Annals of Burns and Fire Disasters - vol. XVII - n. 1 - March 2004
METHOD OF SURGICAL TREATMENT OF AN EXTENSIVE POST-BURN DEFORMITY OF THE ABDOMINAL WALL AND THE LUMBOSACRAL REGION
Moroz V., Adamskaya N., Sarygin P., Yudenich A.A.
Division of Plastic and Reconstructive Surgery, A.V. Vishnevsky Institute of Surgery, Russian Academy of Medical Science, Moscow, Russia
SUMMARY. Thermal injury to the abdominal wall and the lumbosacral region may cause severe disfigurement of the trunk. The proposed method of surgical treatment of patients with scar deformations and defects of soft tissues of the anterior abdominal wall and the lumbosacral region was used in 53 patients. The method is based on large mobilization and acute distension of undamaged fasciocutaneous flaps in neighbouring zones with scar defects. Acute dermotension makes it possible to remove large scar defects and restore the natural integument in patients with burn trauma.
Despite the appreciable successes achieved in reconstructive and plastic surgery and the development of new operative methods, many questions related to the surgical rehabilitation of post-burn deformations of the abdominal wall and the lumbosacral area remain unsolved.
The number of patients with serious scar lesions of the trunk is not decreasing and in recent years makes up about 45% of hospitalized cases.
Thermal injury to the abdominal wall and the lumbosacral region can lead to severe functional and cosmetic disturbances: keloids on the abdominal wall cause contracture of the trunk and hip joints, limit flexion and extension of the trunk, cause kyphosis and scoliosis of the spine, and interfere with the normal course of pregnancy.1,3 Deep burns in the area of the loin leave defects in soft tissues, frequently with ulceration of the scars.
These burn sequelae may also upset the patients’ psychological conditions.
A number of methods are used in the correction of post-burn deformities of the abdominal wall and the lumbosacral region. Basically, treatment is applied for a contracture that is eliminated by creating local flaps (Z-plasty), excising scars, and closing wounds with split skin. Large rotatory flaps are seldom applied,4,5 as also the application of flaps to microvascular anastomoses because of the excess of tissue received, and also because of the limited area of the flaps.6-8 A search of the literature has shown that Z-plasties can remove contractures, but that the deformation remains. The split skin alters the structure. The peculiarity of scar deformities of the trunk is the extensive area, and even their partial excision requires extensive donor sites and layers of split skin that lead to secondary deformation in donor sites.9,10 As currently used, Integra is a very demanding but expensive way of solving this problem.
On the basis of the above considerations, we began to investigate opportunities of extensive fasciocutaneous flaps on the abdominal wall and gluteal region for the closure of wounds on the trunk caused by scar excision.
The blood supply to the anterior abdominal wall is provided by two systems: longitudinal and transversal.10 The superficial longitudinal system is provided by the arteria epigastrica inferior and the arteria superior superficialis. The transversal superficial system is related to the rami perforantes, departing from six lower intercostal and four lumbar arteries, and the arteria circumflexa ilium superficialis (Fig. 1).
1) rr. perforantis superficialis a. intercostalis posterior; 2) rr. perforantis sup. a. epigastrica inf.; 3) r. perforantis superficialis a. circumflexa ilium; 4) a. epigastrica inf. superficialis; 5) a. epigastrica superior profunda; 6) a. intercostalis posterior; 7) a. epigastrica inferior profunda; 8) rr. profundus a. circumflexa ilium prof.
As the blood supply sources are outside the abdominal wall, the separation of extensive fasciocutaneous flaps on the abdominal wall does not give rise to any threats as regards their necrosis.
Patients and methods
Fifty-three patients with extensive abdominal wall and lumbosacral deformities were treated in the Division of Plastic and Reconstructive Surgery at the A.V. Vishnevsky Institute of Surgery, Russian Academy of Medical Sciences, Moscow.
To define the correct tactics in surgical treatment it is important to have a precise definition of the location and prevalence of scars.
We classify scar deformities as follows:
The extent of the damaged area plays the main role in decision-making as regards surgical tactics.
Reconstruction of subtotal superior deformations
The scars were excised to the fascia (Figs. 2a,b).
The mobilization of the fasciocutaneous flap was performed from the lower edge of the wound downwards to the inguinal folds and the pubis. The fasciocutaneous layer was similarly separated on the upper edge of the wound up to the costal arches and the xiphoid process.
The wound was closed primarily in two layers with mobilized fasciocutaneous flaps (Fig. 2c).
A drainage was left in the underflap space for active aspiration and better adherence of the mobilized tissues to the abdominal wall.
It was thus possible, in one stage, to eliminate scars in an area of up to 550 cm2 and to replace them with fasciocutaneous flaps from undamaged areas with suitable qualitative characteristics.
Reconstruction of combined lesions
In cicatricial lesions in the anterior abdominal wall (area up to 730 cm3), with involvement also of the mammary glands (Fig. 3a), a two-stage operation was carried out.
The first stage eliminated about 50% of the cicatricial area (Figs. 3b,c). In this case we mobilized a lower fasciocutaneous flap in the abdominal wall, beginning from the lower scar contour up to the inguinal folds. We then excised the lower half of the scar strip in the abdominal wall, having first removed the umbilicus through an aperture in the mobilized layer in the new position. The wound on the abdominal wall was closed primarily in two layers.
The deformation of the anterior forward abdominal wall was finally eliminated in this patient after 6 months. The remaining strips of scars in the epigastric area and the sub-costal area were excised to a width of 6 cm, without affecting the nipple-areolar complex, which we moved with the undamaged gland to a natural position.
The wound was closed with a mobilized fasciocutaneous flap from the abdominal wall (Fig. 3d).
Reconstruction of anterolateral deformities
In cases of anterolateral lesions of the abdominal wall, the mammary gland was often simultaneously involved.
In such cases, restoration of the gland was achieved by application of circular sutures and reconstruction of an integument by acute or balloon extension, in some cases in combination with split skin. Elimination of the deformation of the abdominal wall was effected using wide mobilization of fasciocutaneous flaps from undamaged areas in the abdominal wall and the back (Figs. 4a,b).
Reconstruction of lumbosacral deformities
Damage to the lumbosacral area is seldom encountered and, as a rule, is the consequence of a contact burn. In this connection, cicatricial damage was combined in all patients with defects in soft tissues and trophic disturbances in scar zones (Figs. 5a,b).
The elimination of this type of deformity was effected using a wide fasciocutaneous flap, mobilized on the back.
Mobilization up to the angle of the scapulas is related to appreciable difficulties because of their close bond to the subject structures, especially the spine.
When a mobilized layer is moved, it has been remarked that the skin of the back is very rigid and stretches badly (Fig. 6a).
The fasciocutaneous layer of gluteal area is richly vascularized with branches of the arteriae gluteus superior and inferior and is well displaced.
After wide mobilization up to the inferior gluteal folds it was easy to move up the fasciocutaneous flap and in one stage close the defect in the lumbosacral area to a width of up to 15 cm (Figs. 6b,c).
Necrosis of the distal 3 cm of the mobilized flaps occurred in five patients, requiring correction. However, the complications did not essentially reduce the effect of the plasty. The observations of over 40 patients out of 53 operated over a period of 1 to 7 years showed that the results of treatment can be regarded as good: scar deformations were completely eliminated, and natural skin coverage was achieved.
RESUME. Les lésions thermiques dans la paroi abdominale et la région lombosacrale peuvent causer des déformations sévères du tronc. La méthode proposée par les Auteurs pour le traitement chirurgical des patients atteints de séquelles cicatricielles et de défauts des tissus mous de la paroi abdominale antérieure et de la région lombosacrale a été employée dans 53 patients. Cette méthode est basée sur la mobilisation étendue et la distension aiguë de lambeaux fasciocutanés intacts dans les zones voisines atteintes de séquelles cicatricielles. Avec la dermotension aiguë il est possible d’éliminer les grosses difformités cicatricielles et de restaurer le tégument naturel des patients brûlés.