SURGICAL TREATMENT AND REHABILITATION

Dayoub A., Barakat 0.

Faculty of Medicine, University of Aleppo, Syria

SUMMARY. Reconstruction and rehabilitation constitute an additional part of burns treatment, concerned with dysfunction and changes in the aspect of the patients, due to cicatricial contraction after the injury.
By transplanting tissues, early surgical treatment, if,possible, can help the patient to resume his social work sooner.
The surgeon must thus be aware of the degree of bum and the amount of tissue damage. The wound heals more rapidly because of easy reepithelization. In such a case, only mild pigmentation or depigmentation occurs on the part involved, unless the patient has a tendency to sear formation. In deep second degree or third degree bums in which the dermis or the entire skin and subcutaneous tissues are destroyed, the wound usually takes longer to heal. It undergoes a process of sloughing, granulating, progressive fibrosis, and ultimately sear formation.
If proper measures have been taken to repair the defects, such as skin grafting or flap transplantation, cicatricial contraction will be minimized. There are usually two types of scar following bums, namely atrophic and hypertrophic scars. The most suitable time for operation is 6 months post-bum because at that time the scar is stable, with less engorgement and hypertrophic reaction, and becomes soft and brown.

Plastic surgery constitutes an integral part of the treatment of bums. It is primarily concerned with the dysfunction and disfigurement caused by cicatricial contraction after burn trauma.
By transplanting tissues, function can be restored and disfigurement corrected so that the patient is able to resume his work and social activities sooner.

When skin is damaged by bum the process of wound healing and the degree of functional interference vary with the severity of tissue damage. In second degree burns, only the epithelium and part of the dermis are involved, so that the wound heals more rapidly because of easy reepithelization. In such a case only mild pigmentation or depigmentation occurs on the part involved unless the patient has a tendency to scar formation.

In deep second degree or third degree bums in which the dermis or entire skin and subcutaneous tissues are destroyed, the wound usually takes longer to heal. It undergoes a process of sloughing, granulating, progressive fibrosis, and ultimately scar formation. If proper measures have been taken to repair the defects, such as skin grafting or flap transplantation, cicatricial contraction will be minimized.

There are usually two types of scar following bums, namely atrophic and hypertrophic scars. The atrophic scar presents as depressed, pink, smooth, and glistening. It is usually located on a joint surface or on the parts with bony prominences, such as around. the knee, ankle, elbow, and wrist. The scar always adheres to the underlying bone, and tends to ulcerate after trauma. Once ulceration occurs it does not heal readily but becomes a chronic ulcer. The hypertrophic scar manifests itself as a raised, dense, and hard mass which in its early stage has a red, engorged appearance with capillary proliferation. In its advanced stage it becomes brown, soft, and flat, although it is still raised from the surface of the surrounding skin.

The most suitable time for operation is six months post-burn because at that time the scar is stable, with less engorgement and hypertrophic reaction, and becomes soft and brown. However, when the hand has been burned and there is severe cicatricial contraction which has already caused dislocation of the joints, fibrosis of tendons, and other deformities, the operation should be carried out earlier in order to restore better function. Ectropion of the eyelids and microstomia arising from cicatricial contraction also deserve early operation.

The wound resulting from scar excision is covered with a split-thickness or full-thickness free skin graft. In deep burns where bones, nerves and tendons are involved, the scar should be replaced with a flap prior to a secondary repair. With regard to repair of the face, a graft with a good colour match and less lendency towards pigmentation and contraction is preferred. For defects at the tip of a finger or on the plantar surface of a foot where weight bearing is to be expected, a full-thickness graft or pedicle flap is more satisfactory.as they are more durable.

Cutting of Skin Graft

1. Partial-thickness grafts
2. Full-thickness grafts
3. Z-plasty: Z-plasty is one of the popular methods used in plastic surgery. It is indicated for linear and webbed cicatricial contractions. The principle of performing it is to excise the scar and to make Z-shaped incisions on the surrounding skin. The two triangular flaps thus formed are transposed.

Indications: the indications for tube repair are:

1. deep burns with involvement of subcutaneous fat and bone
2. electrical burns with involvement of tendons, nerves, and joints
3. loss of thumb or penis
4. amputation of the nose or ear
5. other facial deformities which require contour reconstruction.

On designing a tube one should place its axis parallel to the main vessels of the skin. The ratio of length to breadth is about 3 to 1.

In recent years with the advancements in microvascular surgery and the replantation of amputated limbs, it has become possible to transplant successfully a free flap through microvascular anastomosis of known vessels.

RÉSUMÉ. La chirurgie reconstructive et la réhabilitation constituent une partie additionnelle du traitement des brûlures. Elles s'occupent des dysfonctionnements et des altérations dans l'aspect du patient à la suite des contractions cicatricielles après la lésion. Avec le transplant des tissus, le traitement chirurgique précoce peut aider le patient à reprendre plus rapidement son rôle dans la société.
Le chirurgien doit donc comprendre le degré de la brûlure et l'étendue du dommage tissulaire. La blessure guérit plus rapidement si la réépithélisation est facilitée. En ce cas, la partie blessée subira seulement une pigmentation ou une dépigmentation légère, à moins que le patient n'ait la tendence à la cicatrisation. Dans les brûlures profondes de deuxième degré ou celles de troisième degré où le derme ou la peau entière et les tissus sous-cutanés ont eté détruits, la blessure a besoin d'une période plus longue pour la guérison. Elle subit les phases successives de l'élimination de l'escarre, la granulation, la fibrose progressive et enfin la formation de la cicatrice. Si pour réparer les défauts l'on prend les mesures appropriées, comme la greffe cutanée ou la transplantion du flap, la contraction cicatricielle sera minimisée.
Tout le monde sait qu'il y a deux types de cicatrice à la suite des brûlures, c'est-à-dire les cicatrices atrophiques et hypertrophiques. La période plus appropriée pour l'intervention chirurgicale est six mois après la brûlure, parce que c'est le moment où la cicatrice est stable, avec moins d'engorgement et de réaction hypertrophique, et elle devient souple et brune.