A retrospective survey was made of 123 reconstructive procedures for 108 post-burn face deformities performed since 1978 in the clinic of Hacettepe University Faculty of Medicine Department of Plastic and Reconstructive Surgery. All the patients had suffered severely deforming flame and chemical burns in the face. All were attended with the aim of reconstruction, having received their early treatment in a number of different clinics. None of the patients had received any hypertrophic scar preventive therapy, such as the application of pressure garments, silicone pads, splints, or inserts during the late phases of wound healing. The reconstructive procedures were analysed in two different categories in relation to the time of reconstruction, i.e. essential procedures and elective late procedures of burned face reconstruction (Table I).

For neck release, Z-plasties and local flaps were used to release scar bands, but in cases presenting severe skin defects, skin grafts were the choice of reconstruction, followed by the use of collars (Table II) (Cases 1,2).

As microstomia is an important deformity which alters oral function, it is reconstructed as early as possible. Such cases were released by local mucosal flaps as an initial step. Aesthetic repair of the lips, nasolabial angle, and moustache was postponed to a later stage (Case 3).
Eyelid release was performed as an early reconstructive procedure for the restoration of proper eyelid function, which is essential for the eye. The release of scar tissue by means of skin grafts and the prevention of secondary contraction by tarsorrhaphy are the usual procedures used for eyelids (Case 4).
For the resurfacing of the burned face good quality split-thickness skin grafts were normally used in relation to the aesthetic units of the face. In some cases expanded skin flaps and free flaps were also used to restore the face (Table III) (Cases 5,6,7).

For nasal deformities, partial alar defects were reconstructed by composite grafts and local flaps. For total nasal reconstruction forehead flaps were used without hesitation, even if the forehead was scarred (Table IV) (Case 8).

As partial defects of the ear can be reconstructed by composite grafts or local flaps, the preferred method for total ear reconstruction was a one-stage replacement of costal cartilage frames covered by temporal fascia and skin grafts (Table V). A different procedure not among the classic methods was adopted in a case of total ear loss in which superficial temporal fascia with its overlying alopecic skin was used as a fasciocutaneous flap to cover the ear framework (Case 9).

For moustache reconstruction in three patients, a classic procedure was adopted in three patients, with hair-bearing skin flaps used as island flaps based on the superficial temporal artery (Case 3).
For eyebrow reconstruction composite scalp grafts were the usual choice (Table VI) (Case 10).

Case 1
A 12-year-old boy presented with a neck contracture five months after suffering scald burns. The contracture was released and the skin defect was covered by splitthickness skin grafts. The patient used a cervical collar post-operatively for six months (Fig. 1).

Fig. la - Case 1: Neck contraclure Fig. Ib - Case 1: Released by skin graft.

Case 2
A 10-year-old girl had a severely deforming skin contracture in the neck as a result of scalds seven months before attending. The mandibular movements and mouth opening were limited by the contracture. After release by skin graft the patient was advised to wear a cervical collar for six months. However she abandoned the collar earlier than recommended and the contracture partly recurred (Fig. 2).

Fig. 2a - Case 2: Neck contracture. Fig. 2b - Case 2: Late result after 6 months.

Case 3
A 24-year-old man was severely burned by phosphorus in an industrial accident. His mouth and nostril openings were severely damaged. The microstomia and nostril rims were released immediately and the patient used nostril retainers for six months. After the essential problems had been solved moustache reconstruction with temporal island scalp flaps was performed electively (Fig. 3).

Fig. 3a - Case 3: Severely burned face with microstomia Fig. 3b - Case 3: A release of microstomia.

Case 4
A 47-year-old man presented with left eye ectropion as a result of burns seven months before he attended. As an essential procedure the scar tissue on the left cheek was released and reconstructed by means of a skin graft. Permanent tarsorrhaphy was used until the skin graft took (Fig. 4).

Fig. 4a - Case 4: Ectropion of lower eyelid Fig. 4b - Case 4: Late result after 8 months.

Case 5
This 24-year-old woman had burn scars on the left side of the face which altered the comer of the mouth. The deformity was electively reconstructed by an expanded skin flap from the left mandibular region (Fig. 5).

Fig. 5a - Case 5: Irregular scars Fig. 5b - Case 5: Skin expanded. on left of face Fig. 5c - Case 5: Late result after 6 months.

Case 6
This was a 21-year-old woman with severe flame burns. She was treated first with a mouth splint and nostril retainers to prevent contraction of the mouth and nostril rims during early care. Fourteen months later the lower lip and chin deformities were reconstructed by means of an expanded skin flap from the neck. About two years later, the left cheek and nasal dorsum were reconstructed by a free scapular skin flap (Fig. 6).

Fig. 6a - Case 6: Severe burn deformity on left of face. Fig. 6b - Case 6: Expanded skin from neck used to replace the scars in mandibular region Fig. 6c - Case 6: Nasal dorsum and cheek reconstructed by free scapular flap

Case 7
A 27-year-old man who had been severely burned in childhood and subjected to several reconstructive procedures attended in order to have his face resurfaced. The skin over the nose and cheeks was replaced by free radial forearm flap (Fig. 7).

Fig. 7a - Case 7: Severely deformed face. Fig. 7b - Case : dorsum of nose and bilateral cheeks reconstructed 5 months later.

Case 8
This 34-year-old man had a severely deformed face as a result of chemical burns. The eyelid defects were reconstructed by skin grafts. The nose was electively reconstructed by a nasal hinge flap for the nostril rims and a forehead flap for the dorsum of the nose (Fig. 8).

Fig. 8a - Case 8: Severely burned face. Fig. 8b - Case 8: Lower part of nose reconstructed. Fig. 8c - Case 8: Upper part of nose reconstructed.

Case 9
A 9-year-old girl suffered flame burns in the right side of the face and scalp five years previously. The right car was completely lost and the right half of the scalp was covered by a mesh graft when she attended. A 400 cc tissue expander was placed under the scalp in the left parietal region in order to advance hair-bearing skin to the alopecic region. As the expanded skin was advanced to replace the alopecic area, the ear was reconstructed by a costal cartilage frame covered by the excised alopecic, matched grafted skin as a flap pediculed by the superficial temporal artery. Although it was planned to reconstruct the alopecic area on the occipital part of the head, the patient failed to attend for further treatment (Fig. 9).

Fig. 9a - Case 9: Alopecia in right half of scalp with total ear loss. Fig. 9b - Case 9: Left parietal scalp expanded to restore alopecic right parietotemporal region; this alopecie area was intended to be used as a flap based on the superficial temporal fascia for eat reconstruction. Fig. 9c - Case 9: Left parietal scalp expanded to restore alopecic right parictotemporal region; this alopecic area was intended to be used as a flap based on the superficial temporal fascia for ear reconstruction. Fig. 9d - Case 9: Ear reconstruction achieved by costal cartilage frame covered by temporal fasciocutaneous flap. Fig. 9e - Case 9: Late result after one year.

Case 10
This 10-year-old boy suffered flame burns in the face at the age of three. The alopecic forehead scalp had been reconstructed by the advancement of hair-bearing scalp from the back. The eyebrows were reconstructed by composite scalp grafts (Fig. 10).

Fig. 10b - Case 10: Eyebrow reconstruction by complete scalp grafts. Fig. 10a - Case 10: Face burn as a result of flame.

Facial integrity was functionally restored in all the patients by essential procedures such as neck, microstomia and eyelid release. Neck contracture partly recurred in one case in this group as the patient showed intolerance to collar usage (Case 2).
The results of elective procedures can be accepted as aesthetic improvements rather than as complete restorations of the original. Resurfacing procedures had limited success because of the difficulty of concealing the flap margin in expanded flaps and free skin flaps (Cases 5 and 7). The loosening of free skin flaps was another unwelcome result, giving the face a flaccid, bulky appearance (Case 7). Eyebrow and moustache reconstructions by means of scalp flaps pediculed by a superficial temporal artery were satis-factory - this was the most reliable method of hair-bearing skin flap transfer (Case 3). Eyebrow reconstruction by means of composite skin grafts resulted in partial hair loss (Case 10). For ear reconstruction the best results were obtained by costal cartilage frames covered by temporal fascia with skin grafts as a one-stage procedure (Case 9).

Discussion

Efforts to minimize the potential disabling deformities of head and neck burns should be initiated during the acute period. The priorities include the functional goals of the preservation of visual and oral competence, the minimization of tissue loss, and the prevention of deforming chondritis and neck contracture .4 Specific concerns during the acute phase are the prevention of functional deformities such as eyelid ectropion and microstomia and the preservation of the oral and nostril apertures. Early treatment of these problems may make later surgery unnecessary. After healing of the wound and the use of splint inserts, pressure garments and silicone pads for pressure therapy for the elimination of scars and the correction of deformities, reconstructive procedures can be planned.Most of the patients in this study who attended for reconstruction had received acute burn therapy in other clinics and they presented severe deformities as a result of deficient therapy in the early phase of wound healing.
Ideally, reconstructive efforts for improved appearance are delayed until a mature scar is present. The length of time varies between six months and two years, and may even vary in the same patient from one area to another. In the case of deformities affecting functional goals such as neck contracture, microstomia and eyelid ectropion; early reconstruction is necessary without waiting for scar maturation. These types of reconstructive procedures can be regarded as essential procedures of post-burn face reconstruction.
In particular, eyelid deformities should be considered for early reconstruction in order to prevent comeal ulceration and conjunctivitis. The release should be extensive, and aesthetic units should be considered.' Conjunctival tarsorrhaphy is necessary for several weeks until the graft takes. Tarsorraphy is not otherwise advised because of the deforming effects on eyelid margins.
Neck contractures making intubation difficult and risky and other distorting facial features necessitate early release and reconstruction. For moderate and mild deformities band release by Z-plasties and local skin flaps are usually sufficient, but for severe deformities such as cervicomental and mentosternal adhesions contracture release necessitates tissue transfers such as skin grafts or free skin flaps. Flaps of bulky appearance are not recommended if they deform the cervicomental angle.' For skin-grafted necks, a period of six months of cervical collar usage is advised as otherwise contracture may recur. The patient's compatibility is therefore important in this type of reconstruction.
Other urgent procedures are microstomia release to allow the mouth to open for feeding and breathing functions and for access for anaesthesia and dental care, as well as nostril release for breathing functions. This can be achieved by adjacent mucosal flaps and skin grafts. 10-14 To prevent secondary contracture, nostril retainers and mouth splints are recommended to be used for at least six months.
Aesthetic restoration of the face for an acceptable normal appearance can be delayed until the scars are mature. After a certain time the scars may become less prominent, thus reducing the need for reconstructive procedures.
The resurfacing of the face by means of good quality skin grafts, paying special attention to the different aesthetic units of the face, is the usual method of scar replacement for the restoration of better appearance Staged reconstruction by means of neighbouring flaps and tissue expansion of cervical skin with the subsequent advancement of burned neck skin on to the face is another solution, but this type of reconstruction may limit neck movement and lead to lower lid ectropion by creating tension. In larger areas free skin flaps are recommended, although in some series they are criticized owing to their bulky appearance.
For reconstruction of the nose, local flaps and skin grafts are advised, if they are possible.  In the case of severe deformities needing total nasal reconstruction, forehead flaps or distant tissue transfers may be necessary.21 Forehead flaps are not recommended as they create another scar on the face. 3,4 In the cases presented here, nasal reconstruction was performed by means of flaps from the burn-scarred forehead, the donor area being cover-ed by good quality skin graft. In this way forehead resurfacing was achieved at the same time.
Partial car defects can easily be reconstructed by composite grafts' and local flaps such as post-auricular tube flaps and conchal or helical chondrocutaneous flaps . For total ear reconstruction all the classic techniques for microtia and traumatic ear deformities are recommended. Total reconstruction of the burned ear is more difficult than other deformities because of the poor quality of the skin.' In the cases presented here the best results were obtained by a one-stage reconstruction by means of costal cartilage frames covered by superficial temporal fascia with skin grafts. In alopecic scalps this technique can be modified to a reconstruction with fasciocutaneous flaps for covering the costal cartilage frames, as presented in one case.
Moustache and eyebrow reconstruction by island scalp flaps based on the superficial temporal artery is a classic and reliable method. However, for eyebrow reconstruction, these flaps are not always recommended because of the heavy hair density and the side-effect of temporoparietal alopecia. Instead, composite scalp grafts can be used for this process, although some hair follicles may be lost in the transfer process. To avoid this problem, the technical details of harvesting scalp grafts were studied.

RESUME. Pendant une période de 15 ans (1978-1993) les Auteurs ont effectué 123 procédures pour la reconstruction de difformités du visages dues aux brûlures chez 108 patients. Certaines procédures étaient essentielles, comme par exemple la libération du cou, de la microstomie, et de l'ectropion palpébral, moyennant des greffes cutanées, des plasties en Z, et des lambeaux locaux. Ces procédures de reconstruction, étant les premiers pas vers la réparation du visage brûlé, ont été effectuées aussitôt que possible, même sans attendre la maturation cicatricielle. Comme procédure aesthétique la surface du visage a été recréée moyennant la dermabrasion et l'emploi de greffes cutanées. Dans certains patients les Auteurs ont employé des lambeaux cutanés expansés ou des lambeaux libres. Pour la reconstruction des sourcils ils ont utilisé des greffes cutanées pilifères ou des lambeaux cutanés pilifères avec pédicule dans la fascia temporale, pour la reconstruction du nez des lambeaux locaux ou des lambeaux du front, et pour la reconstruction des moustaches des lambeaux cutanées pilifères de la région temporopariétale. La reconstruction de l'oreille s'est révélée une procédure difficile à cause de la qualité médiocre de la peau; les meilleurs résultats ont été obtenus quand l'oreille a été reconstruite moyennant des structures cartilagineuses costales couvertes par la fascia temporale et par des greffes cutanées.

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