Annals of Burns and Fire Disasters - vol. X1 - n. 3 - September 1998

BURNS SEQUELAE AND THEIR PLACE IN THE ACTIVITY OF OUR CLINIC

Belba G., Isaraj S., Xhepa G., Belba M., Ula N.

Clinic of Burns and Plastic Surgery, University Hospital Centre, Tirana, Albania

SUMMARY. The clinic of Burns and Plastic Surgery at the University Hospital Centre, Tirana, deals with a broad spectrum of surgical diseases. A considerable part of this activity consists of burns sequelae. This paper gives a general view of this activity during 1996, and then concentrates on the surgical treatment of burns sequelae. We compare the different groups of pathologies treated surgically, present a surgical image of our clinic, and discuss medical concepts in a clinic of this type. Statistical data make it clear that medical propaganda, research, and the long-term follow-up of burn patients are the most efficient means of preventing burns and their sequelae.

Severe burns inevitably leave sequelae that later on will require plastic surgery. In our country, Albania, in addition to this group of patients, there is a second category of patients who have sustained minor, unproblernatic burns but who subsequently develop similar sequelae that necessitate surgical procedures. This is either because they have received inadequate, unqualified out-patient treatment or because they have ignored the medical care prescribed to them.
Plastic surgery, clinics in developed countries report an insignificant number of burn patients undergoing plastic surgery, compared with the overall number of burn patients treated. The reason for this is that in advanced countries burns sequelae are prevented, rather than treated. Consequently, most of their activity is taken up by trauma surgery, microsurgery and aesthetic surgery.
Meanwhile, in developing countries, the proportion is changing slowly, with surgeons remaining loyal to their old traditions, so that the surgery of burns sequelae still constitutes the greatest part of their activity. This comes from two constant sources: patients with recent contractures who refused early coverage of the wound, and patients with burns left untreated for a long period of time, leading to abnormal scarring.
We are aware of the importance of introducing new concepts, and in this paper we seek to give a statistical view of the surgical activity of our clinic, concentrating on the surgery of burns sequelae. Our aim is to draw attention to the importance of preventing sequelae in the treatment of burns and of selecting the appropriate surgical procedure in cases where sequelae have already occurred.

Clinical material

In all, during 1996, 732 burn patients were admitted to the Burns and Plastic Surgery Clinic at the University Hospital Centre in Tirana (Albania). Our surgeons carried out 683 surgical operations, as follows:

1. 123 operations on burn patients, i.e. excision and skin grafting applied in 16.8% of burn patients, constituting 18% of all surgical operations
2. 263 operations (38.5%) performed to correct burns sequelae
3. 124 operations (18.2%) concerned with cutaneous and soft tissue neoplasia
4. 120 operations (17.6%) aimed at wound closure (including wounds of various origin: avulsions, pressure sores, phlegmons, abscesses and wounds of neurotrophic origin)
5. 32 operations (4.6%) for aesthetic procedures, mainly rhinoplasty, otoplasty and lipoaspiration

6. 21 operations (3.1%) for corrections of congenital deformities, tattoos, ingrown nail, phymosis, etc.

Regarding the 263 patients operated on for burns sequelae, 120 (45.6%) were male and 143 (54.4%) female; 157 (59.8%) came from urban zones and 106 (20.2%) from rural zones of our country. The distribution of sequelae according to age is shown in Table I. Regarding the different types of sequelac, we treated 98 contractures (37.3% of the operations), 73 scars (27.7%), 19 keloids (7.3%), 79 alopecias (11.0%), 13 ectropions (4.9%) and 31 trophic ulcers (11^). The commonest contracture site was the hand (52 cases); the other sites were the neck (12 cases), elbow (9), axilla (8), foot and fingers (8) and, less frequently, other areas of the body. Deforming scars and keloids were frequently seen in the face (44 cases), while ulcerations mainly involved the lower limbs (21 cases were located in the popliteofemoral, crural and foot regions).
The patients' hospital stay varied from 6 to 40 days, depending on the type of disease. The condition of the patients on discharge from the clinic was generally good, with primarily healed wounds, except for 24 patients who were however considered to have left the clinic in an improved condition following non-definitive treatment of keloids, alopecias or trophic ulcers.

Discussion

The prevalence of operations on burns sequelae in the activity of our clinic indicates a tendency towards a conservative rather than a surgical approach to burns. Although we ourselves consider this wrong and unacceptable, it is an approach that cannot be completely eradicated if we continue to rely only on medical propaganda, without achieving improvements in the social background and general well-being throughout the country. This is related to the underestimate most people make of the gravity of burn wounds, their delayed arrival in specialized burn centres, and their refusal of possible grafting procedures proposed by the medical staff. The prevalence of patients coming from urban zones compared with those from rural areas is due to the higher social background of the urban patients and their vicinity to consultative and therapeutic facilities. More cases from rural areas might be detected through regular checking of burn patients in villages, where for various reasons they do not receive appropriate medical care.
Table I shows that the majority of our patients are children and that hand contractures are common events. To prevent the occurrence of this problem, it is important that as soon as a surgeon detects contractile features in the epithelialization process he/she must persist with explanations to convince the patients' family of the necessity of early surgery.` When faced with the common phenomenon of misguided resistance to surgery, medical propaganda must be persistent and intervene in good time, not surrendering to initial refusal and not considering the first discussion with relatives to be final and definitive. A careful explanation of the importance of preventing tissue fibrosis and joint stiffness will lead to a reduction in the incidence of contractures, which not infrequently cause irreversible functional changes. Complications may of course occur even after surgery, but these will be less problematic and more easily amenable to later surgery. The ultimate aim is to obtain as few bad contractures and abnormal scars as possible. It is better for surgeons to report these cases and the results achieved after surgical correction than to surprise others with their surgical skills and with the indifference they showed when permitting such complications to occur.

The types of surgical procedure applied in cases of burns sequelae are shown in Table II. We consider the application of split-thickness skin grafts, sometimes combined with Z-plasties, to be the best way to correct a contracture. Flaps are used only occasionally, and the simple approximation of wound edges is not used in dealing with contractures because of the certainty of recurrence that follows its application.' Post-burn scars and keloids are treated by multistaged excisions, detachment and approximation of the wound edges. When this procedure is impossible, the only obligatory - and, at the same time, convenient, method - is tissue expansion, which also provides a better final appearance of the wound.

Tissue expansion is considered invaluable in cases of alopecia." Even though there may be a shortage of the necessary materials, this technique is finding broader fields of application. Table II shows how that this technique has been successfully used in a patient with a trophic ulcer, in which the size, local condition, and the absence of defon-ning scars in surrounding tissue made the technique possible.
The application of flaps in eight patients who needed reconstructive procedures after ulcer removal is to be noted. The transfer of flaps with a good blood supply to such poorly trophic areas is a meaningful and progressive concept for definitive, qualitative solutions.
In this context, special attention must be paid to the kind of anaesthesia used in the correction of burns sequelae. Table III shows that general endotracheal anaesthesia was used in 119 cases, general intravenous anaesthesia (with ketamine) in 114 cases, and regional blocks in only a few cases. These figures indicate the balanced selection of the type of anaesthesia by both surgeon and anaesthesiologist. Cases should be neither overestimated or underestimated, but treated in accordance with the pathological involvement of anatomical structures and the duration of the procedure.

Conclusions

1. Surgical treatment of burns is the only effective way to pr vent late burn complications. Medical propaganda must persist in this, in order to prevent the formation of contracting scars that seriously compromise the function of the area involved.
2. Regular examination of burn patients is important to discover cases needing surgical procedures. It is also important to make medical propaganda on the scientific treatment of burns more efficient.
3. The long-term follow-up of paediatric patients and the organizational and curative problems of their treatment must be regarded as the principal part of our work in the prevention of burn disease and, in particular, of late complications.

RESUME. La Clinique des Brûlures et de Chirurgie Plastique du Centre Hospitalier Universitaire de Tirana en Albanie s'occupe d'un large éventail de maladies chirurgicales. Une grande partie de cette activité concerne les séquelles des brûlures. Les Auteurs présentent une description générale de cette activité pendant 1996, suivie par des observations sur le traitement chirurgical des séquelles des brûlures. Après une comparaison entre les divers groups des pathologies traitées avec des interventions chirurgicales, ils présentent l'image chirurgicale de leur clinique et discutent les conceptions médicales à la base d'une clinique de ce type. Les données statistiques indiquent clairement que la propagande médicale, les recherches et le contrôle à long terme sont les moyens les plus efficaces pour prévenir les brûlures et leur séquelles.

BIBLIOGRAPHY

1. Kraemer M.: Burns contractures, incidence, predisposing factors and results of surgical therapy. J. Burn Care, 9: 261-5, 1983.
2. Yano K., Hata Y.: Two severe facial burn scar patients with lagophthalmos left untreated over a long period of time. Ann. Medit. Burns Club, 4: 255-60, 1991.
3. Joannovich L, Panayotou P., Mantas N., Alexakis D.: The treatment of burn scars, our experience. Ann. Medit. Burns Club, 3: 237-40, 1990.
4. Caleffi E., Bocchi A., Toschi S., Papadia R: Plastic surgery reeducation in severely burned patients: from survival to quality of life. Ann. Medit. Burns Club, 4: 180-6, 1991.
5. Antonopulos D.: The treatment of early and late hand contractures following burn injury. Ann. Medit. Burns Club, 5: 100-1, 1992.
6. Caleffi E., Bocchi A., Toschi S., Ghillani M.: Surgical treatment of post-burn contractures of the hand. Ann. Medit. Burns Club, 3: 1215, 1990.
7. Kadry M., Hassan A., Tewfik C, Ismail M.: Recent fasciocutaneous flaps for repair of post-burp neck, axillary and elbow contractures. Ann. Medit. Burns Club,2: ~9-94, 1989.
8. Baux S.: La place de l'expansion cutanée dans les séquelles de brúlures. Ann. Medit. Burns Club, 3: 5-7, 1990.
9. Marinelli L.F., Montone A., Palombo P., De Bellis A.: Trattamento mediante espansore cutaneo delle alopecie cicatriziali da ustione in età pediatrica - nostre esperienze. Riv. Ital. Chir. Plast., 24: 161-5, 1992.
10. Standoli L., Zama M., Cannistra C., Palmieri G., Proia G.: Gli esiti di ustione dell'estremo cefalico nel bambino. Riv. Ital. Chir. Plast., 23: 283-9, 1991.
11. Manders E.K., Graham W.P.: Skin expansion to eliminate large scalp defects. Ann. Plast. Surgery., 12: 305, 1985