy are indicated. If the deformity is stable and there is a need for reconstruction,

an inventory of donor sites and priorities are to be performed. At this point,

tissue deficiency has to be assessed. If there is no deficiency and local tissues can

be easily mobilized, excision and direct closure or Z-plasties can be performed

(see Fig. 11.3). On the other hand, if there is a deficiency in tissue, the need for

reconstruction of underlying structures needs to be addressed. If the deformity

Table 11.7. Techniques available for burn reconstruction

1. Without deficiency of tissue

• Excision and primary closure

• Z-plasty

2. With deficiency of tissue

• Simple reconstruction

- Skin graft

- Transposition flaps (Z-plasty and modifications)

• Reconstruction of skin and underlying tissues

- Axial and random flaps

- Myocutaneous flaps

- Tissue expansion

- Free flaps

affects the skin and subcutaneous tissues, skin autografting, Z-plasties, and all the

modifications of them, such as trident flaps, are advised (see Fig. 11.4). When

reconstruction of underlying structures is necessary, flaps are considered, including

direct cutaneous, musculocutaneous, expanded and free flaps. The choice is

made then on a patient per patient basis. Many times, composite grafts and bone

or cartilage grafts are also necessary in order to perform a complete reconstruction.

The use of alloplastic materials in these circumstances is not advisable because

of their tendency to extrude.

In summary, even though incisional release and skin autografting is still the

technique most used in burn reconstruction, flaps should be used when possible

(remember that Z-plasty and its modifications are transposition flaps). The burn

reconstruction plan needs to be tailored to the individual patient and the chief

complaint since some anatomic areas are best suited to specific techniques.

OVERVIEW OF BURN RECONSTRUCTION

HEAD AND NECK

Burns to the head and neck are still a challenge to the burn team. Residual

deformities produce severe distortion with disfigurement and functional limitations.

Bridging scars from chin to neck to anterior shoulder results in exaggerated

kyphosis with neck flexion and protraction of the shoulders. Prevention of these

deformities is very important to minimize later reconstruction. Neck splinting in

hyperextension, pressure garments, mouth spreaders and facemasks are an important

part of the acute care that affects outcome. Early excision of full thickness

burns to the face and skin autografting in aesthetic units is extremely important

to produce a natural appearance of the grafted face. Contractures to the eyelids

are often urgent procedures that are performed before the rest of the scars are

mature. The most frequent deformity is the ectropion, although more severe cases

present with distraction of the canthal folds, fusion of part of the eyelids and

distortion of the lacrimal punctate. Release of upper and lower eyelid contractures

has to be performed separately, with undermining of the surrounding tissues. Full

thickness grafts are most suitable for lower eyelids where stability is the goal, while

split thickness skin autografts are used for upper eyelids to improve mobility. Microstomia

is another deformity encountered in facial burns. It can interfere with basic

function such as nourishment and speaking. Lip ectropions and deformity of

commissures are common. Skin grafts are most suitable for the former, but local

flaps are better for the latter problem. Small deformities to the lips, however, can

be solved many times with patient-tailored local flaps. The nose is a prominent

focus on the face, since it is an aesthetic landmark. Different degrees of deformities

can be found in this area. Subtotal destruction of the nose and tip can be

restored with a forehead flap, with or without previous expansion. In these situations,

support of the nasal tip area needs to be provided, and for that purpose

mucocartilaginous flaps from the nasal septum or helical rim composite grafts are

of benefit. In less severe deformities, local flaps and composite grafts are the techniques

of choice. Other passive deformities include ear deformities. Ear reconstruction

in burned patients can be done with rib cartilage grafts. If there is no

suitable subcutaneous pocket, a superficial temporalis fascial flap can be used to

provide the framework, with a split thickness skin graft on top. Other times, tissue

expansion to the retroauricular area can be performed prior to the creation of a

rib cartilage framework.

Neck contractures are deformities that affect function and normal living. Generally,

they have to be addressed before any passive reconstruction to the face is

started. It is also advisable that in the presence of a concomitant lower lip ectropion,

a neck release is performed first, and the remainder of the lip ectropion

addressed later, if it is still present. Many times the lower lip ectropion is caused by

severe neck contracture, and after correction the lip contraction subsides or is

minimized. When neck contractures are present and do not respond to physiotherapy,

an early operation is advised. Localized bands are best treated with local

flaps, but more severe contractures require incisional or excisional release, depending

of the extension of the deformity and skin autografting. Silicone inserts

and neck splinting are essential to prevent recurrences.

BURN ALOPECIA

One of the areas where the effects of the burn injury are most noticeable is the

scalp. Healing of deep partial and full thickness burns very often lead to areas of

scalp alopecia. This produces an important psychological impact on the patient

since it affects self-esteem and image. Small areas of patchy alopecia can be effectively

treated with excision and direct closure; however, tissue expansion is still

the gold standard of treatment for burn alopecia. McCauley et al classified burn

scalp alopecia in terms of the pattern and the extension (see Table 11.8). This

classification has proved very useful in our approach. Patchy burn alopecia extending

across the entire scalp or total alopecia are not suitable for reconstruction.

On the other hand, alopecia extending to up to 50% of the scalp can be

corrected with single expansion and closure, whereas larger areas of alopecia or

different concomitant segments of alopecia can be managed with sequential expansion.

Many times overinflation of the expander is necessary, and it is important

to bear in mind that expanded tissue normally contracts 20%. Care of these

patients is similar to any patients undergoing tissue expansion.

UPPER EXTREMITY

Hypertrophic scars and contractures to the upper extremity promote the position

of comfort: protraction and adduction of the shoulder, elbow in flexion and

the “burned hand position”: wrist in flexion, metacarpophalangeal extension, interphalangeal

flexion and first metacarpal extension and adduction. Overall appearance

of the hand is that of a “claw deformity”. Many of these problems can be

prevented with splinting and the arm elevated in the neutral plane or in line with

the glenoid at approximately 15-20° of horizontal flexion and 80° of abduction,

elbow in full extension and hand in the intrinsic plus position with thumb in

flexion and abduction.

Linear contractures to the shoulder can be addressed with local flaps. Many

times four and five flap Z-plasties are very useful. When the contracture extends

to all or nearly all the axilla, incisional release and autografting is preferable, although

regional rotational flaps can be used if available. It has to be noted, however,

that a contracture of the axilla cannot be released at the same time a neck

release is performed since it is not possible to maintain correct neck hyperextension

while abducting the shoulders in the postoperative period. The neck needs to

be addressed first, followed by the shoulder release, allowing a perfect result in

each operation.

Contractures to the elbow normally include flexion deformity, which is best

addressed with local Z-plasties or, when not possible, incisional release and

autografting. It must be noted, however, that heterotopic calcification has to be

ruled out when dealing with limitation of extension.

The most common deformities of the hand are wrist and dorsal contractures

with extension, web space contractures and boutonniere deformities. Extension

deformity to the wrist and dorsum of the hand normally requires an incisional

release and autografting, whereas web space contractures are best reconstructed

with local flaps. Sometimes a skin autograft is necessary to add length to the reconstruction

of the linear contractures. Boutonniere deformities need reconstruction

of the extensor mechanism. If contracture to the palmar surface coexists, a

Table 11.8. Classification of burn alopecia (after McCauley et al)

Type 1: Single alopecia segment

- A, less than 25%

- B, 25-50%

- C, 50-75%

- D, 75%

Type 2: Multiple alopecia segments amenable for tissue expansion

Type 3: Patchy burn alopecia

Type 4: Total alopecia

full thickness graft or a cross finger flap is necessary. Extensor tendon destruction

or adhesions are normally treated with tenolysis, and, if tendon repair is necessary,

a flap must be considered. Finger transfers, thumb lengthening and internal

and external fixation are to be considered in severe and selected cases.

One of the most important parts of the reconstruction of the burned hand is

the rehabilitation plan. It must be started as soon as the skin coverage is stable.

Pressure therapy, web spacers and night splints are necessary to achieve the expected

results.

LOWER EXTREMITY

Severe burns to the lower extremity can be a source of morbidity. Deformity to

the feet can affect gait. Severe destruction may even prevent standing. A good and

durable skin coverage must be supplied to these areas in order to improve weight

bearing and gait. Good acute care can prevent some of the deformities to this area.

Excision and grafting to all full thickness burns with early ambulation and physical

therapy are important to prevent them. When in bed, feet should be in the

neutral position and 90° or greater dorsiflexion. Orthopedic shoes and metatarsal

bars are helpful in positioning foot burns in infants and small children.

Hip flexion is the position of deformity for burns that extend from the abdomen

to the thigh. Bilateral symmetric involvement results in increased lordosis

and/or knee flexion. Knee burns, whether anterior or posterior, most often impose

knee flexion.

The most common deformity to the foot and ankle occurring in deep burns is

equinovarus deformity. It includes ankle in equinus, hind-foot inversion and forefoot

varus and equinus. Intrinsic deformities of the foot occur from extreme extension

of the toes from dorsal foot burns. Rocker bottom foot occurs when both

anterior and posterior scars are present.

Linear scars to the lower extremity should be treated with local transposition

flaps when possible. If wide scar bands extend over and beyond the joints, incisional

release and autografting is performed. Equinovarus deformity is first addressed

with serial casting of the involved area. When this technique is not effective, release

and coverage with local flaps or autografts is advised. Severe and long term

deformities benefit from the Ilizarov technique to reverse burn scar contracture.

Intrinsic deformities to the foot include dorsal deformity of the toes and shortening

of the transverse and longitudinal axis. These are normally best treated with

transverse burn scar releases and skin autografting with extension of the incision

to the longitudinal axis if restoration of the normal transverse arch is needed.

Web contractures to the toes are approached as in the burned hand. Internal fixation

of the toes is sometimes needed when severe subluxation of the metatarsalphalangeal

joint is present.

SUMMARY

Burn patients are an important challenge to the reconstructive surgeon. Reconstruction

starts the first day after the initial injury and may last for a lifetime.

Proper acute care and prompt rehabilitation diminish later reconstructive problems.

A close patient-physician relationship is essential to render the best ultimate

outcome. The reconstructive surgeon becomes at the same time friend, counselor

and physician. All plastic surgery techniques are applicable to burn reconstruction,

but they need to be tailored to the individual. Finally, extreme care on handling

tissues and conscientious postoperative care are essential to optimize the

results.

Burn survivors deserve all the admiration and respect from all health care professionals

involved in their care. A strong commitment from the reconstructive

surgeon is essential.

SELECTED READINGS

1. Total Burn Care. Herndon DN, ed. Saunders. London 1996.

2. Patient care in Plastic Surgery. 2nd edition. In: Barrett BM Jr., ed. St. Louis: Mosby

1996.

3. Operative techniques in plastic and reconstructive surgery. Face burns: Acute

care and reconstruction. In: Engrav LH, Donelan MB. Saunders May 1997.

4. Plastic Surgery. Volume 3 The Face, Part 2. McCarthy JG ed. Philadelphia: Saunders

1990.

5. Burn reconstruction. In: Achauer BM ed. New York: Thieme 1991.

6. Inventory of potential reconstructive needs in the patient with burns. In: Brou

JA, Robson MC, McCauley RL. J Burn Care Rehabil 1989; 10:555-560.