<% vol = 17 number = 4 prevlink = 201 nextlink = 212 titolo = "SURGICAL PREVENTION OF SEQUELAE DURING BURN WOUND TREATMENT" volromano = "XVII" data_pubblicazione = "December 2004" header titolo %>

Hadjiiski O.

Pirogov Emergency Medical Institute, Centre for Burns and Plastic Surgery, Sofia, Bulgaria

SUMMARY. An operative approach is suggested for the plastic surgery coverage of burn wounds in anatomical areas liable to contractures with functional disorder during children’s growth. The clinical material concerns 57 children aged 7 months to 13 years with sequelae after burns treatment. The application of full-thickness skin grafts and the rotation of skin flaps from an adjacent location are advantageous in split-skin grafts, which are easily influenced by fibrosis from the burn wound surface.


In the specialized Centre for Burns and Plastic Surgery in Sofia, Bulgaria, about 210 of the children treated every year have burns sequelae. This finding can easily be explained by the peculiarities of the age and, specifically, by children’s continuous growth.

During the last 15 years, in the Children’s Centre for Burns and Plastic Surgery at the Pirogov Emergency Medical Institute, 41.0% of the juvenile patients have presented burns sequelae. Of these patients, 33.8% were admitted for reconstructive correction, suffering from burn wounds covered by autografts that formed contractures due to the children’s growth.1 It was found that among all the children observed between the age of 7 months and 13 years each patient was subjected to surgery on average 2.91 times. This is a good reason to search for operative methods that in the early operative stage of wound treatment would have a preventive impact for burns sequelae such as functional defects or, in some cases, cosmetic changes.

A long-term analysis of the operative results on burns in children shows that in limited burns (up to 8-10%), which are operated on after the second week, functionally important areas covered by skin grafts are usually slow in their development owing to the formation of skin contractures. Very often these contractures have to be operated on in various stages.3-5 For this reason, in such cases, we apply skin grafts of two types: full-thickness skin grafts or rotation skin flaps from a nearby location.

In all cases we use these grafts in order to try to cut the lines of traction.

Material and methods

Our experience in the preventive treatment of post-burn functional consequences is based on 57 cases of children operated on in the last eight years. The children were aged between 7 months and 13 years and presented total injury of the skin in 2-9% TBSA.

We can divide the patients according to the functional areas involved:

Burn wounds in the anatomical folds were covered using both methods:

<% immagine "Fig. 1","gr0000023.jpg","Scheme for the surgical approach of operative treatment of burn wound in the elbow fold area.",230 %>
<% immagine "Fig. 2","gr0000024.jpg","Rotated flap from the forearm.",230 %> <% immagine "Fig. 3","gr0000025.jpg","Operative result six years later.",230 %>
<% immagine "Fig. 4","gr0000026.jpg","Burn wound in the lower extremity.",230 %> <% immagine "Fig. 5","gr0000027.jpg","Full-thickness skin applied to the fold and split-skin grafting on the next layers.",230 %>
<% immagine "Fig. 6","gr0000028.jpg","Operative results one year later.",230 %>
<% immagine "Fig. 7","gr0000029.jpg","Seven-month-old girl with second-degree scald burns in the mandibular region.",230 %> <% immagine "Fig. 8","gr0000030.jpg","Rotation flap from the chest wall under the ear and split-skin grafting behind it.",230 %>
<% immagine "Fig. 9","gr0000031.jpg","Operative result seven months later.",230 %>

It is our opinion that these operative methods will not obtain the expected results if the edges of the wound are not refreshed by excision of the wound to the healthy tissue. This also should be done to prevent the influence of fibrosis processes on the plastic material applied.

The operative results were sustained by means of kinesitherapy, position treatment, physiotherapy, and pressure garments for a period of 3 to 6 months, while the dynamic of the result was monitored by the surgeon and the rehabilitation personnel.


There are no data on the development of fibrosis followed by skin contracture and functional disorders in the joints in patients operated on using the method of coverage with full-thickness skin.

Over a period of 3-4 months the full-thickness skin applied gradually regained its elastic features and adapted to the anatomical area. In these patients there was never any need to perform operative corrections as there were no contractures or functional disorders.

In cases where the wounds in the functional folds were covered with rotated skin flaps from an adjacent location, the skin applied adapted quickly to the wound without creating any conditions for fibrosis changes. We never found any contractures in the children, and rehabilitation of movement in the areas affected continued for 2-3 months until complete functional recovery.

We did not observe any expressed fibrosis or retraction in split-skin grafts in the operated areas after application of the two methods of skin coverage of burn wounds.


The children subjected to surgery had deep but limited burns, and were admitted to our clinic at a late stage. Early necrectomy was not applied owing to the children’s late admission - this is a well-known and effective surgical protection method against functional burns sequelae in areas of anatomical folds, which are frequently the location of contractures capable of hindering a child’s normal growth.

After the second week following an accident, inflammation processes in the burns site provoke a quick and massive invasion of fibroblasts and consequently collagen deformation owing to their metabolism.

Split-skin grafts 0.2-0.3 mm thick easily yield to any fibrosis under them, and in the process of children’s growth this creates conditions for contractures to occur. Such contractures necessitate corrective operations that may sometimes be multi-stage operations. The smaller the child, the greater the number of operations.

For this reason the two methods proposed for preventing functional disorders have a positive impact.

Fibrosis cannot penetrate the full-thickness grafts, and this leads to rapid functional recovery. Complete excision of the wound as far as the healthy tissue is of extreme importance in the prevention of the process of fibrosis.


A review of our results using the operative method described shows that in limited burns, in functionally important anatomical areas, burns sequelae were prevented and that conditions were achieved for the normal functional development of the area involved.

These operative methods are applicable in children with limited burn injuries (up to 8-10% TBSA) in whom sufficient donor sites can be found for full-thickness skin, or else sections for the rotation of skin flaps.

In more extensive burns (over 10% of total skin destruction), these operative methods can be used if there are sufficient skin reserves.

RESUME. L’Auteur propose une approche opératoire pour la couverture moyennant la chirurgie plastique des brûlures dans les zones anatomiques exposées au risque des contractures accompagnées de problèmes fonctionnels pendant la phase de la croissance des enfants. Le matériau clinique concerne 57 enfants âgés de 7 mois à 13 ans atteints de séquelles à la suite de traitement pour brûlures. L’application de greffes cutanées à toute épaisseur et la rotation de lambeaux cutanés provenant d’un site adjacent offrent des avantages dans les greffes à épaisseur variable, qui sont facilement influencées par la fibrose de la surface lésionnelle.


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<% riquadro "This paper was received on 21 July 2004.
Address correspondence to: Prof. O. Hadjiiski, Pirogov Emergency Medical Institute, Centre for Burns and Plastic Surgery, Sofia, Bulgaria." %>

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